Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Mechanical ventilation in acute respiratory failure complicating COPD

INTRODUCTION

The frequency of invasive mechanical ventilation in patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) varies among studies [1,2]. The variable estimates reflect the different patient populations and definitions of exacerbation included in the studies. Invasive mechanical ventilation is associated with increased ICU mortality and hospital mortality, although the cause of mortality appears to be related to the severity of the underlying disease and not mechanical ventilation per se.

Invasive mechanical ventilation for patients with an acute exacerbation of COPD is discussed in this topic review. Noninvasive positive pressure ventilation (NPPV) is reviewed separately. (See "Noninvasive positive pressure ventilation in acute respiratory failure in adults".)

INDICATIONS

We believe the decision to institute mechanical ventilation should be based on clinical judgment that integrates many clinical variables. As an example, the precipitating illness and its rate of progression should be considered, as well as the patient's symptoms, signs, cardiopulmonary reserve, and comorbidities. Some clinicians advocate specific physiologic measures as indications for mechanical ventilation, but these have never undergone rigorous or systematic evaluation.

Deteriorating gas exchange unresponsive to conservative measures and respiratory distress are the most common reasons for mechanical ventilation in patients with acute respiratory failure due to COPD exacerbation [3-7]. Specifically:

  • Hypoxemia that has not corrected with supplemental oxygen delivered by either a nasal cannula or a face mask.
  • Severe respiratory acidosis, usually due to the precipitating illness or the injudicious administration of oxygen. (See "Use of oxygen in patients with hypercapnia".)
  • Clinical manifestations of distress including severe dyspnea, tachypnea, nasal flaring, accessory muscle recruitment, tracheal tugging, recession of the suprasternal and intercostal spaces, pulsus paradoxus, diaphoresis, and paradoxic motion of the rib cage and abdomen .

                  

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Aug 30, 2011.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. Jeffrey AA, Warren PM, Flenley DC. Acute hypercapnic respiratory failure in patients with chronic obstructive lung disease: risk factors and use of guidelines for management. Thorax 1992; 47:34.
  2. Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995; 274:1852.
  3. Slutsky AS. Mechanical ventilation. American College of Chest Physicians' Consensus Conference. Chest 1993; 104:1833.
  4. Laghi, F, Tobin, MJ. Indications for mechanical ventilation. In: Principles and Practice of Mechanical Ventilation. Tobin, MJ (Ed), McGraw Hill, New York, 2006.p.129.
  5. Tobin MJ, Perez W, Guenther SM, et al. The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation. Am Rev Respir Dis 1986; 134:1111.
  6. Tobin MJ, Guenther SM, Perez W, et al. Konno-Mead analysis of ribcage-abdominal motion during successful and unsuccessful trials of weaning from mechanical ventilation. Am Rev Respir Dis 1987; 135:1320.
  7. Tobin MJ, Perez W, Guenther SM, et al. Does rib cage-abdominal paradox signify respiratory muscle fatigue? J Appl Physiol 1987; 63:851.
  8. Marini JJ, Smith TC, Lamb VJ. External work output and force generation during synchronized intermittent mechanical ventilation. Effect of machine assistance on breathing effort. Am Rev Respir Dis 1988; 138:1169.
  9. Ward ME, Corbeil C, Gibbons W, et al. Optimization of respiratory muscle relaxation during mechanical ventilation. Anesthesiology 1988; 69:29.
  10. Imsand C, Feihl F, Perret C, Fitting JW. Regulation of inspiratory neuromuscular output during synchronized intermittent mechanical ventilation. Anesthesiology 1994; 80:13.
  11. MacIntyre NR. Respiratory function during pressure support ventilation. Chest 1986; 89:677.
  12. Brochard, L, Lellouche, F. Pressure support ventilation. In: Principles and Practice of Mechanical Ventilation, Tobin, MJ (Ed), McGraw Hill, New York, 2006.p.221.
  13. Jubran A, Van de Graaff WB, Tobin MJ. Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995; 152:129.
  14. Parthasarathy S, Jubran A, Tobin MJ. Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med 1998; 158:1471.
  15. Leung P, Jubran A, Tobin MJ. Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med 1997; 155:1940.
  16. Tobin MJ, Jubran A, Laghi F. Patient-ventilator interaction. Am J Respir Crit Care Med 2001; 163:1059.
  17. Esteban A, Anzueto A, Alía I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000; 161:1450.
  18. Marini JJ, Rodriguez RM, Lamb V. The inspiratory workload of patient-initiated mechanical ventilation. Am Rev Respir Dis 1986; 134:902.
  19. Jubran A, Tobin MJ. Reliability of pulse oximetry in titrating supplemental oxygen therapy in ventilator-dependent patients. Chest 1990; 97:1420.
  20. Bickler PE, Feiner JR, Severinghaus JW. Effects of skin pigmentation on pulse oximeter accuracy at low saturation. Anesthesiology 2005; 102:715.
  21. Gibney RT, Wilson RS, Pontoppidan H. Comparison of work of breathing on high gas flow and demand valve continuous positive airway pressure systems. Chest 1982; 82:692.
  22. Sassoon CS, Del Rosario N, Fei R, et al. Influence of pressure- and flow-triggered synchronous intermittent mandatory ventilation on inspiratory muscle work. Crit Care Med 1994; 22:1933.
  23. Giuliani R, Mascia L, Recchia F, et al. Patient-ventilator interaction during synchronized intermittent mandatory ventilation. Effects of flow triggering. Am J Respir Crit Care Med 1995; 151:1.
  24. Aslanian P, El Atrous S, Isabey D, et al. Effects of flow triggering on breathing effort during partial ventilatory support. Am J Respir Crit Care Med 1998; 157:135.
  25. Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. Am Rev Respir Dis 1982; 126:166.
  26. MacIntyre NR, Cheng KC, McConnell R. Applied PEEP during pressure support reduces the inspiratory threshold load of intrinsic PEEP. Chest 1997; 111:188.
  27. Tobin MJ, Jubran A, Hines E Jr. Pathophysiology of failure to wean from mechanical ventilation. Schweiz Med Wochenschr 1994; 124:2139.
  28. Coussa ML, Guérin C, Eissa NT, et al. Partitioning of work of breathing in mechanically ventilated COPD patients. J Appl Physiol 1993; 75:1711.
  29. Smith TC, Marini JJ. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol 1988; 65:1488.
  30. Petrof BJ, Legaré M, Goldberg P, et al. Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1990; 141:281.
  31. Tobin MJ, Lodato RF. PEEP, auto-PEEP, and waterfalls. Chest 1989; 96:449.
  32. Ranieri VM, Giuliani R, Cinnella G, et al. Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 1993; 147:5.
  33. Tobin, MJ, Alex, CA, Fahey, PJ. Fighting the ventilator. In: Principles and Practice of Mechanical Ventilation. Tobin, MJ (Ed), McGraw Hill, New York, 2006.p.1121.
  34. Connors AF Jr, McCaffree DR, Gray BA. Effect of inspiratory flow rate on gas exchange during mechanical ventilation. Am Rev Respir Dis 1981; 124:537.
  35. Laghi F, Segal J, Choe WK, Tobin MJ. Effect of imposed inflation time on respiratory frequency and hyperinflation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 163:1365.
  36. Puddy A, Younes M. Effect of inspiratory flow rate on respiratory output in normal subjects. Am Rev Respir Dis 1992; 146:787.
  37. Dhand R, Duarte AG, Jubran A, et al. Dose-response to bronchodilator delivered by metered-dose inhaler in ventilator-supported patients. Am J Respir Crit Care Med 1996; 154:388.