Approach to Critically Ill Patient with Acute Respiratory ... · Approach to Critically Ill Patient...

Approach to Critically Ill Patient with Acute Respiratory Failure

Ognjen Gajic M.D.

Professor of Medicine

Attending Intensivist

Mayo Clinic

Rochester MN, USA

Multidisciplinary Epidemiology and Translational Research in

Intensive Care and Perioperative Medicine (METRIC - PM)

@ gajic.ognjen@mayo.edu

A…B….C….

Safar P. Community-wide cardiopulmonary resuscitation. J Iowa Med Soc 1964; 54:629–635

Early Appropriate Empiric Antibiotics

Pronovost et al 2002

Rivers et al NEJM 2002

EARLY goal-directed resuscitation

Preventing VILI: Prevention of overdistension and tidal stretch by low tidal volume ventilation

Brower et al NEJM 1999, ACCP J club 2001

Walkey et al. J Crit Care Volume 27, Issue 3, June 2012

450 mL

350 mL

✚

Papazian L, Forel J-M, Gacouin A, et al. Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome. New England Journal of

Medicine;363(12):1107-16.

Neuromuscular blockade in early severe ARDS

The National Heart L, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, .

Comparison of Two Fluid-Management Strategies in Acute Lung Injury N Engl J Med. 2006

Martin et al Crit Care Med 2007

FLUID MANAGEMENT

Estimated CVP

MAP > 60 mm Hg AND off vasopressors

Average urine output < 0.5 ml/kg/hr

Average urine output > 0.5 ml/kg/hr

>8Furosemide*

Reassess in 1 hour Furosemide*Reassess in 4 hours

4-8Give fluid bolus as fast

as possible#

Reassess in 1 hour< 4No intervention

Reassess in 4 hours

*Consider 25%

Albumin-If hypotensive

-Hypoalbuminemic

-RV/LV failure with

anasarca

Preventing fluid overload

Modifying exaggerated inflammatory response (steroids)

Medoff BD et al N Engl J Med. June 9, 2005 2005;352(23):2425-243

Steroids for specific causes

Wake up and Breath

Girard et al Lancet 2008

Physical Therapy

Schweickert et al Lancet 2009

Follow up of ICU Survivors

• “Patients do not die of their disease. They die of the physiologic abnormalities of their disease”

Sir William Osler

(1849-1919)

Acute Physiologic Syndromes• Shock

• Sepsis

• Acute lung injury

• Respiratory failure

• Increased intracranial pressure

• Stroke

• Acute coronary syndrome

• Acute kidney failure

• Acidosis

• Disseminated intravascular coagulation

O2 CO2

Oxygen Trail to The Brain and Other Tissues

What can kill the brain?

• Local damage

•Head injury

•Stroke

• Cardiopulmonary dysfunction

•Airway

•Lungs/chest/neuro

•Heart

• Muscle dysfunction

•Arrhythmia

•(coronary obstruction, preload, afterload, contractility, acidosis, electrolyte disturbance poisoning)

Pathophysiology of Shock and Related Treatments

Imbalance between O2 supply and demand

Cell injury and organ failure

Increased O2 consumption

•Stress response

•Pain

•Dyspnea

Mechanical ventilation

Analgesia & sedation

Paralysis

Hypothermia

Decreased tissue O2 delivery

preload / contractility / afterload

• Cardiac output = stroke volume x heart rate

• Anemia, Hypoxemia

• Decreased perfusion pressure (coronaries)

• Mechanical heart support (VAD, ECMO)

Fluid bolus Inotrope

O2

Hgb

Vasopressor

Anaerobic metabolism

Lactic acidosis

Pacemaker

Case #1: Sepsis

Few days later

Finally…

Crit Care Med 2007 Vol. 35, No. 11

Critical Importance of Timing

911 Emergency Room

ICUOperating room Recovery room

Hospital ward Rapid response team

Bad

Outcome

Good

Outcome

Morning Rounds

Window for Early Treatment & Prevention

Golden Hours: Chaos Theory of Critical Illness

Basic Clinical Examination ESICM PACT module 2005

Critical Importance of Timing

55 year old

Call from the ward

How do you assess acutely ill patient?

Somnolent

- Endotracheal intubation

Accessory muscle use

- Mechanical ventilation

Mottled skin; tachycardia

- IV access

- Fluid bolus

5 minutes later

• Expired CO2 confirmed ETT placement

• After intubation BP 60/30, SpO2 70%

• Decreased breath sounds right upper lung

Bedside Ultrasound

• Emergent bronchoscopy confirms good tube position

• No bleeding

Portable Chest X-ray

ECG

• Respiratory failure secondary to shock and pulmonary edema• - Cardiogenic?

• - Non-cardiogenic? (Acute lung injury)

• Acute coronary syndrome (non-ST elevation)• - Stress related?

• - Heart attack?

• - PE?

• Acidosis• - Mixed metabolic (lactic) and respiratory

• Shock• - Cardiogenic? – heart attack

• - Obstructive? – tamponade/pulmonary embolus

• - Distributive? – sepsis, adrenal insufficiency

• - Hypovolemic? – bleeding

Syndromes in our patient

- Empiric antibiotics (sepsis)

- Vasopressor (norepi, epi, vaso…)

(coronary perfusion)

- Low tidal volume ventilation(prevent VILI/improve hemodynamics)

- Sedation + paralysis (O2 consumption, ventilator synchrony)

- Low (stress) dose hydrocortisone(adrenal mets/bleed; sepsis/ALI)

- Heparin(PE/sepsis/ACS)

Back to our Patient: Persistent Hypoxemia

• Still in shock versus worsening shunt (or both)?• If still in shock, what type?

- cardiogenic/obstructive vs distributive

Stroke Volume

Preload: Frank-Starling Curve

Bedside Ultrasound

Microbiology

• In the morning extubated to noninvasive ventilation

• Discharged from the ICU the next day

• Discharged home from the hospital after 5 days

84 year old man with severe hypoxemia

• Transferred from outside hospital with progressive shortness of breath, dry cough, low grade fever and hypoxemia for 6 days

• Ceftriaxone + Furosemide for 4 days without much improvement

PMH

• PMH• Hypertension

• Dyslipidemia

• CAD/ischemic cardiomyopathy-CABG 1999

• Paroxysmal A-Fib

• Chronic renal Failure

• Hypothyroidism

• DM

• GI bleeding - 2004

• Cataract - left eye 2002

• TURP

• SH• Retired office worker

• Former smoker: 10 PY

• Traveled to Colorado one month ago

• Meds• ASA 81 mg PO once a day

• Coreg 6.25mg PO BID

• Furosemide 80mg IV TID

• Levalbuterol neb. q6hrs

• Levothyroxine 75mcg once a day

• Omeprazole 20mg PO one a day

• Valsartan 80mg PO once a day

• Amiodarone 200 mg once a day

• Coumadin 0.5mg PO once a day

CXR

Outside CT

One Hour After ICU Admission

• Labored respirations 29/min

• O2 Sat 84% on NRB

• ABG 46/31/7.40 FIO2 1.0

1) Intubate

2) Start noninvasive ventilation

3) Give informed consent and assess and

document patient preference

Informed Consent

• Physician: Explained severe nature of the condition with certain death without life support

• Trial of invasive ventilation may be reasonable due to unclear etiology

• Advanced age, chronic cardiac and renal dysfunction and severe gas exchange abnormality suggest high likelihood of failure

• Patient: Clearly agreed for a trial of aggressive support including invasive ventilation and tracheostomy for up to one month

• If he can get back to the previous quality of life

What next?

• 1) Start noninvasive ventilation

• 2) Intubate

Delclaux C et al.. JAMA 2000; 284: 2352-60,

• Shock, metabolic acidosis and severe hypoxemia predict failure of NIV

• Delay in intubation associated with adverse outcome

• Low tidal volume ventilation facilitated with early neuromuscular blockade

• BAL followed by expanded antibiotic coverage (anti-pseudomonas, legionella)

• Steroids for suspected Amiodarone induced ARDS

• Furosemide for negative fluid balance

• Reverse Trendelenburg to prevent aspiration and improve VQ

Three days later

• P/F 148

• Wake up and breathe: sedation holiday and spontaneous breathing trial

• Follows commands, strong cough

• After 30 minutes trial of CPAP 5/PSV5• HR 65, RR 22, spontaneous Vt 450 mL

• Extubated to NIV

• Two days later left the ICU

• Five days later went home

PEEP

• Recruitment• Improved oxygenation

• Improved compliance

• Overdistension• Stretch injury

• Increased dead space

Hubmayr RD. Am J Respir Crit Care Med. 2002 Jun 15;16

Rouby JJ, Lherm T, Martin de Lassale E, et al. Histologic aspects of pulmonary barotrauma in critically ill patients with

acute respiratory failure. Intensive Care Med 1993;19:383–9

Stress distribution in the lung

Hysteresis: rationale for recruitment (“sigh” )

InflationDeflation

Whalen FX, Gajic O, Thompson GB, Kendrick ML, Que FL, Williams BA, Joyner MJ, Hubmayr RD, Warner DO, Sprung J. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. AnesthAnalg. 2006 Jan;102(1):298-305

The effect of recruitment maneuver

Brower RG, Morris A, MacIntyre N, et al.. Crit Care Med 2003;31:2592-2597.

PEEP selected during deflation to prevent both overdistension and derecruitment

(according to compliance, stress index, esophageal balloon?)

Respir Care 2004;49(7):742–760.

Barriers to Implementation of Lung Protective Mechanical Ventilation

Walkey et al. J Crit Care Volume 27, Issue 3, June 2012

Approach to Refractory Hypoxemia

• Step 1 baseline: ABC + Neuromuscular blockade + Increase FIO2 to 100%

• Basic assessment and stabilization (airway assessment, ventilator

circuit, breath sounds, pulse; minimize oxygen consumption)

• Step 2 assessment: CXR+ECHO+VBG+RM

• Shock (low SvO2) vs shunt vs both?

• RV dysfunction/pulmonary hypertension/PE?

• Lobar atelectasis?

• LV dysfunction/intracardiac shunt

• Recruitability: Response to RM/decremental PEEP trial

• Step 3 customized management:

• Bronchoscopy for lobar atelectasis

• Inhaled vasodilators (iNO) for pulmonary hypertension

• Shock treatment based on type of shock

• Prone position or HFO for recruitable lungs without shock

• Consideration of PFO closure for intracardiac shunt

• ECMO for refractory cardiopulmonary dysfunction

Resuscitation Aphorisms

• Trust no one, assume nothing

• “Golden hour”

• When in doubt, treat as sepsis.

• Get as many lines and tubes in as fast as possible.

• Anyone with a heart rate consistently over 130 is being grossly mismanaged.

• If they have ischemic heart disease, the number is 110

• Laboratory tests are rarely useful• Most negative tests are false negatives

• Most positive tests are false positives

Day to day management in the ICU

• Get as many lines and tubes out as fast as possible.

• Listen to the nurses religiously: they are the citizens; you are the visitor

• Sit the patient up, dammit!

• Even if God herself says that small tidal volumes are good, everyone will still be ventilated at 10ml/kg. The knobs adjust themselves!

• Any ritually administered drug (be it dopamine, digoxin or whatever) will cause more harm than good. In fact, avoid all drugs that begin with the letter "D“

• Above all else, keep your patient out of the hands of someone who doesn't obey these rules

“And actually it does not matter what is the source of the patient’s

gasping. You simply have to bring his breathing back in order”

Bjorn Ibsen

Don’t Forget

• Hand holding

• Talking to the patient

• Family

• Your colleagues

• Yourself

©2010 MFMER | slide-60

Golden Hours!

Safar P. Critical care medicine – Quo Vadis? Crit Care Med 1974; 2:1–5.

Hillman K, Cur Opinion Crit Care 2010

• “The most sophisticated intensive care becomes unnecessarily expensive terminal care…”

Peter Safar

The father of critical care (ABCs) whose lifelong goal was to "save the hearts and brains of those too young to die."

50 year old with worsening shortness of breath

• Chief Complaint:• 50 year old with two days history

of cough, hemoptysis, worsening shortness of breath and markedly elevated heart rate

• Past History:• Hepatitis C

• Previous substance abuse on Methadone

• Seizure disorder

• Paroxysmal A fib, s/p ablation, on chronic Coumadin

Anxious, Increased work of breathing with accessory

muscles,

Bronchial breath sounds over R lung

Weak, irregular radial pulse, warm skin, brisk capillary refill

Ultrasound: hyperdynamic LV/RV, collapsing IVC; B lines

RUL, no effusion

Temperature : 38.4 C

Lung Injury Prediction Score (LIPS)

Shock (2) + Pneumonia (1.5) +

Sepsis (1) +Tachypnea (1.5) +

Acidosis (1.5) = 7.5

CLIP Element Clinically Supported Practices

Adequate empiric antimicrobial treatment and source control

According to suspected site of infection, health care exposure, and immune suppression

Lung protective mechanical ventilation Tidal volume <6-8 mL/kg predicted body weight and plateau pressure <25 cm H2O; PEEP≥5 cm H2O, minimize FIO2 (target O2sat 88-92% after early shock)

Aspiration precautions Rapid sequence intubation supervised by experienced providers, elevated head of the bed, oral care with chlorhexidine, gastric acid neutralization

Fluid management:

- Early fluid administration in septic shock

-Limiting fluid overload after resuscitation

- Resuscitation according to institutional protocol and IHI sepsis bundle

- Modified ARDSnet FACCT protocol after early shock

Restrictive transfusion Hemoglobin target >7 g/dL in the absence of active bleeding and/or ischemia; avoid FFP and platelet transfusion in the absence of active bleeding

Appropriate handoff of patients at risk Structured handoff such as SBAR

Checklist for Lung Injury Prevention: CLIP

Rapid sequence intubation

Lung protective ventilation

Goal directed fluid resuscitation

Blood and sputum culture

Cefepime 2 gr IV

Levofloxacine 750 mg IV

Hydrocortisone 50 mg IV

Furosemide

Spontaneous awakening and breathing trial

Short monitoring after extubation

De-escalation to oral antibiotics, steroid taper and transfer

50 year old with shortness of breath and tachycardia

• Chief Complaint:• 50 year old with two days history

of cough, hemoptysis, worsening shortness of breath and markedly elevated heart rate

• Past History:• Hepatitis C

• Previous substance abuse on Methadone

• Seizure disorder

• Paroxysmal A fib, s/p ablation, on chronic Coumadin

Anxious, Increased work of breathing with accessory

muscles,

Bronchial breath sounds over R lung

Weak, irregular radial pulse, warm skin, brisk capillary refill

Ultrasound: hyperdynamic LV/RV, collapsing IVC; B lines

RUL, no effusion

Temperature : 38.4 C

Lung Injury Prediction Score (LIPS)

Shock (2) + Pneumonia (1.5) +

Sepsis (1) +Tachypnea (1.5) +

Acidosis (1.5) = 7.5

CLIP Element Clinically Supported Practices

Adequate empiric antimicrobial treatment and source control

According to suspected site of infection, health care exposure, and immune suppression

Lung protective mechanical ventilation Tidal volume <6-8 mL/kg predicted body weight and plateau pressure <25 cm H2O; PEEP≥5 cm H2O, minimize FIO2 (target O2sat 88-92% after early shock)

Aspiration precautions Rapid sequence intubation supervised by experienced providers, elevated head of the bed, oral care with chlorhexidine, gastric acid neutralization

Fluid management:

- Early fluid administration in septic shock

-Limiting fluid overload after resuscitation

- Resuscitation according to institutional protocol and IHI sepsis bundle

- Modified ARDSnet FACCT protocol after early shock

Restrictive transfusion Hemoglobin target >7 g/dL in the absence of active bleeding and/or ischemia; avoid FFP and platelet transfusion in the absence of active bleeding

Appropriate handoff of patients at risk Structured handoff such as SBAR

Checklist for Lung Injury Prevention: CLIP

Rapid sequence intubation

Lung protective ventilation

Goal directed fluid resuscitation

Blood and sputum culture

Cefepime 2 gr IV

Levofloxacine 750 mg IV

Hydrocortisone 50 mg IV

Furosemide

Spontaneous awakening and breathing trial

Short monitoring after extubation

De-escalation to oral antibiotics, steroid taper and transfer

gajic.ognjen@mayo.edu

Multidisciplinary Epidemiology and Translational

Research in Intensive Care