What are the guideline sources, guidelines and references for Hypercapnic respiratory failure ?
Guideline sources The following summarized guidelines for the evaluation and management of hypercapnic respiratory failure are prepared by our editorial team based on guidelines from the European Respiratory Society (ERS 2017) and the British Thoracic Society (BTS/ICS 2016). 1 2 3 3 3 3 4 Definition Hypercapnic respiratory failure (Type II Respiratory Failure) is a state of reduced alveolar ventilation with subsequent respiratory acidosis (PaCO >50 mmHg). 3 Epidemiology Hypercapnic respiratory failure is most frequently caused by drug overdose, COPD (COPD), obesity hypoventilation syndrome, obstructive sleep apnea (OSA), and the overlap syndrome of COPD and OSA. 3 Pathophysiology The overall prevalence of hypercapnic respiratory failure in patients with severe COPD is approximately 25%. 4 Disease course https://web.pathway.md/diseases/recwW4gUdPXoAtErL 1/4 6/24/23, 12:45 PM Hypercapnic respiratory failure Pathway Acute hypercapnic respiratory failure develops rapidly (within minutes to hours). Clinical manifestations include increasing dyspnea, lethargy, hypoxemic, disorientation, tachycardia, altered mental status, hypoventilation, hyperinflation, and need for ventilatory support. The disease decreases the quality of life with increased risk of readmission and longer periods of hospital stay. 3 Prognosis and risk of recurrence Hypercapnic respiratory failure in hospitalized patients is associated with significant mortality (36%). 3 Guidelines 1. Classification and risk stratification Prognostic tools: consider the use of validated tools to inform discussion regarding prognosis and appropriateness of invasive mechanical ventilation, keeping in mind that such tools are poorly predictive for individual patient use. C 2. Medical management Patients with COPD exacerbation: As per ERS 2017 guidelines, initiate bilevel noninvasive ventilation for patients with acute respiratory failure due to an acute exacerbation of COPD that leads to respiratory acidosis (pH 7.35). A Show 2 more As per BTS 2016 guidelines, initiate noninvasive ventilation in patients with an acute exacerbation of COPD with persistent respiratory acidosis (pH < 7.35 and PaCO > 6.5 kPa or 49 mmHg) despite optimal medical therapy. A Show 3 more Patients with acute asthma: avoid using noninvasive ventilation in patients with acute hypercapnic respiratory failure caused by an acute asthma exacerbation. D Patients with bronchiectasis: initiate noninvasive ventilation in patients with non-cystic fibrosis bronchiectasis following the indications used for acute exacerbations of COPD. B Show 2 more Patients with cystic fibrosis: Use noninvasive ventilation as a first-line strategy in patients with cystic fibrosis in whom ventilatory support is needed. B Provide specialized physiotherapy to aid sputum clearance in patients with cystic fibrosis. B Patients with restrictive lung disease: https://web.pathway.md/diseases/recwW4gUdPXoAtErL 2/4 6/24/23, 12:45 PM Hypercapnic respiratory failure Pathway Provide a trial of noninvasive as a first-line strategy in almost all patients with hypercapnia and chest wall or neuromuscular disease who are acutely unwell. B Consider noninvasive ventilation in patients with chest wall or neuromuscular disease when vital capacity is < 1L and respiratory rate is > 20, even if normocapnic. C Patients with neuromuscular disease: involve senior staff in decision-making for patients with chest wall or neuromuscular disease, in conjunction with home mechanical ventilation specialists, if experience is limited, and especially when the appropriateness of invasive mechanical ventilation is questioned. B Patients with obesity hypoventilation syndrome: initiate noninvasive ventilation in patients with obesity hypoventilation syndrome following the indications used for acute exacerbations of COPD. B 3. Inpatient care General principles: treat the precipitant cause of acute hypercapnic respiratory failure, normalize pH, correct chronic hypercapnia and address fluid overload. B Noninvasive ventilation strategy: use pressure-targeted ventilators as the devices of choice for acute noninvasive ventilation. B Show 2 more Invasive ventilation strategy: minimize dynamic hyperinflation by prolonging expiratory time and setting a low frequency during controlled ventilation. B Show 2 more Oxygenation targets: adjust the FiO to achieve SaO 88-92% in patients with acute hypercapnic respiratory failure treated with noninvasive ventilation. A Sedative agents (noninvasive ventilation): use sedation only with close monitoring in patients on noninvasive mechanical ventilation. B Sedative agents (mechanical ventilation): titrate sedation to a specific level of alertness in patients on invasive mechanical ventilation. B Volume status optimization: consider a BNP-directed fluid management strategy in patients with known LV dysfunction. C Assessment for extubation: use 30-minute spontaneous breathing trials to assess suitability for extubation. B Weaning of ventilatory support: Establish spontaneous breathing as soon as possible in all causes of acute hypercapnic respiratory failure. B Undertake daily assessment of the readiness for weaning of ventilatory support. B Monitoring for ventilator asynchrony: assess patients with agitation for ventilator asynchrony. B https://web.pathway.md/diseases/recwW4gUdPXoAtErL 3/4 6/24/23, 12:45 PM Hypercapnic respiratory failure Pathway 4. Therapeutic procedures Tracheostomy: consider mini-tracheostomy to aid secretion clearance in patients with weak cough due to neuromuscular/chest wall disease, or in patients with excessive airway secretions such as in COPD or cystic fibrosis. C Extracorporeal CO2 removal: consider extracorporeal CO removal when severe hypercapnic acidosis persists despite attempts to optimize invasive mechanical ventilation using lung protective strategies. C Show 2 more 5. Follow-up and surveillance Post-extubation care: consider prophylactic use of noninvasive ventilation to provide post- extubation support in patients with identified risk factors for extubation failure. C Palliative care: ensure the timely availability of palliative care services when providing mechanical ventilation. B Quality improvement: operate noninvasive ventilation services under a single clinical lead having formal working links with the ICU. B References 1. Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016 Apr;71 Suppl 2:ii1 35. Open 2. Rochwerg B, Brochard L, Elliott MW et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug 31;50 2 . pii: 1602426. Open 3. Amber J Meservey, Michael C Burton, Jeffrey Priest et al. Risk of Readmission and Mortality Following Hospitalization with Hypercapnic Respiratory Failure. Lung. 2020 Feb;198 1 121 134. Open 4. Michael Dreher, Pierre-Charles Neuzeret, Wolfram Windisch et al. Prevalence Of Chronic Hypercapnia In Severe Chronic Obstructive Pulmonary Disease: Data From The HOmeVent Registry. 2019 Oct 18;14 2377 2384.2019 Oct 18;14 2377 2384. Open 5. Michael Dreher, Pierre-Charles Neuzeret, Wolfram Windisch et al. Prevalence Of Chronic Hypercapnia In Severe Chronic Obstructive Pulmonary Disease: Data From The HOmeVent Registry. Int J Chron Obstruct Pulmon Dis. 2019 Oct 18;14 2377 2384. Open 6. Janice Wang, Astha Chichra, Seth Koenig. An unusual cause of acute hypercapneic respiratory failure. Clin Med Insights Circ Respir Pulm Med. 2011;5 81 5. Open 7. Amber J Meservey, Michael C Burton, Jeffrey Priest et al. Risk of Readmission and Mortality Following Hospitalization with Hypercapnic Respiratory Failure. 2020 Feb;198 1 121 134.2020 Feb;198 1 121 134. Open https://web.pathway.md/diseases/recwW4gUdPXoAtErL 4/4