1) The document discusses ventilation strategies and goals for patients with obstructive lung disease such as COPD who require non-invasive ventilation (NIV) or mechanical ventilation. 2) Key points addressed include physiology of obstructive lung disease, goals of ventilation including reducing work of breathing and dynamic hyperinflation, settings and troubleshooting for NIV and invasive mechanical ventilation, as well as strategies for weaning and extubation. 3) The case study example illustrates assessing the need for intubation in a COPD patient failing NIV, appropriate ventilation settings, and tips for successful weaning and extubation.

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 . . .