Web Appendix 3 - BTS ICS Guideline Slides.ppt
- 1. Better Lung Health for All BTS/ICS Guidelines for the ventilatory management of acute hypercapnic respiratory failure in adults British Thoracic Society Intensive Care Society
- 2. Better Lung Health for All Introduction • Acute Hypercapnic Respiratory Failure (AHRF) results in 50,000 admissions each year in the UK • Without ventilatory support AHRF is associated with a high mortality rate and a prolonged inpatient stay • The incidence of AHRF is similar to upper GI haemorrhage which is, quite rightly, recognised as a medical emergency and one in which delay in instituting treatment and poor coordination between clinical teams increases mortality
- 3. Better Lung Health for All Introduction • Patients with AHRF are not receiving optimal therapy: • BTS NIV audit reports 2011-13 • Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax 2011 • National COPD Audit Programme: secondary care clinical audit report: “Who Cares Matters 2014” https://www.rcplondon.ac.uk/projects/national- copd-audit-programme • “provision of NIV is often poorly performed, patients not treated until acidosis severe and some patients inappropriately denied admission to the ICU”
- 4. Better Lung Health for All Aims of Guideline • Highlight current suboptimal care for individuals with AHRF in the UK • Review the evidence base for treatment of AHRF by invasive and non invasive ventilation • Promote an integrated AHRF care pathway involving Emergency Departments, Medical Admission Units, Respiratory Wards & Critical Care • Improve patient outcome and experience
- 5. Better Lung Health for All AHRF • May complicate a number of conditions that affect lungs and/or impair the function of respiratory pump • Airway disease : COPD, asthma, Cystic fibrosis and non-CF bronchiectasis • Respiratory pump : neuromuscular disease, chest wall deformity and morbid obesity • AHRF may be acute or acute on chronic
- 6. Better Lung Health for All Acute exacerbations COPD • Commonest cause of AHRF : 20% AECOPD • In COPD signals advanced disease, high risk of future hospitalisations and limited long term prognosis • In COPD mortality 8% without AHRF and up to 30% with AHRF depending on the degree of acidosis
- 7. Better Lung Health for All In all causes AHRF Development of AHRF warrants a change in future care arrangements: • predicts future life threatening episodes • indicates need, in some, for domiciliary NIV
- 8. Better Lung Health for All Treatment of AHRF Prior to availability of non-invasive ventilation: • intubation was required when conventional treatment failed • unclear what criteria guided recognition of this need …...intubation variably offered internationally……limited availability of intensive care beds in UK reduced access to this option
- 9. Better Lung Health for All Prognostic indicators • Mostly investigated in AECOPD, where outcome less good in those with adverse features, especially when multiple • Medical staff infrequently use formal severity scoring and consistently under-estimate survival potential • Scoring poorly predictive on individual basis and, on its own, little help in deciding when mechanical ventilation would be futile • Important that potentially life-saving treatment, including NIV, not inappropriately withheld
- 10. Better Lung Health for All Recommendations (1): Prevention AHRF • Oxygen should be used with care in all individuals at risk of AHRF • Use a target oxygen saturation range of 88-92% in ALL self-ventilating patients at risk of AHRF • If oxygen indicated, start at 24-28% oxygen via a Venturi mask
- 11. Better Lung Health for All Recommendations (2): NIV • Consider starting NIV when pH < 7.35, PCO2 > 6.5 kPa and respiratory rate > 23 • Consider starting NIV in hypercapnic NMD or CWD patients in the absence acidosis • NIV should not be used in acute hypercapnic asthma • Do not delay starting NIV or continue with it when the patient is deteriorating as both increase mortality.
- 12. Better Lung Health for All • The use of NIV should not delay escalation to IMV when this is more appropriate • Intubation is indicated if NIV is failing (unless it is not desired by the patient or agreed not in his/her “best interest”) • Be aware that clinicians can underestimate survival potential in AHRF treated by IMV Recommendations (3): Invasive Ventilation
- 13. Better Lung Health for All Recommendations (4): NIV in the ICU • Patients with higher risk of NIV failure can be predicted and should be considered for direct admission to ICU • In many AHRF patients the planned use of NIV post extubation reduces the need for re-intubation • In COPD, and in many individuals with NM disease, NIV-supported extubation should be employed in preference to inserting a tracheostomy
- 14. Better Lung Health for All Recommendations (5): Organisational aspects Be aware: • A care environment with level 2 equivalence improves the outcome of NIV • Ward-based NIV risks greater delay in expert review and/or escalation to IMV • Coordination of care between the ICU and other patient areas improves outcome
- 15. Better Lung Health for All Recommendations (6): Governance and risk avoidance • Care planning is needed between respiratory, emergency and acute care physicians and the ICU • A senior clinician should lead in the local production of a seamless AHRF patient pathway • Episodes of oxygen toxicity, or unexpected death whilst on NIV, should be critically reported • Rolling programmes of staff training and auditing of performance in AHRF improves outcomes
- 16. Better Lung Health for All Figure 1 Summary for providing acute NIV
- 17. Better Lung Health for All Figure 2 Guide to initial settings and aims with imv
- 18. Better Lung Health for All Figure 3: The three phases of patient management in AHRF
- 19. Better Lung Health for All Further information The guideline can be found on the BTS website at: https://www.brit-thoracic.org.uk/guidelines-and- quality-standards/ventilatory-management-of- acute-hypercapnic-respiratory-failure-guideline/ Contact: bts@brit-thoracic.org.uk