ICU Management in Obstructive Airway Disease

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A simplified approach to management of obstructive airway disease in ICU

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ICU Management in Obstructive Airway Disease :

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

Case 1:

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 O 2 : pH 7.30, PCO 2 60 mm Hg (8 kPa), PO 2 65 mm Hg (8.7 kPa) Dx: COPD Exacerbation 2

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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…..

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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

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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 5 Management of Exacerbation of COPD Assessment of severity

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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)

ICU or Ward?:

ICU or Ward? Severe dyspnea that responds inadequately to initial emergency therapy Changes in mental status (confusion, lethargy, coma) Persistent or worsening hypoxemia (PaO2< 6 0 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

Rx of COPD exacerbation:

Rx of COPD exacerbation Antibiotics Oxygen Steroids Bronchodilators Anticholinergics Nebulized β 2 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 38.8C ABG on 8 L/min O 2 : pH 7.24, PCO 2 60 mm Hg (8 kPa), PO 2 65 mm Hg (8.7 kPa) 9 What type of respiratory support should be initiated?

Candidates for NPPV:

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

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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?

Assess your patient:

Assess your patient

CPAP & BIPAP:

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 O 2 : pH 7.23, PaC O 2 76 mm Hg (8 kPa), Pa O 2 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% O 2 : pH 7.20, PaCO 2 65 mm Hg (8.7 kPa), PaO 2 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?

Indications for intubation:

Indications for intubation Clinical deterioration Respiratory rate > 35 Hypoxia PaO 2 < 60 mmHg Hypercarbia PaCO 2 > 55 mmHg Minute Ventilation < 10L Tidal Volume < 5 -10 ml/kg NIF < 25 cm of H 2 O

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Orotracheal intubation is performed 17 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 18 What ventilator mode should be selected? What tidal volume is optimum? What rate of ventilation should be set? What FIO 2 should be delivered?

Initiation of Mechanical Ventilation:

Initiation of Mechanical Ventilation Familiar ventilation mode Initial FI O 2 = 1.0; decrease to maintain Sp O 2 >92% to 94% Initial tidal volume = 8-10 mL/kg Rate and minute ventilation appropriate for clinical needs PEEP to support oxygenation 19 ®

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Algorithm for the ventilator management of the patient with COPD (A/C), PCV or VCV, V T 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 ↓V T or rate ↓ FiO2 ↑ FiO2 ↑ rate ↑ V T NPPV Continue NPPV Candidate For NPPV Patient tolerates Clinically improved PaO2 mmHg pH Pplat < 25 cm H2O Pplat > 30 cm H2O ↓ rate ↓ V T 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

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Chest radiograph Vital signs Sp O 2 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?

After 35 minutes of ventilation:

After 35 minutes of ventilation Patient became hypoxic and started to to fight with the machine.

Auto-PEEP:

Auto-PEEP Consequences  Inspiratory pressures Hypotension Worsened oxygenation Interventions to decrease auto-PEEP  Respiratory rate  Tidal volume  Gas flow rate 24 ®

Discharge Criteria:

Discharge Criteria β2 agonist therapy is not required more than every 4 hrs. Patient, if previously ambulatory, is able to walk across room. Patient is able to eat and sleep without attacks of dyspnea. Patient has been clinically stable for 12-24 hrs. Arterial blood gases have been stable for 12-24 hrs. Patient (caregiver) understands correct use of medications. Follow-up and home care arrangements have been completed (e.g., visiting nurse, oxygen delivery, meal provisions). Patient, family, and physician are confident patient can manage successfully at home.

Case 2:

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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MANAGEMENT ESTABLISHED TREATMENTS OXYGEN β-AGONISTS ANTICHOLINERGICS CORTICOSTEROIDS AMINOPHYLLINE NON-ESTABLISHED TREATMENTS EPINEPHRINE MAGNESIUM SULPHATE HELIOX ANAESTHETIC AGENTS LEUKOTRIENE ANTAGONISTS BRONCHOALVEOLAR LAVAGE THERAPIES NOT RECOMMENDED Antibiotics Antihistamines Inhaled mucolytics Sedation

After 1 hour:

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, PaCO 2 35, PO 2 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

Noninvasive positive pressure ventilation :

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

Intubation:

Intubation Clinical judgement. Markers of deterioration Rising carbon dioxide levels (normalization in a previously hypocapnic) Exhaustion Mental status depression Haemodynamic instability Refractory hypoxaemia

Which Mode for Asthma?:

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 Asthma START Decrease minute ventilation CMV (A/C), PCV or VCV, V T 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 H2O pH Pplat> 30 cm H2O Administer bronchodilators ↑V T ↑rate ↑FiO2 ↓FiO2 ↓V T ↓rate yes yes yes yes no no no 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

Course in ICU:

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?

Dynamic Hyperinflation:

Dynamic Hyperinflation

Dynamic Hyperinflation:

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?

Watch out !!!:

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

Thank you very much:

Thank you very much Questions?

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