18/Oct/2005Dr. David P. Breen1 COPD- Burden of Disease Initial management of an acute exacerbation.
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Transcript of 18/Oct/2005Dr. David P. Breen1 COPD- Burden of Disease Initial management of an acute exacerbation.
18/Oct/2005 Dr. David P. Breen 1
COPD- Burden of Disease
Initial management of an acute exacerbation
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DefinitionCOPD is a disease state characterized by
airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.
Symptoms, functional abnormalities, andcomplications of COPD can all be explained on the basison this underlying inflammation and the resulting pathology
www.goldcopd.com
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Lung Function decline
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Spirometry is the GOLD Standard for the diagnosis of COPD
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Exacerbations of COPD
Acute exacerbations of COPD present as a worsening of a previously stable conditionImportant symptoms include
Increased sputum purulenceIncreased sputum volumeIncreased dyspnoeaIncreased wheezeChest tightnessFluid retention
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Exacerbation
A new respiratory event or complication superimposed upon established diseaseNew events
PneumoniaPneumothoraxLVF/ Pulmonary OedemaLung CancerUpper airway Obstruction
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Acute exacerbation of COPD1. Airflow Obstruction
a) Dyspnoeab) Wheezec) Chest tightness
2. Respiratory Failurea) Hypoxia
i. Dyspnoea, tachypnoea, cyanosis, confusion
b) Hypercapniai. Warm hands, dilated veins, tachycardia, bounding pulse, flapping
tremor, chemosis, papilloedema, confusion, agitation
3. Cor pulmonalea) Loud P2, RV (L Parasternal Heave), raised JVP, peripheral oedema
4. Infectiona) Increased sputum volume/purulence, fever, raised WCC
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Investigations
Full Blood CountRenal ProfileArterial Blood GasChest X-Ray
PneumoniaBronchiectasisPneumothoraxLVF
Spirometry prior to discharge
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TREATMENT
Airflow Obstruction Bronchodilators- Salbutamol, ipratropium Corticosteroids
Respiratory Failure See later
Cor Pulmonale Daily weight, accurate input/output chart Diuretics Monitor renal function carefully
Infection Antibiotics physiotherapy
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Acute Respiratory Failure
ABG Normal PO2 10.5-12.5 KPa
Normal PCO2 4.5- 6.0 KPa
Type 1 Failure PO2 PCO2 N or
Type 2 Failure PO2 PCO2
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Normally we breath mainly in response to raised PCO2 In Type 1 failure, this response is maintained
High O2 is safeIn COPD, there is usually chronic CO2
retentionThe brain gets tired of responding to the raised PCO2
The main stimulus to breathe is then a decreased PO2
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So, How much O2 should we give?
Oxyhaemoglobin dissociation curve
0
20
40
60
80
100
1 2 3 4
PO2 (KPa) Arterial Blood Gas
O2
del
iver
y to
tis
sues
H
b s
atu
rati
on
(%
)
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In Type 2 Respiratory Failure
PO2 Hypoxic Drive SaO2 O2 Delivery
7.5 maintained 90% adequate/good
<7 maintained <90% poor
5.0 maintained <70% dangerously low
7.5 maintained 90% adequate/good
>8 decreasing >90% good
10 very poor 95% good
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ThereforeLook first at PO2
Maintain PO2 around 7.5-8.0 (SaO2 90-92%)
Do not be afraid to give enough O2 to achieve this
Do not push PO2 above this – very little extra delivery of O2 to all tissues and loss of hypoxic drive now becomes a problem
Monitor PCO2 and clinical conditionIf PCO2 elevated or clinical condition poorConsider N.I.VStart with 24-28% and titrate upwardsMonitor Sats and ABG
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But remember :
Cigarettes are the main culprit!!
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Non-Invasive Ventilation:
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Selection Criteria
Respiratory distressModerate to severe dyspnoeaAccessory muscle useParadoxical movement of abdominal
musclespH<7.35 with PaCO2>6kPaRespiratory rate >25breaths/min
At least two criteria should be present
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Exclusion Criteria (Absolute)
Respiratory Arrest situationCardiorespiratory instability
HypotensionArrhythmiaMyocardial infarction
Uncooperative patientRecent facial, oesophageal or gastric
surgery
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Exclusion Criteria (Absolute)
Craniofacial trauma or burnsHigh aspiration risk
Absent gag reflexInability to manage secretions
Fixed anatomical abnormalities of the nasopharynx
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Relative Contraindications
Extreme anxietyMassive obesityCopious secretionsAdult Respiratory distress
syndrome-ARDS
American Respiratory Care Foundation.
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Complications
Local damage related to mask/strap pressureGastric distensionEye irritationSinus painNasal congestionBarotraumaAir leaksAdverse Haemodynamic effects rareNosocomial pneumonia rare
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Predicting Poor Outcome
Higher APACHE II score (15 Vs 20)Acute physiological and chronic health
evaluationLower pH in those who failed
7.22 Vs 7.28 Ambrosino et alLower FVC Presence of pneumonia
Soo Hoo et al Crit Care Med 1994
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Suggested settingsNIPPY
Aim for IPAP of 20Normal breathing= 1sec insp, 2sec exp,will
probably need to be shortenedSet trigger low eg. 0.5 = less effort required by
patientBIPAP
Suggest starting with IPAP 10 or 12May increase to 20 or higherSuggest starting with EPAP of 4Never use less than EPAP of 4 = CO2
rebreathingMay increase EPAP to 6, seldom require higher
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Effectiveness
Significant decrease in mortality (9% Vs 29%) Brochard et al NEJM 1995
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Effectiveness
Significant decrease in ICU length of stay (13 Vs 32 days) Wysocki et al Chest 1995
Significant decrease in hospital length of stay (23 Vs 35 days) Brochard et al NEJM 1995