An Acute Hypercapnic Exacerbation Acute Hypercapnic Exacerbation o f COPDCOPD

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Dr Mazen QusaibatyMD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail.com

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Acute Exacerbations of COPDä

DefinitionDefinition

Increasing Increasing of Basic Basic SyndromesSyndromes

Cough increases in frequency and severity

Sputum production increases in volume and/or increases in volume and/or

changes character

Dyspnea increases

•• CriteriaCriteria§§Management Management

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§§Management Management at HospitalHospital

to Hospital…..Hospital…..

•• Inadequate response Inadequate response to outpatient outpatient managementmanagement

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managementmanagementor or

•• Emergency Emergency department department managementmanagement

to Hospital…..Hospital…..

• JJJ Dyspnea

over baseline

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over baseline

 New onset resting

dyspnea

to Hospital…..Hospital…..9

• Severe underlying COPD:Â FEV1 ≤50 percent of predicted

to Hospital…..Hospital…..

Inability to eat

or

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or

sleep due to

symptoms

New cyanosis

or worsening HypoxemiaHypoxemia

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toHospital…..Hospital…..

HypoxemiaHypoxemia

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to Hospital…..Hospital…..

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to Hospital…..Hospital…..

Changes Changes in Mental Mental statusstatus

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to Hospital…..Hospital…..

Insufficient Insufficient Home Home supportsupport

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to Hospital…..

History History of frequent exacerbationfrequent exacerbation

• High risk comorbidities including : Pneumonia Cardiac Arrhythmia Heart Failure Heart Failure Diabetes Mellitus Renal Failure Liver Failure

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ManagementManagement

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ManagementManagement

Healthy AdulteHealthy AdulteHealthy AdulteHealthy Adulte

At restAt restAt restAt rest

Fixed airway Fixed airway obstructionobstructionFixed airway Fixed airway obstructionobstruction

Images by courtesy of Dr. de Zeeuw, Wuppertal

Healthy AdulteHealthy AdulteHealthy AdulteHealthy Adulte

During ExerciseDuring ExerciseDuring ExerciseDuring Exercise

COPDCOPDCOPDCOPDFixed Fixed airway airway obstructionobstructionFixed Fixed airway airway obstructionobstruction

Images by courtesy of Dr. de Zeeuw, Wuppertal

Healthy AdulteHealthy AdulteHealthy AdulteHealthy Adulte

During ExerciseDuring ExerciseDuring ExerciseDuring Exercise

COPDCOPDCOPDCOPDFixed Fixed airway airway obstructionobstructionFixed Fixed airway airway obstructionobstruction

Images by courtesy of Dr. de Zeeuw, Wuppertal

Body plethysmography

21Mason: Murray and Nadel's Textbook of Respiratory Medicine, 5th ed.Copyright © 2010 Saunders, An Imprint of Elsevier

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Seve

rity

of E

xace

rbat

ion Mild

Only 1 of the 3 cardinal

symptom

Þ Dyspnea

Þ Sputum volume

Þ Sputum purulence

Seve

rity

of E

xace

rbat

ion

Moderate or severe

At least 2 of the 3 cardinal

symptom

Þ Dyspnea

Þ Sputum volume

Þ Sputum purulence

Global strategy for the diagnosis, management, and prevention of COPD: Updated 2015. Global Initiative for Chronic Obstructive Lung Disease (GOLD). http://www.goldcopd.org (Accessed on December 06, 2015).

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• To target a pulseoxygen saturation ofof

 88 to 92%or

 PaO2 of 60 to 70 mmHg(7.98 to 9.31 kPa)

VenturiVenturi mask can be useful for mask can be useful for titrating titrating FiOFiO22

• High FiO2

ÂUsually not ÂUsually not needed_Hypercapnia

Noninvasive positive pressure Noninvasive positive pressure Noninvasive positive pressure Noninvasive positive pressure ventilation (NPPV)ventilation (NPPV)

++

During Inspiration

Flow

End of Inspiration

No No Flow

During Expiration

++

Flow

End of Expiration

No No Flow

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++--

Expiration Inspiration

++ --

Expiration Inspiration

Intraalveolar Pressure During Unassisted Breathing- VT

3232

Continuous Continuous PositivePositive--airway airway

PressurePressure

(CPAP)(CPAP)

Bilevel Positive Bilevel Positive Airway PressureAirway Pressure

(BPAP)(BPAP)

N Engl J Med 2015;372:e30

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End of Expiration

No No Flow

CPAP _Positive end-expiratory pressure (PEEP)= beginning of inspiration

VT: 6ml/Kg PEEP=5cmH2O

Bilevel Positive Airway Pressure (BPAP)Bilevel Positive Airway Pressure (BPAP)

In In BPAPBPAP

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++Inspiratory Inspiratory

PositivePositive--airway airway

Pressure Pressure

++Expiratory Expiratory PositivePositive--

In In BPAPBPAP

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Pressure Pressure (IPAPIPAP))

PositivePositive--airway airway

Pressure Pressure (EPAP) (EPAP)

IPAP > EPAP IPAP > EPAP

ÞÞ VTVT ÞÞ VentilationVentilation

N Engl J Med 2015;372:e30

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BPAP:BPAP:EPAP : PEEP : CPAPEPAP : PEEP : CPAP

Pressure support (PS): (IPAP Pressure support (PS): (IPAP –– EPAP)EPAP)

pH >pH >77..35 35

NIV not NIV not

pH pH 77..3030––77..35 35

NIV NIV

pH <pH <77..30 30

NIV NIV NIV not NIV not indicatedindicated

NIV NIV isadvisedadvised

NIV NIV isstrongly strongly advisedadvised

IPAPIPAP10 cmH2O15 cmH2O20 cmH2OEPAPEPAP

5 cmH2O

In In BPAPBPAP

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20 5 cmH2O8 cmH2O

IPAP > EPAP IPAP > EPAP

N Engl J Med 2015;372:e30

BPAP BPAP S/T : S/T : Spontaneous-and-Timed

Modify Modify respiratory raterespiratory rate of the of the patientpatient

BPAP BPAP S/T : S/T : Spontaneous-and-Timed

•• Patient’s Patient’s respiratory respiratory rate rate ((Spontaneous)•• Machine respiratory rate Machine respiratory rate (The (The backup backup rate)rate)

(15 breaths min-1)(15 breaths min-1)•• Patient’s respiratory rate Patient’s respiratory rate ≤ Machine Machine

respiratory respiratory rate rate ÆÆ trigger trigger "" thethe inspiratory inspiratory time(Itime(I--time)time)

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Oronasal Mask

MonitoringMonitoring

•• Intermittent : Intermittent : ObservationObservation for

ÂÂLeaks around Leaks around theÂÂLeaks around Leaks around the

interfaceinterfaceÂÂPatientPatient––

ventilator ventilator synchrony synchrony

MonitoringMonitoring

• Continuous ÂOxygen

saturationsaturation ECG if the patient is

tachycardic or there isevidence of

arrhythmia

MonitoringMonitoring

• Intermittent Arterial blood gas  Arterial blood gas

sampling Recording of

respiratory rate

The only absolute Contraindications to BPAP and

CPAP 54N Engl J Med 2015;372:e30

Complications of endotracheal endotracheal intubationintubation

• Diminished cardiac output and hypotension

• Pulmonary barotrauma (eg, pneumothorax)(eg, pneumothorax)

• Ventilator-associated lung injury

• Auto-PEEP (ie, intrinsic PEEP)

• Elevated intracranial pressure

https://www.uptodate.com/contents/mechanical-ventilation-of-adults-in-the-emergency-department?search=complications%20of%20invasive%20mechanical%20ventilation&sectionRank=1&usage_type=default&anchor=H5&source=machineLearning&selectedTitle=1~150&display_rank=1#H5