a 66 yr old - kiranraja

[ArchivalUser]

A 66 year-old man with a long history of COPD comes to the emergency department with severe dyspnea. Over the past few days he has had increasing amounts of purulent sputum production, as well as a worsening cough. After being evaluated in the emergency room, he is admitted to the medicine service with the diagnosis of acute exacerbation of chronic bronchitis. The patient receives intravenous steroids and antibiotics, but continues to have severe dyspnea. Physical examination reveals a moderately distressed, ill-appearing man who has difficulty finishing sentences, needing to pause to catch his breath. Lung examination reveals coarse upper respiratory breath sounds, symmetrical respirations, and extensive use of accessory respiratory muscles. Thoracoabdominal disassociation is present. An arterial blood gas reveals mild acidemia, as well as a pO2 of 53 mm Hg and a pCO2 of 80 mm Hg. The patient has been intubated in the past, and is worried that this will happen again. He is willing to undergo this intervention if no other options are necessary, but begs to have anything else possible tried first. Which of the following is the most appropriate intervention?

A. Bilevel positive airway pressure (BiPAP) support
B. Continuous positive airway pressure (CPAP) support
C. Immediate intubation and positive pressure support
D. Nonrebreather face mask with 100% oxygen
E. Venturi mask with maximum of 50% oxygen

[ArchivalUser]

b.

[ArchivalUser]

whats the answer kiran

[ArchivalUser]

The correct answer is A.

BiPAP is a proven form of noninvasive positive pressure ventilation that is particularly useful for COPD patients. Although this patient may eventually need intubation and mechanical ventilatory support (choice C), BiPAP has been proven to reduce the need for such interventions by up to two-thirds when compared with traditional medical management. BiPAP is delivered at the bedside, with a special BiPAP ventilator, and can be given via a nasal or full-face mask.

CPAP (choice B) is also useful in COPD patients but is not as efficacious as BiPAP. This patient appears to be tiring, as evidenced by the use of accessory muscles of breathing and thoracoabdominal disassociation, an ominous sign portending respiratory exhaustion. The additional inspiratory pressure support provided by BiPAP, compared with CPAP, may prevent this patient from progressing to intubation.

A nonrebreather face mask (choice D) with high-flow O2 should not be used in patients with severe COPD. High-flow O2 results in worsening hypercapnia from a combination of ventilation/perfusion mismatch from recruiting diseased lung segments, and from the Haldane effect, where oxygen initially displaces CO2 from erythrocytes.

A Venturi mask (choice E) is an appropriate way to provide supplemental O2 to a COPD patient. However, this patient needs an intervention that will reduce the work of breathing, not just supplemental O2. BiPAP is much more likely to reduce the need for future intubation.

[ArchivalUser]

whats the difference between nippv and the the choices a and b
cuz i know u cant first try nippv.

[ArchivalUser]

thx 4 the quest..

[ArchivalUser]

what was mentioned as NIPPV in UW is BiPAP now.
thanx kiran
http://www.wisegeek.com/what-is-bipap.htm

[ArchivalUser]

thanks orthop for the information.

[ArchivalUser]

u r welcome kiran