Workshop/Conference

  2017 Workshop/Conference Title: 59F with nocturnal episodes of altered sensorium Active participants:  Rakesh Biswas  ,  Avinash Kumar  , ...

Saturday, 6 March 2021

ICU with severe hypercapnia

 

We have a 55 year old man in ICU with severe hypercapnia refractory to positive pressure ventilation with PCO2 ranging from 100-120 mm of Hg after 24 hours of ventilation. Any inputs
Rajendra
,
Angira
,
Boudhayan
,
Amit
,
Praveen
You, Shweta Gupta, डॉ यश तलेरा and 8 others
79 comments
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  • Amit Taneja
    Can u tell me more clinical details. Thanks
    1
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    • 4 y
  • Angira Dasgupta
    Knowing Ventilator settings would be helpful
    1
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    • 4 y
  • Rakesh Biswas
    Admin
    He appears to have a history of Bronchial asthma since childhood. Perhaps for the last 45 years. His last three years appear to have been spent in perennial shortness of breath and wheeze. He has a barrel shaped chest and his CXR pa shows pushed down … 
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    • 4 y
  • Ambarish Bhattacharya
    Sir.
    Sedate + paralyse and ventilate for a few hours.
    Repeat ABG if feasible every 2 to 3 hours. … 
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    1
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    • 4 y
  • Clinical review: Mechanical ventilation in severe asthma
    NCBI.NLM.NIH.GOV
    Clinical review: Mechanical ventilation in severe asthma
    Clinical review: Mechanical ventilation in severe asthma
    1
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    • 4 y
  • Amit Taneja
    What's the pH. How is the patient clinically and hemodynamically. How are vent pressures.
    1
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    • 4 y
  • Rakesh Biswas
    Admin
    Patient is hemodynamicaly stable. He was sedated on ACMV and ventilated for the last 24 hours with PCO2 rising and pH dropping to 7.03 to 7.08
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    • 4 y
  • Angira Dasgupta
    A rise in PCO2 possibly indicates hypoventilation. May be worthwhile to attempt increasing expiratory time.
    1
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    • 4 y
  • Rakesh Biswas
    Admin
    Was tried. I was looking at some literature and this seems to be not an uncommon problem and people have tried strategies such as Partial extracorporeal CO2 removal here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3732765/
    Removing extra CO2 in COPD patients
    NCBI.NLM.NIH.GOV
    Removing extra CO2 in COPD patients
    Removing extra CO2 in COPD patients
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    • 4 y
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    • Rakesh Biswas
      Admin
      Although i must admit i haven't come across such a problem earlier.
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      • 4 y
  • Amit Taneja
    Managing severe asthma on a ventilator is one of the most challenging clinical problems. In general if the patient is clinically okay, I ignore or tolerate hypercapnia. (Permissive hypercapnia). In general as status asthmaticus gets better, hypercapnia will get better. Attempts at increasing minute ventilation are reasonable-if that does not lead to dynamic hyperinflation (so called auto-peep). If on the other hand increasing minute ventilation leads to increased auto PEEP (can be inferred by vent graphics and clinically presents with hypotension ), I tolerate hypercapnia.
    Attempts at deep sedation and paralysis are reasonable and often required.
    Of course IV steroids and nebulized bronchodilators would be given.
    If refractory wheezing, consider IV aminophyline.
    May consider changing sedative to propofol as it may have some bronchodilator properties.
    Only once I had to go to V-V Ecmo for status asthmaticus.
    Be careful and ensure prolonged expiration time or a short I:E ratio
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    • 4 y
    • Edited
  • Rakesh Biswas
    Admin
    Thanks 
    Amit
    . These were very useful inputs.
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    • 4 y
    • Aadipta Ghosh
      Would u consider shifting him to a setup with ECMO?
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      • 4 y
    • Rakesh Biswas
      Admin
      Is there any center in Kolkata practicing “partial” CO2 removal in Kolkata 
      Angira
      , 
      Boudhayan
      ?
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      • 4 y
    • Amit Taneja
      Quite honestly decision for ECMO should be based not just on PCO2, but on clinical situation.
      1
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      • 4 y
    • Angira Dasgupta
      Not sure. Apollo might
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      • 4 y
  • Rakesh Biswas
    Admin
    We did find some improvement after hiking up his bronchodilators and steroids and his PCO2 has improved to 80s-90s.
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    • 4 y
  • Rajendra Takhar
    increasing minute ventilation, moderate to high doses IV steroids if not contraindicated and very frequently nebulized bronchodilators and simultaneous IV aminophyline are often sufficient to revert this kind of hypercapnea.
    2
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    • 4 y
  • Rajendra Takhar
    Good to know pt already improving 😀
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    • 4 y
  • Praveen Ky
    From neurological point of view -is there associated ptosis/eom abnormality/ neck weakness/upper limb or lower limb power and reflexes.Muscle disease like polymyositis/metabolic myopathies,Neuromuscular diseases like myssthenia gravis can present sim… 
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    • 4 y
  • Rakesh Biswas
    Admin
    Today's update: Was doing well till morning rounds (PCO2 of 70s) after which the only change made was in his paralytic agent , atracurium, which was stopped and his PCO2 again climbed up to undesirable levels of 90 and he appeared distressed. Evening p… 
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    • 4 y
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  • Rakesh Biswas
    Admin
    His calcium levels are slightly low at 7.5 mg%. His steroids and bronchodilators have been hiked up as his PCO2 is still spiking at times.
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    • 4 y
  • DrDeepanjan Bhattacharya
    Sir, has a magnesium level been done?
    1
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    • 4 y
  • Rakesh Biswas
    Admin
    Yes that was normal
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    • 4 y
  • Amit Taneja
    Was his initial clinical presentation all compatible with asthma. Are we missing the correct dx?
    2
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    • 4 y
  • Rakesh Biswas
    Admin
    Thanks 
    Amit
    , His CXR pa view appears to suggest a pushed down diaphragm and tubular heart that suggests he could be having additional emphysema. Can such CXR pa findings be seen in Hyperinflated lungs due to bronchial asthma as well? 
    Rajendra
    , 
    Angira
    ?
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    • 4 y
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  • Rajendra Takhar
    CXR pa view having a pushed down diaphragm and tubular heart suggesting hyperinflation due to air trapping or emphysema. These features are usually present in cases of COPD but may also present in acute exacerbation of Br Asthma.
    1
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    • 4 y
  • Rajendra Takhar
    Again presence of Br Asthma for long term is itself a risk factor for the development of COPD.
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    • 4 y
  • Boudhayan Dm
    Rajendra Takhar
     
    Amit Taneja
     sir would like u to discuss the maximum dosage and frequency of bronchodilator s........... Also the advantages and disadvantages of sedatives and muscle relaxants esp wrt this patient
    1
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    • 4 y
    • Edited
  • Dev Basu
    When mag sulf, inhaled and parentral steroids with nebs, sedation, paralytics dont appear to be working then can consider parenteral beta agonists, racemic epi, epi sq or heliox but might be difficult to obtain maybe a pde
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    • 4 y
  • Dev Basu
    This is all assuming the airways are the problem.
    1
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    • 4 y
  • Rakesh Biswas
    Admin
    DrSatabdi
     would be great if you can add the current update on this patient here.
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    • 4 y
  • Vivek Poddar
    Admin
    Updates on the same patient:
    A case of AECOPD with resp. Acidosis on mechanical ventilator was found to have total WBC count increasing overtime (15300 (ICU 2nd Day)/ 18500/ 27500/ 35600 (13th day). So, we started empirically with Clavum & Augmentin a… 
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    • 4 y
    • Edited
  • Rakesh Biswas
    Admin
    He went home today 
    Vivek
    ?
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    • 4 y
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    • Boudhayan Dm
      Can you upload the X ray images old vs new pls.
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      • 4 y
  • Vivek Poddar
    Admin
    OLD CT scan film 1
    No photo description available.
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    • 4 y
  • Vivek Poddar
    Admin
    Old CT scan Film 2
    No photo description available.
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    • 4 y
  • Rakesh Biswas
    Admin
    Update : Discharged a few days back and doing quite well at home
    2
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    • 4 y
  • Rakesh Biswas
    Admin
    Thanks 
    Amit
    , 
    Angira
    , 
    Rajendra
    , 
    Ambarish
     and all others for your informational support.
    2
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    • 4 y
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  • Angira Dasgupta
    I don't think I did a lot! Thanks
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    • 4 y
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    • 3 y
    • Vivek Poddar
      Admin
      Oh shit. Thanks for commenting here.
      1
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      • 3 y
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  • Avinash Kumar
    Admin
    & current WBC counts are 30,000
    No photo description available.
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    • 3 y
    • Edited
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    • 3 y
  • Vivek Poddar
    Admin
    Amit Taneja
     sir, 
    Rajendra Takhar
     sir, 
    Monika Agrawal
     ma'am this patient currently in KIMs hospital for his FNAC but repeat CxR pa and Usg chest shows no mass. Can you see the repeat Xray uploaded in the blog and below and see if you would like to test … 
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    No photo description available.
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    • 3 y
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    • Rakesh Biswas
      Admin
      Thanks 
      Amit
      . He did receive the pneumococcal vaccine too. Any reviews on its outcomes efficacy 
      Amy
      ?
at

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