High flow nasal cannula therapy in emergency room: may it change the path for COPD patients with exacerbation?
Emergency Department, M. Bufalini Hospital, Cesena, Italy
High flow nasal cannula (HFNC) therapy is a relatively new device that have been proven to be safe and useful in many clinical situation, as well as in ED (1-3). In this case, we want to discuss a potential use of HFNC therapy when NIV is recommended but is neither feasible nor tolerated.
An 82-years-old man was admitted to our ED for dyspnea. His past medical history included COPD and chronic atrial fibrillation in anticoagulant therapy. Four months before he presented another exacerbation of COPD. Physical examination showed bilateral wheezes in the lung. Bed-side US described rare B lines, so patient was treated with IV corticosteroids and inhalatory beta agonist and anticholinergics. His values were: pH 7.28, pCO2 81.7 mmHg, pO2 72 mmHg, HCO3 – 38 mmol/L, FiO2 45% and Lac 1.84 mmol/L. Chest X-ray was suggestive for COPD exacerbation. NIV was started with PSV 8 cmH20 and PEEP 7 cmH20, but quickly removed because of intolerance. Second assessment of gas exchange was performed after this short time of ventilation and resulted in pH 7.31, pCO2 77.1 mmHg, pO2 101 mmHg, HCO3- 38 mmol/L, Lac 1.55 mmol/L, FiO2 30%. Then, high flow nasal therapy (AIRVO 2 Fisher and Paykel) was administered to patient with the following settings: 37°C, 50 L/min and FiO2 33%. Patient reported great comfort and showed high tolerance to the device and settings. A third gas assessment after one hour of treatment revealed decreasing level of CO2 (pCO2 68.7 mmHg) with stable pH and oxygenation (pH 7.33, pO2 61.7 mmHg, HCO3- 36.1 mmol/L and Lac 1.45 mmol/L). The reduction in CO2 was stable during the following three hours and after, and it allow us to transfer the patient in general ward and not in sub-ICU.
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