Tasty Morsels of EM 108 – #FRCEM COPD and NIV

4 Aug

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

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

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

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…

When should we use NIV?

From the BTS guidelines

  • 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

What prognostic features should we take into consideration in NIV?

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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