This post is part of the bleeding edge series–you have been warned!
What you'll hear….
Two Phenotypes of Critical COPDers
- Severe Bronchospastic Crisis
- Hypercapneic Encephalopathy
This episode primarily talks about #2
The New Reflex Actions for Coma/AMS
- Check Fingerstick
- Look at the Pupils/Resp Rate
- Look for Stigmata of Seizure/Recently Completed Seizure
- Get a VBG
The Controlled Burn for Hypercapneic Encephalopathy in COPD
This is the bleeding edge part. I am super-curious to hear what you think. Place your comments below.
Articles to Read
Additional New Information
More on EMCrit
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit Wee (392.5) – Naughty or Nice? Bad Behavior in Healthcare with Liz Crowe, PhD - January 15, 2025
- EMCrit 392 – All Things Defibrillation with Sheldon Cheskes - January 10, 2025
- EMCrit 391 – Pericardiocentesis and Tamponade Temporization - December 27, 2024
WHY VBG and not ABG?
think you have that backwards. the ? when getting an abg should always be, why not a vbg.., unless pt already has an a-line
I went to a rapid response call a few weeks ago in which the patient had worsening LOC over a period of a couple hours, which prompted an ABG, which revealed sky high PCO2. We used BVM to hyperventilate for about 5 minutes before the patient woke up and tore the mask off. In response to Scott’s question of “should we try this, and how to go about it?” I would ask – What’s the downside? In my scenario, I believe the main downside was risk of gastric insufflation/aspiration- the person on the bag was hammering away at 30-40/min and… Read more »
great stuff
It seems to boil down to: Risk of aspiration with NIPPV vs. risk of morbidity associated with MV.
If we consider that standing by a bedside with a yankauer, ready to turn the patient’s head and suction MIGHT save ICU cost, VAP, delirium, iatrogenic tube insertion and that a certain percentage of patients will vomit when intubated anyway… the strategy seems quite reasonable.
Given the number of people presenting with hypercapnia encephalopathy, it should not be difficult to design a study of “vigilant bedside BiPAP vs. early intubation”.
very interesting, both the pod , scott, and the comments. i would need to discuss with the RT team, to get them thinking about this all. we would need the RT team and the nurses to be on board , esp if we are trialing with the vent.
Prob easiest might be simply hyperventilating for 3-5 minutes with the BVM?
thanks again, scott.
looking foward to your conference at january’s end.
tom
Thanks for this revised look at hypercapneic encephalopathy.
Would there be a potential role for bringing back respiratory stimulants, such as IV Theophylline or the old drug IV Doxapram in this scenario?
Have used doxapram in India, not available in Qatar where I currently work. So I have used adrenaline 10 mcg boluses every 2-3 mins – and found this works often.
interesting on both counts. Never have seen or used doxapram so can’t comment. Is there a reason or downside that caused it to disappear? What is the putative mechanism of the epinephrine?
Great post, as always.. The LMA idea is fascinating. Why not ketamine?
i want to see them wake up
Hi Scott, I have found adrenaline useful in these hypo-ventilating patients with hypercapneic encephalopathy. Adrenaline 10 mcg boluses every 2-3 mins, Maybe sometimes it takes an adrenaline “nightmare” to wake up from the “deep sleep”? (That is what a patient who “woke up” and avoided intubation told me – it felt like a nightmare)
Hi. Any idea if this has anything to do with beta agonist effects of Adrenaline improving bronchodilation and therefore V/Q matching. Certainly there is an added benefit in brain adrenergic brain stimulation.
gotcha. what effect do you see on vitals. is the tachycardic response blunted?
Scott,
Have been doing something like this for years. Rather than wait for NIV to fail, however, I typically put the patient on NIV. Check their minute ventilation and rate. Then increase the rate if possible. I do this ASAP. Then they blow off the co2 over the WHOLE time they are on
NIV. With our machines we can compensate for leak, see flow/volume loops as well as minute ventilation, this makes it pretty easy
yep. putting folks on a rate is pretty much the same thing. it is also pushing the NIPPV envelope and works well.
I like it. Definitely will give it a shot. Usually I just turn up RR with NIV vent, but now I think it would be better to stand behind pt, who’s sitting up, and just hold regular BVM mask and do the jaw trust (just to make sure airway is open).
If he’s not better in 5-10min, we’ll.. At least it was good preox before tubing. I don’t see any downsides and, if it succeeds, ICU will cry tears of joy 🙂
let me know how it goes
Cool idea. The hypercapnic coma patients like the ones you describe are mostly OSA/OHS at my hospital (south Louisiana, average BMI is mid 40’s down here). They tend to be much more refractory to BiPAP, in my experience. Maybe I’m not using high enough settings? A few concerns I would have: 1. These patients rarely wake up in a good mood, especially if they wake up with me smashing a mask on their face and doing a jaw thrust. Would need a premeditated plan about how to handle that agitation without using benzo’s or other sedatives, which would only sabotage… Read more »
not sure about your hand math–one person to hold cricoid and squeeze the bag, the other with 2 hands on the mask. but really you are better off using the vent or an oxylator as your bvm, so just one person on the mask and one tohold cric. that would take about 30 seconds to set up. I have never had one of these patients take a swing at me when they wake up, but that may be a regional thing. I hear you though, everywhere is different.
n=1 Elderly, postpolio syndrome severe COPD hypercapnic with decreased LOC no other apparent cause, with very poor baseline function, not a candidate for intubation, needing jaw thrust and OP then NP airway to maintain airway edentulous unable to get bag mask seal or BIV mask seal, went to LMA then NIV BiPAP via LMA, worked really well
nice
I have been thinking about this concept for years but felt too early in my training to bring it up! Most patients This obtunded would tolerate an NG, which could reduce aspiration risk.
A few thoughts- -I think reduced GCS is usually fairly obvious from walking in that they are COPD v say opiate aetiology? -if they are that obtunded, make sure they don’t have a pneumothorax (quick US or slower CXR) -I had an amazing result with expiratory chest squeeze on CO2. I did about 10 external (lateral, slow and hard on expiration) squeezes and brought the CO2 down from over 100 to less than 60. Unreal. As I recall the patient was tubed, and we were struggling to reduce the C02 on an oxylog 3000. Maybe consider in these ‘awake’ patients… Read more »
Scott great information! Is there a POD cast on the VBG? for some reason this scares me more than an ABG but it shouldn’t I know. Being on Rapid Response Team I’m always looking for the ABG and the Lacate however I know we can do the same with the VBG.This is common practice where I am and we have loads of patients on Bipap
Interesting pod cast… More because I thought this was an old concept. I’m an Australian emergency trainee, and we do this often & rarely have a complication. I won’t go into the philosophical differences in our healthcare system that leads to this, but I’ve had patients admitted to the medical ward, with a nurse special, for hypetcarbic encephalopathy due to COPD who get sometimes days of BIPAP to gradually bring down their CO2. Usually, their off BIPAP by the time they go to the ward. However, BIPAP is our standard approach to this patient, and if they get worse on… Read more »
Great post as usual, keep up good work. Due to poor resources, no vent. No cpap, usually use bmv to blow off CO2 in these patients to avoid intubation as our ICU is very small. Tried it 2 ways with O2 attracted to bvm and secondly to avoid hyperoxemia and furher v/q mismath placed a nasal canula underneath the bvm and took O2 line off the Bvm.( got the idea from DSL) . two handed technique to get good seal as nasal canula makes it a lil more difficult….. What u think abt this latter approach if u have to… Read more »
Scott, I too have thought about doing this. Never done it yet. You’ve got me interested enough now to try it. And since I’m an anesthesiologist skilled enough with sedation and with an LMA, I’ll try it with an LMA sometime too. Just have to wait for the appropriate patient.
By the way, we stopped doing ABGs almost 15 years ago. Since most ICU patients have a central line and adequate pulse oximetry, a central venous blood gas (which can be obtained at the drop of a hat from the central line) and the Sat are all you need to get information on ventilation, perfusion, oxygenation, and the metabolic state. What I teach the new nurses is that the CVBG is the most important lab test we get (esp when the blood gas machine give us a lactic acid also). And I’m glad to say the academic literature has finally… Read more »