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Sr. Consultant & Chairman Dept. of Critical Care Medicine & Emergency Medicine Dr. BL Kapur Memorial Hospital, New Delhi
Introduction
Severe asthma and COPD exacerbations
causing respiratory failure remains a potentially reversible, life-threatening condition that imposes significant morbidity and mortality.
About 10% of asthmatics admitted to hospital
ventilation are associated with morbidity & Am J Respir Crit Care Med 1998, 157:1804-1809. Ann Allergy Asthma Immunol 2004, mortality. (1-8 per 100 000 annually)
Introduction
ICU admission identifies an asthmatic patient as a
Chest 1992;101:6213,
It is of paramount importance to properly triage patients hypotension and refractory respiratory acidosis. with COPD and asthma so that those who are at risk of It is of paramount importance to properly triage death benefit from an ICU environment patients with COPD and asthma so that those who are at risk of death benefit from an ICU environment
ventilated immediately Warning signs of impending respiratory arrest are lethargy, obtundation, silent chest and cyanosis, bradycardia and hypotension. No current system that predicts survival or weaning failure for a particular patient with severe exacerbation of COPD - ventilatory support should be given to all patients with severe exacerbation of COPD requiring ventilatory assistance.
Patient deterioration despite optimal treatment with progressive increase of PaCO2 is a sign of impending respiratory exhaustion and a predictor of fatal asthma, even before the occurrence of severe hypercapnia
Airflow Obstruction
Critical increase in airway resistance pressures required for airflow may overload
Air trapping can not also function as Regions of lung& iPEEPproperly empty & a threshold load to trigger return to their resting volume (Air trapping)mechanical breaths. iPEEP/Auto PEEP further worsen respiratory muscle function.
Overinflated regions may compress healthy
overload.
regional hyperventilation.
Dead space & loss of capillaries - over Overload on right ventricle -hypoxic
Gas Trapping
Severe asthma exacerbation bronchoconstriction,
Gas Trapping
Gas-trapping occurs because low expiratory flow
rates mandate long expiratory times if the entire inspired volume is to be exhaled.
If the next breath interrupts exhalation, then gas-
trapping results.
Trapped gas in lungs results in additional pressure at
end expiration (auto-PEEP or intrinsic PEEP) above applied PEEP, leading to dynamic hyperinflation.
Auto-PEEP, intrinsic PEEP and dynamic hyperinflation
Gas Trapping
Dynamic hyperinflation: Failure of lung to return to its
volumes, the increase in airway diameter and elastic recoil pressure enhances expiratory flow
But excessive dynamic hyperinflation can cause
Measuring lung hyperinflation using VEI. VEI, volume of gas at end-inspiration above FRC
expiration, the proximal airway pressure will equilibrate with alveolar pressure & permit measurement of auto-PEEP (end-expiratory pressure above applied PEEP) at the airway opening.
Expiratory muscle contraction can elevate auto-PEEP
without adding to dynamic hyperinflation. for accurate measurement patient should be relaxed.
ventilator.
If inspiratory flow begins before expiratory
communication with the proximal airway in severe asthma. (complete airway closure in those segments).
Occult auto-PEEP has all bad effect of auto PEEP
in Pplat is not explained by in respiratory system compliance during volume-cycled ventilation. paralyzed or heavily sedated for reliable measurements.
trapping.
Gradient -5 0
-5
-15
first step.
Strategies
Controlled hypoventilation ( tidal volume, R/R)
controversial.
Theoretical advantages:
the WOB & hence CO2 production, while limiting
gas-trapping by splinting the airways open. Intensive Care Med 2004, 30:1311-1318. inspiratory muscle effort required to overcome auto-PEEP & initiate an inspiration.
Am
individually, with an average of 80% of the autoPEEP being tolerated before the plateau pressures
reliably. If extrinsic PEEP > auto-PEEP, gas trapping will worsen. Recommendations: Use extrinsic PEEP minimally, or not use it at all in patients with severe asthma. Chest 2004, 125:1081-1102, Curr Opin Crit Care
2002, 8:70-76.
-5
medical therapy
Intervene fast- Adequate oxygenation &
ventilation.
Choices are
NIV Invasive ventilation
NIPPV
It is possible that some patients with severe asthma
improve lung function & possibly reduce the need for hospitalization.
In COPD with severe airflow limitation a number of
prospective randomized trials have shown that NIV reduces the need for endotracheal intubation, length of hospital stay and in-hospital mortality rate,
NIV
controversial.
reasonable approach would be to use NIV in patients who do not respond to initial medical therapy, and have no contraindications for the use of NIV.
When to intubate?
The decision to intubate should be based on
clinical judgement.
Signs of deterioration: CO2 levels (+
normalization in a previously hypocapnic patient), exhaustion, mental status depression, hemodynamic instability & refractory hypoxemia.
Decision should not be based solely on ABG.
Guidelines for the Diagnosis and Management of Asthma, National Institutes of Health; 1997. Am Rev Respir Dis 1988, 138:535-539.
Intubation
Explain & reassure the patient. Pre-oxygenation. Factors that may cause catastrophic
hypotension :
Dehydration PEEPi Loss of endogenous catecholamines Vasodilating properties of the anaesthetic/sedative
agents. To avoid hypotension Volume resuscitation before anaesthesia, keep vasoconstrictors (ephedrine or metaraminol) handy.
dehydrated patients.
Longer term sedation by infusion of midazolam
Ketamine
It has sympathomimetic and bronchodilating
properties
It has been used before, during, and after
analgesia
Avoid Morphine- causes histamine release &
causes less histamine release but large boluses may cause bronchospasm and chest wall rigidity.
depending on nebuliser design, driving gas flow, ventilator tubing, and size of ET tube.
Humidification may reduce drug deposition by
unloading.
Reduce TV as much as possible to limit the
efforts.
Helps to keep inspiratory time short
(expiratory long).
Better synchrony with patients spontaneous
breathing efforts.
hyperinflation/gas-trapping.
tidal volume, frequency, or set pressure.
tolerated.
Permissive hypercapnia: pH > 7.20, PaCO2 < 90
hyperinflation, seen as in Pplat. Benefit is modest when the baseline MV is 10 l/min or less & R/R is low. Changing I/E ratio is important to gas-trapping but single most effective way is by MV.
periods of time and only when absolutely necessary ( patient ventilator asynchrony).
Ventilatory Setting
Start with pressure control mode
Thorax 2003;58;81
Bronchoscopy
Severe mucus impaction could be an issue in
status asthmaticus, bronchoscopic examination of the airways and removal of secretions may be beneficial [Crit Care Med 1994,
22:1880-1883 54].
worsen lung hyperinflation and increase the risk for pneumothorax [Thorax 1986, 41: 459-463. 55]
to be removed under anaesthesia with the confident expectation of rapid recovery once the anaesthetic is discontinued.
Conclusion
While the prevalence of asthma has increased,
outcomes of severe asthma appear to be improving, with lower complication rates and fewer in-hospital deaths.
Ventilation management in acute severe
understand why gas-trapping occurs, how to measure it and how to limit its severity. They should employ a strategy to minimise gas
daughter to the emergency department of your hospital because of progressive difficulty in breathing. On arrival, the patient is non-responsive and has a dark purple colour, without perceptible breathing movements or any perceptible pulse. What is your immediate action
hand. After one dose of epinephrine 1 mg intravenously, you have a good carotid pulse and the purple colour is disappearing. You transfer the patient to the ICU. The daughter tells you that her father is a heavy smoker, that he doesn't like to go to the doctor, and that he doesn't take any medicine. She says his condition has worsened over the past ten days. As well as having increasing difficulty breathing, in the last two days he could no longer walk and he was coughing up a lot of
500 ml (the patient weighs 70 kg), zero PEEP, and FiO2 of 1.0, you measure a PaO2 of 200 mmHg, a PaCO2 of 60 mmHg, and a pH of 7.3. The peak airway pressure is 60, the plateau pressure 35 cmH2O.
Why peak and plateau pressures are high