Just a Pneumonia!

Summary
 MR, 62, Lady, Housewife,
 Transferred by Ambulance from Letterkenny 1/52 ago for further
continuous Critical Care Management
 On the background of
 6/ 52 refractory CAP complicated by

 3/7 Acute Tubular Necrosis

 1/7 uncompensated Respiratory Failure 1 (Uncompensated

Resp Acidosis with RF 2?)

 Currently
 Intubated, sedated

 HFOV for ARDS

 CVVHD for ARF

 Inotrophic support

 Enteral feeding via NG tube

CAP
 Treated by GP 2/52
 Co-Amoxiclav PO
 Admitted to Letterkenny on the 3rd week
 Weight loss, 1 stone!
 Fatigue
 Progressive dypsnoea
 Increase green sputum production
 IV Co-Amoxiclav + IV Clarithromycin  IV
Piperacillin 4.5g TDS 13/7 via Microbiology
advice
5th week
 Apyrexia
 Decrease O2 requirement
 Decrease CRP
 Decrease bilateral pulmonary infiltration
 Bronchoscopy planned for the 29th due to
persistency
The week! 6th!!
 28/9/2010  Kidneys acting up!
 Creatinine 203 Urea 14.2
 2+ blood 2+ protein
 50-100 RBC on microscopy
 Kidney biopsy + Nephritic Workup
 ATN, MPGN pattern
 ANA and anti Ro +
 29/9/2010  Lung acting up!  Respiratory failure 1
 Increase O2 demand
 CRP 327
 CT  bilateral mid and lower lobe infiltration
 O2 and IV Meropenem + IV Teicoplanin start
 30/9/2010  uncompensated RF 1?
 Intubated + SIMV
 Liaison with BH  advice handover
Relevance
 Nil Past Med
 MJTHREAD nil
 Nil Past Surge
 NKDA
 Nil Family History
 Married, housewife, non smoker
BH ICU
 ARDS
 Targets
 pO2 > 10
 pCO2 < 7
 pH > 7.2
 BiPAP  SIMV  Swan  ARDS  HFOV
 ARF
 2/9/2010  Renal consult due to anuria
Continuos Veno-Venous Haemodialysis start
What happen in the ICU?
 Nurse at 30 degrees
 Sedation, Muscle Relaxant and Pain Killer
 Inotropes + Central Line + Pulmonary Arterial
Catheter/Swan-Ganz + Cardiac Monitor
 Enteral feeding via NGT
 IV fluids
 DVT prophylaxis  Heparin+TEDS
 Pressure Sore management
 Urinary catheter
 Bronchial/Subglotic Secretion toileting
ICU medications
 Meropenem 1g IV TDS
 Teicoplonin 400mg IV OD
 Amphotericin B 250mg IV OD
 Co-trimoxazole 2.5g IV TDS
 Omeprazole 40mg IV OD
 Methyprednisolone 250g IV OD
 Heparin  target aptt 70-90
 Folic Acid 5mg via NGT Once
 Pulmocare 1.5kCal/ml
ICU titrated medications
 Adrenaline
 Noradrenaline
 Midazolam
 Morphine
 Cisatracurium
 Nitric Oxide
 Actrapid
 KCl
 MgSO4
 NaPO4 PRN
Day to Day Investigation
 FBC
 U&E
 LFT
 Coagulation
 Serial Chest X-ray
 ABG
 LDH
 Lactase
 Ca2+, PO4, Mg2+
Ventilators, O2, CO2
18
SIMV BiPAP SIMV HFOV HFOV HFOV HFOV
16
14 pCO2
12
pO2
10
8 pH
6
4
2
0
Letterkenny BH
1 2 3 4 5 6 7
Respiratory Failure  paO2 < 8kPa/ <60
mmHg
Type 1 (hypoxia) Type 2 (hypoxia+hypercapnia)
 PaCO2 normal  PaCO2 > 6kPa/> 40mmHg
Signs and Symptoms
Hypoxia Hypercapnia
 Restless  Headache
 Confuse  Dyspnoea
 Cyanosis  Drowsy
 Cor pulmonale  Asterixis
 coma  Warm periphery
 Chemosis
 Increase ICP
Aetiology  all Resp disease!
Type 1 Type 2
 Low FiO2  high altitude  Increase CO2 production
 Fever
 Normal FiO2
 sepsis
 Diffusion problems
 Interstitial lung disease  Alveolar hypoventilation
 V/Q mismatch  Asthma

 Asthma  COPD
 COPD  Low total ventilation
 PE  Brainstem stroke
 pneumonia  Myasthenia gravis
 Shunting  GBS
 Alveolar collapse
 Tired!
 RL cardiac shunt
 Low O2 content
 anaemia
FiO2 and PaO2

PaO2 approx <10 FiO2 value!

Eg 55% O2 via Nasal Prong, PaO2 45

Treatment
Type 1 Type 2
 Treat causes  Treat causes
 Face mask 35-60% O2  O2 titration 24% + ABG after
 Assisted Ventilation if paO2 20mins
<8 kPa  If paCO2 increase > 1.5kPa
 Respiratory stimulant

Or
 Assisted Ventilation

 Invasive Ventilate
 Mechanical
Ventilator

Non Invasive Invasive

So what’s the fuss?
Non Invasive Invasive
 Nasal/Face Mask  ETT
 ± Sedation  Need sedation
 OK speech and eating  Always PEEP
 Good Airway control due to
high pressure
 Need brochial toileting
 When to ventilate?
 Respiratory Failure 1 and 2
 Refractory hypoxaemia
 Respiratory Acidosis
 Respiratory Arrest
 Respiratory muscle fatigue
 Surgical procedures
 ARDS
 Obtundation or coma
 Hypotension
 Neuromuscular disease
General mechanics
 Support gas exchange
 Hi FiO2 + PEEP
 Reverse hypoxemia/hypercarbia
 Increase lung volume
 Reverse Atelectasis
 Relieve respiratory distress
 Reduce work of breathing
 Reverse ventilator muscle fatigue
 Reduce systemic and myocardial oxygen demand
 What is CPAP?
Constant pressure!

Breath in and out!

Alveoli will not collapse!!

Bilevel Positive Airway Pressure
(BiPAP) ?
Breath in Breath out

Increase pressure low constant pressure is

given given

CPAP wannabe! But not 100% committed

NIPPV Contraindication

 Cardiac/Respiratory arrest
 Nonrespiratory organ failure
 GCS <10
 Severe upper GI bleed
 Facial surgery/trauma
 Upper Airway Obstruction
 High risk of aspiration
 Inability to cooperate/Protect Airway
 What is PEEP (Positive End-
Expiratory Pressure) ?
Apply pressure at end of expiration so
that alveoli will not collapse

Breath out  PEEP applied  ↑ Alveolar Pressure 

↑ Alveolar Volume  Alveolar stays open  increase
V/Q on expiration
Synchronous Intermittent Mandatory
Ventilation (SIMV)

Pre-set ventilation within a time period

+
Patient spontaneous breathing
Synchronous Intermittent Mandatory
Ventilation (SIMV)
In the time Period Outside time Period
 Patient breath in  On your own!
start pre-set ventilation Spontaneous
 Help only on the 1st ventilation
spontaneous
inspiration
 Don’t breath  deliver
pre-set at the end of
time period
Ventilator Complications

 General
 Problems with weaning
 Sedation withdrawal
 Cardiovascular=Hypotension
 Increase intrathoracic pressure
 Decrease venous return
 Decrease cardiac output
Ventilator Complications
 Pulmonary
 Barotrauma
 pulmonary interstitial emphysema
 Pneumomediastinum
 Pneumoperitoneum
 Pneumothorax/ tension pneumothorax
 High O2free radical cellular damage
 VAP >72hrs high risk
 tracheal stenosis
 laryngeal dysfunction
Ventilator Complications

 GIT and renal  decrease CO

 Stress ulcer  PPi prophy
 Decrease UO and Na excretion
Thanks!
ABGs

Parameter Normal range

pH 7.35-7.45
[H+] mmol/L 35-45
PaCO2 kPa 4.5-6.0
PaO2 kPa 11.0-14.5
O2 Sat % >95%
HCO3 mmol/L 22.0-26.0

Anion Gap=Na-(Cl+HCO3) [12±2]

Urine Anion Gap=Una+Uk-Ucl
 Anion Gap=Na-(Cl+HCO3) [12±2]
Urine Anion Gap=Una+Uk-Ucl
pH
7.35-7.45

Alkalosis
pH>7.45
Metabolic Acidosis

Normal Anion Gap High Anion Gap

 Renal (+ Urine Anion  Lactic Acidosis
Gap)  Aspirin
 Tubular acidosis  Methanol=wood spirits
 Carbonic anhydrase
inhibitors
 Uraemia
 GIT (- Urine Anion Gap)
 DKA
 Diarrhoea  Propylene glycol=hand
 Small bowel fistula sanitizer
 Isopropyl glycol=solvent
 Ethylene glycol=coolant
Metabolic Alkalosis

 Increase base
 Blood transfusion
 Milk alkali syndrome
 Loss Cl
 Vomitting
 Loss K
 Diuretics (thiazide)
 Burns
Respiratory

Alkalosis Acidosis
 Head injury/Stroke  CNS trauma
 High altitude  hypoventilation
 hyperventilation  COPD
 Asthma
 ARDS
References

 http://emedicine.medscape.com/article/81012
6-overview
 Toronto notes
 http://www.ccmtutorials.com/index.htm
 http://www.scribd.com/doc/7106291/Non-Inva
sive-Positive-Pressure-Ventilation-NIPPV?se
cret_password=&autodown=pdf