Mechanical Ventilation of Patient with COPD Exacerbation lecture presented by Dr Andres Esteban at the Egyptian Critical care Summit 2015 held at Cairo, egypt. The Egyptian Critical Care Summit is the leading medical event and exhibition for Intensive Care Medicine in Egypt.

1. Egyptian Critical Care Summit 2015
Cairo, 12-15,January 2015
Andrés Esteban ,Fernando Frutos
Frutos-VivarHospital Universitario de Getafe
Mechanical Ventilation of Patients
with COPD exacerbation.

2. Faculty Disclosures
Andres Esteban MD, PhD
No relevant ( or irrelevant ) commercial interest

3. COPD is the 5th leading cause
of death
Chronic bronchitis accounts for
approximately 85% of COPD

4. Rennard S Eur Respir J. 2002.
1.616 cases / 100.000 inhabitans/year
13,8% of patients admited at the hospital in the last
year
Seneff. JAMA 1995
Moran. Crit Care Med 1998
Groenewegen. Chest 2003
Gunen. Eur Respir J. 2005
11% a 74% need admission in the UCI

5. COPD
Incidence Age (SD) BMI (SD) SAPS II
1998 (n=522) 10.1 % 59 (17) 44 (17)
2004 (n=267) 5.4 % 59 (17) 27 (7) 43 (18)
2010 (n=524) 6.4 % 61 (17) 26.6 (6.5) 45 (18)
-
- -

6. Have more complications
Use more resources
Have more difficulty weaning from
mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD
EXACERBATED
CANDIDATES TO RECIVE MECH.
VENTILATION

7. Have more complications
Use more resources
Have more difficulty weaning
from
mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD
EXACERBATED
CANDIDATES TO RECIVE MECH.
VENTILATION

8. Results:
Complications
%

9. COPD 507 10.1 % 15 9.7 %
Pneumonia 691 13.7 % 30 19.5 %
ARDS 216 4.3 % 15 9.7 %
Aspiration 123 2.4 % 6 3.9 %
Trauma 393 7.8 % 14 9.1 %
Neuromuscular disease 89 1.8 % 5 3.2 %
Asthma 74 1.5 % 5 3.2 %
Chronic interstitial lung
disease
54 1.1 % 6 3.9 %
PATIENTS
WITHOUT
BAROTRAUMA
PATIENTES
WITH
BAROTRAUMA
n = 5029 n = 154
A. Anzueto, F. Frutos, A. Esteban, et al
Intensive Care Med 2004;30

10. Have more complications
Use more resources
Have more difficulty weaning from
mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD
EXACERBATED
CANDIDATES TO RECIVE MECH.
VENTILATION

11. Days with mechanical ventilation
(Esteban A, et al. 2º ISMV. AJRCCM 2008
Mean (SD)
COPD: 6,0 days (6,5)
No COPD: 6,2 days (7,0)
p = 0,72
Median (P25, P75)
COPD: 4 days (2,7)
No COPD: 4 days (2, 8)
p = 0,73
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
COPD No COPD

12. Days of stay
(Esteban A, Frutos F, et al. 2º ISMV. AJRCCM 2008
ICU
Mean (SD)
COPD: 11 days (11)
No COPD: 12 days (13)
p = 0,34
Median (P25, P75)
COPD: 8 days (5, 13)
No COPD: 8 days (4, 15)
p = 0,70
Hospital
Mean (SD)
COPD: 20 days (18)
No COPD: 25 days (28)
p = 0,007
Median (P25, P75)
COPD: 17 days (10 , 26)
No COPD: 17 days (9, 31)
p = 0,12

13. Long time mechanical ventilation
Mechanical ventilation > 14 days
COPD
Acute lung
failure
Neurologic
Esteban et al.
JAMA 2002
3,4% 8,6% 7,1%
Esteban et al.
AJRCCM 2008
7,9% 9,4% 5,7%

14. Results:
Tracheostomy
COPD No COPD
N (% ) 51 (10%) 494 (11%)
Days 12 ± 7 13 ± 8

15. Results:
Pharmacology
COPD No COPD
SEDATIVES N (%) 335 (64%) 3197 (69%)
Days 4 ± 4 5 ± 5
NEUROMUSC.
BLOCKERS
N (%) 26 (5%) 445 (9.5%)
Days 3 ± 2 3 ± 4

16. Have more complications
Use more resources
Have more difficulty weaning from
mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD
EXACERBATED
CANDIDATES TO RECIVE MECH.
VENTILATION

17. Days of weaning
(Esteban A, et al. 2º ISMV. AJRCCM 2008
Mean (SD)
COPD: 2,5 days (2.3)
No COPD: 2,3 days (2.7)
p = 0,51
Median (P25, P75)
COPD: 2 days (1 , 3)
No COPD: 1 days (1 , 2)
p = 0,10
10
9
8
7
6
5
4
3
2
1
0
COPD No COPD

18. Difficult Weaning
Weaning > 2 weeks
COPD
Acute
respiratory
failure
Neurologic
Esteban et al.
JAMA 2002
1,5% 1,2% 1,2%
Esteban et al.
AJRCCM 2008 0,8% 1,0% 0,8%

19. Have more complications
Use more resources
Have more difficulty weaning
from
mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD
EXACERBATED
CANDIDATES TO RECIVE MECH.
VENTILATION

20. 0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
1 3 5 7 9 11 13 15 17 19 21 23 25 27
COPD
Asthma
ARDS
ARF non
ARDS
Probability
of survival
Days from the start of
mechanical ventilation
A.Esteban, A. Anzueto, F. Frutos, I. Alía et
JAMA 2002;287:345-355

21. ICU MORTALITY
COPD 21.4 % 25.9 %
Asthma 8.2 % 8.3 %
ARDS 47.3 % 53.5 %
Postoper. 15.3 % 19.8 %
CHF 24.8 % 33.8 %
C. Pneum. 32.4 % 40.3 %
Hosp. Pneum. 33.9 % 43.1 %
Sepsis 41.9 % 52.1 %
Trauma 19.3 % 22.8 %
Coma 27.8 % 38.8 %
MORTALITY

22. Mortality is 4% in hospitalized with mild
to moderate disease
Mushlin AI, et al. JAMA 1991;226:80-83
24 % mortality in patients admitted to an ICU
with respiratory failure (COPD exacerbated)
Connors AF, et al (Support) AJRCCM
1996;154:959-967

23. Mortality Associated With Severe
AECOPD
Connors et al. Am J Respir Crit Care Med 1996;154:959.
MortalityRate(%)
Mortality Following Hospitalization
for Severe AECOPD

24. DEAD 116 / 522
(22.2%)
COPD Ventilated >12 h.
NO
DEAD
80/466 (17%)
< 18
DEAD
64/437 (14.7%)
> 18
DEAD
16/29 (55%)
YES
DEAD
36/56 (64%)
NO
DEAD
50/402 (12.5%)
YES
DEAD
14/35 (40%)
RENAL
FAILURE
DAYS OF
MECH. VENT.
SHOCK

25. 1 Renal failure 56 64 % 12.7 6.8 - 23.6
2
Not renal failure
Days of M.V. >18
29 55 % 8.7 3.9 - 19.1
3
Not renal failure
Days of M.V. <18
Shock
35 40 % 4.7 2.2 - 9.8
4
Not renal failure
Days of M.V. <18
No shock
402 12.5% 1.0 ---
nº Exitus OR CI 95%
COPD (n=522)

26. Length of
ICU Stay
Length of
Hosp. Stay
Mortality
ICU
Mortality
Hospital
1998 8 (5-13) 17 (10-27) 22.2 % 30.2 %
2004 7 (5-12) 17 (10-26) 20.6 % 29.6 %
2010 7 (4-12) 14 (9-24) 21 % 26.5 %

27. 0
0
10
20
30
40
50
60
70
80
90
100
500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Eficiency(%)
SE
LLC
ACVA
CHF
EPOC
CT
ES
CH
ALI/ARDS
Trauma
Cost in €
(Iapichino G, et al. Acta Anaesthesiol Scand.
2004)

28. Have more complications
Use more resources
Have more difficulty weaning
from mechanical ventilation
Have a higher mortality
THE PATIENTS WITH COPD EXACERBATED
CANDIDATES TO RECIVE MECH. VENTILATION
NOT
NOT
NOT
NOT

29. Treatment of the exacerbation
1. Oxigen if hypoxemia
2. Broncodilators
• Beta-agonists
• Anticolinérgyc
3. Non-Invasive Mechánical Vent.
4. Steroids
5. Antibiótics
6. Metilxantins

30. Canadian Thoracic Society recomendations
for management of chronic obstructive
pulmonary disease -2008 update – highlights
for primary care.
ACUTE EXACERBATIONS
“Oral or parenteral corticosteroids (dosage of
25 mg to 50 mg of prednisone equivalent per
day for between sever and 14 days) are
recomended in most patients with moderate
to severe AECOPD”.
D.E. O’Donnell, et al.
Can Resp J 2008;15:1A-8A

31. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
National clinical guideline on management of chronic obstructive
pulmonary disease in adults in primery and secondary care
The guideline will include recommendations in the following areas.
Management of stable patients, management of exacerbations and
prevention of progression of the disease, to include:
 smoking cessation, including pharmacological and non-
pharmacological approaches as they relate specifically to COPD
 bronchodilator management including methods of delivery &
methods of assessing effcacy inhaled and oral corticosteroid
therapy
 non-pharmacological interventions, including pulmonary
rehabilitacion, lifestyle advice and self-management techniques
 oxygen therapy
 non-invasive ventilation
 indications for surgery
 criteria for admission and/or management at home, and the
problems of respiratory failure
Thorax 2004;59:1-232

32. ORIGINAL INVESTIGATION
Efficacy of Corticosteroid Therapy in Patients With an Acute
Exacerbation of Chronic Obstructive Pulmonary Disease
Receiving
Ventilatory Support
Inmaculada Alıa, MD; Miguel A. de la Cal, MD; Andres Esteban, MD, PhD; Ana Abella, MD;
Ricard Ferrer, MD; Francisco J. Molina, MD; Antoni Torres, MD, PhD; Federico Gordo, MD;
Jose. Elizalde, MD; Raul de Pablo, MD; Alejandro Huete, MD; Antonio Anzueto, MD, PhD
Arch Intern Med. 2011;171(21):1939-1946
COPD exacerbation with IMV and NIMV
40With Placebo
38With Corticoids
Primary outcome: Duration of MV; length of stay in ICU;
Intubation
in patients with NIV
Secundary outcome: Mortality ; Length of stay in Hospital

33. Characteristic Placebo
Group
(n = 40)
Corticostero,
Group
(n = 43)
p value
Reason for acute
exacerbation of COPD
Respiratory infection
Cardiac failure
Sepsis
Postoperative
Unidentified cause
Others
28 (70%)
9 (22%)
1 (2%)
1 (2%)
0 (0%)
2 (5%)
30 (70%)
8 (19%)
1 (2%)
0 (0%)
4 (9%)
3 (7%)
0,72
Initial ventilatory support
Non-invasive
Conventional
19 (47%)
21 (52%)
18 (42%)
25 (58%)
0,60
Baseline characteristics of the 83 patients
according to treatment assignment
I Alia,M A de la Cal,A Esteban,et al.
Arch Internal Med 2011;171:1939

34. Characteristic Placebo
Group
(n = 40)
Corticosteroid
Group
(n = 43)
p
value
Blood gases
PaO2/FIO2 (mm Hg)
PaCO2 (mm Hg)
pH
191,5 ±75,9
68,7 ± 18,5
7,31 ± 0,10
197,8 ± 83,7
69,9 ± 19,7
7,27 ± 0,11
0,72
0,78
0,12
Blood glucose (mg/dl) 158,7 ± 65,7 193,3 ± 60,6 0,016
White-cell count (per mm3)
10.515 ±
3.645
12.166 ±
5.268
0,10
Baseline characteristics of the 83 patients
according to treatment assignment
I Alia,M A de la Cal,A Esteban,et al.
Arch Internal Med 2011;171:1939

35. Event Placebo
Group
(n = 40)
Corticosteroid
s Group
(n = 43)
p
value
Superinfection 6 (15%) 5 (12%) 0,65
Gastrointestinal
bleeding
2 (5%) 2 (5%) 0,60
Arterial hypertension 4 (10%) 2 (5%) 0,42
Hyperglycemia 10 (25%) 20 (46%) 0,04
Ventilator-associated
pneumonia
3 (7%) 4 (9%) 0,77
Delirium 3 (7%) 1 (2%) 0,35
ICU-acquired paresis 0 0
Frecuency of adverse events
I Alia,M A de la Cal,A Esteban,et al.
Arch Internal Med 2011;171:1939

36. 0
1
2
3
4
5
6
7
8
9
10
Baseline Day 1 Day 2 Day 3 Day 4 Day 5
IntrinsicPEEP(cmofwater)
Corticosteroids Placebo

37. Corticosteroids Placebo
30
35
40
45
50
55
60
65
70
75
Baseline Day 1 Day 2 Day 3 Day 4 Day 5
PaCO2(mmHg)
* *

38. Outcomes Placebo
Group
(n = 40)
Corticostero
ids Group
(n = 43)
p
value
Duration of mechanical
ventilation (days)
Non-invasive ventilation
Conventional ventilation
4 (3-7)
4 (2-5)
7 (4-11)
3 (2-6)
2 (2-3)
5 (3-7)
0,036
0,008
0,09
Length of ICU stay (days)
Non-invasive ventilation
Conventional ventilation
7,5 (5-12)
5 (4-9)
10 (7-18)
6 (4-10)
4 (3-5)
9 (6-12)
0,09
0,042
0,18
Length of hospital stay (days)
Non-invasive ventilation
Conventional ventilation
15 (11-21)
15 (9-20)
17 (12-31)
13 (8-21)
14 (8-19)
13 (8-22)
0,30
0,99
0,07
Outcome measures
I Alia,M A de la Cal,A Esteban,et al.
Arch Internal Med 2011;171:1939

39. Outcomes Placebo
Group
(n = 40)
Corticosteroi
ds Group
(n = 43)
p value
In-ICU mortality
Non-invasive ventilation
Conventional ventilation
4 (10%)
1/19 (5%)
3/21 (14%)
5 (12%)
0/18 (0%)
5/25 (20%)
0,81
0.04
0,17
Failure of non-invasive
ventilation
7/19 (37%) 0/18 (0%) 0,004
Reintubation within 48
hours*
5/26 (19%) 3/22 (14%) 0,71
Outcome measures
I Alia,M A de la Cal,A Esteban,et al.
Arch Internal Med 2011;171:1939

40. The treatment with corticosteroids of patients with
COPD exacerbations requiring mechanical ventilation
(invasive and non-invasive)
 Was not associated with and increased risk of
gastrointestinal bleeding, superinfections,
psychiatric disorders, or adquired neuromuscular
weakness.
 Is associated with a significantly increase in the
success of NIV.
 Is associated with a reduction in the duration of
invasive mechanical ventilation.
SUMMARY