Its about How to ventilate a COPD patient in both non invasive and invasive mechanical ventilation .

1. - Dr.Gowthaman MD DM CCM
AIIMS BHOPAL
VENTILATION IN OBSTRUCTIVE
DISEASE

2. OVERVIEW
• PHYSIOLOGY
• COPD PATHO- MECHANISMS
• VENTILATION GOALS
• NIV
• INVASIVE MV
• SETTINGS TO BE MADE / TROUBLE SHOOTING
• WEANING + EXTUBATION
• NEW EVIDENCE / STUDIES .

3. • 2 Major Factors :
1. Resistance
2. Compliance
• Resistance  Obstruction to airflow by conducting airways .
• WOB  Energy required to overcome the Resistance
• Resistance = P peak – P plat / Inspiratory flow ( L/sec ) .
• Compliance  V / P ( T c = L c + CW c ) .

4. DYNAMIC
COMPLIANCE
STATIC
COMPLIANCE

5. COPD – PATHOPHYSIO SEQUENCES

8. AIRWAY
OBSTRUCTION
RESISTANCE
EXP AIRFLOW
LIMITATION
DYNAMIC
HYPERINFLATION
WOB
PEEP int .
DYSPNEA
CO2 RETAINS
COPD

10. RVF IN COPD

12. CASE :
55 / Female , Known COPD has presented to us with
1. SOB aggravation – 3 days .
2. cough + expectoration .
O/E ,
GCS : E3V4M6 , Drowsy , arousable .
HR : 120 /min , BP: 160/100 MG Hg .
Spo2 : 88 % RR : 25/ min B/L reduced AE + , wheeze + .
ABG : PH- 7.27 Co2 - 75 mm Hg Po2- 60 Hco3 -30 .
WHAT TO DO NOW ????????

13. STRATEGY
• NIV – 1st Choice
• Assisted CMV ( If Intubated )
• Focus on PH than co2 .
• Optimise Sedation
• Avoid Muscle relaxants
• Plan Early Weaning & Extubate with NIV .

14. GOALS
• Reduce DHI , Tackle AUTO PEEP
• Improve Gas exchange
• Reduce WOB
• Reduce cardiac complications
• Improve patient ventilator synchrony
• Prevent Barotrauma

15. VENTILATOR is NOT THE TREATMENT
TREAT the CAUSE
VENTILATOR IS NOT THE TREATMENT
TREAT the CAUSE

16. 2007 – 6 RCT , 9 non-RCT .
Pao2 in NON RCT
PaCo2 in NON RCT

17. Pao2 in RCT
PaCo2 in RCT

19. • Absolute
• Relative
• PH < 7.35
• CO2 > 45 – 80 ( NON
responders)
• RR > 23
• Post extubation
• DNI patients .
NIV IN COPD
INDICATIONS CONTRA INDICATIONS

20. HOW TO START ??????????
MODE :
1. CPAP ( Spontaeous )
2. BILEVEL ( IPAP/ EPAP )
3. S/T  Preferred
PROVIDER :
BIPAP vs VENTILATOR

21. BIPAP MACHINES

22. SINGLE TUBING IN BIPAP

27. WHAT ALL TO OPTIMISE ?????
• Minimise Mask Leak
• Avoid HEAD FLEXION
• Avoid Asynchrony
Trouble shoot :
1. Leak
2. IPAP, EPAP , Ti , Trigger sensitivity .
.

28. CAN I TROUBLE SHOOT …..?

29. 1. Humidification in NIV ??
HME : WOB , Dead space , R aw
2. Sedation in NIV ???
Anxiolysis

30. IS SHE FAILING NIV TRIAL …?
HACOR score
> 5 in one hour of NIV
NIV failing

31. CASE CONTINUED …..
After a couple of hours , patient GCS -8 , Co2 : 90 , Spo2 85 % ,
HR -125 , BP : 90/60 mm Hg PH 7.15 , RR -30
What to do ??????????
INTUBATE / Medications / Vasopressors .

32. INDICATIONS TO INTUBATE :
MAJOR :
1.Respiratory arrest
2. LOC
3.Severe psychomotor agitation
4.Hemodynamic instability
MINOR :
1. RR > 35 /min .
2. Ph < 7.25 , P/F < 200 .
3. Decreasing GCS

33. WHAT TO KEEP IN MIND BEFORE INTUBATING A
COPD PATIENT ????
• Volume status
• Ketamine / Propofol / Etomidate F/B NMB
• Shock Worsening  Disconnect ventilator and MANUALY
SQUEEZE the thoracic cage ( less evidence )

34. INITIATION OF VENTILATOR …
• 3 FACTORS :
1. MV  MOST IMPORTANT FACTOR .
2. Flow .
3. I:E ratio , RR .
TO TARGET :
1. AUTO peep / DHI .
2. PH ( not Pco2 ) .

36. SETTINGS TO START WITH …

37. HOW TO REDUCE DHI / AUTO – PEEP ???
1. Optimum sedation & Analgesia + Medications .
2. Reduce Ventilatory demand & adequate MV ( Vt and Low RR )
3. Prolonged Exp. time .
4. High Inspiratory Flow rate .
5. Extrinsic peep ( Controversial )
6. Adjust Trigger sensitivity .

38. HOW DOES PATIENT TRIES ON HIS OWN ???
CONCEPT OF EPP

40. WHAT ABOUT SETTING THE PEEP IN COPD ???
•

41. 60 -80 % E-PEEP …

42. WATERFALL EFFECT ???

43. AUTO PEEP 12

44. • SHALL I DO THE SAME with Asthma patients ???
NO  But Why ?????
I WONT APPLY E-PEEP ( FIXED OBSTRUCTION)

45. HOW TO SEE I - PEEP ???

46. F V LOOP :

47. WHEN SHALL I START WEANING ???
• CNS : GCS - 15
• Underlying cause is treated .
• CVS : Hemodynamically stable
• NO organ failure
• RS : RSBI < 105 , ABG – N , Compliance N .
• RENAL : Electrolytes-N , Equi / Neg balance .

48. YES
MV
Hemodynamic stable
P/F > 200
PEEP <6
N Sensorium , Good cough reflex , Swallowing + , Cuff leak
RSBI
SAT/ SBT
30 -120 min
RR > 35
SPO2 < 90 %
HR > 140 , BP
Anxiety
Sweating
EXTUBATION
> 105
NO
< 105

49. WHICH WEANING MODE SHOULD I USE ????
• PSV
• ASV / PAV .
• NAVA
• Extubation F/B NIV

50. WHAT ALL TO SET ???
• PS : Adequate enough . Insp. FLOW  High
• TRIGGER : Prefer Flow ( High sensitivity , prevent auto triggering )
• RISE Time / Slope : Prefer Steep Slope
• CYCLING : Higher the Exp Trigger  Lesser the “ DELAYED
CYCLING“ SYNCHRONY .

51. CAN I WEAN HER SUCCESFULLY ???
Yes – But How ??
TIPS :
1. Careful Suction .
2. SAT , SBT .
3. Avoid NM Blockers / Excess sedation .
4. Avoid drugs causing Broncho constriction .

52. NAVA

53. ANY RECENT NEW EVIDENCE IN-LANE ….?????
2020 – 6 RCT , 2 COHORT

55. HFNC VS NIV IN COPD
JUNE 2020

56. July 2020

58. TAKE THIS HOME ….
• Treat the UNDERLYING CAUSE  Ventilator is not the
treatment .
• Give a try / Prefer NIV than IMV .
• Focus on MV, insp Flow , I;E ratio , Low RR .
• Target DHI , AUTO-peep reduction .
• Target PH and not Co2 .
• External peep  Individualize ( Controversial . . . .)
• Start EARLY SAT/SBT .
• Extubate + NIV

59. THANK YOU ALL !!!
For your patient listening . . .