College Answer

This elderly lady with severe chronic lung disease is admitted with acute on chronic hypercarbia and drowsiness. She is intubated.

a)   Initial management should involve:

-     continued  resuscitation  (check  position  of  ETT,  establish  ventilation  to  rest  the  respiratory muscles, assess and restore the circulation with fluid bolus/inotrope etc)
-     mode of ventilation should be appropriate for her strength of respiration and in the first instance may involve sedation and either SIMV, CMV or PSV. The principle will be to allow a long expiratory time with TV 6-8mls/kg, rate 8-10 and PEEP no greater than the measured auto-PEEP. Auto-PEEP  greater  than  5  or  incomplete  expiration  should  be  treated  with  slower  rate  and increased bronchodilator.
-     diagnosis   of   precipitating   event   (acute   bronchitis,   pneumonia,   sputum   retention,   CCF, pneumothorax,  asthma,  sedation,  B-blocker,  aspiration,  hypokalaemia),  chronic  status,  other comorbidities. This requires talking to family, GP and specialist, examining from head to toe and getting a chest X-ray
-     complete medical history, allergies, medications etc
-     establishment of monitoring
-     contact with family/friends to gather information and establish lines of communication
-     continued  support  and  treatment  overnight  with  ventilation,  bronchodilators, antibiotics  (eg erythromycin, cefotaxime), steroids as indicated.

Discussion

This is another question about the management of an intubated COPD patient.

After doing an entire hundred-or-so CICM questions on respiratory failure, the constant appearance of COPD becomes rather tedious.

Oh well.

Management will consist of attention to the ABCs with simultanoues rapid focused physical examination, and brief history.

• Airway
  • keep intubated for now;
  • assess for extubation at the earliest practical opportinuty, and extubate on to NIV
• Breathing
  • PEEP to match AutoPEEP
  • titrate FiO2 to PaO2 55-65
  • Slow resp rate, decreased I:E ratio
  • bronchodilators (IV or nebulised)
• Circulation
  • maintenance of adequate fluid volume
  • atention to co-existing heart failure
• Supportive management
  • Nutrition (high fat, low carbohydrate)
  • Attention to pressure areas
  • sedation with short acting drugs eg. propofol, to minimise delirium
  • correction of electrolyte abnormalities
• Specific management
  • history to determine aetiological cause of the COPD exacerbation
  • management of infective cause with antibiotics
  • management of bronchospasm with bronchodilators and steroids
  • family discussion regarding goals of care