Moffitt Pearls 6.7.17 – Hypercalcemia and Indications for BiPAP

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!!

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Key Learning Pearls

  1. Approach hypercalcemia by looking at PTH (see image below)
  2. Indications for BiPAP include the following:
    1. Cardiogenic pulmonary edema
    2. Moderate to severe COPD exacerbation
    3. Hypoxemic respiratory failure
    4. Post-extubation
    5. Immunocompromised patient with acute respiratory failure
    6. Those with neuromuscular or chest wall disease
  1. Consider intubation with pH < 7.2 or RR >35  For those who would like more information

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For those who would like more information. 🙂

NONINVASIVE POSITIVE PRESSURE VENTILATION (NIPPV): BiPAP or CPAP

  1. 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

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Diagnostic Approach and Differential Diagnosis for Hypercalcemia

hypercal

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