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140
L. C. McNamara et al.
2. Respiratory support for patients during short breaks from NPPV.
3. Post-extubation respiratory support if patients are unable to tolerate BPAP,
which should otherwise be the device of choice [162].
Similar to NPPV, the major contraindication to HFNC is if the patient otherwise
requires intubation and invasive mechanical ventilation. Other contraindications
include altered mental status and intolerance of the device [169].
6.5.3 Invasive Mechanical Ventilation
Invasive mechanical ventilation (IMV) is a way to provide oxygenation and mandatory ventilation to patients, most often via an endotracheal tube or at times via a
tracheostomy, for patients who have already undergone this procedure or who
require prolonged IMV. These connections allow for a completely closed system by
which critical care clinicians can provide high levels of respiratory support. When
patients receive IMV via an endotracheal tube, analgosedation should be optimized
to ensure patient comfort.
In patients with ECOPD, IMV is indicated for severe respiratory distress or lifethreatening respiratory failure, failure of noninvasive options like BPAP or HFNC,
or airway protection. We dene failure of noninvasive options as worsened work of
breathing or gas exchange. More specically, pH <7.25 after 2hours of BPAP has
been associated with a >90% need for intubation [154]. Furthermore, if patients are
unable to be liberated from BPAP within 48hours, we recommend consideration of
IMV. Beyond bedside observation, scoring tools such as the BAP-65 (which includes
BUN, mental status, HR, and age) can help predict which patients with ECOPD will
require IMV [170, 171]. Although many patients treated with NPPV initially will
ultimately require endotracheal intubation, studies suggest that attempting NPPV
does not cause harm and importantly identies patients who do not require intubation; as such, this can lead to improved patient outcomes, specically lower mortality and ICU LOS [172, 173].
After intubation, attention should focus on optimizing ventilator settings to
enhance ventilation, oxygenation, resistance, and compliance, along with ensuring
proper analgesia and sedation. These conversations should occur at the bedside with
input from multiple members of the care team, including but not limited to the clinicians, respiratory therapists, and nurses. Many ventilator settings are dependent on
the brand and model of the ventilator as well as the selected mode of support.
Strategies for patients undergoing IMV are aimed at supporting the patient’s oxygen
and ventilation needs, while also preventing dynamic hyperination and its deleterious sequela (described in more detail in Sect. 6.2.2). In order to achieve these goals,
we recommend:
1. Adhering to the general principles of lung-protective ventilation described else-
where in order to minimize ventilator-associated lung injury [174]. There should
be a particular emphasis on low tidal volumes (4–8cc/kg of ideal body weight),
6 Acute Exacerbations ofChronic Obstructive Pulmonary Disease
141
which reduces the risk of dynamic hyperination by providing smaller volumes
that are easier to expire.
2. Prolonging the expiratory time to ensure complete exhalation and avoidance of
dynamic hyperination. This can be achieved by slowing the respiratory rate and
adjusting the inspiratory to expiratory ratio (I:E ratio) so that it is at least 1:3.
3. Permitting hypercapnia, as long as the pH is within a hemodynamically and
metabolically safe range (i.e., >7.2), to allow for the lower tidal volumes and
longer expiratory time discussed above.
4. Promoting ventilator-patient synchrony and reducing patient work of breathing,
acknowledging that sedation and even paralysis may be required to achieve
this [175].
5. Utilizing best PEEP titration strategies (i.e., pressure-volume loop, decremental
PEEP, esophageal manometry) to help reduce patient’s work of breathing and to
stent open distal airways, thus improving total airway resistance [176]. The
amount of applied PEEP should never exceed the amount of intrinsic PEEP [177].
Further titration of ventilator settings should take into account the patient’s oxygen saturation, acid-base status, measurements of intrinsic PEEP, airway resistance,
and compliance [178]. Patients should be assessed daily for spontaneous awakening
and breathing trials and should be weaned from the ventilator safely but expeditiously, using NPPV and/or HFNC as post-extubation support (as discussed in detail
in Sects. 6.5.1 and 6.5.2) [179].
6.6 Conclusion
COPD exacerbations result in signicant utilization of healthcare resources, including ICU admissions, and high patient morbidity and mortality [180]. Optimization
of pulmonary physiology during an acute exacerbation requires a multidisciplinary
approach to address potential triggers, decrease airway inammation, reduce airway
resistance, and support adequate oxygenation and ventilation.
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