Management of Critically Ill Patient with COPD

1
MANAGEMENT OF CRITICALLY ILL PATIENT
WITH C.O.P.D. ( WITH REVIEW OF O2 THERAPY ) DR
D.R. JOSHI, B.J.Medical College,Pune lt
drjaydr_at_pn3.vsnl.net.in gt
2
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
3

• FACTORS PRECIPITATING ACUTE FAILURE
• Sputum retention
• Bronchospasm
• Infection
• Pneumothorax
• Large bullae
• Uncontrolled O2 - administration
• Pulmonary embolism
• Left-ventricular failure
• Sedation
• End-stage disease

4

• 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

5
PATHO-PHYSIOLOGY.contd AIR-FLOW
OBSTRUCTION PROLONGED EXPIRATION PULMONARY
HYPERINFLATION DUE TO AIR-TRAPPING INCREASED
WORK OF BREATHING DYSPNOEA
6
PATH-PHYSIO..CONTD ALVEOLAR DISTORTION AND
DESTRUCTION LOSS OF
HYPOXIA CAUSING CAPILLARY
BED PULMONARY

VASOCONSTRICTION
PULMONARY HYPERTENSION
SECONDARY VASCULAR CHANGES
COR-PULMONALE
7
INCREASED AIRWAY OBSTRUCTION DUE TO INCOMPLETE
EXPIRATION RAISED MVV RAISED F R C
PULMONARY HYPER-INFLATION
8
LUNG FIBRE
LENGTH VOLUME OF
DIAPHRAGM WORK OF
BREATHING VENTILATORY
REQUIREMENT
9
IF WORK OF BREATHING FAILS TO MEET
VENTILATORY REQUIREMENT OF A
PATIENT CHRONIC HYPERCARBIA RESULTS.
10
CLINICAL PRESENTATION PATT
ERN-I CANT 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
11
CLINICAL PRESENTATION PATTERN II
WONT BREATH
( DECREASING DYSPNOEA )
LESS COMMON REDUCED CONSCIOUSNESS
LEVELS .. DRUGS
ILLNESS
UNCONTROLLED OXYGEN THERAPY REDUCED
CENTRAL RESPIRATORY DRIVE
RESPIRATORY MUSCLE FATIGUE
CO2 NARCOSIS A B G
RESPIRATORY ACIDOSIS
HYPOXIA
12

• 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

13
DIAGNOSIS OF A R F IN COAD . 2 E C
G - NORMAL - RT AXIS
DEVIATION - RAH ( P PULMONALE)
- RVH WITH RV STRAIN
- RBBB
14
DIAGNOSIS OF A R F IN COAD 3
Arterial Blood Gas Hypoxia
Respiratory acidosis
- Compensated
- Un-compensated Exclude
metabolic alkalosis If
bicarbonates high
contd
15


POINTS TO RECOLLECT EVERY 10
mm Hg RISE IN pCO2 gt
RISE OF 1mmol/L in HCO3 in
ACUTE RESPIRATORY ACIDOSIS
AND EVERY 10 mm Hg RISE IN
PCO2 gt RISE OF
3 3.5 mmol/L in HCO3 in CHRONIC
RESPIRATORY ACIDOSIS
16
OTHER INVESTIGATIONS
SPUTUM
BACTERIOLOGY TOTAL BLOOD COUNTS
THEOPHYLLINE LEVELS WHERE INDICATED
C T THORAX TO R / O SMALL PNEUMOTHORAX
VENTILATION / PERFUSION STUDY

17
DIFFERENTIAL DIAGNOSIS
Left ventricular failure Pulmonary
embolism Pneumothorax Upper
air-way obstruction
18

• MANAGEMENT..
• CONSERVATIVE
• Oxygen
• Bronchodilators
• Steroids
• Antibiotics
• Non-invasive secretions clearance
• Other measures
• NON-CONSERVATIVE
• Invasive techniques for sputum clearance
• Mechanical ventilation

19

• CONSERVATIVE MANAGEMENT
• OXYGEN THERAPY
• Clear benefit of long term o
• 2 TRIALS-
• N O T T ( Nocturnal O2 Ttherapy trial )
• M R C ( Medical Rsearch Council, UK )
• Continuous O2 (24 hrs/day) better than
  nocturnal O2 (12 hrs/day) which is
  better than no O2

C
20
OXYGEN THERAPY MODES OF OXYGEN DELIVERY
APPARATUS O2 FLOW
CONC. (L / MIN)
NASAL CATHETER 2 6 25 40 SEMI
RIGID MASK 4 15 35
- 70 VENTURI MASK 6 12 24,
28, 35, 40, 50, 60 SOFT PLASTIC MASK 4
15 40 80 VENTILATORS VARYING
21 100 CPAP CIRCUITS VARYING 21
100 OXYGEN TENT 7 10 60 - 80
21

• PATIENTS FOR HOME OXYGEN THERAPY
• STABLE COURSE OF DISEASE
• 2 ABGs AT ROOM AIR AT REST FOR 20 MNTS
• RESTING PaO2 lt 55 FOR gt 3 WKS
• OR PaO2 55 59 CLINICALLY COR
  PULMONALE
• AND / OR HAEMATOCRIT gt 55
• NOCTURNAL HYPOXEMIA OR HAEMATOCRIT gt
  55
• OR CLINICAL PULMONARY HYPERTENSION
• NORMOXIC PATIENT WITH LESS DYSPNOEA
  
• INCREASING EXERCISE CAPABILITY WITH
  O2

22
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
23

• CONTROLLED O2 THERAPY
• MODERATE TO SEVERE HYPOXIA (PaO2 lt55 mm Hg)
  IN COPD CAN CAUSE MORTALITY
• SHOULD BE CORRECTED IMMEDIATELY
• INCREASE PaO2 TO 60 mmHg WHILE MAINTAINING PH gt
  7.25
• SEVERITY OF ACIDOSIS IS A BETTER PROGNOSTIC GUIDE
  THAN ABSOLUTE pCO2 LEVELS.
• 
  contd

24
CONTROLLED OXYGEN THERAPY
contd NORMALLY 24 - 26 INSPIRED OXYGEN
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 /lt 7.25 LATER CHANGING TO
NORMAL WITH FALL IN PCO2 3.
IF UNCONTROLLED OXYGEN THEN RAPID RISE IN
PCO2 AND DROP IN pH lt7.25 . CAN BE
LETHAL.
25

• 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

26
DOMESTIC OXYGEN SYSTEM . Contd
OXYGEN CONCENTRATOR - LOW
COST - CONVENIENT
- ATTRACTIVE EQUIPMENT
- WIDE-SPREAD AVAILABILITY BUT
- ELECTRICITY REQUIRED
- NOT PORTABLE
- MAY NEED BACK-UP TANK
27

• DOMESTIC OXYGEN SYSTEM CONTD
• COMPRESSED GAS
• LOW COST IN GENERAL
• WIDE-SPREAD AVAILABILITY
• BUT
• MULTIPLE TANK REQUIREMENT
• FREQUENT DELIVERIES REQUIRED
• HEAVY UNSIGHTLY TANKS
• DIFFICULT AMBULATION.

28

• 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
  

29

• 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

30

• MANAGEMENT NONINVASIVE
• BRONCHODILATORS
• ROUTINELY GIVEN
• HELP RESIDUAL BRONCHODILATION
• AND MUCO-CILIARY CLEARANCE
• I.V.AMINOPHYLLINE / B2-AGONIST /
  IPRATROPIUM
• 
  CONTD

31
CONSERVATIVE MANAGEMENT .contd
ANTIBIOTICS STEROIDS AVOID IN ARF
DUE TO INFECTION OTHER
STEAM / PHYSIOTHERAPY / ENCOURAGE COUGH
GENERAL
HYDRATION DIURETICS / LOW DIGOXIN IF
LVF HEPARIN S /C FOR D V T / PULM
EMBOLISM NUTRITION
RESPIRATORY STIMULANTS
32

• 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 gt SEVEN DAYS

33
MECHANICAL VENTILATORY SUPPORT SETTINGS WITH

NO OVER-INFLATION LOW TIDAL VOL
NO INCREASE IN AUTOPEEP 8-10 ML /KG ,
MV 5-6 L/MIN 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 ALLOWS TIME
FOR EXPIRN FiO2 0 . 5 TO 0 . 7
FAST CORRECT OF HYPOXIA SEDATION
MACHINE CAN TAKE-OVER
34
MECHANICAL VENTILATION . . . CONTD.
BRING DOWN PaCO2 GRADUALLY
IN 24 48 HOURS UPTO 50 MM Hg
PaO2 60 MM MAY SUFFICE WEANING
BY TRADITIONAL METHODS IF DIFFICULT
WEANING CAN USE
PRESSURE SUPPORT
35

• 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

36

• 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

37
THANK-YOU