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

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

2

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

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

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

6

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)

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

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

• 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)

9

What type of respiratory support should be initiated?

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

› 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

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

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?

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?

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

Orotracheal intubation is performed

17

What ventilator mode should be selected?

What tidal volume is optimum?

What rate of ventilation should be set?

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?

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

®

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

› Chest radiograph› Vital signs› SpO2

› Patient-ventilator synchrony

› Arterial blood gas

› Inspiratorypressures

› Inspiratory:expiratory ratio

› Auto-PEEP› Ventilator

alarms

21

What monitoring and assessment is needed after initiation of mechanical ventilation?

After 35 minutes of ventilation

Patient became hypoxic and started to to fight with the machine.

Auto-PEEP

› Consequences Inspiratory pressures Hypotension Worsened oxygenation

› Interventions to decrease auto-PEEP Respiratory rate Tidal volume Gas flow rate

24

®

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

Assessment of asthma severity Pulsus paradoxus, when present, indicates severe asthma

MANAGEMENTESTABLISHED TREATMENTS

OXYGENβ-AGONISTS

ANTICHOLINERGICSCORTICOSTEROIDS

AMINOPHYLLINE

NON-ESTABLISHED TREATMENTS

EPINEPHRINEMAGNESIUM SULPHATEHELIOX

ANAESTHETIC AGENTSLEUKOTRIENE ANTAGONISTSBRONCHOALVEOLAR

LAVAGE

THERAPIES NOT RECOMMENDED

Antibiotics Antihistamines Inhaled mucolytics Sedation

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

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

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?

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…?

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

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

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 !!!

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 muchQUESTIONS?