This document provides an overview of the management of critically ill patients with chronic obstructive pulmonary disease (COPD) experiencing an acute respiratory failure (ARF), with a focus on oxygen therapy. It discusses the pathophysiology of COPD exacerbations and ARF, factors that can precipitate acute failure, clinical presentation patterns, diagnosis, differential diagnosis, and management approaches including conservative treatments like oxygen therapy and bronchodilators as well as non-conservative interventions like mechanical ventilation. It also outlines indications for intensive care unit admission, complications of ARF in COPD patients, and future trends in oxygen therapy.

1. MANAGEMENT OF
CRITICALLY ILL PATIENT WITH
C.O.P.D.
( WITH REVIEW OF O2 THERAPY )
DR D.R. JOSHI,
B.J.Medical College,Pune
< drjaydr@pn3.vsnl.net.in >

2. # Acute exacerbations
in C O A D are common
# They carry high
morbidity and mortality
but are reversible
# Prognosis of patients
who recover is good

3. FACTORS PRECIPITATING
ACUTE FAILURE
•Sputum retention
•Bronchospasm
•Infection
•Pneumothorax
•Large bullae
•Uncontrolled O2 - administration
•Pulmonary embolism
•Left-ventricular failure
•Sedation
•End-stage disease

4. PATHO- PHYSIOLOGY….
FACTORS AFFECTING AIR-FLOW
• Mucosal edema
• Hypertrophy of mucosa
• Increased secretions
• Increased bronchospasm
• incr. Airway tortuosity
• More airway turbulance
• Loss of lung recoil

5. PATHO-PHYSIOLOGY….contd
AIR-FLOW OBSTRUCTION
PROLONGED EXPIRATION
PULMONARY HYPERINFLATION
DUE TO AIR-TRAPPING
INCREASED WORK OF BREATHING
DYSPNOEA

6. PATH-PHYSIO…..CONTD
ALVEOLAR DISTORTION
AND DESTRUCTION
LOSS OF HYPOXIA CAUSING
CAPILLARY BED PULMONARY
VASOCONSTRICTION
PULMONARY HYPERTENSION
SECONDARY VASCULAR CHANGES
COR-PULMONALE

7. INCREASED AIRWAY OBSTRUCTION
DUE TO
INCOMPLETE EXPIRATION + RAISED MVV
RAISED F R C
PULMONARY HYPER-INFLATION

8. LUNG FIBRE LENGTH
VOLUME OF DIAPHRAGM
WORK OF BREATHING
VENTILATORY REQUIREMENT

9. ‘ IF WORK OF BREATHING FAILS
TO MEET
VENTILATORY REQUIREMENT
OF A PATIENT…’
CHRONIC HYPERCARBIA RESULTS.

10. CLINICAL PRESENTATION…
PATTERN-I ‘’ CAN’T BREATH ‘’
( INCREASING DYSPNOEA)
# MORE COMMON
# IMPAIRED AIR-FLOW & GAS EXCHANGE
# RESPIRATORY DRIVE – NORMAL
# INABILITY TO ACHIEVE ADEQUATE
VENTILATION DESPITE MAXIMUM
VENTILATORY EFFORTS
# HYPERPNOEA
# INCREASED SPUTUM / COUGH / WHEEZE &
REDUCED EXERCISE TOLERANCE
# RESPIRATORY MUSCLE FATIGUE

11. … CLINICAL PRESENTATION
PATTERN – II ‘’ WON’T BREATH ‘’
( DECREASING DYSPNOEA )
# LESS COMMON
# REDUCED CONSCIOUSNESS LEVELS ..
DRUGS
ILLNESS
UNCONTROLLED OXYGEN THERAPY
# REDUCED CENTRAL RESPIRATORY DRIVE
# RESPIRATORY MUSCLE FATIGUE &
CO2 NARCOSIS
# A B G = RESPIRATORY ACIDOSIS
HYPOXIA

12. DIAGNOSIS OF A R F IN COAD …
1} X-RAY CHEST
• Hyper - inflation
• Flattened diaphragm
• Less lung markings
• Increased hilum / pulm.Art.Size
• RA / RV dilated
• Existing pathology

13. DIAGNOSIS OF A R F IN COAD ….
2} E C G
- NORMAL
- RT AXIS DEVIATION
- RAH ( ‘P’ PULMONALE)
- RVH WITH RV – STRAIN
- RBBB

14. DIAGNOSIS OF A R F IN COAD …
3] Arterial Blood Gas
# Hypoxia
# Respiratory acidosis
- Compensated
- Un-compensated
# Exclude metabolic alkalosis
If bicarbonates high
… contd

15. …
POINTS TO RECOLLECT …
EVERY 10 mm Hg RISE IN pCO2 =>
RISE OF 1mmol/L in HCO3
in ACUTE RESPIRATORY ACIDOSIS
AND
EVERY 10 mm Hg RISE IN PCO2 =>
RISE OF 3 – 3.5 mmol/L in HCO3
in CHRONIC RESPIRATORY ACIDOSIS

16. …
… OTHER INVESTIGATIONS
# SPUTUM BACTERIOLOGY
# TOTAL BLOOD COUNTS
# THEOPHYLLINE LEVELS {WHERE INDICATED}
# C T THORAX TO R / O SMALL PNEUMOTHORAX
# VENTILATION / PERFUSION STUDY

17. DIFFERENTIAL DIAGNOSIS …
# Left ventricular failure
# Pulmonary embolism
# Pneumothorax
# Upper air-way obstruction

18. MANAGEMENT..
CONSERVATIVE
• Oxygen
• Bronchodilators
• Steroids
• Antibiotics
• Non-invasive secretions clearance
• Other measures
NON-CONSERVATIVE
• Invasive techniques for sputum clearance
• Mechanical ventilation

19. C
CONSERVATIVE MANAGEMENT
OXYGEN THERAPY
Clear benefit of long term o
2 TRIALS-
• N O T T ( Nocturnal O2 Ttherapy trial )
• M R C ( Medical Rsearch Council, UK )
Continuous O2 (24 hrs/day) better than
nocturnal O2 (12 hrs/day) which is better than
no O2

20. OXYGEN THERAPY
MODES OF OXYGEN DELIVERY
APPARATUS O2 FLOW CONC.
(L / MIN) %
NASAL CATHETER 2 – 6 25 – 40
SEMI RIGID MASK 4 – 15 35 - 70
VENTURI MASK 6 – 12 24, 28, 35,
40, 50, 60
SOFT PLASTIC MASK 4 – 15 40 – 80
VENTILATORS VARYING 21 – 100
CPAP CIRCUITS VARYING 21 – 100
OXYGEN TENT 7 – 10 60 - 80

21. PATIENTS FOR HOME OXYGEN THERAPY
• STABLE COURSE OF DISEASE
• 2 ABGs AT ROOM AIR AT REST FOR 20 MNTS
* RESTING PaO2 < 55 FOR > 3 WKS
OR PaO2 55 – 59 + CLINICALLY COR PULMONALE
AND / OR HAEMATOCRIT > 55 %
* NOCTURNAL HYPOXEMIA OR HAEMATOCRIT > 55 %
OR CLINICAL PULMONARY HYPERTENSION
* NORMOXIC PATIENT WITH LESS DYSPNOEA +
INCREASING EXERCISE CAPABILITY WITH O2

22. OXYGEN DOSE
# CONTINUOUS O2 FLOW 1 – 2 L/MIN
WITH SINGLE / DOUBLE NASAL CANNULA
WITH ADEQUATE SaO2
# LOWEST FLOW TO RAISE PaO2 TO 60-65 mm
OR SaO2 88-94 %
# INCREASE BASE -LINE FLOW BY 1 L / MIN
DURING SLEEP AND EXERCISE

23. CONTROLLED O2 THERAPY
•MODERATE TO SEVERE HYPOXIA
(PaO2 <55 mm Hg) IN COPD
CAN CAUSE MORTALITY
•SHOULD BE CORRECTED IMMEDIATELY
•INCREASE PaO2 TO 60 mmHg WHILE
MAINTAINING PH > 7.25
•SEVERITY OF ACIDOSIS IS A BETTER
PROGNOSTIC GUIDE THAN ABSOLUTE
pCO2 LEVELS.
…contd

24. CONTROLLED OXYGEN THERAPY …contd
NORMALLY 24% - 26% INSPIRED OXYGEN
UPTO 30% IF HYPOXIA UNRELIEVED.
RESPONSE ---
1. RELIEF OF HYPOXIA + REDUC. IN PCO2 + CLINICAL
IMPROVEMENT
2. RELIEF OF HYPOXIA + INITIAL RISE IN PCO2
AND pH /< 7.25 LATER CHANGING TO NORMAL WITH
FALL IN PCO2
3. IF UNCONTROLLED OXYGEN THEN RAPID RISE IN
PCO2 AND DROP IN pH <7.25 . CAN BE LETHAL.

25. DOMESTIC OXYGEN SYSTEM …
# LIQUID – PORTABLE DEVICE ..
• LIGHT WEIGHT
• LONG – RANGE PORTABLE CANNISTER
• PRACTICAL AMBULATORY SYSTEM
BUT
• MORE EXPENSIVE THAN CONCENTRATOR
ALONE
• NOT AVAILABLE IN SMALLER PLACES
..contd

26. DOMESTIC OXYGEN SYSTEM …. Contd
# OXYGEN CONCENTRATOR
- LOW COST
- CONVENIENT
- ATTRACTIVE EQUIPMENT
- WIDE-SPREAD AVAILABILITY
BUT
- ELECTRICITY REQUIRED
- NOT PORTABLE
- MAY NEED BACK-UP TANK

27. DOMESTIC OXYGEN SYSTEM …
CONTD
# COMPRESSED GAS
• LOW COST IN GENERAL
• WIDE-SPREAD AVAILABILITY
BUT
• MULTIPLE TANK REQUIREMENT
• FREQUENT DELIVERIES REQUIRED
• HEAVY & UNSIGHTLY TANKS
= DIFFICULT AMBULATION.

28. FUTURE TRENDS IN OXYGEN THERAPY
1) TRANS-TRACHEAL OXYGEN
• Reduction in supplemental o2
• Improved exercise tolerance
• Reduced hospitalisation
• Better patient compliance
• Cosmetic value
• Hypoxia & sleep disorders avoided
cont

29. FUTURE TRENDS IN OXYGEN THERAPY
OXYSPECS / OXYFRAMES
• CONCEALED OXYGEN TUBINGS
• SINGLE / DOUBLE NASAL CANNULA
• COSMETICALLY MORE ACCEPTABLE
• USES SMALLER BATTERY- POWERED
OXYGEN CONCENTRATORS
DEMAND CANNULA / DEMAND SYSTEMS
• ALLOWS O2 FLOW DURING
INSPIRATION ONLY
• SAVES 50 % OXYGEN

30. MANAGEMENT – NONINVASIVE
# BRONCHODILATORS
• ROUTINELY GIVEN
• HELP RESIDUAL BRONCHODILATION
AND MUCO-CILIARY CLEARANCE
[ I.V.AMINOPHYLLINE / B2-AGONIST / IPRATROPIUM ]
…CONTD

31. CONSERVATIVE MANAGEMENT ….contd
# ANTIBIOTICS
# STEROIDS … AVOID IN ARF DUE TO INFECTION
# OTHER
* STEAM / PHYSIOTHERAPY / ENCOURAGE COUGH
* GENERAL HYDRATION
* DIURETICS / LOW DIGOXIN IF LVF
* HEPARIN S /C FOR D V T / PULM EMBOLISM
* NUTRITION
* RESPIRATORY STIMULANTS

32. MANAGEMENT - NON CONSERVATIVE….
1. INVASIVE TECHNIQUES FOR SPUTUM CLEARANCE
• OROPHARYNGEAL / NASOPHARYNGEAL SUCTION
• NASO-PHARYNGEAL AIR-WAY
• THERAPEUTIC AND DIAGNOSTIC F O B
• MINI TRACHEOSTOMY/ CRICOTHYROTOMY FOR
SUCTION
• ENDOTRACHEAL INTUBATION
* FOR BETTER ACCESS
* FOR VENTILATORY SUPPORT
• TRACHEOSTOMY
* IF VERY THICK SECRETIONS
* INTUBATION > SEVEN DAYS

33. MECHANICAL VENTILATORY SUPPORT
SETTINGS WITH
NO OVER-INFLATION
LOW TIDAL VOL NO INCREASE IN AUTOPEEP
8-10 ML /KG , MV = 5-6 L/MIN REDUCE PEAK INFLATION
REDUCE BAROTRAUMA
FLOW CAN BE INCREASED TO 40 – 60 L / MIN
I/E RATIO GOOD DISTRIBUTION OF GASES
1 : 2 OR 1 : 3 ALLOWS TIME FOR EXPIRN
FiO2 0 . 5 TO 0 . 7 FAST CORRECT OF HYPOXIA
SEDATION MACHINE CAN TAKE-OVER

34. MECHANICAL VENTILATION . . . …CONTD.
# BRING DOWN PaCO2 GRADUALLY
IN 24 – 48 HOURS UPTO 50 MM Hg
# PaO2 = 60 MM MAY SUFFICE
# WEANING BY TRADITIONAL METHODS
# IF DIFFICULT WEANING –
CAN USE PRESSURE SUPPORT

35. INDICATIONS FOR I C U ADMISSION
• SEVERE NON-RESPONDING DYSPNOEA
• DEVELOPING CONFUSION / LETHARGY
• RESPIRATORY MUSCLE FATIGUE
• PROGRESSIVE WORSENING DESPITE TREATMENT
OF HYPOXIA / RESPIRATORY ACIDOSIS
• NEED FOR INVASIVE / NON-INVASIVE
MECHANICAL VENTILATION

36. COMPLICATIONS OF A R F IN COPD
• NOSOCOMIAL INFECTIONS
• FLUID / ELECTROLYTE IMBALANCE (HYPOKALEMIA)
• ACID / BASE – DISTURB. -- METABOLIC ALKALOSIS
• CARDIAC ARRHYTHMIAS / FAILURE
• PNEUMOTHORAX
• PULMONARY THROMBOEMBOLISM
• HYPOTENSION DUE TO AUTO - PEEP
• G.I. BLEEDING
• MENTAL DEPRESSION

37. THANK-YOU