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Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease.

ABSTRACT: A 67-year old female with moderate chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder presents with three episodes of severe hypercapnic respiratory failure over the previous three months without a clear precipitant that were treated with invasive and non-invasive ventilation. These episodes were labelled as acute exacerbations of COPD, however she lacked any typical features or triggers and responded faster than expected to treatment and she underwent extensive investigations to identify an alternative etiology. While admitted and under observation, she became extremely anxious, began to hyperventilate and went into hypercapnic respiratory failure, which was successfully aborted with sublingual lorazepam causing resolution of tachypnea. It became clear that the patient was suffering from panic attacks as the precipitant for her respiratory failure and she was successfully treated with psychiatric medication and breakthrough anxiolytics. Anxiety and panic disorders are more prevalent in patients with COPD than the general population and effective management is important as patient's with anxiety and COPD have worse clinical outcomes than with COPD alone. Additionally, panic attacks should be considered as an etiology for hypercapnic respiratory failure in patients with COPD and anxiety when the clinical presentation is atypical.

SUBMITTER: Oleynick C

PROVIDER: S-EPMC7118310 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease.

Oleynick Christopher C

Respiratory medicine case reports 20200327

A 67-year old female with moderate chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder presents with three episodes of severe hypercapnic respiratory failure over the previous three months without a clear precipitant that were treated with invasive and non-invasive ventilation. These episodes were labelled as acute exacerbations of COPD, however she lacked any typical features or triggers and responded faster than expected to treatment and she underwent extensive invest ...[more]

PMID: 32257794

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Project description:BackgroundThe use of ward-based noninvasive ventilation (NIV) for acute hypercapnic respiratory failure (AHRF) unrelated to chronic obstructive pulmonary disease (COPD) remains controversial. This study evaluated the outcomes and failure rates associated with NIV application in the ward-based setting for patients with AHRF unrelated to COPD.MethodsA multicentre, retrospective cohort study of patients with AHRF unrelated to COPD was conducted. COPD was not the main reason for hospital admission, treated with ward-based NIV between February 2004 and December 2018. All AHRF patients were eligible; exclusion criteria comprised COPD patients, age < 18 years, pre-NIV pH < 7.35, or a lack of pre-NIV blood gas. In-hospital mortality was the primary outcome; univariable and multivariable models were constructed. The obesity-related AHRF group included patients with AHRF due to obesity hypoventilation syndrome (OHS), and the non-obesity-related AHRF group included patients with AHRF due to pneumonia, bronchiectasis, neuromuscular disease, or fluid overload.ResultsIn total, 479 patients were included in the analysis; 80.2% of patients survived to hospital discharge. Obesity-related AHRF was the indication for NIV in 39.2% of all episodes and was the aetiology with the highest rate of survival to hospital discharge (93.1%). In the multivariable analysis, factors associated with a higher risk of in-hospital mortality were increased age (odds ratio, 95% CI: 1.034, 1.017-1.051, P < 0.001) and pneumonia on admission (5.313, 2.326-12.131, P < 0.001). In the obesity-related AHRF group, pre-NIV pH < 7.15 was associated with significantly increased in-hospital mortality (7.800, 1.843-33.013, P=0.005); however, a pre-NIV pH 7.15-7.25 was not associated with increased in-hospital mortality (2.035, 0.523-7.915, P=0.305).ConclusionPre-NIV pH and age have been identified as important predictors of surviving ward-based NIV treatment. Moreover, these data support the use of NIV in ward-based settings for obesity-related AHRF patients with pre-NIV pH thresholds down to 7.15. However, future controlled trials are required to confirm the effectiveness of NIV use outside critical care settings for obesity-related AHRF.

Project description:RationaleAcute hypercapnic respiratory failure (AHRF) treated with non-invasive ventilation in the ICU is frequently caused by chronic obstructive pulmonary disease (COPD) exacerbations and obesity-hypoventilation syndrome, the latter being most often associated with obstructive sleep apnea. Overlap syndrome (a combination of COPD and obstructive sleep apnea) may represent a major burden in this population, and specific diagnostic pathways are needed to improve its detection early after ICU discharge.ObjectivesTo evaluate whether pulmonary function tests can identify a high probability of obstructive sleep apnea in AHRF survivors and outperform common screening questionnaires to identify the disorder.MethodsFifty-three patients surviving AHRF (31 males; median age 67 years (interquartile range: 62-74) participated in the study. Anthropometric data were recorded and body plethysmography was performed 15 days after ICU discharge. A sleep study was performed 3 months after ICU discharge.ResultsThe apnea-hypopnea index was negatively associated with static hyperinflation as measured by the residual volume to total lung capacity ratio in the % of predicted (coefficient = -0.64; standard error 0.17; 95% CI -0.97 to -0.31; p<0.001). A similar association was observed in COPD patients only: coefficient = -0.65; standard error 0.19; 95% CI -1.03 to -0.26; p = 0.002. Multivariate analysis with penalized maximum likelihood confirmed that the residual volume to total lung capacity ratio was the main contributor for apnea-hypopnea index variance in addition to classic predictors. Screening questionnaires to select patients at risk for sleep-disordered breathing did not perform well.ConclusionsIn AHRF survivors, static hyperinflation is negatively associated with the apnea-hypopnea index in both COPD and non-COPD patients. Measuring static hyperinflation in addition to classic predictors may help to increase the recognition of obstructive sleep apnea as common screening tools are of limited value in this specific population.

Project description:BackgroundAcute decompensation (AD) of liver cirrhosis (LC) and subsequent acute-on-chronic liver failure (ACLF) are fatal and impair quality of life. Insufficient knowledge of the highly heterogeneous natural history of LC, including decompensation, re-compensation, and possible recurrent decompensation, hinders the development and application of novel therapeutics. Approximately 10%-50% of AD/ACLF is reported to be precipitated by any indeterminate (unidentifiable, cryptogenic, or unknown) acute insults; however, its clinical characteristics are unclear.MethodsWe conducted a single-center observational study of 2165 consecutively admitted patients with LC from January 2012 to December 2019. A total of 466 episodes of AD/ACLF in 285 patients, including their 285 first indexed AD/ACLF, were extracted for analysis. Stratified analyses of different acute precipitants, classified as indeterminate (AD/ACLFIND), bacterial infection (AD/ACLFBAC), gastrointestinal bleeding, active alcoholism, and miscellaneous, were performed.ResultsAD/ACLFIND was the leading acute precipitant (28%), followed by AD/ACLFBAC (23%). AD/ACLFIND showed better survival outcomes than AD/ACLFBAC (P = 0.03); however, hyperbilirubinemia, hyponatremia, or leukocytosis significantly and uniquely characterized subgroups of AD/ACLFIND with comparable or even worse survival outcomes than those of AD/ACLFBAC. Patients with subsequent AD/ACLF significantly tended to suffer from AD/ACLF with any organ failure in AD/ACLFIND but not in AD/ACLFBAC (P = 0.004, for trend). In competing risk analysis, patients with AD/ACLFIND were significantly more vulnerable to suffer from recurrent episodes of AD/ACLF within 180 days, compared to those triggered by other precipitants (P = 0.04).ConclusionsAD/ACLFIND, the leading acute precipitant, also plays a role in subsequent AD/ACLF. An abruptly exacerbating, remitting, and relapsing nature of systemic inflammation underlying AD/ACLF may also be useful for risk estimation.

Project description:Background:Although the efficacy and safety of high-flow nasal cannula (HFNC) in hypoxemic respiratory failure are widely recognized, it is yet unclear whether HFNC can effectively reduce the intubation rate and mortality in hypercapnic respiratory failure. We performed a systematic review and meta-analysis to assess the safety and efficiency of HFNC in these patients. Methods:A systematic search of PubMed, Embase, and Cochrane Library (CENTRAL) was carried out. Two reviewers independently screened all references according to the inclusion criteria. We used the Cochrane risk-of-bias tool and the Newcastle-Ottawa Quality Assessment Scale to assess the quality of randomized controlled trials (RCTs) and cohort studies, respectively. Data from eligible trials were extracted for the meta-analysis. Results:Eight studies with a total of 621 participants were included (six RCTs and two cohort studies). Our analysis showed that HFNC is noninferior to noninvasive ventilation (NIV) with respect to intubation rate in both RCTs (OR?=?0.92, 95% CI: 0.45-1.88) and cohort studies (OR?=?0.94, 95% CI: 0.55-1.62). Similarly, the analysis of cohort studies showed no difference in reducing mortality rates (OR?=?0.96, 95% CI: 0.42-2.20). Based on RCTs, NIV seemed more effective in reducing mortality (OR?=?1.33, 95% CI: 0.68-2.60), but the intertreatment difference was not statistically signi?cant. Furthermore, no significant differences were found between HFNC and NIV relating to change of blood gas analysis or respiratory rate (MD?=?-0.75, 95% CI: -2.6 to 1.09). Likewise, no significant intergroup differences were found with regard to intensive care unit stay (SMD?=?-0.07, 95% CI: 0.26 to 0.11). Due to a physiological friendly interface and variation, HFNC showed a significant advantage over NIV in patients' comfort and complication of therapy. Conclusion:Despite the limitations noted, HFNC may be an effective and safe alternative to prevent endotracheal intubation and mortality when NIV is unsuitable in mild-to-moderate hypercapnia. Further high-quality studies are needed to validate these findings.

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Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease.

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Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease.

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