Chronic Lung Disease and Debilitated Elderly in Critical Care
LONG-TERM NONINVASIVE MANAGEMENT FOR CHRONIC LUNG DISEASE
People who have symptomatic chronic lung disease (e.g. obstructive or infiltrative) and low baseline oxygen saturation in the blood (O2 sat measured with an oximeter) need to be managed with conventional therapies, which include:
Chest physical therapy (Chest PT)
However, these people are also at risk of having breathing muscle dysfunction. This can result in or worsen chronic accumulation of carbon dioxide in the blood (known as hypercapnia); ventilatory insufficiency and oxygenation impairment follow. Conventional management overwhelmingly supports the use of bi-level positive airway pressure (bi-level PAP) for symptomatic individuals with hypercapnia despite the fact that for people with chronic obstructive pulmonary disease, bi-level PAP can:
Increase air trapping
Increase respiratory distress
Further, these people are at risk of having barotrauma, which is injury to the lung caused by a change in air pressure. In this case, barotrauma can be caused by applying inspiratory pressures.
Yet, for a number of reasons, the benefits of long-term use of bi-level PAP during sleep (which is sometimes extended into daytime hours) can outweigh the risks. Benefits include relieving hypercapnia and lowering work of breathing, which decreases strain placed on diaphragm and other breathing muscles.
When these people have episodes of serious breathing problems, such as acute on chronic respiratory insufficiency, which is most often due to trapping of airway secretions, they may require intubation. Then, there is a strong tendency to resort to tracheotomy rather than attempt long-term noninvasive respiratory management (which includes assisted airway secretion mobilization and assisted coughing). At times, tracheotomy and even intubation may be necessary.
There are centers in Europe that use iron lungs to avoid intubation for many patients with hypoxic hypercapnic coma (OCL1,OCL2). Centers in Europe have also reported successful avoidance of intubation for 80% of patients comatose from high CO2 levels in the blood due to chronic obstructive pulmonary disease (COPD), cardiogenic shock, or hypercapnic respiratory failure due to other causes by using bi-level PAP at settings (OCL3):
Inspiratory PAP up to 30 cm H2O
Expiratory PAP of 5 cm H2O
Supplemental oxygen to maintain O2 sat at 92% or above.
Bi-level PAP should be used at an inspiratory-minus-expiratory span > 18 cm H2O (IPAP - EPAP > 18 cm H2O). This is termed high-span bi-level PAP and can provide full ventilatory support for patients with normal or increased pulmonary compliance. In addition, it has been estimated that noninvasive ventilatory support (NVS) can be used to avoid intubation for lung disease patients about 70% of the time (OCL4).
The following patients are examples of how noninvasive respiratory management can be safe and effective:
1. The patient in Figure OCLD1 is a 62-year-old man with COPD, atherosclerotic heart and coronary artery disease, hypertension, peptic ulcers, steroid-induced diabetes, and a history of tachyarrhythmias. He was placed on continuous oxygen therapy. His baseline PaCO2 was 48 to 61 mm Hg before he suddenly developed acute on chronic respiratory failure. He had an Advance Directive refusing intubation. He developed agonal breathing and coma.
First, we attempted nasal NVS at full support settings, but all of the air leaked out of the mouth with his agonal expiration. Next, we attempted NVS via a lipseal, which prevents leakage of air from the mouth. His PaCO2 decreased, O2 sat on room air became 94 to 95%, and he awoke using continuous NVS (CNVS) via a 15-mm angled mouthpiece. He was discharged home directly from the intensive care unit (ICU), and he avoided prolonged stays in long-term acute care facilities and chronic ventilator units. He continued to be CNVS-dependent using daytime mouthpiece and noctural nasal interfaces for the next two years. Noninvasive respiratory management with CNVS not only permitted him to avoid tracheotomy, but also gave him two additional years of life in his home environment.
2. A man developed acute on chronic respiratory failure with agonal breathing and severe hypercapnia. His lungs had been damaged in an explosion. In the past, he had been intubated 24 times over a 19-year period. He had an Advance Directive refusing any further intubation. After he attempted and failed nasal NVS, he attempted NVS via a lipseal, awoke, and was dependent on CNVS for 11 months before dying at home.
OUTCOMES OF EXTUBATION OF CHRONIC LUNG DISEASE
AND DEBILITATED ELDERLY IN CRITICAL CARE
Removal of an airway tube passed down the throat (i.e. endotracheal tube).
As of 2014, there were at least nine randomized controlled trials comparing extubation of 1144 critical care patients (including those with COPD), who passed ventilator weaning parameters and spontaneous breathing trials, to (A) bi-level PAP vs. (B) supplemental oxygen only. When compared with extubation to supplemental oxygen, extubation of patients to bi-level PAP for up to three days resulted in a significantly decreased rate of:
ICU lengths of stay.
Sometimes, patients have some combination of primary lung disease, respiratory muscle dysfunction, and generalized debility; and they are intubated without having been offered NVS or mechanical insufflation-exsufflation (MIE). Other times, patients develop respiratory failure because of inadequate or ineffective home MIE use; MIE should be used as frequently as needed to maintain oxygen saturation above 94%.
Once intubated, after ventilator weaning parameters and spontaneous breathing trials fail, the patients are told that tracheotomy is necessary for survival. However, this may not always be true.
Typically, there are two reasons for extubation failure:
1. Some patients have severe central nervous system disorders (and may be demented and unable to cooperate), but they have effective reflex ability to breathe once airway congestion is cleared. With conventional management, oxygen desaturation below 95% is “treated” with supplemental oxygen administration, the airways remain congested, and extubation attempts fail. Rather, we recommend that patients use MIE via the airway tube to maintain oxygen saturation above 94%.
2. Other patients fail extubation because they are too weak to breathe even when oxygen saturation remains over 94% on room air. When patients fail ventilator weaning parameters and spontaneous breathing trials, or if they fail extubations, then physicians will recommend palliative care (extubation to death) or tracheotomy (an invasive airway tube passed through the neck and into the windpipe). Tracheotomy results in:
The need for prolonged hospitalization or institutional stays
The need for expensive ongoing nursing care
Possibly increased mortality
Decreased quality of life
Complications and inconveniences of invasive tracheostomy mechanical ventilation (TMV).
Often, tracheostomy tube cuffs are not deflated, so speech is impossible; and the tracheostomy tube results in more difficulty with swallowing food. In fact, the ethics of performing tracheotomy on 80 to 95-year-old people are routinely debated, but few centers use CNVS and MIE to avoid tracheotomy or the need for palliative care.
For intubated patients with mild to moderate lung disease, but without severe air trapping or decreased pulmonary compliance, minute ventilation must be increased to maintain PaCO2 below 40 mm Hg. As long as PaCO2 is maintained below 40 mm Hg, an attempt should be made to maintain the patient's oxygen saturation above 94% on room air. This can be accomplished by using MIE via the endotracheal airway tube without supplemental oxygen. If this fails, then supplemental oxygen can be administered to titrate oxygen saturation to approach 95%.
Supplemental oxygen should never be used in place of NVS (or adequate high-span bi-level PAP) for sufficient ventilatory assistance. Adequate and frequent MIE via the endotracheal tube (and other airway mobilization methods) should be used to eliminate airway mucus-associated desaturations. Supplemental oxygen administration should be avoided because it results in:
MIE should be used via the endotracheal airway tube to eliminate airway mucus when the oxygen saturation decreases below 95% or at the patient's request. However, unlike for a patient with normal lung tissue, people with lung disease are more susceptible to barotrauma. To minimize risk, the MIE can be used at an inspiratory pressure equal to that of the patient’s ventilator, but the expiratory pressures should be 50 to 60 cm H2O in order to achieve rapid and full clinical chest deflation and expulse airway secretions.
Debilitated elderly people are weakened and often malnourished during long stays in intensive care units (ICUs) for serious illnesses related to any organ system. During the stay, they become too weak to breathe, are intubated, and are told that they need tracheotomy. However, this may not always be true.
Once the primary reason for hospitalization and secondary lung conditions (e.g. pneumonia) are treated, the debilitated elderly person can become a candidate for safe and effective extubation to NVS and MIE (JBCV197,JBCV235). The patient should be medically stable without cardiovascular instability. MIE should be used via the endotracheal airway tube to maintain oxygen saturation above 94% on room air. Supplemental oxygen administration should be avoided.
The successful extubations of 20 critical care myopathy patients (e.g. debilitated elderly people weakened by long intensive care unit stays), who all failed ventilator weaning parameters and spontaneous breathing trials, has been recently reported (JBCV197,JBCV235).
OUTCOMES OF DECANNULATION OF CHRONIC LUNG DISEASE
AND DEBILITATED ELDERLY IN CRITICAL CARE
Removal of an airway tube passed through the neck and into the windpipe (i.e. tracheostomy tube).
In 1993 and 1994, Lou Saporito and Dr. Bach directed the ventilator unit of Kessler Rehabilitation Institute (West Orange, NJ). The majority of patients had COPD and used tracheostomy mechanical ventilation (TMV). They had previously failed ventilator weaning parameters and spontaneous breathing trials in long-term acute care facilities. Yet, they were candidates for tracheostomy tube removal (known as decannulation). After decannulation, most patients subsequently weaned to sleep-only NVS.
Weaning is accomplished by grabbing a mouthpiece for NVS fewer and fewer times as needed. The breathing muscles gradually regain strength. Because of difficulty clearing airway secretions, decannulation for people with COPD or related lung disease generally takes 6 to 8 weeks.
Decannulation permits people to return to the community, while avoiding the need for residence in ventilator units of nursing facilities (JBCVReports4).
The steps for decannulation of debilitated elderly people in critical care are the same as those needed for decannulation of SCI or NMD patients as described in those sections (JBCV231):
Through the tracheostomy tube, MIE pressures of 60 to 70 cm H2O are typically needed to achieve rapid and full apparent chest expansion followed by immediate full apparent lung deflation with adequate exsufflation cough flows.
Decannulation to CNVS should not be performed before the patient has sufficiently practiced CNVS with a capped fenestrated cuffless tracheostomy tube (JBCV231). Changing of the tracheostomy tube to this variety may be a necessary intermediate step.
After decannulation, MIE should be administered regularly by the patient's family member to maintain oxygen saturation above 94% on room air. Unless the patient had chronic bronchitis before undergoing tracheotomy, airway secretions typically resolve within two days of ostomy closure. Ostomy closure usually occurs in 1-3 days, but occasionally can take up to two months. If not closed by two months, suturing may be required.
The patient in Figure OCLD2 is a 53-year-old with Milroy’s disease. In the past, he had a right middle lobe pneumonectomy (age 11). He has a long history of loculated pleural effusions, pneumonias, thoracocenteses, and sclerosing procedures. He has a long history of morning headaches, daytime drowsiness, “asthmatic wheezing,” and bronchodilator administration. He has a six-month history of ambulation limited to 200 feet and stair climbing limited to five steps due to dyspnea.
He has three admissions for acute respiratory failure. On previous admissions, he had been discharged home. However, on this third episode, he required immediate intubation and bilateral chest tube placement for massive pleural effusions. He was treated for right lower lobe pneumonia, had another pleural sclerosing procedure, and had a biopsy that revealed pulmonary fibrosis. He failed ventilator weaning parameters and underwent tracheotomy on the 52nd day of hospitalization.
Although the pleural effusions and infiltrates eventually cleared, ventilator weaning continued to be impossible during the next four months. He became too debilitated to walk or perform other activities of self-care and daily living. He could no longer feed himself and swallowing was impaired by the prolonged intubation and tracheostomy tube, which transcended his swallowing muscles. He underwent gastrostomy. His maximum recorded vital capacity was 660 mL, and he had no ventilator-free breathing ability.
At this point, he was transitioned to CNVS via nasal and mouthpiece interfaces, used MIE via the tracheostomy tube, and was later decannulated to CNVS and MIE after 2 weeks with a cuffless fenestrated tracheostomy tube. His ostomy closed spontaneously; he became able to re-take all nutrition by mouth; and after 7 months of hospitalization, he was discharged to a rehabilitation facility, where he resumed ambulation with a rolling walker. Despite being CNVS-dependent, he returned to full-time employment as an accountant and was completely independent for all activities for the next 11 years. This patient had seven ventilators: three at home, three at work, and one for use while driving.
"We have received enormous gratitude from our decannulated patients, and none of hundreds that we have decannulated, except for several ALS patients, ever underwent re-tracheotomy."
-Dr. John R. Bach, MD
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