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Imtiaz Ahmad, MD, FCCP 21 st Century Oncology

Lee Health Medical Grand Round. If You Can’t Breathe, Nothing Else Matters Myths and Facts about Managing Patients with Respiratory Failure lungcare.net/medical-grand-rounds/. Imtiaz Ahmad, MD, FCCP 21 st Century Oncology. Acknowledgement. Ruth Milien Jonathas, ARNP

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Imtiaz Ahmad, MD, FCCP 21 st Century Oncology

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  1. Lee Health Medical Grand Round If You Can’t Breathe, Nothing Else Matters Myths and Facts about Managing Patients with Respiratory Failure lungcare.net/medical-grand-rounds/ Imtiaz Ahmad, MD, FCCP 21st Century Oncology

  2. Acknowledgement • Ruth Milien Jonathas, ARNP • Bindu Asok Kumar, ARNP

  3. Smoking Cessation is the Key! • Prevention of smoking remains to be the key to reduce the risk of pulmonary diseases

  4. Disclosure None

  5. Learning objectives • Pneumonia, asthma, and COPD are common etiologic factors for respiratory failure. Explain pathophysiology and critical management issues in both inpatient and outpatient setting. • Discuss myths and facts surrounding the length of stay, re-admission, and quality of life of patients with respiratory failure.

  6. Key Points • Acute respiratory failure :Why it matters • Common etiology • NIV: Management principles • COPD / Asthma: Myths/Facts • Common issues • Re-admission and transitional care • Home oxygen • OSA screening

  7. $30,210,000,000

  8. Respiratory failure • Failure of lung to meet metabolic demands • PaO2<60 mm or PaCO2>50 mm or PaO2/FiO2≤200 • Oxygenation vs ventilation failure

  9. Respiratory Failure • Hospitalization for ARF 1.9 million • Mortality 21% (4th leading cause) • LOS 7.1 days • Mean cost per case $15,900 • Age • >=65 yrs : 59% • 45-65 yrs: 31%

  10. Respiratory Failure • Etiology • Pneumonia- 46% • CHF - 37% • COPD/Asthma 35% • Sepsis 21% • ARDS - 16% • Ventilation • Mechanical : 42% • Non-invasive 10% • Mortality 21% Proportion of patients with acute respiratory failure with the 5 most common medical conditions from 2001 to 2009.

  11. Respiratory Failure : A Case for NIV • 74 y WM with AMS, SOB with 2-3 hr, ? benzodiazepine for anxiety prior to transfer to ER • PMH :COPD, HTN, DM, CKD, AF, Cardiomyopathy • Ex-smoker 25 PY • VS: BP111/89, HR 96/min, RR 24/min, O2 sat 100% (FIO2 100%), T 96.7 • PE: • Morbidly obese, unresponsive, tachypneic, ↑ WOB, BS diminished, edema 2+, chronic skin changes in LE • JVD neg, no focal deficit • Lab: WBC 5.1, Hb 9, CO2>40, BUN/Cr 38/1.2, BNP 6230↑,trop NA • Echo : EF 55%, RVSP 48, LV dilated, LAE, LVH

  12. Respiratory Failure : A Case for NIV • ABG#1: (100%) 7.19/139/392/98% • Baseline ABG: (36%) 7.34/58/73/94% • BPAP 15/5, FIO2 50% started • ABG#2 (1913 hr): (50%) 7.22/121/170/98% (MS improving, barely responsive) • RX bronchodilator, IV steroid, antibiotics • ABG#3 (0318hr): (35%) 7.33/78/94/96% • BPAP changed to O2 3LNC at 6AM • ABG on D/C day (RA) 7.48/48/56/91%

  13. Respiratory Failure : A Case for NIV

  14. Respiratory Failure : A Case for NIV • Discharge diagnosis: • Acute on chronic respiratory failure • COPD exacerbation • OSA/OHS (clinical) • Pulmonary edema due to diastolic CHF • Pulmonary hypertension

  15. Respiratory Failure : Myths & Facts about NIV • Learning points: • Patient selection (hypercapnic COPD exac, pulm edema) • Trial of NIPPV worthwhile if there is no need for emergent intubation • Close monitoring (Clinical/ABG) • Hypercapnic encephalopathy is not a contraindication • MS should improve by 1-2 hr • Early intubation, • if no improvement in ABG • Hemodynamically unstable • Sepsis • AMI

  16. Respiratory Failure: NIV vs MV 45 mm Hg 40 mm Hg 60 mm Hg

  17. NIV: Failure to watch • No improvement of O2/CO2 in 2 hours • Worsening tachypnea or increased WOB • Declining mental status or agitation • Inability to clear secretions • Intolerance of mask or ventilator

  18. NIV: Monitoring by Numbers

  19. NIV: CPAP vs BPAP

  20. NIV : Options • CPAP • CHF/OSA/PNA/ARDS • Setting: APAP 5-15 cm • BiPAP • COPD/Asthma/PNA/ARDS • Setting: 10/5 cm, titrate for TV/PO2/PCo2 • Max IPAP/EPAP: 25/15 cm • Backup rate 12-16/min • Titrate IPAP by 2 cm for hypercapnia • Titrate IPAP/EPAP by 2 cm for hypoxia

  21. NIV : AVAPS

  22. NIV : Options • AVAPS • Adjust PS to guarantee an average tidal volume. • COPD/OHS/Restrictive lung disease • Setting • Tidal volume: 8 ml/kg (IBW) • IPAPmax: 25-50 cm, IPAPmin : EPAP + 4 cm • EPAP : 6 cm • Rate : 8-12 BPM (2 below resting rate) • I-Time: 1.5 sec (patient comfort) • Rise time : 2 sec (patient comfort) • Monitor : PO2/PCo2/O2 sat

  23. Evidence for efficacy and strength of recommendation: Noninvasive ventilation in acute respiratory failureNicholas S. Hill, MD; John Brennan, MD; Erik Garpestad, MD; Stefano Nava, MD 2007 Strength of Recommendation Recommended: first choice for ventilatory support in selected patients Guideline:can be used in appropriate patients but careful monitoring advised Option: suitable for a very carefully selected and monitored minority of patients. Level of evidence A: multiple randomized controlled trials and meta-analyses B: more than one randomized, controlled trial, case control series, or cohort studies C: case series or conflicting data

  24. NIV in ARF: Hi Flow Nasal Cannula (HFNC) • MECHANISMS • Warming and humidification of secretions. • Washout of nasopharyngeal dead space • CPAP effect • Accurate delivery of oxygen • Decreased inspiratory effort

  25. NIV in ARF: Hi Flow Nasal Cannula (HFNC)

  26. NIV in ARF: Hi Flow Nasal Cannula (HFNC) • Setting • Flow rate: 20 to 35 L/minute (range 5 to 60 L/minute) • FIO2: 40% (set to target a desired peripheral oxygen saturation) • Downgrade to low-flow nasal cannulae • flow rate ≤20 L/minute and FiO2 ≤35 percent. • Outcome: No improvement in clinically meaningful outcomes • Contraindication: • Abnormalities or surgery of the face, nose, or airway

  27. ARF : NIV-Heliox • Heliox: helium 79% and oxygen 21% • Lower Density (6x) • Indication • Upper airway obstruction • COPD/asthma exac • VCD • Respiratory failure • Benefits • improves air flow by transforming turbulent flow into laminar flow.

  28. Myths vs Facts

  29. Myths vs Facts: Oxygen Therapy in COPD Myths Facts • Oxygen therapy in COPD exacerbation cause hypoventilation leading to hypercapnia • Not everyone • Etiology is unclear • VQ mismatch • Haldane effect • ?Hypoventilation • Excessive O2 therapy leads to poor outcome • Goal: Titrated O2 therapy O2 sat 88-92%

  30. Myths vs Facts : Oxygen helps COPD patient live longer Yes No

  31. Myths vs Facts : COPD is same as Asthma

  32. Myths vs Facts : COPD is same as Asthma COPD Anti-inflammatory Rx • Steroid • Azithromycin • Roflumilast (PDE4 Inhibitor) • Statin

  33. Myths vs Facts : COPD is same as Asthma Asthma Anti-inflammatory Rx • Steroid • Leukotriene modifiers • Mast cell stabilizers • Anti-IL5 (mepolizumab/benralizumab) • Anti-IL4 (Dupilumab) • ?Bronchial thermoplasty

  34. Facts vs Myth Facts Myths • IV and oral steroids are equally effective for COPD exacerbation • IV steroids are more effective

  35. Facts vs Myth Facts Myths • Bronchoscopy has no role in COPD exacerbation • Bronchoscopy improves patient’s dyspnea, wheezing and shortens the LOS

  36. Myth vs Facts Myths Facts • Patient does not need steroid if there is no ‘wheezing’ • Steroid is effective in COPD exacerbation • Treatment failure • Improve FEV1 • Improve PaO2

  37. Common Issues to Consider

  38. COPD: When to Admit • Admission criteria • Acute respiratory failure • Failure of outpatient rx for COPD • Comorbidities (PNA, organ failure) • Unexplained symptoms (AMS, anorexia) • ICU admission criteria • Severe dyspnea • MS changes • Hypoxia/acidosis despite NIV • Hemodynamic instability/organ failure

  39. COPD: Readmission & Prevention Risk for Readmission Intervention

  40. COPD/Asthma: Other Discharge Considerations • Early ambulation • Home oxygen evaluation • Steroid for 2-3 weeks • Anti-inflammatory Rx (azithromycin) • Comorbidity management • OSA • CHF • Smoking cessation

  41. Home Oxygen Criteria • Indication • Pulmonary disorder (chronic) • Hypoxia related sign/symptoms • Tests (< 48hrs) • ABG • Pulse oximetry at rest or during exercise (6MWT) • Overnight oximetry (qualifies nocturnal O2 only) • Criteria

  42. Asthma: Step-up to more air BT/Nucala/Fasnera/Dupixent

  43. Overnight Oximetry : Clues to Identify

  44. Overnight Oximetry : Clues to Identify

  45. COPD/Asthma :Anxious for Breath • Role of anxiolytic for dyspnea • Benzo: No role, ?detrimental • Buspirone: Potential benefits w/o risks • Opioid: Palliative, risk vs ?benefit

  46. COPD: Infection vs Inflammation • Antibiotics for COPD • Exacerbation • Anti-inflammatory for LT management

  47. Thank You Imtiaz Ahmad, MD, FCCP Allergy Sleep & Lung Care 21st Century Oncology

  48. Supplementals

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