© Borgis - New Medicine 3/2003, s. 79-80
Zygmunt Chodorowski, Jacek Sein Anand, Marek Wisniewski
Noninvasive positive pressure ventilation in the process of respiratory discontinuation in an elderly patient with chronic obstructive pulmonary disease: a case report
1st Department of Internal Medicine and Toxicology, The Medical University of Gdansk, Poland
Head: prof. Zygmunt Chodorowski MD, PhD
Summary
The authors report the case of a 66-year old patient with exacerbated chronic obstructive pulmonary disease in whom noninvasive positive pressure ventilation (NPPV) was used for weaning him from mechanical ventilation. In view of respiratory acidosis, hypercapnia, hypoxaemia, laboured breathing, and progressively impaired consciousness, invasive ventilation was performed. On stabilized condition and repeated discontinuation of mechanical ventilation with the SIMV and PSV modes, and following a two-hour positive spontaneous breathing trial (SBT), extubation was carried out on the 6th treatment day. Due to progressively impaired respiratory function, there was a need for reintubation and continuation of invasive ventilation. Since the previous attempt failed, the second extubation was followed by noninvasive positive pressure ventilation using the BiPAP Harmony device (parameters: IPAP 20 cm H20, EPAP 5 cm H20, respiratory rate 10/min, inspiratory phase 1.5 sec, increasing inspiratory time 600 msec). The patient required a continous NPPV for 72 hours, after which he was smoothly weaned from the device, and transferred to a medical ward. Conclusion: noninvasive positive pressure ventilation seems to be a safe procedure facilitating discontinuation of invasive ventilation in elderly patients with exacerbations of chronic obstructive pulmonary disease. It is particularly important in patients, in whom apparently successful conventional weaning is followed by a markedly impaired respiratory function after extubation.
Introduction
Chronic obstructive pulmonary disease (COPD) is the fourth main cause of death worldwide, and it is also the most frequent respiratory disease resulting in chronic respiratory insufficiency (10). Patients with COPD exacerbations are frequently treated at hospital, and most severely ill patients with a life-threatening hypercapnic respiratory failure require a decision to be made to institute invasive ventilatory support. The decision is not easy, also due to the fact that the patients are elderly and have severe, and frequently irreversible changes in the respiratory tract (2, 8, 10). Noninvasive positive pressure ventilation (NPPV), which involves the administration of a mixture of oxygen and air at a volume related to programmed pressures without intubation, decreases the frequency of complications due to the intubation, reduces the patient´s hospital stay and diminishes the mortality rate (1, 2, 6, 8, 10, 11, 12).
The objective of the present study was to assess the efficacy of NPPV in weaning the elderly patient treated for COPD exacerbations from the invasive ventilation support system.
Case report
A 66-year old patient with severe chronic obstructive pulmonary disease was admitted to the 1st Department of Internal Medicine, the Medical University, Gdańsk. He was acutely distressed, markedly dyspnoeic and poorly cooperative. The main physical findings included hypotension of 100/60 mmHg, tachycardia 160/min, decreased breath sounds, single wheezes and cyanosis. Arterial blood gases showed pH 7.23, p CO2 71 mmHg, PO2 43 mmHg, SO2 68%. Chest x-ray revealed inflammatory lesions in the right lower lobe. The patient was intubated, and ventilation was started using Puritan Bennett 740 device with a CMV mode (TV 680 ml; FiO2 O.55; f 10/min; PEEP). A repeat chest x-ray done at 5 days of hospital stay showed significantly regressive inflammatory lesions. Arterial blood gases had improved (pH 7.44; pCO2 52 mmHg; pO2 56 mmHg; SO2 90%). After multiple repeated and well-tolerated trials, weaning from the mechanical ventilation support, using breathing techniques with the SIMV and PSV modes, and subsequent two-hour daily trials of spontaneous breathing, the patient was extubated at 6 days. However, due to progressively exacerbating respiratory function, it was mandatory to reintubate the patient; the invasive ventilation was continued for another 24 hours. In view of the previous failure, the decision was made to introduce noninvasive positive pressure ventilation using the BiPAP Harmony device with the following parameters: inspiratory pressure (IPAP) 20 cm H2O, expiratory pressure (EPAP) 5 cm H2O, respiratory rate 10 breaths/min, inspiratory phase 1.5 sec, increasing inspiratory time 600 msec. For the next 72 hours, the patient required a continuous NPPV. The weaning from the device was successfully carried out from day 4 to day 7 of the treatment.
During the NPPV treatment the patient responded well to nasal-and-orofacial mask oxygen therapy. Respiratory shunt, mainly due to an inadequately fitting standard-size mask, was compensated by the Auto-Trak Sensitivity system installed in the device.
Discussion
Weaning a COPD patient from invasive ventilation may produce difficulty, and may even be hazardous. So far, no uniform measures have been established, and various methods are still being discussed (3, 7, 10). The most popular procedures are those involving repetitive trials to resume own respiration by the patient, pressure-support ventilation (PSV), and synchronised intermittent mandatory ventilation (SIMV) (3,7,10). In the present case, both the SIMV, PSV modes and multiple trials of spontaneous breathing were performed with a transient beneficial effect. Comparing various strategies of weaning from PSV, Esteban et al. report a high, approximately 82% efficacy of the spontaneous breathing. However, they agree that among patients with good initial tolerance of spontaneous breathing, approximately 15% of sufferers required reintubation and reintroduction of invasive ventilation (3). Noninvasive positive pressure ventilation is a generally accepted method of respiratory support in patients with exacerbations of COPD (1, 2, 6, 8, 10, 11, 12). However, instituting NPPV during weaning from invasive ventilation seems to be a reasonable alternative to conventional management. NPPV helps perform an earlier extubation; at the same time, it decreases the frequency of numerous complications due to invasive ventilation, and reduces the treatment costs (4, 7, 8). In their studies, Nava et al. showed that NPPV allowed shortening the patient´s length of stay at the intensive care unit, increased a 60-day survival rate, and decreased the rate of pneumonias (9). Hilbert et al. described effective noninvasive ventilation in patients with an impaired postextubation respiratory function. They also indicated an over threefold decrease in the need for reintubation in patients after NPPV as compared with that in a control group (20% NPPV vs 67% controls) (5). In the present case, there were significant difficulties in weaning the patient from invasive ventilation, and only due to the noninvasive positive pressure ventilation performed for 7 days, the outcome of the respiration therapy was successful.
Conclusions
1.The positive effect of spontaneous breathing trial in the elderly patient with exacerbation of chronic obstructive pulmonary disease proved to be a failure in maintaining spontaneous respiration after discontinued invasive ventilation.
2.In this patient, noninvasive positive pressure ventilation proved to be an effective treatment in weaning him from invasive ventilation.
Piśmiennictwo
1. Baldwin D.R., Allen M.B.: Non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. Brit. Med. J. 1997; 314:163-4. 2. Brochard L.: Non-invasive ventilation for acute exacerbations of COPD: a new standard of care. Thorax 2000; 55:817-8. 3. Esteban A. et al.: Spanish Lung Failure Collaborative Group. A comparison of four methods of weaning patients from mechanical ventilation. N. Engl. J. Med. 1995; 332:345-50. 4. Girault C. et al.: Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratosy failure: a prospective, randomized controlled study. Am. J. Respir. Crit. Care Med. 1999; 160;86-92. 5. Hilbert G. et al.: Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur. Respir. J. 1998; 11:1349-53. 6. Lightowler J.V. et al.: Non-invasive positive pressure ventiation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. Brit. Med. J. 2003; 326:185. 7. Maclntyre N.R. et al.: Americal College of Chest Physicians; Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120:375S-95S. 8. Mehta S., Hill N.S.: Noninvasive ventilation. Am. J. Respir. Crit Care Med. 2001; 163:540-77. 9. Nava S. et al.: Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann. Intern. Med. 1998; 128:721-8. 10. Pauwels R.A. et al.: GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): executive summary. Respir. Care. 2001; 46:798-825. 11. Plant P.K., Elliott M.W.: Non-invasive ventilation in acute exacerbations of COPD. QJM 1998; 91:657-60. 12. Vanpee D. et al.: Non-invasive positive pressure ventilation for exacerbation of chronic obstructive pulmonary patients in the emergency department. Eur. J. Emerg. Med. 2001; 8:21-5.
