Management of Critically Ill Patient with COPD

MANAGEMENT OF CRITICALLY ILL PATIENT WITH C.O.P.D. ( WITH REVIEW OF O2 THERAPY ) DR D.R. JOSHI, B.J.Medical College,Pune < drjaydr@pn3.vsnl.net.in > # # Acute exacerbations in C O A D are common They carry high morbidity and mortality but are reversible Prognosis of patients who recover is good # FACTORS PRECIPITATING ACUTE FAILURE •Sputum retention •Bronchospasm •Infection •Pneumothorax •Large bullae •Uncontrolled O2 - administration •Pulmonary embolism •Left-ventricular failure •Sedation •End-stage disease PATHO- PHYSIOLOGY…. FACTORS AFFECTING AIR-FLOW • • • • • • • Mucosal edema Hypertrophy of mucosa Increased secretions Increased bronchospasm incr. Airway tortuosity More airway turbulance Loss of lung recoil PATHO-PHYSIOLOGY….contd AIR-FLOW OBSTRUCTION PROLONGED EXPIRATION PULMONARY HYPERINFLATION DUE TO AIR-TRAPPING INCREASED WORK OF BREATHING DYSPNOEA PATH-PHYSIO…..CONTD ALVEOLAR DISTORTION AND DESTRUCTION LOSS OF CAPILLARY BED HYPOXIA CAUSING PULMONARY VASOCONSTRICTION PULMONARY HYPERTENSION SECONDARY VASCULAR CHANGES COR-PULMONALE INCREASED AIRWAY OBSTRUCTION DUE TO INCOMPLETE EXPIRATION + RAISED MVV RAISED F R C PULMONARY HYPER-INFLATION LUNG VOLUME FIBRE LENGTH OF DIAPHRAGM WORK OF BREATHING VENTILATORY REQUIREMENT ‘ IF WORK OF BREATHING FAILS TO MEET VENTILATORY REQUIREMENT OF A PATIENT…’ CHRONIC HYPERCARBIA RESULTS. CLINICAL PRESENTATION… PATTERN-I ‘’ CAN’T BREATH ‘’ ( INCREASING DYSPNOEA) # # # # MORE COMMON IMPAIRED AIR-FLOW & GAS EXCHANGE RESPIRATORY DRIVE – NORMAL INABILITY TO ACHIEVE ADEQUATE VENTILATION DESPITE MAXIMUM VENTILATORY EFFORTS # HYPERPNOEA # INCREASED SPUTUM / COUGH / WHEEZE & REDUCED EXERCISE TOLERANCE # RESPIRATORY MUSCLE FATIGUE … CLINICAL PRESENTATION PATTERN – II ‘’ WON’T BREATH ‘’ ( DECREASING DYSPNOEA ) # LESS COMMON # REDUCED CONSCIOUSNESS LEVELS .. DRUGS ILLNESS UNCONTROLLED OXYGEN THERAPY # REDUCED CENTRAL RESPIRATORY DRIVE # RESPIRATORY MUSCLE FATIGUE & CO2 NARCOSIS # ABG = RESPIRATORY ACIDOSIS HYPOXIA DIAGNOSIS OF A R F IN COAD … 1} • • • • • • X-RAY CHEST Hyper - inflation Flattened diaphragm Less lung markings Increased hilum / pulm.Art.Size RA / RV dilated Existing pathology DIAGNOSIS OF A R F IN COAD …. 2} ECG NORMAL RT AXIS DEVIATION RAH ( ‘P’ PULMONALE) RVH WITH RV – STRAIN RBBB DIAGNOSIS OF A R F IN COAD … 3] Arterial Blood Gas # # # Hypoxia Respiratory acidosis - Compensated - Un-compensated Exclude metabolic alkalosis If bicarbonates high … contd … POINTS TO RECOLLECT … EVERY 10 mm Hg RISE IN pCO2 => RISE OF 1mmol/L in HCO3 in ACUTE RESPIRATORY ACIDOSIS AND EVERY 10 mm Hg RISE IN PCO2 => RISE OF 3 – 3.5 mmol/L in HCO3 in CHRONIC RESPIRATORY ACIDOSIS … OTHER INVESTIGATIONS … # SPUTUM BACTERIOLOGY # TOTAL BLOOD COUNTS # THEOPHYLLINE LEVELS {WHERE INDICATED} # C T THORAX TO R / O SMALL PNEUMOTHORAX # VENTILATION / PERFUSION STUDY DIFFERENTIAL DIAGNOSIS … # # # Left ventricular failure Pulmonary embolism Pneumothorax # Upper air-way obstruction MANAGEMENT.. CONSERVATIVE • • • • • • Oxygen Bronchodilators Steroids Antibiotics Non-invasive secretions clearance Other measures NON-CONSERVATIVE • • Invasive techniques for sputum clearance Mechanical ventilation CONSERVATIVE MANAGEMENT C OXYGEN THERAPY Clear benefit of long term o 2 TRIALS• N O T T ( Nocturnal O2 Ttherapy trial ) • MRC ( Medical Rsearch Council, UK ) Continuous O2 (24 hrs/day) better than nocturnal O2 (12 hrs/day) which is better than no O2 OXYGEN THERAPY MODES OF OXYGEN DELIVERY APPARATUS O2 FLOW (L / MIN) 2–6 4 – 15 6 – 12 4 – 15 VARYING VARYING 7 – 10 CONC. % 25 – 40 35 - 70 24, 28, 35, 40, 50, 60 40 – 80 21 – 100 21 – 100 60 - 80 NASAL CATHETER SEMI RIGID MASK VENTURI MASK SOFT PLASTIC MASK VENTILATORS CPAP CIRCUITS OXYGEN TENT PATIENTS FOR HOME OXYGEN THERAPY • STABLE COURSE OF DISEASE • 2 ABGs AT ROOM AIR AT REST FOR 20 MNTS * RESTING PaO2 < 55 FOR > 3 WKS OR PaO2 55 – 59 + CLINICALLY COR PULMONALE AND / OR HAEMATOCRIT > 55 % * NOCTURNAL HYPOXEMIA OR HAEMATOCRIT > 55 % OR CLINICAL PULMONARY HYPERTENSION * NORMOXIC PATIENT WITH LESS DYSPNOEA + INCREASING EXERCISE CAPABILITY WITH O2 OXYGEN DOSE # CONTINUOUS O2 FLOW 1 – 2 L/MIN WITH SINGLE / DOUBLE NASAL CANNULA WITH ADEQUATE SaO2 # LOWEST FLOW TO RAISE PaO2 TO 60-65 mm OR SaO2 88-94 % # INCREASE BASE -LINE FLOW BY 1 L / MIN DURING SLEEP AND EXERCISE CONTROLLED O2 THERAPY •MODERATE TO SEVERE HYPOXIA (PaO2 <55 mm Hg) IN COPD CAN CAUSE MORTALITY •SHOULD BE CORRECTED IMMEDIATELY •INCREASE PaO2 TO 60 mmHg WHILE MAINTAINING PH > 7.25 •SEVERITY OF ACIDOSIS IS A BETTER PROGNOSTIC GUIDE THAN ABSOLUTE pCO2 LEVELS. …contd CONTROLLED OXYGEN THERAPY NORMALLY 24% - 26% INSPIRED OXYGEN …contd UPTO 30% IF HYPOXIA UNRELIEVED. RESPONSE --1. RELIEF OF HYPOXIA + REDUC. IN PCO2 + CLINICAL IMPROVEMENT 2. RELIEF OF HYPOXIA + INITIAL RISE IN PCO2 AND pH /< 7.25 LATER CHANGING TO NORMAL WITH FALL IN PCO2 3. IF UNCONTROLLED OXYGEN THEN RAPID RISE IN PCO2 AND DROP IN pH <7.25 . CAN BE LETHAL. DOMESTIC OXYGEN SYSTEM … # • • • LIQUID – PORTABLE DEVICE .. LIGHT WEIGHT LONG – RANGE PORTABLE CANNISTER PRACTICAL AMBULATORY SYSTEM BUT MORE EXPENSIVE THAN CONCENTRATOR ALONE • • NOT AVAILABLE IN SMALLER PLACES ..contd DOMESTIC OXYGEN SYSTEM …. # OXYGEN CONCENTRATOR - LOW COST - CONVENIENT Contd - ATTRACTIVE EQUIPMENT - WIDE-SPREAD AVAILABILITY BUT - ELECTRICITY REQUIRED NOT PORTABLE - MAY NEED BACK-UP TANK DOMESTIC OXYGEN SYSTEM … CONTD # COMPRESSED GAS • LOW COST IN GENERAL • BUT • WIDE-SPREAD AVAILABILITY MULTIPLE TANK REQUIREMENT • • FREQUENT DELIVERIES REQUIRED HEAVY & UNSIGHTLY TANKS = DIFFICULT AMBULATION. FUTURE TRENDS IN OXYGEN THERAPY 1) • TRANS-TRACHEAL OXYGEN Reduction in supplemental o2 Improved exercise tolerance Reduced hospitalisation Better patient compliance • • • • • Cosmetic value Hypoxia & sleep disorders avoided cont FUTURE TRENDS IN OXYGEN THERAPY OXYSPECS / OXYFRAMES • • CONCEALED OXYGEN TUBINGS SINGLE / DOUBLE NASAL CANNULA • • COSMETICALLY MORE ACCEPTABLE USES SMALLER BATTERY- POWERED OXYGEN CONCENTRATORS DEMAND CANNULA / DEMAND SYSTEMS • ALLOWS O2 FLOW DURING INSPIRATION ONLY • SAVES 50 % OXYGEN MANAGEMENT – NONINVASIVE # • BRONCHODILATORS ROUTINELY GIVEN • HELP RESIDUAL BRONCHODILATION AND MUCO-CILIARY CLEARANCE [ I.V.AMINOPHYLLINE / B2-AGONIST / IPRATROPIUM ] …CONTD CONSERVATIVE MANAGEMENT # ANTIBIOTICS ….contd # STEROIDS … AVOID IN ARF DUE TO INFECTION # OTHER * STEAM / PHYSIOTHERAPY / ENCOURAGE * GENERAL HYDRATION * DIURETICS / LOW DIGOXIN IF LVF * HEPARIN S /C FOR D V T / PULM EMBOLISM * NUTRITION * RESPIRATORY STIMULANTS COUGH MANAGEMENT - NON CONSERVATIVE…. 1. INVASIVE TECHNIQUES FOR SPUTUM CLEARANCE • • • OROPHARYNGEAL / NASOPHARYNGEAL SUCTION NASO-PHARYNGEAL AIR-WAY THERAPEUTIC AND DIAGNOSTIC F O B • MINI TRACHEOSTOMY/ CRICOTHYROTOMY FOR SUCTION • ENDOTRACHEAL INTUBATION * FOR BETTER ACCESS * FOR VENTILATORY SUPPORT • TRACHEOSTOMY * IF VERY THICK SECRETIONS * INTUBATION > SEVEN DAYS MECHANICAL VENTILATORY SUPPORT SETTINGS WITH NO OVER-INFLATION LOW TIDAL VOL 8-10 ML /KG , MV = 5-6 L/MIN NO INCREASE IN AUTOPEEP REDUCE PEAK INFLATION REDUCE BAROTRAUMA FLOW CAN BE INCREASED TO 40 – 60 L / MIN I/E RATIO GOOD DISTRIBUTION OF GASES 1 : 2 OR 1 : 3 FiO2 0 . 5 TO 0 . 7 SEDATION ALLOWS TIME FOR EXPIRN FAST CORRECT OF HYPOXIA MACHINE CAN TAKE-OVER MECHANICAL VENTILATION . . . …CONTD. # BRING DOWN PaCO2 GRADUALLY IN 24 – 48 HOURS UPTO 50 MM Hg # # PaO2 = 60 MM MAY SUFFICE IF DIFFICULT WEANING – CAN USE PRESSURE SUPPORT # WEANING BY TRADITIONAL METHODS INDICATIONS FOR I C U ADMISSION • • • SEVERE NON-RESPONDING DYSPNOEA DEVELOPING CONFUSION / LETHARGY RESPIRATORY MUSCLE FATIGUE • • PROGRESSIVE WORSENING DESPITE TREATMENT OF HYPOXIA / RESPIRATORY ACIDOSIS NEED FOR INVASIVE / NON-INVASIVE MECHANICAL VENTILATION COMPLICATIONS OF A R F IN COPD • NOSOCOMIAL INFECTIONS • FLUID / ELECTROLYTE IMBALANCE (HYPOKALEMIA) • ACID / BASE – DISTURB. -- METABOLIC ALKALOSIS • CARDIAC ARRHYTHMIAS / FAILURE • PNEUMOTHORAX • PULMONARY THROMBOEMBOLISM • HYPOTENSION DUE TO AUTO - PEEP • G.I. BLEEDING • MENTAL DEPRESSION THANK-YOU