High Dependency Units Definitions

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• 2008 by the author

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A case of pneumonia complicated by multiple
respiratory arrests.

• Dr Mark Elliott
• St Jamess University Hospital
• Leeds, UK

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• 48 year old male
• 10 days flu like symptoms, pyrexia, myalgia,
  anorexia, nausea and vomitting, slight headache.
• 3 days unable to get out of bed
• Increasing breathlessness, much worse last 24
  hours.
• Cough productive increasing amounts green sputum,
  small streaks of blood.

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• Shortness of breath with hills last 9 or 10
  months
• No orthopnoea or PND
• As a result stopped smoking
• Continued work as a postman.
• Recent holiday Gran Canaria - one month
  previously - no air conditioning, spas etc

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Examination

• Temp 38o C
• Pulse 120 BPM
• BP 165/95
• Resp rate 32 BPM
• Not confused
• Right base crackles, dullness to percussion and
  reduced breath sounds.

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Investigations

• White cell count 25
• Sodium 139 (135 to 145)
• Urea 8.5 (2.2 to 7.7)
• Albumin 25 (37 to 49)
• ALT 51 (0 to 35)
• CRP 250 ( lt5)

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Investigations

• FiO2 24
• pH 7.35
• PaO2 10.0 kPa
• PaCO2 5.8 kPa
• HCO3 24.2

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Q1.
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Q2.
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Community Acquired Pneumonia

• 255 consecutive admissions with CAP
• Admitting medical team failed to appreciate who
  would die or require intensive care in 21 of
  admissions

Neill et al Thorax 1996 511010-16
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Community acquired pneumonia

• Primary
• Resp rate gt 30
• Diastolic BP lt 60
• Urea gt 7
• 2 out of 3 gt 21 x inc risk of death 1
• Confusion
• 2 out of 4 gt36 fold increased risk of death 2

• Secondary
• PaO2 lt 8 kPa
• PaCO2 gt 6 kPa
• Multilobe shadows
• Leucopenia

1. BTS Guidelines. Br J Hosp Med 1993
49346-350. 2. Neill et al Thorax 1996
511010-16 3. Lin et al Thorax 2001 56296-301
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Progress

• 12 hours later
• Increasing shortness of breath
• Exhausted
• Unable to speak in sentences
• Some wheeze
• pH 7.326 PaO2 10.0 PaCO2 6.4 HCO3 25
• Added in nebulised salbutamol, IV aminophylline,
  FiO2 to 40.

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Progress

• 2 hours later
• No improvement
• pH 7.274 PaO2 14.8 PaCO2 7.5 HCO3 26

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Q3.
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Meta-analysis (n8)

• NPPV resulted in
• decreased mortality (RR 0.41 95 CI 0.26,
  0.64),
• decreased need for ETI (RR 0.42 95CI 0.31,
  0.59)
• Greater improvements within 1 hour in
• pH (WMD 0.03 95CI 0.02, 0.04),
• PaCO2 (WMD -0.40 kPa 95CI -0.78, -0.03),
• RR (WMD 3.08 bpm 95CI 4.26, -1.89).
• Complications associated with treatment (RR 0.32
  95CI 0.18, 0.56) and length of hospital stay
  were also reduced with NPPV (WMD 3.24 days
  95CI 4.42, -2.06)

Lightowler, Elliott, Wedzicha Ram ERS 2002
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NIV in ARF
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NIV in ARF

• Serious complications 1,3,4
• Pneumonia or sinusitis 1,4
• Shorter ICU stay 1,2,3,4
• shorter period ventilation 1
• CPAP no effect on outcome

1. Antonelli et al NEJM 1998 339429-35 2.
Confalonieri et al AJRCCM 1999 1601585-1591 3.
Antonelli et al JAMA 2000 283235-41 4. Hilbert
et al NEJM 2001 344481-7
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• Started NIV (IPAP 16 EPAP 5)
• Tolerated well
• 4 hours later - much better.
• 2l O2 and NIV pH 7.39 PaO2 10.6 PaCO2 5.0 HCO3 23
• Came off NIV to take medication - saturation
  dropped to 70

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• Remained on NIV all day - well. Saturations
  maintained 95 - 96
• Evening came off NIV to have a drink of water and
  take medication.
• Cyanosed, unresponsive - crash call
• Resuscitated, intubated and transferred to ICU

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CPAP in acute lung injury

• PaO2/FIO2 203 vs 151 mm Hg P 0.02
• ETI 21 (34) vs 24 (39) P 0.53
• Hospital mortality 19 (31) vs 18 (30) P 0.89
• ICU LOS 6.5 vs 6.0 days P 0.43
• Adverse events 18 vs 6 P 0.01
• Trend towards increase cardiorespiratory arrests

Delclaux et al JAMA 2000 2842352-60
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• Day 2 CPAP and PSV 5 and 12
• FiO2 35
• Day 3 - sat out on CPAP 5. Comfortable.
• Normal PaCO2 gt extubated
• Rapidly desaturated to 50.
• Face mask CPAP - SaO2 96.
• While setting NIV up decr chest movement
• Sats to 50 gt reintubated.

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Q4.
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• Extubated onto NIV
• History taken again with partner
• 3 months morning headaches
• More sleepy during the day (working antisocial
  hours)
• Snores , occasional witnessed apnoeas
• Orthopnoea with acute illness (nil previously)

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• Occasional diplopia
• Wife thought eyelids a little more droopy
• Difficulty chewing steak
• Tensilon test - strongly positive
• Ach receptor antibodies - strongly positive.

• Diagnosis - myasthenia gravis

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• Further respiratory arrest - reintubated
• No further attempts extubation
• Daily plasmapharesis
• After 5th plasmapharesis extubated without
  incident
• Treated with pyridostigmine, azathioprine and
  prednisolone
• CT - small thymoma - referred for thymectomy

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Respiratory failure in myasthenia gravis

• May be the presenting feature
• respiratory muscle weakness
• vocal cord paralysis
• May require ventilatory support
• Usually responds well to treatment

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Conclusion

• Use objective criteria to assess severity in all
  patients with pneumonia
• Consider respiratory muscle weakness in any
  patient with unexplained respiratory failure
• PaCO2 5.8 kPa at admission
• The patient who decompensates rapidly when NIV
  discontinued for a short period is at high risk
  for cardiorespiratory arrest.