Thank you to Geoffrey for presenting 2 mini cases today in report. In the first case we discussed an elderly woman presenting from an OSH with hypercalcemia who was found to have a retroperitoneal mass w/ histology c/f B-cell lymphoma! We broadly discussed the differential and diagnostic approach to hypercalcemia. In the next case, we discussed a middle aged man presenting with severe hypoxemic and hypercapnic respiratory failure from unknown trigger c/f COPD exacerbation and the indications for BiPAP and ICU admission. There are never bad cases!!
Key Learning Pearls
- Approach hypercalcemia by looking at PTH (see image below)
- Indications for BiPAP include the following:
- Cardiogenic pulmonary edema
- Moderate to severe COPD exacerbation
- Hypoxemic respiratory failure
- Immunocompromised patient with acute respiratory failure
- Those with neuromuscular or chest wall disease
- Consider intubation with pH < 7.2 or RR >35 For those who would like more information
For those who would like more information. 🙂
NONINVASIVE POSITIVE PRESSURE VENTILATION (NIPPV): BiPAP or CPAP
- Clinical Indications for NIPPV:
- Moderate-severe COPD exacerbation (PaCO2 >45 mmHg or pH <7.3): BiPAP is first-line treatment.
- Decreased mortality, intubation rate, treatment failure, hospital length of stay and complications related to treatment.
- Cardiogenic pulmonary edema: CPAP and BiPAP decrease afterload, decrease wall stress, improve oxygenation, and improve dyspnea.
- Shown to lower in-hospital mortality.
- Hypoxemic respiratory failure:
- Decreased ICU mortality and intubation in patients with community-acquired pneumonia WITHOUT significant secretions
- Decreased ICU mortality, intubation rate, and ICU length of stay in immunosuppressed patients with pulmonary infiltrates and fever (likely due to decreased ventilator-associated pneumonia in these vulnerable patients).
- Immediately post-extubation (planned NIPPV)
- Decreased all-cause mortality, ICU length of stay, hospital length of stay, and rates of VAP. No increased rate of extubation failure or reintubation. Benefits greatest in COPD patients.
- Severe asthma exacerbation:
- Data inconclusive, though suggest decreased rate of hospitalization
Diagnostic Approach and Differential Diagnosis for Hypercalcemia