The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

Use of noninvasive positive pressure ventilation in the emergency room to prevent subsequent intubation: an exceptional case

Michael A Gentile, Jhaymie L Cappiello, Dennis Yetsko
Duke University Medical Center, Durham, NC USA

Introduction: It has been established that noninvasive positive pressure ventilation (NPPV) reduces the need for endotracheal intubation in acute exacerbation of chronic obstructive pulmonary disease (COPD). NPPV also reduces morbidity and mortality rates as well as length of stay in intensive care unit (ICU) and hospitalization stay. We describe the use and outcome of NPPV initiated in our emergency room (ER) for a severe case of acute respiratory failure (ARF).

Case Summary:  A 56 y/o male with a history of COPD arrived via stretcher at our ER with shortness of breath. Physical examination revealed the patient to be lethargic, unable to speak, pale, and coughing. Vital signs were: HR 114, RR 28, BP 178/118. Chest auscultation revealed poor air movement with bilateral expiratory wheezes. After two doses of inhaled Albuterol, the patient was place on NPPV with a full face mask. NPPV was performed using a T-Bird ventilator, FiO2 adjusted to maintain saturations > 90%, Pressure assist mode with rate 0, inspiratory pressure 15 cmH2O, inspiratory time 1.0 seconds, and PEEP 5 cmH2O. Albuterol dosing was repeated q1h via MDI. Following 30 minutes of NPPV, neurological status improved and the patient was transferred to the Medical Intensive Care Unit (MICU) after three hours of ER treatment. After seven hours of NPPV, the patient refused to use NPPV and was placed on a nasal cannula at a flow of 5 lpm. The patient was discharged from the MICU after twenty six hours. The below table represents gas exchange and ventilator settings.  

ABG results were as follows:
  0 Hr  30min 1 Hr  7 Hr 
pH  7.07 7.16 7.25 7.32

PaCO184 135 115 84

PaO2  58  106 68  84

IPAP  15  15 12 N/A

EPAP  5  5 5  N/A

Discussion: This case illustrates the successful use of early initiation of NPPV in the emergency room for patients with ARF. In this setting, NPPV was initiated to stabilize a failing respiratory drive in an oxygen dependant, non-hypotensive COPD patient. Thus, allowing for the progression of a more detailed assessment of the patients condition and placement of arterial and venous access lines. This patient responded favorably. In supporting the respiratory drive and reversing respiratory pump failure, hemodynamic stress is decreased, lung aeration is improved and the patient can be more clearly examined for the underlying cause of their illness. Early use of NPPV, in this regard, can assist the clinician in developing an appropriate course of therapy directed toward the cause of failure uncomplicated with the use of sedatives and paralytics needed for invasive airway placement and maintenance. Further study is warranted in the use of NPPV as a first line therapeutic adjunct for non-hypotensive ARF in the emergency room setting.

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