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Copd critically ill

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COPD

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Copd critically ill

  1. 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 < drjaydr@pn3.vsnl.net.in >
  2. 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. 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. 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. 5. PATHO-PHYSIOLOGY….contd AIR-FLOW OBSTRUCTION PROLONGED EXPIRATION PULMONARY HYPERINFLATION DUE TO AIR-TRAPPING INCREASED WORK OF BREATHING DYSPNOEA
  6. 6. PATH-PHYSIO…..CONTD ALVEOLAR DISTORTION AND DESTRUCTION LOSS OF HYPOXIA CAUSING CAPILLARY BED PULMONARY VASOCONSTRICTION PULMONARY HYPERTENSION SECONDARY VASCULAR CHANGES COR-PULMONALE
  7. 7. INCREASED AIRWAY OBSTRUCTION DUE TO INCOMPLETE EXPIRATION + RAISED MVV RAISED F R C PULMONARY HYPER-INFLATION
  8. 8. LUNG FIBRE LENGTH VOLUME OF DIAPHRAGM WORK OF BREATHING VENTILATORY REQUIREMENT
  9. 9. ‘ IF WORK OF BREATHING FAILS TO MEET VENTILATORY REQUIREMENT OF A PATIENT…’ CHRONIC HYPERCARBIA RESULTS.
  10. 10. 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
  11. 11. … 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 # A B G = RESPIRATORY ACIDOSIS HYPOXIA
  12. 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. 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. 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. 15. … 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
  16. 16. …… OTHER INVESTIGATIONS # SPUTUM BACTERIOLOGY # TOTAL BLOOD COUNTS # THEOPHYLLINE LEVELS {WHERE INDICATED} # C T THORAX TO R / O SMALL PNEUMOTHORAX # VENTILATION / PERFUSION STUDY
  17. 17. DIFFERENTIAL DIAGNOSIS … # Left ventricular failure # Pulmonary embolism # Pneumothorax # Upper air-way obstruction
  18. 18. MANAGEMENT.. CONSERVATIVE • Oxygen • Bronchodilators • Steroids • Antibiotics • Non-invasive secretions clearance • Other measures NON-CONSERVATIVE • Invasive techniques for sputum clearance • Mechanical ventilation
  19. 19. C 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
  20. 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. 21. 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
  22. 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. 23. 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
  24. 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 /< 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.
  25. 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. 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. 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. 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. 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. 30. MANAGEMENT – NONINVASIVE # BRONCHODILATORS • ROUTINELY GIVEN • HELP RESIDUAL BRONCHODILATION AND MUCO-CILIARY CLEARANCE [ I.V.AMINOPHYLLINE / B2-AGONIST / IPRATROPIUM ] …CONTD
  31. 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. 32. MANAGEMENT - NON CONSERVATIVEMANAGEMENT - 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
  33. 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
  34. 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. 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. 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. 37. THANK-YOU

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