This statement is taken out of context more than it is taken in context, hence the hate. "Assess your patient and correlate findings" is a much better way of saying this than a hackneyed EMS saying.
CPAP and BiPAP in asthma
- Thread starter zzyzx
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I'm gonna be highly hesitant to intubate an obstructive patient with improving physiologic parameters. HIGHLY. All I'm doing in the case of NPPV is buying time for the meds to work. I'm going to pull out the big gun meds like mag and epi drips before I tube this patient. By the same token of treat the patient and not the monitor....sometimes patients are unreliable.
Just to be the obvious guy:
Whatever PaCO2 / FEV1 at which the patient continues to deteriorate, and is either (1) showing signs of fatigue despite maximal medical therapy, or (2) is becoming progressively altered to the point that it's either interfering with patient care or there becomes potential for aspiration.
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I posted the questions simply as trivia. I was reviewing that topic myself for an exam, and thought a couple people might learn something looking it up and maybe find it interesting.
Instead, everyone seem to default to "I'll just tube 'em when they need it". Oh well. "Treat the patient, not the monitor, right"?
Instead, everyone seem to default to "I'll just tube 'em when they need it". Oh well. "Treat the patient, not the monitor, right"?
It looks like I completely missed the point! Sorry.
My understanding, from talking to some critical care and ER physicians who are much smarter than me, is that there's not really a specific PaCO2 or pH at which intubation is mandatory, providing the patient is maintaining their airway, and is maintaining or improving.
I think someone else already made a good point about the FEV, to the point of, if they can perform dynamic spirometry, then they don't need to be intubated yet, i.e. they're compliant / obeying commands.
What I was taught, is that intubation is to be avoided for as long as possible, and that it is there to maintain the airway when the patient cannot, to assist ventilation when they fail, and is not going to address any of the underlying issues, which are a function of airway resistance that needs to be addressed pharmacologically.
This isn't to say that these numbers aren't useful; they provide objective information about the patient's ventilatory status, which can be correlated with subjective clinical findings.
https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=59&seg_id=1860
http://www.anesthesia.org/winterlude/wl95/wl95_8.html
http://emcrit.org/podcasts/vent-part-2/
http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&ved=0CEUQFjAE&url=http://www.emergpa.net/wp/wp-content/uploads/2011/03/asthma-intubation.pdf&ei=C4NZVPWuC8eQyATM1oLQDA&usg=AFQjCNF2PhNAQzjRu9dY2hyg_SWWU6fWeg
http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0CE4QFjAF&url=http://www.thoracic.org/statements/resources/allergy-asthma/asthma.pdf&ei=C4NZVPWuC8eQyATM1oLQDA&usg=AFQjCNHTK86I1kp0-d_8TGyHRmRFsJT2GQ
* Looking through some of these resources, it seems like there's a consensus that pH < 7.20 is probably a sufficient reason to intubate. This probably corresponds to a PaCO2 ~> 55mHg, that being said, the majority of physicians I've talked to have said that they base their decision as to whether to intubate on physical exam findings and whether they've already exhausted other options.
Jeff Rehman
Forum Ride Along
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BiPAP is indeed more appropriate but I believe that one of the best (albeit somewhat Draconian) techniques the medic can employ would be to gently FORCE exhalations
with the patient so long as they re awake and understand what you're doing and why.
The 'bear hug' has it's place in assisting to release trapped dead air, affording the space to introduce more O2 and bronchodilators. If their LOC or work of breathing becomes too compromised, then the lost art of NASAL INTUBATION should be employed as the work of breathing needs to be totally assumed by the provider. In these cases I usually administer a couple mG of Versed (midazolam) to chill the patient out and get him/her to trust that we won't let them down in terms of breathing for them.
Nebulizing in Albuterol and Atrovent go, of course, without saying... But the early administration of Solu-Medrol and even MGSO4 if Epi isn't indicated- are crucial. Normalizing the ETCO2 readings take a front seat here, as I've come to learn in my eld. I've seen that the early administration of Ketamine (sedative and bronchodilator as well) in the ER - is wonderfully effective in bringing that totally shut-down patient back into the fold.
with the patient so long as they re awake and understand what you're doing and why.
The 'bear hug' has it's place in assisting to release trapped dead air, affording the space to introduce more O2 and bronchodilators. If their LOC or work of breathing becomes too compromised, then the lost art of NASAL INTUBATION should be employed as the work of breathing needs to be totally assumed by the provider. In these cases I usually administer a couple mG of Versed (midazolam) to chill the patient out and get him/her to trust that we won't let them down in terms of breathing for them.
Nebulizing in Albuterol and Atrovent go, of course, without saying... But the early administration of Solu-Medrol and even MGSO4 if Epi isn't indicated- are crucial. Normalizing the ETCO2 readings take a front seat here, as I've come to learn in my eld. I've seen that the early administration of Ketamine (sedative and bronchodilator as well) in the ER - is wonderfully effective in bringing that totally shut-down patient back into the fold.
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Certainly no reason to apologize.
The answers to the original question:
Fev1 = <25% of normal
Pc02 = >50mmHG despite aggressive bronchodilator therapy
Stoelting's Anesthesia & Coexisting Diseases
FiremanMike
Just a dude
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What is it about these trade forums that inevitably brings out the **** measuring contest on every topic possible. I'm not really sure why we couldn't have a mature and enlightening discussion where perhaps people could learn from our collective experience? Instead, you go directly for arrogant vitriol in an effort to show everyone how much you know..
FiremanMike
Just a dude
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Despite the way my words are interpreted, I am always highly hesitant to intubate anyone, but I'm also not afraid of it. The scenarios I speak of (medics leaving patient's on CPAP despite no patient improvement) are not necessarily the norm, but they also aren't uncommon. The latest information I knew said that CPAP in COPD/emphysema/severe asthma wasn't really concrete and that it "works sometimes, not always, and we're not really sure why", and this has mirrored my own experience with CPAP in those patients. Obviously CHF is a different story...
The specific scenario I spoke of was, to date, a once in a lifetime run. A patient with a previous history of intubations for exacerbations, in respiratory failure, and not responding to treatments other than his SpO2 increase. At the point I decided to sedate and intubate him, he was obtunded and diminished, he didn't even have enough energy to hold the nebulizer in his mouth (he was in relatively good shape for a COPDer, this finding was unexpected). The case was reviewed by the EMS supervisor and then the medical director who had access to the patient's in-hospital report, both agreed that intubation was the right choice in this patient. My respiratory protocol includes epi, mag, and decadron beyond albuterol/atrovent and I can and have used different treatment methods in different patients.
Perhaps I was too flippant with my "treat the patient and not the monitor" and you are correct that sometimes you should consider treating the monitor and not the patient. The most universal statement on this thread so far is to treat both the monitor and the patient, which is always the best way to practice.
Remember guys and gals, there are new and inexperienced medics who read these forums. We should all take a step back and realize that those of us with a bit of experience have a lot to offer those new folks and should spend our time educating them and each other as opposed to bickering.
tl:dr - The original point I was trying to make before this thread devolved to its current state is that we cannot be dependent on CPAP to fix our COPD/emphysema/asthma patients. It might work, but maintain vigilant in monitoring your patient and don't be afraid to back off your current treatment and move on to the next.
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If that is directed towards me, I don't know what you are talking about.
You might want to read back through the thread and see who was responding to whose posts with BS.
FiremanMike
Just a dude
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On second thought, 2 way communication is just not possible..
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