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Care of the critically Ill COPD patient in the ICU


Parvaiz A Koul
MD, FACP, FCCP, FRCP (London)

 

1. When does the COPD patient need admission to the ICU?      
Whenever an exacerbation of the patient is severe, the physician may decide to admit the patient to the Intensive care unit for a closer supervision of his management. Usually there is an evidence of respiratory failure for admission to the intensive care unit which is manifested by severe breathlessness, irritability, clouding of consciousness which may lead to a totally unconscious state. Other features that might accompany a severe exacerbation include a high heart rate, use of accessory muscles of respiration, jerky movements of the body and a low blood pressure. Patients over 65 years of age and those with co-morbid illnesses like heart disease, etc are more prone to a severe exacerbation requiring hospitalization.

2. How is the COPD patient managed in the ICU?                
The condition of the patient requires oxygen therapy which is administered to the patients thorough nasal cannulae or various kinds of masks. The rate and the mode of delivery is assessed by the physician periodically and modified as per the requirements of the patient.
Not infrequently the patient requires some sort of assistance for his respiration which is carried out by mechanical means and is termed as mechanical ventilation.

3. What are the various modes of mechanical ventilation and what is non-invasive ventilation?          
Mechanical ventilation is broadly classified as ‘Invasive’ and ‘non-invasive’ depending upon the requirement of the placement of an endotracheal tube (tube in the trachea—main breathing pipe). If there is no tube placed inside the trachea for ventilation, it is termed non-invasive ventilation. This has become one of the most frequently used modalities for management for patients with acute exacerbation of COPD. Air supplemented with oxygen is delivered at high pressures to the airway through an interface and this helps the patient’s breathing to be assisted and reversing of the respiratory failure. Higher pressures are utilized during inspiration and lower pressures during expiration in order to mimic the patterns of normal respiration. Non-invasive ventilation has been able to obviate the use of invasive ventilation in most circumstances.

4. When is Invasive ventilation needed?         
If the patient’s condition worsens on non-invasive ventilation and if any contraindications exist to its use (like an obtunded patient), an endotracheal tube is placed and ventilation is a carried out invasively using an artificial invasive ventilator. In this mode of ventilation, the patients are sedated or paralyzed to assist the process of ventilation. Invasive ventilation is always aimed to be a temporary phenomenon. What are other measures of management in the ICU? 
Apart from the support to ventilation, patients receive antibiotics, bronchodilators, steroids, etc as dictated by the patient’s condition. A number of invasive and non-invasive monitoring devices may be placed to monitor various parameters like the heart rate and rhythm, blood pressure, oxygen status, etc. These are normal in an ICU patient and help the physician assess the patient’s condition periodically.

5. When in the patient taken off the ventilator?                          
The ventilation of every patient is reviewed periodically and at the first instance of a safe weaning, the patients are taken off the ventilator. Routine management of the patient may continue in the ward for some days before the patient is finally sent home with an advice to adhere to medication, stay away from risk factors like smoking, etc and take annual vaccination.

        Author: Parvaiz A Koul, 
MD, FACP, FCCP, FRCP (London)
Professor & Head
Department of Internal & Pulmonary Medicine,
Chief, Clinical Research/Geriatrics
SheriKashmir Institute of Medical Sciences,
Soura, Srinagar 190011, J & K (India)
Phone no: +91-9419004822
Web: www.skims.ac.in
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