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ICU Management in
Obstructive Airway Disease
Muhammad Asim RanaBSc, MBBS, MRCP(UK), MRCPS(Glasg), FCCP, EDIC, SF-CCMCritical Care MedicineKing Saud Medical City
ADULT MECHANICAL VENTILATION COURSE 2014
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Case 1• 65 yrs old, Hx of 30 pack yrs of smoking• Dx as COPD chronic bronchitis 2 yrs ago on
Rx• Presented to A&E with SOB for last 8 hrs• Examination:• HR 110 beats/min, BP 160/110 mm Hg, RR
30 breaths/min, T 38.8C, audible wheezes• ABG on 8 L/min O2: pH 7.30, PCO2 60 mm Hg
(8 kPa), PO2 65 mm Hg (8.7 kPa)• Dx: COPD Exacerbation
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Management of Exacerbation of COPD
Assessment of severity
Determining cause of exacerbation
You are the ICU physician on duty as OUT REACH TEAM
You are called for…..
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Management of Exacerbation of COPD
Determining cause of exacerbation
>60% infective cause
Around 20% heart failure
±20% others
Fever, CXR, CBC, PCT……
CXR, ECG, Cardiac Enzymes, Echo……
Environmental Pollution, Unknown etiology
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American Thoracic Society/European Respiratory Society (ATS/ERS) Inadequate response of symptoms to outpatient management Marked increase in dyspnea Inability to eat or sleep due to symptoms Worsening hypoxemia Worsening hypercapnia Changes in mental status Inability to care for oneself (ie, lack of home support) Uncertain diagnosis High risk comorbidities including pneumonia, cardiac arrhythmia, heart
failure, diabetes mellitus, renal failure, or liver failure
5Management of Exacerbation of COPD
Assessment of severity
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Management of Exacerbation of COPD
Assessment of severityClassification based upon the increased need for bronchodilators and antibiotic use, corticosteroid
administration and hospitalization (Burge et al. ERJ 2003)
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ICU or Ward? Severe dyspnea that responds inadequately to
initial emergency therapy Changes in mental status (confusion, lethargy,
coma) Persistent or worsening hypoxemia (PaO2<60
mmHg), and/or severe/worsening hypercapnia (PaCO2>60 mmHg), and/or severe/worsening respiratory acidosis (pH<7.25) despite
supplemental oxygen and noninvasive ventilation Need for invasive mechanical ventilation Hemodynamic instability — need for
vasopressors These patients should be transferred to the ICU
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Rx of COPD exacerbation Antibiotics Oxygen Steroids Bronchodilators
Anticholinergics Nebulized β2 agonists Aminophyllin
Secretion clearing techniques CPT Nebulized mucolytics Oro/nasopharyngeal suction Fibroptic bronchoscopy
• Hydration• Diuretics• Control of AF if present• Electrolytes correction
– K+– Mg++– PO4
• Prophylaxis– DVT– Stress Ulcers
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• 65-year-old with an exacerbation of COPD• Using accessory muscles and wheezing after
2 bronchodilator treatments• HR 110 beats/min, BP 160/110 mm Hg, RR
30 breaths/min, T 38.8C• ABG on 8 L/min O2: pH 7.24, PCO2 60 mm Hg
(8 kPa), PO2 65 mm Hg (8.7 kPa)
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What type of respiratory support should be initiated?
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Candidates for NPPV
Condition expected to improve in 48-72 hours Alert, cooperative Hemodynamically stable Able to control airway secretions Able to coordinate with ventilator No contraindications
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› Avoids complications of intubation› Preserves airway reflexes› Improved patient comfort› Less need for sedation› Shorter hospital/ICU stay› Improved survival
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What are advantages of using non-invasive positive pressure ventilation in this patient?
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Assess your patient
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CPAP & BIPAP
Parameters CPAP-PEEP 5-10 cm H2O BIPAP is when add PS 10-20
cm H2O Triggered by pt Limited by pressure Cycled by time
Indications When medical Rx fails ↑Tachypnea ↑ Hypoxemia ↑ Respiratory acidosis
Use in conjunction with Steroids Antibiotics Bronchodilators
CPAP is essentially contant PEEP while BIPAP is PEEP with Pressure Support
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ABG on 8L/min O2: pH 7.23, PaCO2 76 mm Hg (8 kPa), PaO2 65 mm Hg (8.7 kPa)
HR 110 beats/min, BP 160/110 mm Hg,RR 36 breaths/min
What are the goals for respiratory support?
What settings should be selected for NPPV?
How should the patient be monitored?
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After 1 hr of NPPV, the patient has not improved
Arterial blood gas on 40% O2: pH 7.20, PaCO2 65 mm Hg (8.7 kPa), PaO2 58 mm Hg (7.8 kPa)
HR 115 beats/min, BP 142/98 mm Hg, RR 32 breaths/min
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What is the next step?
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Indications for intubation Clinical deterioration Respiratory rate > 35 Hypoxia PaO2 < 60 mmHg Hypercarbia PaCO2> 55 mmHg Minute Ventilation < 10L Tidal Volume < 5 -10 ml/kg NIF < 25 cm of H2O
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Orotracheal intubation is performed
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What ventilator mode should be selected?
What tidal volume is optimum?
What rate of ventilation should be set?
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Patient with COPD exacerbation who failed NPPV
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What ventilator mode should be selected?
What tidal volume is optimum?
What rate of ventilation should be set?
What FIO2 should be delivered?
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Initiation of Mechanical Ventilation
› Familiar ventilation mode› Initial FIO2 = 1.0; decrease to
maintain SpO2 >92% to 94%› Initial tidal volume = 8-10 mL/kg› Rate and minute ventilation
appropriate for clinical needs› PEEP to support oxygenation
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®
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Algorithm for the ventilator management of the patient with COPD
(A/C), PCV or VCV, VT 8-10 mL/kg, Pplat < 30 cm H2O, rate 10/min, Ti 0.6-1.2 s, PEEP 5 cm H2O, FiO2 for SpO2 90-95%
Clear secretionsAdminister bronchodilators
↑PEEP if missed trigger efforts↓VT or rate
↓ FiO2↑ FiO2
↑rate↑VT
NPPVContinue
NPPV
CandidateFor
NPPV
Patienttolerates
Clinicallyimproved
PaO2mmHg
pHPplat <
25 cm H2OPplat >
30 cm H2O
↓rate ↓VT
Auto-PEEP
Auto-PEEP
STARTyes yes yes yes
yes
yes
no
no
yes
no
yes
no
>75
55-75 mmHg
<55
7.30-7.45
<7.30>7.45
intubateintubate intubate
Fumeaux T et al Intensive Care Med 2001;27:1868Gladwin MT et al Intensive Care Med 1998;24:898Nava S et al Ann Intern Med 1998; 128:721
No No
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› Chest radiograph› Vital signs› SpO2
› Patient-ventilator synchrony
› Arterial blood gas
› Inspiratorypressures
› Inspiratory:expiratory ratio
› Auto-PEEP› Ventilator
alarms
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What monitoring and assessment is needed after initiation of mechanical ventilation?
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After 35 minutes of ventilation
Patient became hypoxic and started to to fight with the machine.
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Auto-PEEP
› Consequences Inspiratory pressures Hypotension Worsened oxygenation
› Interventions to decrease auto-PEEP Respiratory rate Tidal volume Gas flow rate
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Case 2
A young boy 23 years old known case of BA Presented to ER after exposure to polluns Severe SOB You are requested to see that patient
Awake and alert Answering your questions Low grade fever HR 98/min, RR 26/min, SpO2 on 4L/min 96% Using accessory muscles, looks anxious, wheezy
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Assessment of asthma severity Pulsus paradoxus, when present, indicates severe asthma
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MANAGEMENTESTABLISHED TREATMENTS
OXYGENβ-AGONISTS
ANTICHOLINERGICSCORTICOSTEROIDS
AMINOPHYLLINE
NON-ESTABLISHED TREATMENTS
EPINEPHRINEMAGNESIUM SULPHATEHELIOX
ANAESTHETIC AGENTSLEUKOTRIENE ANTAGONISTSBRONCHOALVEOLAR
LAVAGE
THERAPIES NOT RECOMMENDED
Antibiotics Antihistamines Inhaled mucolytics Sedation
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After 1 hour
You are called by ER physician to reassess the boy
You found RR 32, SpO2 89 on 8L/m, wheezy pH 7.20, PaCO2 35, PO2 68, HCO3 20
You planned NIPPV to support the patient The ER physician remembers that this pt had
been admitted to ICU twice in last 6 months Last time was 2 and a half month ago when he
was intubated and ventilated for 2 days
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Noninvasive positive pressure ventilation
Possible Limited data 2 small randomised trials Some observational studies Success of NPPV depends on a variety of factors
including clinician experience patient selection and interfaces
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Intubation
Clinical judgement. Markers of deterioration
Rising carbon dioxide levels (normalization in a previously hypocapnic)
Exhaustion Mental status depression Haemodynamic instability Refractory hypoxaemia
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Which Mode for Asthma?
Volume Control Predictable volume Peak-Plat gradient Monitor Plateau
pressure Better acidosis control
Pressure Control Minimizes over-
distention Monitor tidal volume Volume may increase
excessively when…?
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Algorithm for Mechanical Ventilation of Patient with AsthmaSTART
Decrease minute ventilation
CMV (A/C), PCV or VCV, VT 8 mL/kg, Pplat 30 cm H2O≦rate 8-20/min, Ti 1 s, PEEP 5 cm H2O, FiO2 1.0
SpO2
Auto-PEEP
Auto-PEEP
Pplat<25 cm H2OpHPplat>
30 cm H2O
Administer bronchodilators
↑VT ↑rate
↑FiO2↓FiO2
↓VT↓rate
yes
yes
yesyes
no
nono
92-95%
>95% <92%
>7.45 <7.30
7.30-7.45
Afzal M et al Clin Rev Allergy Immunol 2001 20:385Mansel JK et al Am J Med 1990 89:42Koh Y Int Aneshesiol Clin 2001 39:63
no
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Course in ICU
After intubating in ER you ask to bring the patient to ICU
Patients arrives in ICU 30 minutes after You receive him with ER nurse only (no MD)
Cyanosed Tachycardiac Hypotensive
What is the first step you will do?
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Dynamic Hyperinflation
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Dynamic Hyperinflation
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The patient’s CXR showed consolidation Rt lung mid and lower zones
Will it change your Rx plan? What antibiotics? His FiO2 requirement creeping up now 70% Chest is almost silent What is the role of heliox?
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Watch out !!!
Heliox in hypoxemic patient…. Contraindicated Always try to identify the high risk patient Early monitoring in ICU vs observing in ER Other therapeutic measures Monitoring during ventilation Auto PEEP and its management Decision to wean off
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Thank you very muchQUESTIONS?