Question

A 55-year-old man is hospitalized in the ICU with acute onset of respiratory distress. He has a long history of chronic obstructive pulmonary disease (COPD) with frequent exacerbations leading to multiple hospitalizations. He has never been intubated before for any of these exacerbations. On physical examination, he is afebrile, blood pressure is 170/100 mm Hg, and heart rate is 123 beats/min. There is jugular venous distention. Although the patient is in apparent respiratory distress, he is still able to answer questions and follow directions. Decreased breath sounds are heard in both lungs. There is 1+ lower extremity edema. A chest radiograph shows hyperinflation without infiltrates or pneumothorax. The remainder of the physical examination is normal. Laboratory results are below:

Arterial Blood Gas Studies	Result   h(Normal Reference Range)
pH	7.48 (7.35-7.45)
Paco2	30 mm Hg (36-45 mm Hg)
PaO2	60 mm Hg (>80 mm Hg)
FiO2	100% with PEEP 5
PaO2/Fio2 ratio	60 (>350)
HCO3	26 mEq/L (22-26 mEq/L)
Hemoglobin	18.0 g/dL (13.8-17.2 g/dL)

1. What is the next best step in managing this patient’s respiratory status?
2. What other treatment options should be considered concurrently?
3. What are the primary goals of NIPPV?
4. What are the main complications and interventions for NIPPV?

Answer 1

(1) The next best step in managing the patient's respiratory status is, Nasal Intermittent Positive Pressure Ventilation (NiPPV) via nasal or facial mask or helmet. It is indicated in such acute respiratory distress with exacerbation of COPD.

(2) Other treatment options includes

• Bronchodilators like selective beta 2 adrenergic agonists,
• Anticholinergics
• Theophilline
• Combination of these drugs
• Continuos positive airway pressure
• Invasive mechanical ventilation
• Treatment for other symptoms

(3) The chief goals of NiPPV are:

• Improve oxygenation
• Improve oxygen saturation in blood
• Relax or unload respiratory muscles
• Releive breathlessness or dyspnea
• Adequate patient tolerance and comfort
• Minimize the damage to lungs.

(4) complications of NIPPV are:

• Pneumothorax
• Subcutaneous emphysema
• Pneumoperitoneum
• Pulmonary barotrauma
• Dry mouth
• Facial injury
• Retained secretion

Indications(interventions) of NIPPV:

• COPD
• Post-extubation
• Asthma
• Bronchiectasis
• ARDS
• Pneumonia
• Pulmonary edema
• ILD-1