Hypercapnic Respiratory Failure

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Hypercapnic Respiratory Failure

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1. Hypercapnic Respiratory Failure Erik van Lunteren, M.D.

3. Carbon Dioxide

4. Carbon Dioxide: History Discovered by Jan Baptista van Helmont around 1630 as the gas given off by burning wood, who called it sylvestre ("wood gas"). Studied extensively by Joseph Black (1728–1799), who proved that carbon dioxide occurred in the atmosphere and that it could form other compounds. He also identified carbon dioxide in the breath exhaled by humans. First practical use of carbon dioxide was by Joseph Priestley (1733–1804) in the mid-1700s. Priestley found that by dissolving carbon dioxide in water he could produce a fresh, sparkling beverage with a pleasant flavor.

5. Properties of Carbon Dioxide Colorless Odorless Non-combustible Density ~1.5 times that of air

6. Properties of Carbon Dioxide

7. Some Uses of Carbon Dioxide Carbonated soft drinks Coolants and refrigerants Fire extinguishers (especially for electrical and oil fires, which can not be put out with water) Retarding food spoilage Propellant for guns BB guns Paintball guns Lasers

8. Carbon Dioxide and Environment Carbon dioxide captures heat radiated from earth’s atmosphere Responsible for keeping the planet sufficiently warm to allow life Increasing concentrations of carbon dioxide are raising earth’s temperature One of the three most important “greenhouse” gasses

9. Atmospheric Concentrations of CO2

10. Carbon Dioxide Emissions

11. CO2 Air Pollution: Asthma

13. Hypercapnic Disorders: Definitions Hypercapnia: PaCO2 = 45 mm Hg Hypercapnic respiratory failure: hypercapnia plus acidosis Acute: no or minimal metabolic compensation Chronic: appropriate metabolic compensation

14. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental Iatrogenic

15. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental Iatrogenic

16. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental Iatrogenic

17. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental Iatrogenic

18. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental – Industrial, Natural Iatrogenic - Drugs, Ventilators

19. Causes of Hypercapnic Resp. Failure Neural & Neuromuscular Brain Drugs Motor neurons Neuromuscular junction Respiratory muscles Chest Wall Kyphoscoliosis Ankylosing spondylitis Flail chest “Medical” Diseases COPD Severe asthma Late stage interstitial lung disease Pulmonary edema Sleep apnea / obesity-hypoventilation Hypothyroidism Environmental – Industrial, Natural Iatrogenic - Drugs, Ventilators

20. Neuromuscular Causes of Hypercapnic Respiratory Failure Skeletal Muscle Diseases Some (but not all) of the Muscular Dystrophies Duchenne muscular dystrophy Merosin-negative congenital muscular dystrophy Myotubular myopathy 1 Autosomal dominant distal myopathy One of the autosomal recessive limb-girdle muscular dystrophies Myotonic Dystrophy Polymyositis/dematomyositis

21. Neuromuscular Causes of Hypercapnic Respiratory Failure Neuromuscular Junction Disorders Myasthenia gravis Lambert Eaton myasthenic syndrome Botulism Organophosphate poisoning Motor Neuron Disorders Amyotrophic lateral sclerosis Guillain-Barre syndrome Poliomyelitis Spinal cord injury

22. Famous People & Motor Neuron Disorders Guillain Barre Joseph Heller, Andy Griffith Polio vs Guillain Barre Franklin D Roosevelt Polio Sports: Jack Nicklaus Acting/Movies: Alan Alda, Francis Ford Coppola, Mia Farrow Musicians: Donovan, Joni Mitchell, Itzhak Perlman, David Sanborn, Neil Young, Dmitri Shostakovich Other: Arthur Guyton, Arthur C. Clarke Amyotrophic lateral sclerosis Lou Gehrig, Lead Belly, Catfish Hunter Stephen Hawking may have different type of motoneuron disease Spinal cord injury Christopher Reeve

23. Iatrogenic Hypercapnia and Mechanical Ventilation Study of low vs conventional tidal volume / pressure mechanical ventilation for ARDS Much higher incidence of hypercapnia (pCO2 > 50 mm Hg) in low tidal volume / low pressure group

24. Iatrogenic Hypercapnia and Mechanical Ventilation ? “Permissive Hypercapnia” Study of low vs conventional tidal volume / pressure mechanical ventilation for ARDS Much higher incidence of hypercapnia (pCO2 > 50 mm Hg) in low tidal volume / low pressure group

25. Pickwickian Syndrome

26. Pickwickian Syndrome

27. Obesity Hypoventilation Syndrome (OHS) Definition BMI > 30 kg/m2 Awake arterial pCO2 > 45 mm Hg No other causes for hypercapnia

28. OHS in Hospitalized Patients Studied 4332 admissions to medical services 277 (6%) were severely obese (BMI > 35 kg/m2) OHS present in 31% with severe obesity Mean pCO2 of 52 ± 7 vs 37 ± 6 mm Hg in subjects with simple obesity When BMI > 50 kg/m2, prevalence OHS was 48%

29. Outcome Following Discharge Survival curves for patients with obesity-associated hypoventilation or simple obesity after discharge from hospital Adjusted for age, sex, body mass index, electrolyte abnormalities, renal insufficiency, history of thromboembolism, and history of hypothyroidism.

30. Prevalance OHS Among OSA Obesity hypoventilation syndrome (OHS) among subjects with obstructive sleep apnea (OSA) Prevalence of 20-30% Predictors of OHS: Serum bicarbonate level (P < 0.001) Apnea hypopnea index (P = 0.006) Lowest oxygen saturation during sleep (P < 0.001) Threshold bicarbonate level of 27 mEq/l: Sensitivity 92% Specificity 50%

31. US President with Probable OSA

32. US President with Probable OSA

33. US President with Probable OSA

34. President Taft

36. Lake Nyos, Cameroon

37. Limnic Eruption of Lake Nyos Geology Deep lake high on an inactive volcano Pocket of magma lies beneath its waters and leaks carbon dioxide into the waters Water in deep layers is supersaturated with carbon dioxide August 1986, the lake released a large cloud of carbon dioxide in a limnic eruption Deep water layers came to surface, and reduction in pressure resulted in CO2 release 1.6 million tons of CO2 were released Killed 1,746 people and up to 3,500 livestock Mainly carbon dioxide, with traces of carbon sulfide, hydrogen sulfide and sulfur dioxide

38. Long-Term Sequela from Lake Nyos Study compared 381 exposed with 128 non-exposed subjects No difference in frequency of dyspnea, cough, sputum No difference in peak expiratory flow

39. Danger of Repeated Episode Carbon dioxide levels have built up again to previous levels, so another limnic eruption could occur Natural dam holding lake in place is said to be weak, which could release deep supersaturated waters and cause carbon dioxide release

40. Degassing Lake Nyos

42. Management of Hypercapnia Is it acute or chronic or acute on chronic? What is the underlying etiology? Treatment options Specific therapy for underlying cause No mechanical ventilation Non-invasive mechanical ventilation Invasive mechanical ventilation

43. Hypercapnic Respiratory Failure Early Treatment Modalities

44. Polio -- Iron Lung Ward – 1950’s

45. Mechanical Ventilation for Acute Hypercapnic Respiratory Failure Intubation with conventional mechanical ventilation Non-invasive positive pressure ventilation (NPPV)

46. Selection criteria (at least two should be present) Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion Moderate to severe acidosis (pH 7.30-7.35) and hypercapnia (PaCO2 45-60 mm Hg) Respiratory frequency > 25 breaths/min Criteria for Non-Invasive Ventilation in COPD

47. Criteria for Non-Invasive Ventilation in COPD Exclusion criteria (any may be present) Respiratory arrest Cardiovascular instability (hypotension, arrythmias, MI) Somnolence, impaired mental status, uncooperative patient High aspiration risk Viscous or copious secretions Recent facial or gastroesophageal surgery Craniofacial trauma Fixed nasopharyngeal abnormalities Extreme obesity

48. Masks for Non-Invasive Ventilation Types of mask Nasal More comfortable Patient can eat Minimal aspiration risk Communication easier Whole face No entrainment of room air May allow better ventilation Choice of mask Hypercapnic respiratory failure Nasal mask often sufficient Sometimes need whole face mask Hypoxic respiratory failure Always need whole face mask

49. Ventilator Devices for Non-Invasive Ventilation Types of Ventilator Devices BiPAP Simple BiPAP – oxygen set by liter flow Advanced BiPAP – can set FiO2 Conventional Ventilator Choice of Ventilator Device Hypercapnic respiratory failure Simple BiPAP is sufficient Any of above may be used Hypoxic respiratory failure Need advanced BiPAP or conventional ventilator

50. Inspiratory and Expiratory Pressures Hypercapnic respiratory failure Inspiratory pressure typically in 12 to 20 cm H2O range Lower values better tolerated Higher values give better ventilation Expiratory pressure not really needed Except: many BiPAP machines require several cm H2O to function properly Hypoxic respiratory failure Inspiratory pressure typically in 12 to 20 cm H2O range Expiratory pressure gradually increased to improve oxygenation

51. COPD – Non-Invasive Ventilation Total of 85 patients with COPD exacerbation from five hospitals in France, Italy and Spain Non-invasive ventilation Face mask with foam inside to reduce dead space Pressure support ventilator system with back-up rate Inspiratory pressure 20 cm H2O, no expiratory pressure Oxygen to achieve saturation > 90% At least 6 hours/day, up to 22 hours/day if needed

52. COPD – Non-Invasive Ventilation

53. COPD – Non-Invasive Ventilation

54. COPD – Non-Invasive Ventilation Outcomes Reduced need for intubation Non-invasive group 26% intubated (11/43) Conventional group 74% intubated (31/42) (P < 0.001) Reduced complication rate Non-invasive group 16% (7/43) Conventional group 48% (20/42) (P = 0.001) Improved survival to hospital discharge Non-invasive group 91% (39/43) Conventional group 71% (30/42) (P = 0.02)

55. COPD – Non-Invasive Ventilation Outcomes (cont’d) Reduced length of stay in hospital Non-invasive group 23 ± 17 days Conventional group 35 ± 33 days (P = 0.02) Lower proportion with length of stay > 4 weeks Non-invasive group 18% (7/43) Conventional group 47% (14/42) (P = 0.004)

56. Meta-Analysis: COPD and Non-Invasive Ventilation

57. Meta-Analysis: COPD and Non-Invasive Ventilation

58. Meta-Analysis: COPD and Non-Invasive Ventilation

59. Meta-Analysis: COPD and Non-Invasive Ventilation

60. Other significant outcome improvements with non-invasive ventilation in COPD Reduced rate of complications Reduced hospital length of stay Improved pH, pCO2 and respiratory rate within one hour of initiation Meta-Analysis: COPD and Non-Invasive Ventilation

61. Ventilation for Chronic Hypercapnia Clear role for chest wall and neuromuscular disease, and congenital central hypoventilation syndrome Often used for obesity-hypoventilation with sleep apnea (ie use BiPAP rather than CPAP) Controversial for obstructive lung diseases For neuromuscular diseases, often able to start with nocturnal only, and then move to 24 hours/day with disease progression Non-invasive ventilation generally preferred over invasive ventilation, unless prominent bulbar problems or subject completely dependent on ventilator (eg. high spinal cord injury)

62. Long-Term Non-Invasive Ventilation and Restrictive Disorders

63. NPPV and Restrictive Disorders

64. Use of Home Chronic Ventilation Prospective 7 year follow up of patients treated at home with nasal positive pressure ventilation Two university hospitals and a pulmonary rehabilitation center Mean 6.9 hours of ventilation per 24 hours

65. Ventilator Modality

66. Blood Gas Changes

67. Survival: 7 Year Follow Up

68. Examples of People Undergoing Long Term Mechanical Ventilation

69. Long-Term Ventilation Not for Everyone

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