6/9/2020 CO COPD/Chr hroni onic Re Respirat atory Fa Failure - - PDF document

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CO COPD/Chr hroni

• nic Re

Respirat atory Fa Failure Ov Overlap/W erlap/Wrap ap‐ar around nd Sy Syndrome me

Ron Hosp, MS, RRT Vice President, National Accounts Breathe, LLC

Sessio Session Obj Objectiv ctives es

• Following this presentation the participant will be able to:
• Label the anatomy and pathophysiology of respiration and ventilation
• Describe the definition of COPD including classification
• Explain COPD as a wrap‐around disease
• Distinguish the best PAP modes and features to treat the condition

Qu Quick Re Review

• Conducting zone =
• ventilation (air movement in and out)
• filters
• warms
• humidifies
• Conducting zone = dead space

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Qu Quick Re Review

• Respiratory zone =
• comprised of small airways
• exchange of gases between

alveoli and blood

PUL PULMONAR ARY ME MECHANICS ANICS

Inhalation = ACTIVE 1.) Diaphragm contracts (moves downward) 2.) Thoracic Volume Increases 3.) Pleural Pressure Decreases 4.) Air Moves In Pressure gradient is what drives air into the lungs.

PUL PULMONAR ARY ME MECHANICS ANICS

Exhalation = PASSIVE 1.) Diaphragm relaxes (moves upward) 2.) Thoracic Volume Decreases 3.) Pleural Pressures Increase 4.) Air Moves Out Pressure gradient is what drives air our of the lungs.

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ASSE ASSESSMEN ENT OF OF VENTILA VENTILATIO ION

Qualitative

• Respiratory pattern
• Accessory muscle use
• Prolonged expiration
• Shortness of Breath
• Cyanosis
• Minute ventilation

SPIR SPIROMETR ETRY

By measuring the volumes of air in the lung (lung capacities) and the flow of air out of the lungs we can answer the following questions:

• Is lung disease present?
• What type of lung disease?
• Single or multiple diseases present?
• Is the disease reversible and to what

degree?

ASSE ASSESSMEN ENT OF OF VENTILA VENTILATIO ION

Quantitative

• Arterial blood gases (ABG)
• Pulse oximetry
• Capnography
• Spirometry

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ASSE ASSESS SSMENT OF OF VENT VENTIL ILATION With ith ABG’ ABG’s

• pH ‐ indicates acidity or alkalinity of blood. (7.35‐7.45 )
• PaCO2 ‐ partial pressure of carbon dioxide in the arterial blood.

(35‐ 45 mmHg)

• PaO2 ‐ partial pressure of oxygen in the arterial blood. (80‐ 100

mmHg)

• HCO3 – Level of bicarbonate in the blood. Buffers pH.

(22 – 26 mEq/L)

• Compensatory mechanism

CO2 LEVELS IN OUR BLOOD STIMULATE OUR DRIVE TO BREATH

Re Respiratory Acid Acidosis is

• The normal reference range for PaCO2 is 35‐45 mm Hg
• Acute respiratory acidosis ‐ PaCO2 (ie, >45 mm Hg)

accompanying acidemia (ie, pH < 7.35)

• Chronic respiratory acidosis ‐ PaCO2 is elevated with normal
• r near‐normal pH secondary to renal compensation and an

elevated serum bicarbonate levels (ie, >30 mEq/L)

Chr Chronic Re Respiratory Acid Acidosis is

• May be secondary to many disorders, e.g., COPD
• Hypoventilation in COPD involves multiple mechanisms,

including the following:

• Decreased responsiveness to hypoxia and hypercapnia
• Increased ventilation‐perfusion mismatch leading to

increased dead space ventilation

• Decreased diaphragmatic function due to fatigue and

hyperinflation

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Chr Chronic Re Respiratory Acid Acidosis is

• Chronic respiratory acidosis also may be secondary to
• Obesisty Hypoventialtion (OHS—ie, Pickwickian

syndrome),

• Neuromuscular disorders
• Severe restrictive ventilatory defects
• Interstitial Fibrosis
• Thoracic Restrictive Disease

GOLD GOLD CO COPD De Definition finition

“A disease state characterized by airflow limitation that is not fully

• reversible. The airflow limitation is usually both progressive and

associated with an abnormal inflammatory response of the lungs to noxious particles or gases.”

Wh What is is CO COPD?

• Blanket term covering 3 illnesses‐

‐ Chronic Bronchitis ‐ Asthmatic Bronchitis ‐ Emphysema

• Chronic‐ Long‐term
• Obstructive‐ Trouble getting air
• ut of chest
• Pulmonary‐ Relating to the lung
• Disease‐ An abnormal condition

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Ins Insidious Dev Develo lopmen ent Ins Insidious Dev Develo lopmen ent

“The typical symptoms and signs of COPD occur late in its evolution…. Patients who are symptomatic or who have chest x‐ray abnormalities have moderately severe or advanced disease.”

Frontline Treatment of COPD

Caus Causes es of

• f CO

COPD

• Smoking
• Occupational
• Environmental
• Genetic Factors
• Predisposition
• Alpha1 Antitrypsin

Defficiency

Pi Pink nk Pu Puff ffer

• Pink
• Thin
• Hyperventilation
• Pursed Lips
• Dyspneic
• Hypocapnic

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Cl Classic assic “Blu “Blue Bl Bloater”

• Cyanosis
• Overweight
• Hypoventilation
• Hypercapnic
• Less dyspnea
• Edematous
• Productive Cough

Sign Signs and and Sy Sympto toms ms of

• f Nocturnal

Nocturnal Desa satu turations tions Sign Signs and and Sy Sympto toms ms of

• f Nocturnal

Nocturnal Desa satu turations tions

• Restless Sleep
• Paroxysmal Nocturnal Dyspnea

(PND)

• Orthopnea
• Excessive Daytime Sleepiness

(EDS)

• Severe Snoring
• Observed Apneas
• Morning Headaches
• Dyspnea on Exertion
• Resting SpO2 < 93%
• Sleep in recliner or w/ 2 or

more pillows

• CHF/Dependent Edema

CO COPD Prev evalence ence in in the the US US Ac According ing the the CDC CDC

• 24 million people who currently suffer from COPD
• 6.3% of the US population
• Top 5 States are
• 1. Kentucky 9.3%
• 2. Alabama 9.1%
• 3. Tennessee 8.7%
• 4. West Virginia 8%
• 5. Oklahoma 8%

Williams, S., The Motley Crew, September 14, 2014, also published by RT for Decision Makers, September 12, 2014

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Es Estim timated CO COPD Prev evalence ence in in Okl Oklahom homa

State Population Kentucky 4.4 million Alabama 4.8 million Tennessee 6.5 million West Virginia 1.8 million Oklahoma 3.8 million

• This data indicates that there may be approximately

304,000 individuals afflicted with Stage 1-4 COPD in Oklahoma.

Ov Overlap erlap Sy Syndrome me

• "Overlap syndrome", the combination of COPD and obstructive sleep

apnoea/hypopnoea syndrome (OSAH), is said to predispose to daytime hypercapnia and hypoxaemia independently of lung function [10].

• Chaouat A, et. al., Association of chronic obstructive pulmonary

disease and sleep apnea syndrome. Am J Respir Crit Care Med 1995; 151: 82–86.

Pre Prevalence es estim timates of

• f maj

major como morb rbid idit itie ies in in COPD OPD

Comorbidity Prevalence Associations with

• utcomes

Allergic disease 18–42%186–188 Cough, phlegm, wheezing Health care utilization Anemia 7–43.9%68–70 Mortality Hospitalization, length of stay, readmission risk Dyspnea Cardiovascular 29–70% (general CVD) 4.7–60% (CHF) 7.1–31.3% (CHD)142,144,218 Mortality Quality of life, health status Dyspnea, exercise capacity Hospitalization Health care utilization and expenditures

Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s‐0035‐1556063

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Prev evalence ence es estim timates of

• f maj

major comorb rbid iditie ies in in CO COPD

Cognitive impairment 2–20%28 Quality of life, health status Length of hospital stay Depression 16.5–42%35–42 Mortality Dyspnea, exercise capacity Quality of life, health status Rehospitalization risk Exacerbation risk Inability to perform ADLs Diabetes 10.1–23%126,127,130 Mortality Hospitalization Exercise capacity

Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s‐0035‐1556063

Prev evalence ence es estim timates of

• f maj

major comorb rbid iditie ies in in CO COPD

Obesity 29.1–43%94–96 Quality of life, health status Dyspnea, exercise capacity Health care utilization Osteoporosis 21–66%66,174–176,178–180,182 Sleep apnea 22.3–51.4%83–86 Mortality Exacerbation risk Health care expenditures Cardiovascular outcomes

Nirupama, P., et al, Semin Respir Crit Care Med. 2015 Aug; 36(4): 575–591. Published online 2015 Aug 3. doi: 10.1055/s‐0035‐1556063

CO COPD and and Hea Heart Fa Failure

Gulmisal, G., et al, European Journal of Heart Failure (2014) 16, 1273‐1282., doi 10, 1002/ejhf. 183

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Fr Frequ equent co coexi existen tence ce of

• f chr

chronic nic heart heart failur ilure and and chr chronic nic ob

• bstructi

ructive pulm pulmonary ry disea disease

• The prevalence of CHF in the 378 surveyed COPD patients was 11.9%

(95% confidence interval 8.8–16.6)

• prevalence of COPD in 375 CHF patients was 31.5% (95% confidence

interval 26.8–36.4)

Griffo, Raffaele, Et. Al, Frequent coexistence of chronic heart failure and chronic obstructive pulmonary disease in respiratory and cardiac outpatients: Evidence from SUSPIRIUM, a multicentre Italian survey, European Journal of Preventive Cardiology, Vol 24, Issue 6, 2017

COPD Management Steps

Treatment standards for COPD suggest a step approach to the management of COPD as severity increases. Treatment As lung function worsens, there is a tendency but not a direct relationship for symptoms to worsen. Symptoms such as dyspnea and cough may be more or less severe than the levels listed above based on spirometry.

Stage At Risk Mild Moderate Severe Very Severe

Symptoms Morning cough or no symptoms Dyspnea on exertion, cough, or no symptoms Dyspnea on exertion, may experience some limitation in activity More dyspnea with less exertion, more limitation in activity Severe dyspnea on mild exertion or rest, severe limitation in activity Dyspnea Not troubled with breathlessness except with strenuous exercise. Troubled by shortness of breath when hurrying or walking up a slight hill. Walks slower than people

• f the same age due to

breathlessness or has to stop for breath when walking at own pace on the level. Stops for breath after walking ~100 m or after a few minutes on the level. Too breathless to leave the house or breathless when dressing or undressing. Exacerbation None or infrequent exacerbations generally managed as an outpatient. Generally increasing frequency and severity of exacerbations that may require hospitalization. Exacerbations may include episodes of respiratory failure. Spirometry Normal spirometry but risk factors for COPD (eg, smoker, family history of COPD, etc.) FEV1/FVC < 0.7 and FEV1 > 80% Predicted FEV1/FVC < 0.7 and FEV1 50 - 80% Predicted FEV1/FVC < 0.7 and FEV1 30 - 50% Predicted FEV1/FVC < 0.7 and FEV1 < 30% Predicted or FEV1 30 - 50% w/ Respiratory Failure or Right Heart Failure Eliminate Risk Factors (eg, Smoking) Spirometry Q 1-2 years Inhaled Short-Acting Bronchodilator (eg, albuterol) When Needed Regular Treatment with Long- and Short-Acting Bronchodilators (eg, formoterol, albuterol, ipratropium, tiotropium) Pulmonary Rehab w/ Plan for Early Response to Exacerbations Include inhaled Steroid (eg, budesonide) if Repeated Exacerbations

• r FEV1 Response

Oxygen for Desaturation during Sleep and/or Activity Continuous Oxygen for Resting Hypoxemia Noninvasive Positive Pressure Ventilation for Elevated CO2 ( > 52 mm Hg ) Evaluate for Lung- Reduction Surgery

Tr Treatment Optio Options

• Oxygen therapy followed by Long‐Term Home Oxygen Therapy (HOT)
• CPAP
• Bilevel
• Respiratory Assist Device (RAD)
• Bilevel with backup rate
• Bilevel with backup rate and volume assured pressure support
• Noninvasive Positive Pressure Ventilation (NIPPV)
• Noninvasive Ventilation (NIV) includes Negative Pressure Ventilation
• Advanced NIV with advanced algorithms

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Le Let’s ta take a look

• ok at som

some re recent nt lit literature

Doe Does av average vo volume‐assured assured pr press essure suppo support (A (AVAPS) mak make an any di difference com compar ared ed wi with Bi BiPAP?

Results:

Greater improvement in PH and CO2 Greater patient comfort Lower sedation needed

Conclusion: AVAPS had positive effects on pH, gas variation and patient comfort; therefore, it can be confidently used in clinical practice.

Canpolat G, Ozgultekin A, Turan G, Iskender A, Adiyeke E, Ekinci O. Does average volume‐assured pressure support make any difference compared with BIPAP? Critical Care. 2014;18(Suppl 1):P265. doi:10.1186/cc13455.

Po Positive ve out

• utcome of
• f av

averag age vo volum lume‐assu ssured pr pressure suppor pport mo mode de of

• f a

Respir pironic

• nics V60

V60 Ve Ventilator in in ac acut ute ex exacer erba bation tion of

• f chr

chronic obstruct ctiv ive pul pulmonary dis disease: a case case repor report

Conclusion:

In cases such as this, in which patients with severe acute respiratory failure requiring full‐time noninvasive positive pressure ventilation therapy also show sleep‐disordered breathing, different ventilator settings must be used for waking and sleeping. On such occasions, the Respironics V60 Ventilator, which is equipped with an average volume‐ assured pressure support mode, may be useful in improving gas exchange and may achieve good patient compliance, because that mode allows ventilation to be maintained by automatically adjusting the inspiratory force to within an acceptable range whenever ventilation falls below target levels.

Okuda M, Kashio M, Tanaka N, Fujii T, Okuda Y. Positive outcome of average volume‐assured pressure support mode of a Respironics V60 Ventilator in acute exacerbation of chronic obstructive pulmonary disease: a case report. Journal of Medical Case Reports. 2012;6:284. doi:10.1186/1752‐1947‐6‐284.

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Re Retros

• spect

pective Asse ssess ssment of

• f Ho

Home Ventilat latio ion to to Re Reduce duce Rehosp spitaliz lizatio ion in in Ch Chronic Obs Obstructiv ive Pu Pulmonar

• nary Di

Disease

• Coughlin S., Liang WE, Parthasarathy S. Retrospective Assessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive

Pulmonary Disease. J Clin Sleep Med. 2015 Jun 15;11(6):663‐70.

PP PPaP

• Hospital Savings
• For a hospital covering 250 severe COPD patients, reduction of

readmissions led to cumulative savings of with a multifaceted therapy approach using Philips Trilogy in‐home advanced NIV therapy versus no NIV treatment or less advanced NIV therapy devices.

• After examining 1,000 COPD patients being treated with this

same combined treatment method using Trilogy, hospitals saved $1.6 million in the first 30 days and $1.8 million in 90 days compared to no NIV treatment or less advanced NIV therapy devices.

• Results are based on a single‐center initiative and may vary by
• institution. See “Cost Savings from Reduced Hospitalizations”

study limitations section.

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• Payer Savings
• Payers studying admissions of 100,000 severe COPD

patients had cumulative 3‐year savings of $326 million when using home NIV in comparison to no NIV treatment.

• Additionally, payers saved $1.04 billion cumulatively

when using home NIV treatment compared to using a less advanced NIV therapy device over a three year period.

Ques Questi tions???

• ns???

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