Respiratory Management in Critical Care Respiratory Management in Critical Care Edited by M J D Griffiths and T W Evans Edited by M J D Griffiths and T W Evans ___________________________________________________ Respiratory Management in Critical Care Edited by MJD Griffiths Unit of Critical Care, Imperial College of Science, Technology and Medicine, Royal Brompton Hospital, London, UK TW Evans Unit of Critical Care, Imperial College of Science, Technology and Medicine, Royal Brompton Hospital, London, UK iii © BMJ Publishing Group 2004 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2004 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1729 3 Typeset by BMJ Electronic Production Printed and bound in Spain by GraphyCems, Navarra iv Contributors K Atabai Lung Biology Center, Department of Medicine, University of California, San Francisco, USA SV Baudoin Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK GJ Bellingan Department of Intensive Care Medicine, University College London Hospitals, The Middlesex Hospital, London, UK RM du Bois Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK RJ Boyton Host Defence Unit, Royal Brompton Hospital, London, UK S Brett Department of Anaesthesia and Intensive Care, Hammersmith Hospital, London, UK JJ Cordingley Department of Anaesthesia and Intensive Care, Royal Brompton Hospital, London, UK PA Corris Department of Respiratory Medicine, Cardiothoracic Block, Freeman Hospital, Newcastle upon Tyne, UK J Cranshaw Unit of Critical Care, NHLI Division, Imperial College of Science, Technology and Medicine, Royal Brompton Hospital, London, UK J Dakin Unit of Critical Care, NHLI Division, Imperial College of Science, Technology and Medicine Royal Brompton Hospital, London, UK AC Davidson Departments of Critical Care and Respiratory Support (Lane Fox Unit), Guys & St Thomas’ Hospital, London, UK SC Davies Department of Haematology and Sickle Cell Unit, Central Middlesex Hospital, London, UK J Dunning Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge and Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK TW Evans Unit of Critical Care, NHLI Division, Imperial College of Science, Technology and Medicine, Royal Brompton Hospital, London, UK S Ewig Institut Clinic De Pneumologia i Cirurgia Toracica, Hospital Clinic, Servei de Pneumologia i Al.lergia Respiratoria, Barcelona, Spain CS Garrard Intensive Care Unit, John Radcliffe Hospital, Oxford, UK A Gascoigne Department of Respiratory Medicine and Intensive Care, Royal Victoria Infirmary, Newcastle upon Tyne, UK J Goldstone Department of Intensive Care Medicine, University College London Hospitals, The Middlesex Hospital, London, UK P Goldstraw Department of Thoracic Surgery, Royal Brompton Hospital, London, UK. JT Granton University Health Network, Mount Sinai Hospital and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada ME Griffith Department of Renal Failure, St Mary’s Hospital NHS Trust, London, UK MJD Griffiths Unit of Critical Care, NHLI Division, Imperial College of Science, Technology and Medicine, Royal Brompton Hospital, London, UK N Hart Sleep and Ventilation Unit, Royal Brompton and Harefield NHS Trust, London, UK AT Jones Adult Intensive Care Unit, Royal Brompton Hospital, London, UK BF Keogh Department of Anaesthesia and Intensive Care, Royal Brompton Hospital, London, UK OM Kon Chest and Allergy Department, St Mary’s Hospital NHS Trust, London, UK vii SE Lapinsky Mount Sinai Hospital and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada RM Leach Department of Intensive Care, Guy’s & St Thomas’ NHS Trust, London, UK JL Lordan Department of Respiratory Medicine, Cardiothoracic Block, Freeman Hospital, Newcastle upon Tyne, UK V Mak Department of Respiratory and Critical Care Medicine, Central Middlesex Hospital, London, UK MA Matthay Cardiovascular Research Institute and Departments of Medicine and Anesthesia, University of California, San Francisco, USA K McNeil Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge and Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK DM Mitchell Chest and Allergy Department, St Mary’s Hospital NHS Trust, London, UK ED Moloney Imperial College School of Medicine at the National Heart and Lung Institute, Royal Brompton Hospital, London, UK NW Morrell Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge and Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK P Phipps Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia AK Simonds Sleep and Ventilation Unit, Royal Brompton and Harefield NHS Trust, London, UK AS Slutsky Department of Critical Care and Department of Medicine, St MichaelÆs Hospital, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada SR Thomas Department of Respiratory Medicine, St George’s Hospital, London, UK A Torres Institut Clinic De Pneumologia i Cirurgia Toracica, Hospital Clinic, Servei de Pneumologia i Al.lergia Respiratoria, Barcelona, Spain DF Treacher Department of Intensive Care, Guy’s & St Thomas’ NHS Trust, London, UK AU Wells Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK T Whitehead Department of Respiratory Medicine, Central Middlesex Hospital, London, UK viii Contents Contributors vii Introduction MJD Griffiths, TW Evans 1 1. Pulmonary investigations for acute respiratory failure J Dakin, MJD Griffiths 3 2. Oxygen delivery and consumption in the critically ill RM Leach, DF Treacher 11 3. Critical care management of community acquired pneumonia SV Baudouin 19 4. Nosocomial pneumonia S Ewig, A Torres 24 5. Acute lung injury and the acute respiratory distress syndrome: definitions and epidemiology K Atabai, MA Matthay 31 6. The pathogenesis of acute lung injury/acute respiratory distress syndrome GJ Bellingan 38 7. Critical care management of severe acute respiratory syndrome (SARS) JT Granton, SE Lapinsky 45 8. Ventilator induced lung injury T Whitehead, AS Slutsky 52 9. Ventilatory management of acute lung injury/acute respiratory distress syndrome JJ Cordingley, BF Keogh 60 10. Non-ventilatory strategies in acute respiratory distress syndrome J Cranshaw, MJD Griffiths, TW Evans 66 11. Difficult weaning J Goldstone 74 12. Critical care management of respiratory failure resulting from chronic obstructive pulmonary disease AC Davidson 80 13. Acute severe asthma P Phipps, CS Garrard 86 14. The pulmonary circulation and right ventricular failure K McNeil, J Dunning, NW Morrell 93 15. Thoracic trauma, inhalation injury and post-pulmonary resection lung injury in intensive care ED Moloney, MJD Griffiths, P Goldstraw 99 16. Illustrative case 1: cystic fibrosis SR Thomas 106 17. Illustrative case 2: interstitial lung disease AT Jones, RM du Bois, AU Wells 110 18. Illustrative case 3: pulmonary vasculitis ME Griffith, S Brett 114 19. Illustrative case 4: neuromusculoskeletal disorders N Hart, AK Simonds 117 20. Illustrative case 5: HIV associated pneumonia RJ Boyton, DM Mitchell, OM Kon 120 21. Illustrative case 6: acute chest syndrome of sickle cell anaemia V Mak, SC Davies 125 22. Illustrative case 7: the assessment and management of massive haemoptysis JL Lordan, A Gascoigne, PA Corris 128 Index 135 v ___________________________________________________ Introduction M J D Griffiths, T W Evans T he care of the critically ill has changed radically during the past 10 years. Technologi- cal advances have improved monitoring, organ support, and data collection, while small steps have been made in the development of drug therapies. Conversely, new challenges (e.g. severe acute respiratory syndrome [SARS], multiple antimicrobial resistance, bioterrorism) continue to arise and public expectations are elevated, sometimes to an unreasonable level. In this book we summarize some of the most important medi- cal advances that have emerged, concentrating particularly on those relevant to the growing numbers of respiratory physicians who pursue a subspecialty interest in this clinical arena. EVOLUTION OF INTENSIVE CARE MEDICINE AS A SPECIALTY In Europe intensive care medicine (ICM) has been one of the most recent clinical disciplines to emerge. During a polio epidemic in Denmark in the early 1950s mortality was dramatically reduced by the application of positive pressure ventilation to patients who had developed respi- ratory failure and by concentrating them in a designated area with medical staff in constant attendance. This focus on airway care and ventilatory management led to the gradual intro- duction of intensive care units (ICU), principally by anaesthesiologists, throughout Western Eu- rope. The development of sophisticated physio- logical monitoring equipment in the 1960s facili- tated the diagnostic role of the intensivist, extending their skill base beyond anaesthesiology and attracting clinicians trained in general inter- nal medicine into the ICU. Moreover, because res- piratory failure was (and still is) the most common cause of ICU admission, pulmonary physicians, particularly in the USA, were fre- quently involved in patient care. ARE INTENSIVE CARE UNITS EFFECTIVE? Does intensive care work and does the way in which it is provided affect patients’ outcomes? A higher rate of attributable mortality has been documented in patients who are refused intensive care, particularly on an emergency basis. 1 Clinical outcome is improved by the conversion of so-called “open” ICU to closed facilities in which patient management is directed primarily by intensive care specialists. 23 Superior organisa- tional practices emphasising strong medical and nursing leadership can also improve outcome. 4 The emergence of intermediate care, high de- pendency, or step down facilities has attempted to fill the growing gap between the level of care that may be provided in the ICU and that in the general wards. Worryingly, the time at which patients are discharged from ICU in the UK has a demonstrable effect on their outcome. 5 Early identification of patients at risk of death—both before admission and after discharge from the ICU—may decrease mortality. 6 Patients can be identified who have a low risk of mortality and who are likely to benefit from a brief period of more intensive supervision and care. 7 Designated teams that are equipped to transfer critically ill patients between specialist units have a crucial role to play in ensuring that patient care and the use of resources are optimized. 8 Finally, long term follow up of the critically ill as outpatients following discharge from hospital may identify problems of chronic ill health that require active management and rehabilitation. 9 TRAINING IN INTENSIVE CARE MEDICINE Improved training of medical and nursing staff and organisational changes have undoubtedly played their part in improving the outcome of critical illness. ICM is now a recognised specialty in two European Union member states, namely Spain and the UK. Where available, training in ICM is of variable duration and is accessible vari- ably to clinicians of differing base specialties. In Spain 5 years of training are required to achieve specialist status, 3 years of which are in ICM. In France, Germany, Greece, and the UK, 2 years of training in ICM are required, in addition to thos needed for the base specialty (usually anaesthesi- ology, respiratory or general internal medicine). In Italy, only anaesthesiologists may practice ICM. There is considerable variation between members states of the European Union regarding the amount of exposure to ICM in the training of pulmonary physicians as a mandatory (M) or optional (O) requirement: France and Greece 6 months (O), Germany 6 months (M, as part of general internal medicine), UK 3 months (O), and Italy and Spain none. TRAINING IN INTENSIVE CARE MEDICINE IN THE UK An increasing number of appointments in ICM are now available to trainees in general internal medicine at senior house officer level, usually for a period of 3 months. For specialist registrars, a number of options have emerged. First, in some specialties (e.g. respiratory medicine, infectious diseases) specialist registrars are already encour- aged to undertake a period of training in ICM. Second, 6 months of training in anaesthesia plus 6 months of ICM (in addition to 3 months of experience as a senior house officer) in approved programmes confers intermediate accreditation by the Inter-Collegiate Board for Training in ICM (http://www.ics.ac.uk/ibticm_board.html). Finally a further 12 months of experience in recognised units can lead to the award of a Certificate of Completion of Specialist Training (CCST) com- bined with base specialty. Importantly, up to 12 months of such experience can be substituted for 6 months in general internal medicine (for anaesthesia) and respiratory medicine (for ICM). Thus, a period of 5 years is needed for intermediate accredita- tion in ICM plus a CCST in general internal and respiratory medicine, and 6 for the award of a treble CCST. Programmes are now becoming available in all regions to enable trainees with National Training Numbers from all base specialties to achieve these training requirements and the proscribed com- petencies in ICM. THE FUTURE FOR INTENSIVE CARE MEDICINE: A UK PERSPECTIVE The changing requirements and increased need for provision of intensive care were recognised in the UK in the late 1990s by the Department of Health which commissioned the report entitled “Comprehensive Critical Care” produced by an expert group to provide a blue print for the future development of ICM within the NHS. 10 A central tenet of the report is the idea that the service should extend to the provision of critical care throughout the hospital, and not merely to patients located within the traditional confines of the ICU. To this end, the adoption of a new classification of illness severity based on dependency rather than location was recommended. Tra- ditionally, the critically ill were defined according to their need for intensive care (delivered at a ratio of one nurse to one patient) and those requiring high dependency care (delivered at a ratio of one nurse to two or more patients). The new classification is based on the severity of the patient’s illness and on the level of care needed (table 1). The report therefore represents a “whole systems” approach encompassing the provision of care, both before and after the acute episode within an integrated system. To initiate and oversee the implementation of this policy, 29 local “networks” have been established, with an administra- tive and clinical infrastructure. Networks will be used to pilot national initiatives and enable groups of hospitals to establish locally agreed practices and protocols. Critically ill patients will be transferred between network hospitals if facilities or expertise within a single institution are inadequate to provide the necessary care, thereby obviating the problems associated with moving such patients over long distances to access a suitable bed. CONCLUSION How should the respiratory physician react to these develop- ments? We suggest that an attachment in ICM for all respira- tory trainees is necessary. Indeed, specialty recognition and the increased availability of training opportunities should encourage some trainees from respiratory medicine to seek a CCST combined with ICM. Second, we suggest that changes in the organisational and administrative structure of intensive care services heralded by the publication of “Comprehensive Critical Care” are likely to impact most heavily on respiratory physicians. For example, respiratory support services using non-invasive ventilation are particularly attractive in provid- ing both “step up” (from the general wards) and “step down” (from the ICU) facilities. In the USA, respiratory physicians have for a long time been the major providers of critical care. In the UK and the rest of Europe, given appropriate resources and training, the pulmonary physician is ideally suited to become an integral component of the critical care service within all hospitals. 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Table 1 Proposed classification of critical illness 10 Level 0 Patients whose needs can be met through normal ward care in an acute hospital Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team Level 2 Patients requiring more detailed observations or intervention including support for a single failing organ system or postoperative care and those “stepping down” from higher levels of care Level 3 Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multiorgan failure 2 Respiratory Management in Critical Care [...]... Cephalosporin II or Cephalosporin III • Cefuroxime • Cefotaxime • Ceftriaxone or Aminopenicillin/β-lacatamase inhibitor Third or fourth generation quinolone or Clindamycin/aztreonam Late onset, no risk factors • Amoxicillin/clavulanic acid • Levofloxacin • Clindamycin • Aztreonam Quinolone or Aminoglycoside • Ciprofloxacin • Gentamicin • Tobramycin • Amikacin plus Antipseudomonal β-lactam/β-lactamase inhibitor... Efficacy of chest radiography in a respiratory intensive care unit A prospective study Chest 1985;88:691–6 70 Greenbaum DM, Marschall KE The value of routine daily chest x-rays in intubated patients in the medical intensive care unit Crit Care Med 1982;10:29–30 71 Strain DS, Kinasewitz GT, Vereen LE, et al Value of routine daily chest x-rays in the medical intensive care unit Crit Care Med 1985;13:534–6 72... strategy would increase VO2 and prevent multiple organ failure DO2 was increased using vigorous intravenous fluid loading and inotropes, usually dobutamine The mathematical linkage caused by calculating both VO2 and DO2 using common measurements of Qt and CaO23 and the “physiological” linkage resulting from the metabolic effects of inotropes increasing both VO2 and DO2 were confounding factors in many of... ultrasound-aided thoracentesis in mechanically ventilated patients Intensive Care Med 1999;25:955–8 86 Keske U Ultrasound-aided thoracentesis in intensive care patients Intensive Care Med 1999;25:896–7 87 Miller WT Jr, Tino G, Friedburg JS Thoracic CT in the intensive care unit: assessment of clinical usefulness Radiology 1998;209:491–8 88 Intensive Care Society Guidelines for the transport of the critically ill adult... normal during hypoxia because the metabolic pathways utilising glucose during aerobic metabolism may be blocked at several points.31 Inhibition of phosphofructokinase blocks glucose utilisation without an increase in lactate concentration In contrast, endotoxin and sepsis may inactivate pyruvate dehydrogenase, preventing pyruvate utilisation in the Krebs cycle resulting in lactate production in the absence... guidelines for diseases caused by Aspergillus Infectious Diseases Society of America Clin Infect Dis 2000;30:696–709 46 McWhinney PH, Kibbler CC, Hamon MD, et al Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years’ experience Clin Infect Dis 1993;17:397–404 47 Denning DW, Evans EG, Kibbler CC, et al Guidelines for the investigation of invasive fungal infections... mortality in NIV treated patients is delay in intubation which was demonstrated in the emergency room study The message is clear Non-invasive respiratory support (CPAP or NIV) should only be given to patients with severe CAP in designated and properly staffed critical care areas In addition, enthusiasm for non-invasive support should not delay intubation, particularly in patients without COPD Respiratory Management. .. by failure to maintain enteral nutrition In sepsis and experimental endotoxaemia the oxygen extraction ratio is reduced and the critical DO2 increased to a greater extent in splanchnic tissue than Respiratory Management in Critical Care in skeletal muscle.23 This tendency to splanchnic ischaemia renders the gut mucosa “leaky”, allowing translocation of endotoxin and possibly bacteria into the portal... ischaemia-reperfusion injury than rejection or infection.20 21 A recent study retrospectively examined the strategy of performing BAL and TBB simultaneously rather than as staged procedures in mechanically ventilated patients with unexplained pulmonary in ltrates.22 Pneumothorax occurred in nine out of 38 patients, six requiring intercostal tube drainage; four out of 38 suffered significant bleeding that was self limiting... of computed tomography in the initial assessment of the critical care patient with chest trauma Crit Care Med 2000;28:1370–5 96 Enderson BL, Abdalla R, Frame SB, et al Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use J Trauma-Injury Infect Crit Care 1993;35:726–9; discussion 729–30 Respiratory Management in Critical Care 97 Wolfman NT, Gilpin JW, Bechtold RE, et . (O), and Italy and Spain none. TRAINING IN INTENSIVE CARE MEDICINE IN THE UK An increasing number of appointments in ICM are now available to trainees in general internal medicine at senior house. rehabilitation. 9 TRAINING IN INTENSIVE CARE MEDICINE Improved training of medical and nursing staff and organisational changes have undoubtedly played their part in improving the outcome of critical illness a subspecialty interest in this clinical arena. EVOLUTION OF INTENSIVE CARE MEDICINE AS A SPECIALTY In Europe intensive care medicine (ICM) has been one of the most recent clinical disciplines to emerge.