Respiratory Guidelines

So… what better to do on Christmas Day than post a blog about respiratory guidelines…

So here are carefully selected highlights of BTS and NICE Guidelines to aid your digestion!

BTS Guidelines on NIV

taken from:

BTS NIV Guidelines

Non Invasive Ventilation in COPD with type 2 respiratory failure

Indications:
• persisting respiratory acidosis after max 1 hour of standard medical therapy
• pH <7.26 may benefit but have higher risk of failure therefore should be managed in HDU or ICU

How to do it:

• Full face mask should be used for 1st 24hours

• IPAP 10 to start, then increase as toleratied

• EPAP 4-5cms H2O
• ABG at 1hour, 4 hours and 12 hours after starting
• management plan in the even to NIV failure should be made at the outset
• Minimum ratio 1 nurse to 2 NIV patients

So… what is ‘standard medical therapy‘ then?
• O2 88-92
• nebulised salbutamol 2.5 – 5mg
• nebulised ipratropium 500 micrograms
• prenisolone 30mg
• antibiotics
• within 1st hour
Must be
Clinical criteria
• Sick but not moribund
• *Able to protect airway
• *Conscious and cooperative
• No excessive respiratory secretions
• Potential for recovery to quality of life acceptable to the patient
• Patient’s wishes considered
Exclusion criteria for NIV
• facial burns/trauma/recent facial or upper airway surgery
• vomiting
• fixed upper airway obstruction
*Consider NIV if unconscious and endo-tracheal intubation deemed inappropriate or NIV is to be provided in a critical care setting. There are data 36 [1B] to support the use of NIV in patients who are in a state of coma secondary to hypercapnoea and who respond rapidly to this treatment
Exculsion criteria

• undrained pneumothorax
• upper gastrointestinal surgery
• inability to protect the airway
• copious respiratory secretions
• life threatening hypoxaemia
• haemodynamically unstable requiring inotropes/pressors (unless in a critical care unit)
• severe co-morbidity
• confusion/agitation
• bowel obstruction
• patient declines treatment

NIV is not the treatment of choice in patients who have heart failure or radiological consolidation but is sometimes used if escalation to intubation and ventilation is deemed inappropriate.

Asthma

So we’ve all had it drummed into us that asthmatics should NEVER become acidotic, shouldn’t have a normal pCO2 (unless they’re quite well, obviously), and can become unwell quite quickly…

The ones I find are the ones to look out for are the COPD patients who still have quite a high degree of reversibility (I think, obviously I don’t whip out a PFT machine to check) but who get under treated and an acidosis tolerated.

So here you go:

Asthma

https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2014/

 

Main points

4 types

• moderate – criteria of exclusion
• acute severe  – any 1 of the criteria: PEF, RR >25, >110/min, inability to complete sentences in 1 breath
• life threatening asthma: any 1 of <33%, SpO2 <92%, PaO2 <8kPa, normal PaCO2, silent chest, cyanosis, poor resp effort, arrhythmia, exhaustion, altered conscious level, hypotension
• near fatal asthma – raised PaCo2 and/or requiring mechanical ventilation with raised inflation pressure

 

Management

• Admit if any feature of life threatening or near fatal asthma attack
• admit if any feature of severe asthma attack persisting after initial treatment
• If PEFR >75% best or red 1 hour after initial treatment may be discharged unless other reasons why admission may be appropriate

 

Treatment

• o2
• steroids
• ipratropium if features of acute severe or life threatening asthma or poor response to beta agonises

Need to let GP know within 24hours 

COPD: NICE

I love a good guideline!  Particularly if it backs up my gut instinct about admission/discharge.

Definition:

• airflow obstruction that is not fully reversible
• does not changed markedly over several months
• is usually progressive

Management of exacerbations

• give self management advice on responding promptly to symptoms
• starting appropriate treatment
• use of NIV
• use of hospital at home or assisted discharge schemes

MRC dyspnoea scale ***easy marks in FCEM***

1. Not troubled by breathlessness except on strenuous exercise
2. Short of breath when hurrying on a level or when walking up a slight hill
3. Walks slower than most people on the level, stops after a mile or so, or stops after 15 mins walking at own pace
4. Stops for breath after walking 100 yds
5. Too breathless to leave the house, or breathless on dressing

Table 7 Factors to consider when deciding where to treat the patient

Factor	Treat at home	Treat in hospital
Able to cope at home	Yes	No
Breathlessness	Mild	Severe
General condition	Good	Poor/ deteriorating
Level of activity	Good	Poor/confined to bed
Cyanosis	No	Yes
Worsening peripheral oedema	No	Yes
Level of consciousness	Normal	Impaired
Already receiving LTOT	No	Yes
Social circumstances	Good	Living alone/not coping
Acute confusion	No	Yes
Rapid rate of onset	No	Yes
Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes)	No	Yes

© NICE 2010. All rights reserved.

 

Chronic obstructive pulmonary disease (CG101)

SaO2 < 90%	No	Yes
Changes on chest radiograph	No	Present
Arterial pH level	≥ 7.35	< 7.35
Arterial PaO2	≥7kPa	<7kPa

 

Patients should be encouraged to respond promptly to symptoms of an exacerbation if

• sputum purulent: antibiotics
• increased breathlessness: increase bronchodilators
• steroids if increased breathlessness interferes with ADLS

NICE Pneumonia Guidelines ***NEW***

• Pneumonia  = infection of lung tissue
  • symptoms and signs of LRTI with CXR showing new shadowing that is not due to another cause
• Lower respiratory tract infection

Consider pneumonia as a cause if:

Acute illness with cough as main symptom with at least 1 other lower rest tract symptoms (severe, sputum prod, breathlessness, wheeze or chest discomfort and no alternative explanation

• If presenting with symptoms and in primary care, use CRP if a diagnosis of pneumonia has not been made and therefore it is not clear whether antibiotics should be prescribed

if <20, no antibiotics

if >20 but <100 consider delayed prescription

give if CRP >100

• Antibiotics

5 day course if low severity

• Explain

1 week fever should resolve

4 weeks chest pain and sputum should have decreased

6 weeks cough and breathlessness should have reducted

• 3 months most symptoms resolve but fatigue may still be present
• 6 months most people will feel back to normal

• CRB65 test remains unchanged

If moderate or high severity

• take blood and sputum cultures and consider pnuemococcal and legionella urinary antigen tests

 

Antibiotics:

• amoxicillin in pref to macrolide or tetracycline
• consider extending for longer than 5 days if symptoms do not respond after 3 days
• 7-10 days if moderate or high severity community acquired pneumonia, consider dural management for mod and high, with betalactamase stable anti b if high severity

 

Discharge

Do not discharge from hospital if in past 24 hours they have had 2 or more

• temp higher than  37.5 (and consider delaying if temp higher than 37.5
• RR>24
• HR >100/min
• SBP <90 bpm
• O2 <90%
• abnormal mental status
• inability to eat without assistance

 

http://www.nice.org.uk/guidance/cg191/resources/pneumonia-in-adults-diagnosis-and-management-35109868127173

That’s all for today!