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A6778 - COPD and Severe Ventilatory Failure: Intubation Vs Noninvasive Ventilation Is Not by Number
Author Block: P. Ward1, E. Ortiz-Diaz2, G. Pesola3; 1Internal medicine, Harlem Hospital Center, New York, NY, United States, 2Department of Medicine, Pulmonary Medicine Division, Harlem Hospital Center, New York, NY, United States, 3Harlem Hospital/Columbia University, New York, NY, United States.
Introduction Acute hypercapnia with paCO2 levels >120 mmHg invariably result in intubation. We describe a patient with COPD who developed acute on chronic ventilatory failure and was managed with noninvasive ventilation (NIV) despite extreme hypercapnia. Case Report A 60 year old male smoker (BMI 15.7) was admitted to the MICU with COPD exascerbation. He was intubated in the ED with admission ABG: pH 7.10, pCO2 120 mmHg, pO2 262 mmHg and lactate of 2.9 mmol/L. Serum HCO3 was 42 meq/L. Toxicology was positive for cocaine and alcohol. After two days of intravenous steroids, antibiotics and bronchodilators he was extubated with plan to bridge to NIV but he refused. Post-extubation ABG revealed a pH 7.08, pCO2 125 mmHg, pO2 380 mmHg and lactate of 2.95 mmol/L. When told he would be re-intubated as his work of breathing had increased, he then agreed to bi-level positive airway pressure at 11/5/30%/16-rate. After 30 minutes, ABG improved to a pH 7.31, pCO2 71 mmHg, pO2 124 mmHg with lactate 0.82 mmol/L. He was subsequently transferred to the medicine floors and discharged. Discussion Respiratory failure secondary to advanced COPD is often treated with NIV to prevent intubation. It would have been reasonable to intubate this patient with an elevated pCO2 of 125 mmHg by most if not all clinicians. Fortunately, clinical bedside judgment and the use of bi-level prevented re-intubation. In addition, pulmonary/critical care physicians were managing this patient and would probably be most comfortable with this scenario. We are not aware of any patients with a pCO2 of 125 mmHg who were managed only with bi-level (and not intubation). Conclusion Severe hypercarbia is not an absolute indication for intubation. This patient was not intubated at the time because he was hemodynamically stable although it could be argued he was not respiratory stable. Since his baseline pCO2 estimated 80 mmHg, he was partly compensated at the pCO2 of 125 mmHg and this made it easier for bi-level to get him back to baseline. Undoubtedly, a patient without COPD would not tolerate a pCO2 of 125 mmHg acutely and intubation would be necessary. With NIV as an adjunct in a conscious and well monitored patient, severe hypercarbia can in some instances be rapidly reversed and managed without intubation. Reference Cao Z, Luo Z, et. al. Volume-targeted versus pressure-limited NIV in subjects with acute hypercapnic respiratory failure: a multicenter randomized controlled trial. Respir Care 2016;61:1440-50