Simon Baudouin Senior Lecturer in Critical Care University of Newcastle
Conventional definitions ◦ Type 1 PaO 2 < 8 kPa on air ◦ Type 2 PaO 2 6 kPa Not helpful! ◦ Ultimately all severely ill patients become hypercapnic without intervention Acute Chronic Acute on chronic Reach ITU v intubate in EAU
Hypoxaemia – V/Q mismatch & shunt Hypercapnia ◦ Hypoventilation ◦ Increase in deadspace ventilation ◦ V/Q mismatch
Uk National COPD audit 2003; Thorax 2006;61: 234 UK acute hospitals 40 consecutive acute COPD admissions 7259 patients 90 day readmission rate 31.4%!
16-47% hypercapnia Half will need ventilatory support - Plant et al, Thorax, 2000; 55: year survey in Leeds 983 admissions 2.2% ICU admissions 73% hospital mortality in ICU admissions 70 NIV patients/year/250,000 population
Explanation of hypoxaemia and hypercapnia Multiple inert gas elimination Broad V/Q distribution Hypercapnia = ventilation to under-perfused units Hypoxaemia = shunting Respiratory muscle fatigue? Altered central drive?
Hypoxaemia is usually correctable with low flow O 2 The optimal target SaO 2 is unknown > 90% - O 2 dissociation curve > 85% (ARDS net) One small study (n = 36) 6.6hPa v 9.0 hPa -no difference (underpowered) High flow O 2 will worsen Hypercapnia Change to controlled O 2 will reduce PaCO 2
pH < or = 7.35 Mortality %
Randomised controlled trials in NIV Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre, randomised, controlled trial. Plant et al. Lancet, 2000; 355: UK Hospitals n = 236 Mortality p = 0.05 Intubation p = 0.02
BMJ 2003;326: Typical UK hospital will avoid 3-9 ICU admissions/year Save £12, ,000
“The use of non-invasive positive pressure ventilation in the emergency department” RCT 6/12 study NIV vs. conventional support 87 screened -34 “immediate” intubation -27 entered -11 conventional -16 NIV Wood. Chest, 1998; 113:
Time to intubation Standard 4.8 hrs NIV 26.0 hrs NIV in A&E
Should all patients receive NIV in a critical care area? No RCTs Majority of trials are in Critical Care areas Plant
Recommendations of the COAD and NIV Standards of Care sub-committees of the British Thoracic Society, RCP & Modernisation Agency Every acute admissions unit should have an NIV service
-Failure rate 7-50% -delay intubation Acidosis APACHE II -Indications for HDU admission For intubation if NIV fails Initial pH 7.25 or less Worsening pH on NIV
Patient choice Failure of NIV Usually obvious clinically ◦ Fatigued “awful looking” patient ◦ Worsening hypercapnia and LOC ◦ A&E arrest/peri-arrest situation
Patient/ventilator interactions Weaning Tracheostomy Nutrition The “unweanable” patient
Rapid trial of extubation (onto NIV) Early tracheostomy Regular Sedation cessation Weaning protocols A little progress every day!
N=43 (most with COAD failed wean for 3 days Shorter ICU & hospital LOS Less need for tracheostomy 90 day survival Am J Respir Crit Care Med 2003;168:70-6
COPD admissions will increase NIV is effective in both survival and prevention of intubation Outcome of ventilation in COPD is no worse than in other conditions Patient choice and informed decisions
Previously fit 24 year old women First pregnancy No problems until week 35 “Cough and cold” “Shivery” Increasingly breathless over 24 hours Brought to maternity ward by husband Clearly very unwell SaO2 air 79% RR 35/min Crackles ++ Foetus alive Critical Care outreach called
Early corticosteroids in severe influenza A/H1N1 pneumonia and acute respiratory distress syndrome. Am J Respir Crit Care Med May 1;183(9): French national registry – no benefit; possible early harm European SICM database Cox analysis no benefit from steroids
Critical Care obstetric intensivist Separate the two patients Foetus is viable Ventilation for the Mother is inevitable Experience from other units Urgent Caesarean section Ventilated with Critical Care ventilator during section Healthy girl delivered Mother transferred to critical care unit
Substitute for the respiratory muscle pump Complex multi- functional machines Efficacy established during polio epidemics 1960s Led to development of modern, centralised critical care services
Broncho- pulmonary dysplasia Well + Tierney rats ventilated with peak airway pressures 45 cm H 2 O developed pulmonary oedema Carlton Lung overexpansion increases lymph flow in lambs Lymph flow ml/Kg
Mortality at 180 days Protection 31.0% Conventional 39.8% P = 0.007
Normal lung Partial collapse/floodingComplete collapse recruitable
5 cm PEEP
N = 1000 60 day mortality Liberal v conservative fluid
Improved oxygenation Increased ventilator free days No increase in shock or dialysis
N = 549 How much PEEP? Higher versus lower PEEP in patients with ARDS New Engl J Med 2004;351: Lower PEEP = 8 cm H 2 O Higher PEEP = 13 cm H 2 O
Often improves oxygenation Proposed mechanisms -recruitment of dorsal collapsed lung units -improved respiratory mechanics -increased secretion drainage -decreased injury from mechanical forces
Prone positioning in ARDS N=304 N=791
Initial improvement in PaO2/SaO2 to 90% Gradual fall to SaO2 84% CXR – no mechanical cause
Rescue = desperation Rescue = no high grade evidence Rescue = risks as well as possible benefits ◦ Oscillator ventilation ◦ ECMO
Rate 60 – 100 bpm TV below anatomic deadspace Alveoalar derecruitment & overdistention limited
Large, multi-centre RCT Conventional v high frequency ventilation Complete recruitment 2012 Over 800 patients
ECMO
Outcome in 1 ECMO centre (Glenfields) Protocolised care Experienced experts Average outcome in 92 conventional centres 11 referral centres Non protocolised care Variable experience Variable clinical cover/team
Hypoxaemia is the greatest immediate threat Severe oxygen induced hypercapnia is rare Oxygen induced hypercapnia only occurs in chronic respiratory failure Previously well patients with hypercapnia are severely ill Hypercapnia does not equate to COPD