I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here
(Featured image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 6410)
There are two guidelines here, NICE COPD in 2010 and BTS has one on hypercapnic failure in 2016
How do you define COPD?
- airflow obstruction: FEV1/FVC = <0.7
- note if FEV1 is >80% predicted then needs some additional symptoms
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Who needs admitted?
- there’s quite a list in the NICE guidance p37 but of note there are a lot of very reasonable things like home circumstances and bed bound etc… not just numbers on an ABG
- of note the numbers they use are sats <90 and PaO2 <7 for admission
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What investigations should be done on exacerbations referred to ED?
- there’s the usual list in here including the dreaded ABG on everyone…
- there’s little evidence for most of these of course but good to know what’s in the guidelines
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How should we treat exacerbations?
- if hypercapnic nebs with air not oxygen
- steroids for most if not all
- 30mg for 7-14 days
- antibitoics for purulent sputum (penicillin, macrolide or doxy all fine as per NICE)
- of note aminophylline is still in here as an option
- doxapram is only to be used if no NIV available or if you’re trapped in a time machine to the late 90s…
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When should we use NIV?
- ph<7.35
- pCO2>6.5
- despite optimal medical Rx
- they have a nice statement that it’s OK to try NIV even on the severely acidotic patient but only if everything is ready for intubation if needed
- the above are for COPD but there 2 othe important categories
- obesity hypoventilation syndrome where the criteria are pretty much the same as COPD
- neuromuscular disease where vital capacity < 1 L or the usual type II RF
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What prognostic features should we take into consideration in NIV?
- advanced age alone shouldn’t preclude a trial
- worsening physiology means it’s not working (duh…)
- of note they emphasise that we tend to underestimate survival in COPD patients who are intubated and sometimes that’s a much better option than NIV. Here Kirsty Challen talk about it here on the RCEM Learning podcast
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How should we do NIV?
- recommend machines specific for NIV (so against my love of the oxylog for this…)
- intermittent measurement of CO2 and ph needed but they don’t say how you do this
- aim sats 88-92
- change the vent settings before increasing the FiO2
- from figure 1 in the BTS guidelines the recommended initial settings are
- EPAP 3
- IPAP 15
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“neuromuscular disease where…”
Talk about leaving us hanging…
Thanks for these, they’re very helpful!
oops! added now. Thanks