A 72 year old woman (55kg), Mrs X, with a history of severe emphysema and chronic bronchitis is intubated in the Emergency Department (ED) because of drowsiness associated with hypercarbia after her initial arterial blood gas analysis revealed:
- pH 7.219
- PC02 98mmHg
- PO2 48mmHg
- HC03 39mmol/l
- lactate 2.5 mmol/l
You are called to the ED to assess and admit this woman to ICU.
The history from her daughter reveals that Mrs X lives independently but is limited by severe breathlessness with exercise. (b) Does this change your management?
College Answer
NO. The degree of incapacity is not inconsistent with the presentation and does not indicate a particularly good or poor prognosis. The management at this stage is intensive while resting the patient for 24hrs, treating the precipitant and awaiting an opportunity to start weaning.
Discussion
One is startled by the forceful "NO" form the college. Clearly, this examiner favours a gentle approach to the elderly COPD patient.
The question text does not mention the exact degree of exercise intolerance, which would be crucial in determining the prognosis. Mortality in the end-stage bed-bound or house-bound group increases significantly in the 12 months following extubation, so perhaps they shouldn't be intubated. That, of course, is a 1989 study, but still.... it sounds grim. And it continues to be grim in the modern era. A recent study from Thorax (Hajizadeh et al, 2015) retrospectively observed a cohort of 4791 end-stage oxygen dependent COPD patients who were itnubated, and foud that 23% died in the hospital, and 45% died in the subsequent 12 months, with 26.8% discharged to a nursing home within 30 days.
References
Menzies, R., William Gibbons, and Peter Goldberg. "Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure." CHEST Journal 95.2 (1989): 398-405.
Hajizadeh, Negin, Keith Goldfeld, and Kristina Crothers. "Audit, research and guideline update: What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow-up study." Thorax 70.3 (2015): 294.