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Invasive mechanical ventilation in acute respiratory failure complicating chronic obstructive pulmonary disease

Gilman B Allen, MD
Section Editors
James K Stoller, MD, MS
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD


Invasive mechanical ventilation is a means of life support typically reserved as a last option for acute respiratory failure in chronic obstructive pulmonary disease (COPD). Mechanical ventilation in this population is specifically associated with complications including dynamic hyperinflation and barotrauma that can lead to cardiovascular collapse and death.  

Details of invasive mechanical ventilation for acute respiratory failure in patients with COPD are discussed in this topic. The use of noninvasive positive pressure ventilation and other aspects of the management of acute respiratory failure in COPD are reviewed separately. (See "Management of exacerbations of chronic obstructive pulmonary disease", section on 'Noninvasive ventilation' and "Noninvasive ventilation in acute respiratory failure in adults".)


The indications for intubating patients with chronic obstructive pulmonary disease (COPD) are similar to those for all patients with acute respiratory failure (eg, life-threatening respiratory distress, failure of oxygenation and ventilation). The decision to institute invasive mechanical ventilation in this population is typically based upon a constellation of clinical signs and symptoms in the context of the patient's preferences for life support. While in the past, patients were traditionally intubated late in the course of their acute illness (eg, respiratory arrest) clinical practice now supports earlier intubation. (See "The decision to intubate" and "Rapid sequence intubation for adults outside the operating room".)  

The majority of patients with acute respiratory failure due to acute exacerbations of COPD (AECOPD) should undergo a trial of noninvasive mechanical ventilation (NIV) because intubation can be successfully avoided and mortality reduced with this intervention [1-7]. Exceptions include contraindications to NIV, failure of NIV, and severe respiratory distress. These are summarized below. (See "Noninvasive ventilation in acute respiratory failure in adults".)

This initial approach can take the form of noninvasive positive pressure ventilation (NIPPV) via nasal or full facemask, but can also be approached with oxygen delivered through high flow nasal cannula (HFNC). There are now data in patients with hypoxic respiratory failure that support the use of HFNC as a means of avoiding the need for intubation [8]. In fact, preliminary data suggest that HFNC may be more effective than NIPPV in avoiding the need for intubation, and is potentially associated with fewer long-term complications than NIPPV [8]. (See "Continuous oxygen delivery systems for infants, children, and adults", section on 'High flow'.)

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Literature review current through: Oct 2017. | This topic last updated: Nov 22, 2016.
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