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Icu management in obstructive airway disease
1. ICU Management
in
Obstructive Airway Disease
Muhammad Asim Rana
BSc, MBBS, MRCP(UK), MRCPS(Glasg), FCCP, EDIC, SF-CCM
Critical Care Medicine
King Saud Medical City
ADULT MECHANICAL VENTILATION COURSE 2014
2. 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 38.8 C, 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
2
3. 3
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…..
4. 4
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
5. 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
5
Management of Exacerbation of COPD
Assessment of severity
6. 6
Management of Exacerbation of COPD
Assessment of severity
Classification based upon the increased need for
bronchodilators and antibiotic use, corticosteroid
administration and hospitalization
(Burge et al. ERJ 2003)
7. 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
9. • 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 38.8 C
• ABG on 8 L/min O2: pH 7.24, PCO2 60 mm Hg
(8 kPa), PO2 65 mm Hg (8.7 kPa)
9
What type of respiratory support should
be initiated?
10. 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
10
11. › Avoids complications of intubation
› Preserves airway reflexes
› Improved patient comfort
› Less need for sedation
› Shorter hospital/ICU stay
› Improved survival
11
What are advantages of using non-invasive
positive pressure ventilation in this patient?
13. 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
14. 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?
15. 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
15
What is the next step?
17. Orotracheal intubation is performed
17
What ventilator mode should be selected?
What tidal volume is optimum?
What rate of ventilation should be set?
18. Patient with COPD exacerbation
who failed NPPV
18
What ventilator mode should be selected?
What tidal volume is optimum?
What rate of ventilation should be set?
What FIO2 should be delivered?
19. 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
19
®
20. 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 secretions
Administer bronchodilators
↑PEEP if missed trigger efforts
↓VT or rate
↓ FiO2↑ FiO2
↑rate
↑VT
NPPV
Continue
NPPV
Candidate
For
NPPV
Patient
tolerates
Clinically
improved
PaO2
mmHg
pH
Pplat <
25 cm H2O
Pplat >
30 cm H2O
↓rate
↓VT
Auto-PEEP
Auto-PEEP
START
yes yes yes yes
yes
yes
no
no
yes
no
yes
no
>75
55-75 mmHg
<55
7.30-7.45
<7.30>7.45
intubate
intubate intubate
Fumeaux T et al Intensive Care Med 2001;27:1868
Gladwin MT et al Intensive Care Med 1998;24:898
Nava S et al Ann Intern Med 1998; 128:721
No No
21. › Chest radiograph
› Vital signs
› SpO2
› Patient-ventilator
synchrony
› Arterial blood
gas
› Inspiratory
pressures
› Inspiratory:
expiratory ratio
› Auto-PEEP
› Ventilator alarms
21
What monitoring and assessment is needed after
initiation of mechanical ventilation?
22. After 35 minutes of
ventilation
Patient became hypoxic and started to to fight
with the machine.
25. 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
26.
27. Assessment of asthma severity
Pulsus paradoxus, when present, indicates severe asthma
29. 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
30. 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
31. Intubation
Clinical judgement.
Markers of deterioration
Rising carbon dioxide levels
(normalization in a previously hypocapnic)
Exhaustion
Mental status depression
Haemodynamic instability
Refractory hypoxaemia
32. 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…?
33. Algorithm for Mechanical Ventilation of Patient with Asthma
START
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 H2OpH
Pplat>
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 20:385
Mansel JK et al Am J Med 1990 89:42
Koh Y Int Aneshesiol Clin 2001 39:63
no
34. 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?
37. 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?
38. 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