Type 2 Resp Failure

Type 2 Resp Failure

75 year old male, 2 day history of productive cough and fever. Increasing DIB and confusion.
— PMH: COPD, with poor ET, mobilises 15 yards

Observations

A – Patent

B – RR 30 Sats 97% (15L)

C – HR 120 Bp 90/70

D – GCS 14 (E4 V4 M6)

E – Temp 38°C

Clinical Findings

  • Bilat wheeze

  • Increased work of breathing


Why We Simulated

Whilst the differential for a patient who is short of breath is quite wide, many patients with a history of COPD will present in a recognisable way. It is therefore important we are familiar with the actions that are needed for this patient population and how to manage type 2 respiratory failure.

The  NICE guidelines from 2010 are briefly summarised below:

Investigations:

All patients with an exacerbation of COPD should have:

  • CXR

  • ABG and the inspired oxygen concentration should be recorded

  • ECG (to exclude comorbidities)

  • FBC & urea and electrolyte concentrations

  • Theophylline levels in patients on theophylline therapy at admission

  • If sputum is purulent, a sample should be sent for microscopy and culture

  • Blood cultures should be taken if the patient is pyrexial

Drug Therapy:

  • Short acting bronchodilators: If hypercapnic or acidotic a nebuliser should be driven by compressed air, with supplemental oxygen given by nasal cannula.
  • Steroids: In the absence of significant contraindications oral corticosteroids should be used
  • Antibiotics: should be used to treat exacerbations of COPD associated with a history of more purulent sputum.
    • Without more purulent sputum antibiotic therapy is not needed unless there is consolidation on CXR or clinical signs of pneumonia
  • Intravenous theophylline: should only be used as an adjunct to the management of exacerbations of COPD if there is an inadequate response to nebulised bronchodilators.

Non-Invasive Ventilation:

  • NIV should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy
  • For patients started on NIV there should be a clear plan covering what to do in the event of deterioration & ceilings of therapy should be agreed.

References/Further Reading:

Learning Points

  1. Consider the contraindications for BiPAP/NIV – but bear in mind when this is the ceiling of treatment they may be considered as relative contraindications.

  2. BiPAP can be uncomfortable so ensure you have warned the patient and consider holding the mask to their face to begin with rather than strapping it on.

  3. Remember to maximise treatments as well as BiPAP, such as nebs and steroids if indicated.

Positive Feedback

  • Brought Team Together for discussion of findings on blood Gas.

  • Sought Senior Support appropriately.

  • Good use of the type 2 resp failure management tool.

A big thank you to the team for bearing with us despite #SimMan's tech failure and persistant apnoea...
#RCEM16Beach Posters

#RCEM16Beach Posters

Drug Anaphylaxis

Drug Anaphylaxis