Mechanical Ventilation in COPD Lecture presented by Dr Lluis Blanch at Venti Cairo Mechanical Ventilation Course held on 14-15 November at Cairo, Egypt.

1. Mechanical Ventilation in
Obstructive Lung Disease
Dr. Lluís Blanch Torra
Senior Critical Care
Former President of SEMICYUC
WFSICCM Council member
Director of Institut d’Investigació I
Innovació Parc Taulí I3PT
Cairo, 14 November 2015

2. COPD
Asthma Enfisema
Bronquitis
Crónica
Asthma Enphysema
Chronic
Bronchitis

3. COPD
Diaphragm operates in an unfavorable part of
their length-tension curve.

4. Enphysema & AutoPEEP
Dynamic airway collapse & flow limitation due to loss of
lung elasticity and altered airway & alveolar geometry

5. Paw R C
Paw = Palv + (1/C V) + (R V)* *
.
The Equation of Motion

6. Alveolar Heterogeneity during Histamine Challenge
AutoPEEP: Pendelluft Effect
Romero P, Lopez J, Blanch L. Pulmonary mechanics beyond
peripheral airways. In: Milic_Emili J, ed. Applied Physiology in
Respiratory Mechanics. Springer 1997; p.190-210.

7. Tidal Insufflation
Lung Regional Differences in Airflow Obstruction
Effects of Mechanical Ventilation
End Expiration
C. Perret & F. Feihl

8. Tuxen DV et al. Am J Respir Crit Care Med 1994;150:870-74
Effects of Tidal Breathing in Asthma during MV

9. 43210
-1.0
-0.5
0.0
0.5
1.0
AutoPEEP
Time (s)
Airflow
(L/s)
AutoPEEP Generation: Lengthen Ti at equal Ttot
(Airflow decreased for a similar VT)
Blanch L, Bernabe F, Lucangelo U. Respir Care 2005;50:110-123

10. Effect of Increasing Resistance during CF.VCV
Upward Shift in the Pao(t) Curve

11. Lucangelo U, Bernabè F, and Blanch L. Resp Care 2005; 50 : 55-65
Progressive increase of inspiratory pause during VCV

12. Effects of Breathing Pattern (Flow & TE) on
Respiratory Mechanics in COPD Patients
Georgopoulos D et al. Intensive Care Med 1995;21:880-6
Ttot & VT constant
EIP EIP

13. Lucangelo U, Bernabè F, Blanch L. Resp Care 2005; 50 : 55-65
VCV with progressive increase of inspiratory
time, but with constant pause

14. Effect of Different
Ventilator Settings on
Airway Pressure and
Lung Volume during
VCV in Patients with
Airflow Obstruction
Tuxen DV & Lane S.
Am Rev Respir Dis
1987; 136:872.
Airflow 100, 70, 40 L/min
&
VE 10, 16, 26 L/min
Same VT, increase rate

15. Durante G et al. Am J Respir Crit Care Med 2002; 165:1271.
ARDS-Net Lower VT Strategy May Generate
Intrinsic PEEP in Patients with ARDS

16. Pepe PE, Marini JJ. Am Rev Respir Dis 1982;126:168.
Effect of Discontinuation of MV in a Patient
with Severe Airflow Obstruction

19. INTRINSIC PEEP (PEEPi)
in static and dynamic conditions
Flow
(l/s)
0
Dynamic
PEEPi (4cm H20)
Tracheal
Pressure
(cmH2O)
0
1
10
20
30
Static
PEEPi (8 cmH20)
END EXPIRATORY
OCCLUSION

20. Respir Care 2005;50(1):110-123

21. Leatherman JW et al. Crit Care Med 1996; 24:541-546
Expiratory Airway Occlusion in Asthma
Measured AutoPEEP = 5 cmH2O
5

23. Airway Pressure
Tracheal Pressure

24. Before
Time (sec)
Flow(L/min)
PEFR
After
Long TE
Higher PEFR
Shorter TE
Response to Bronchodilator
Rajiv Dhand. Respiratory Care 2005 (February). Vol 50. Nº 2.

25. Koutsoukou A et al. Am J Respir Crit Care Med 2000;161:1590-6
Expiratory Flow Limitation & PEEPi in ARDS

26. Ventilatory Strategy: Effect of PEEP

27. PEEP & AutoPEEP in COPD Patients
Blanch L, Fernandez R. In: Mancebo J, Brochard L, eds. Arnette 1996; 329-345.

28. PEEP-Induced Changes
in Lung Volume &
Cardiac Index in COPD
Patients
Changes occur only
when external PEEP is
higher than the critical
pressure value:
85% of autoPEEP
Ranieri et al
ARRD 1993;147:5-13
Baigorri F et al.
Crit Care Med 1994;22:1782-91

29. Expiratory Flow Limitation & PEEPi in ARDS
Koutsoukou A et al. Am J Respir Crit Care Med 2000;161:1590-6

30. Haluszca J, et al. Am Rev Respir Dis 1990;141:1194-7
Intrinsic PEEP in Stable COPD Patients
Significant correlation between PEEPi & PaCO2
and PEEPi & FEV1.

31. Marini JJ. COPD. Cherniak NS, ed. 1990
PEEP & AutoPEEP. The Effect on Breathing Effort

32. Mancebo J et al. Anesthesiology 2000;93:81-90
Patient & Ventilator Interactions
Presence of AutoPEEP during PSV
autoPEEP = 6 cmH2O

33. Mancebo J et al. Anesthesiology 2000;93:81-90
Patient & Ventilator Interactions
PEEP to Counterbalance AutoPEEP during PSV

34.  Non invasive MV : potentially useful
 MV & moderate hypoventilation
 reduced risk of hypotension & barotrauma
 hypercapnia usually well tolerated
 Minute ventilation < 10 L/min.
 Low respiratory rates seldom required
 PEEP level to reduce autoPEEP
 Minimize dyssynchronies. Adequate PEEP, airflow,
inspiratory pressure and cycling off criteria.
TIPS To Ventilate Severe Airflow
Obstructed Patients