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    ICU Management of COPD & Asthma 2

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    Parvathy R Nair
    This document discusses the management of COPD and asthma exacerbations in the ICU. Key points include: using controlled oxygen therapy and bronchodilators like beta-agonists to improve gas exchange and lung function; corticosteroids to reduce inflammation; treating any precipitating infections early; considering non-invasive ventilation first before invasive ventilation; and addressing other issues like secretion clearance and nutrition support. Mechanical ventilation aims to support gas exchange while preventing further lung injury, and weaning criteria focus on normalizing carbon dioxide and ensuring adequate respiratory muscle function. Education is also important to prevent future exacerbations.

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    ICU Management of COPD & Asthma 2

    Uploaded by

    Parvathy R Nair
    40 views35 pages
    This document discusses the management of COPD and asthma exacerbations in the ICU. Key points include: using controlled oxygen therapy and bronchodilators like beta-agonists to improve gas exchange and lung function; corticosteroids to reduce inflammation; treating any precipitating infections early; considering non-invasive ventilation first before invasive ventilation; and addressing other issues like secretion clearance and nutrition support. Mechanical ventilation aims to support gas exchange while preventing further lung injury, and weaning criteria focus on normalizing carbon dioxide and ensuring adequate respiratory muscle function. Education is also important to prevent future exacerbations.

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    This document discusses the management of COPD and asthma exacerbations in the ICU. Key points include: using controlled oxygen therapy and bronchodilators like beta-agonists to improve gas exchange and lung function; corticosteroids to reduce inflammation; treating any precipitating infections early; considering non-invasive ventilation first before invasive ventilation; and addressing other issues like secretion clearance and nutrition support. Mechanical ventilation aims to support gas exchange while preventing further lung injury, and weaning criteria focus on normalizing carbon dioxide and ensuring adequate respiratory muscle function. Education is also important to prevent future exacerbations.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    40 views35 pages

    ICU Management of COPD & Asthma 2

    Uploaded by

    Parvathy R Nair
    This document discusses the management of COPD and asthma exacerbations in the ICU. Key points include: using controlled oxygen therapy and bronchodilators like beta-agonists to improve gas exchange and lung function; corticosteroids to reduce inflammation; treating any precipitating infections early; considering non-invasive ventilation first before invasive ventilation; and addressing other issues like secretion clearance and nutrition support. Mechanical ventilation aims to support gas exchange while preventing further lung injury, and weaning criteria focus on normalizing carbon dioxide and ensuring adequate respiratory muscle function. Education is also important to prevent future exacerbations.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 35

    ICU Management of COPD &

    Bronchial Asthma
    COPD
    • Airflow limitation that is not fully reversible
    (Global initiative for chronic obstructive
    lung disease or GOLD)
    • Persistent & progressive
    • Risk factors
    Smoking
    Poor lung function in childhood
    LBW
    Bronchial hyper responsiveness
    Precipitating factor

    • Infection
    • Atmospheric pollution
    • Temperature change
    • Intercurrent illnesses like cardiac failure,
    Pulmonary embolism, pneumonia
    • Postoperative
    • Excessive use of sedatives & O2
    • Trauma
    Clinical features
    • Increase in dyspnea, cough
    • Sputum volume & purulence
    • Fever, tachycardia, bounding pulse
    • Tachypnea, cyanosis
    • Pursed lip breathing
    • Accessory muscle use
    • Hypotension
    • Flapping tremor
    • Impaired level of consciousness
    Diagnosis
    • Spirometery
    • FV loop
    • Chest Xray
    • CTscan
    • ECG
    • ABG
    Therapeutic Goals
    • Improvement in gas exchange
    • Reduction of lung volume & increase in
    expiratory flow
    • Reduction of pulmonary inflammation
    • Treatment of precipitating factor
    Improvement in gas exchange
    • Controlled oxygen therapy
    • Achieve SpO2>90%
    • Risk of hypercarbia
    • Monitor ABG
    • For nebulisation use air with nasal prongs
    Reduction of lung volume &
    increase in expiratory flow
    Bronchodilators
    • ß2-agonists
    • Ipratropium bromide
    • Methylxanthines
    Treatment of precipitating factor
    • Antibiotics
    • Antiviral agent
    • Analgesia
    • Heparin
    Reduction of pulmonary
    inflammation
    • Corticosteroids
    • Mediator antagonists
    • Antioxidants
    • Retinoic acid
    Mechanical ventilation
    Support the gas exchange & fatigued resp
    muscles
    • Non- invasive ventilation
    • Invasive mechanical ventilation
    NIV

    • 1ST line treatment in moderate resp acidosis


    PH<7.35
    • Unload resp muscles & prevent resp failure
    • Adv-few complication, less failure, lower
    mortality, less nosocomial infections
    Contraindications to noninvasive
    ventilation
    • Impaired consciousness
    • Confusion, agitation
    • Significant risk of vomiting
    • Profound hypoxemia
    • Excessive secretions
    • Facial or upper airway trauma or surgery
    Indications of Invasive ventilation
    • Severe dyspnea
    • RR>35/min
    • Life threatening hypoxemia( Pao2<40 or
    PaO2/FiO2<200
    • pH<7.25 or PaCO2> 60
    • Resp arrest
    • Impaired mental status
    • CV complications
    • Failure of NIPPV
    Ventilatory Management
    Ventilatory settings
    • Low RR
    • Limited TV
    • I:E- 1:3
    • PEEP-0-5
    Modes of ventilation
    Weaning
    Non-ventilatory issues
    • Hydration
    • Mucolytics
    • Expectorants
    • Controlled cough
    • Physical therapy
    • Fibroptic bronchoscopy
    • Diuretics, digoxin & vasodilators
    • Nutrition
    Summary
    • Controlled O2 therapy
    • ß2- agonist along with ipratropium
    • Corticosteroids are effective in shortening the duration
    of attack & relapse
    • Aminophylline ,doxapram & digitalis are of little use
    • Early trial of NIV
    • With mech vent risk of alkalosis, air trapping,
    barotrauma & difficult weaning
    • Conventional weaning criteria are met less frequently
    • Prognosis is better than commonly believe
    Asthma
    • Airway obstruction that is reversible
    • Airway inflammation
    • Increased airway responsiveness

    Status asthmaticus
    Mortality-1-3%
    Upto 40% when mechanical ventilation is used
    Risk factors for SAE
    Pt related factors
    • Poor compliance
    • Accustomed to disability
    • Unable to gauge the severity of an attack
    • Underuse of peak flowmeters
    Doctor related factor
    • Underestimate the severity of the attack
    • Under use of ß2 –agonist & steroids
    • Overuse of ß2-agonist
    • Injudicious use of sedatives
    • Theophylline levels not monitored
    Pathophysiology of SAE
    • Sudden onset (3-6hr) <15%, responds to bronchodialator
    • Slower onset-Airway wall inflammation, bronchospasm &
    accum of mucus
    • Pt with SAE shows critical airflow obstruction leads to
    DHI
    • DHI places diaphragm at mech disad
    • Incomplete exhalation elevates alveolar vol & P
    • Auto PEEP increases work of breathing-Vent Failure
    • V-Q mismatch
    • Adverse cardipulmonary interaction
    Clinical features
    • Dyspnea at rest
    • Upright posture
    • Inability to complete the sentence in one
    breath
    • Disturbance in level of consciousness
    • RR>30/min, HR>120
    • Silent chest
    • Pulsus paradox
    Features of imminent resp arrest
    • Altered mental status
    • Paradoxical respiration
    • Bradycardia, cyanosis
    • Quiet chest
    • Absence of pulsus paradoxus
    Clinical assessment
    • Medical history
    • Physical examination
    • D/D
    Cardiac asthma
    Airway obstruction
    Pulm embolism
    Angioneurotic edema
    Laryngeal spasm
    Foreign body
    Factitious asthma
    Monitoring
    • Measures of airflow obstruction-PFR
    • SpO2
    • ABG
    • Chest-X ray
    • Hematology
    • Sputum analysis
    • Electrolytes
    Treatment
    • O2 therapy-Improve O2 delivery, reverses HPV, stimulate
    bronchodilation
    • Humidified, low flow, SpO2 >90%
    • Nebulized ß2-agonist or MDI with spacer
    • Salbutamol 2.5 mg in 2-3 ml NS every 20 min
    • Salmetrol addition after 48 hrs improves FEV1
    • In long term long acting ß-agonist with steroids lessens SAE
    • SC epineph or terbutaline used in altered mental status &
    near arrest situations
    • IV ß2- agonist- rapid onset but more side effects
    • Ipratropium Bromide –In combination improve
    FEV1, PEFR
    • Steroids- prednisolone/Methylpred 120-180mg in
    divided doses for 48 hrs & then 60-80 mg/day
    until PEFR>70% predicted
    • Inhaled steroids(flunisolide) also showed benefit
    in combination therapy
    • Theophylline-controversial
    • MgSo4- conflicting results
    • Heliox-80-20% mixture –conflicting results
    • Anaesthetic agents
    • Leukotrien modifiers
    Zafirlukast 160mgor Montelukast
    10mg
    • Less hospital stay, relapses, decrease dose
    of ß2-agonists & steroid use
    • Antibiotics -not recommonded
    • Bronchoalveolar lavage
    • Mechanical ventilation
    NIV
    • NIPPV or NINPV
    • NIPPV help in overcoming inspiratory
    threshold created by auto- PEEP
    • Face mask or nasal mask
    • CPAP of 5 or 7.5 cm of H2O
    • BiPAP
    • Complications
    • Discomfort ,dyspnea,air leak,gastric
    distension,pressure sores
    Indications of Invasive ventilation
    •Fatigue or impending resp failure
    •Deteriorating consciousness
    •Refractory hypoxia
    •Failure of secretion clearance
    •Respiratory arrest
    Oral ETT
    Post intubation hypotension & pneumothorax
    Assessment of ventilation
    • Plateau P
    • PEEPi
    Adjuvants
    • Use of sedation & Paralysis
    • Use of mucolytics & expectorants
    • Inhalational agent
    • Chest physiotherapy
    •
    Weaning & Extubation
    • No validated criteria's
    • Spontaneous breathing trial
    Paco2 normalises
    Airway resistance <20 cm of H2O
    • Pt follows commands
    • No neuromuscular weakness
    Conclusion
    • Any asthmatic can develop SAE
    • General appearance gives imp clues
    • 1st line Tt- ß2-agonist, sys corticosteroids, low flow O2
    • Alternate Tt-ipratropium bromide, MgSo4, leukotrien
    modifiers, heliox & NIV
    • Hypotension after intubation, trial of apnea or hypopnea is
    diagnostic
    • Permissive hypercapnia limit hyperinflation
    • Avoid prolong use of muscle relaxant
    • Education, environmental control measures & anti-
    inflammatory drugs for future

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