December 2, 2011
Disclosures
I am on the Speakers Bureau for the following
companies:
Grifols, CSL Behring, Genentech
Spirometry:
FVC 2.67L, 53% predicted
FEV1 0.87L, 24% predicted
FEV1/FVC 33
FEF25-75% 0.23L, 7% predicted
F/V loops show a severe obstructive defect
Underwhelming definition?
Classifying COPD
Should the classification be based on
Imaging?
FEV1?
Symptoms?
Exacerbations
Exacerbations
Deterioration
Exacerbations
End of Life
Time
Donaldson GC, et al. Relationship between exacerbation frequency and lung function decline in
chronic obstructive pulmonary disease. Thorax 2002;57:847-852
COPD Exacerbation
Expiratory flow limitation, as a consequence of
airway inflammation, is the pathophysiological
hallmark of COPD
ODonnell DE, Parker CM. COPD Exacerbation. Pathophysiology. Thorax 2006; 61: 354-361
Classification of COPD severity and
exacerbations
Mild Stage I 80
1.0 Group A
Patients with no acute
exacerbations
Probability of surviving
0.8
A
p<0.0002 Group B
0.6
Patients with 12 acute
B p<0.0001
exacerbations of COPD
0.4 requiring hospital management
p=0.069
C
0.2 Group C
Patients with 3 acute
exacerbations of COPD
0 1 2 3 4 5 6 requiring hospital management
0 0 0 0 0 0
Time (months)
(Exacerbation history)
(C) (D) >2
A: Less symptoms, low risk
Risk
Risk
Symptoms
Consequences of COPD exacerbation
ODonnell DE, Parker CM. COPD Exacerbation. Pathophysiology. Thorax 2006; 61: 354-361
COPD exacerbations
MacIntyre N, Huang YC. Acute exacerbations and respiratory failure in COPD. Proc Am Thor Soc 2008;5:530-535
Messer B, et al. The prognostic variables of mortality in patients with an exacerbation of COPD
admitted to the ICU: an integrative review. QJM 2012; 105: 115-126
Mohan A, et al. Clinical presentation and predictors of outcome in patients with severe acute exacerbation of
COPD requiring admission to intensive care unit. BMC Pulmonary 2006;6:27
Mohan A, et al. Clinical presentation and predictors of outcome in patients with severe acute exacerbation of
COPD requiring admission to intensive care unit. BMC Pulmonary 2006;6:27
COPD Exacerbation
Therapeutic Options
Ai-Ping C, et al. Patients treated in the ICU for acute exacerbation of COPD. Chest 2005; 128:518-524
Median ICU days 3 d
Median hospital stay 9 d
In-hospital mortality 24.5%
Of the survivors who were
discharged
Most required readmission
for exacerbation
Median time to the next
exacerbation: 5 months
Those who required a
second ICU admission had a
mortlality rate of 39% at 6
months, 42.7% at 1 year,
61.2% at 3 years
Indications
Accessory muscle use, short of respiratory
failure/agonal breathing
Patient cooperative (exclused agitation, belligerent,
coma)
Showing signs of retaining pCO2
Assess the pCO2 with the respiratory rate, not what a normal
value is (pH 7.1-7.3)
RR> 25
Hypoxemia; P/F ratio < 200
COPD Exacerbation
Contraindications to NIV
Cardiovascular instability
Inability to protect airway
Impaired mental status (GCS <8)
Aspiration risks, recent facial surgery or injury
Poor clearance of secretions
Potential for upper airway obstruction
Angioedema
Extrinsic compression of the trachea (eg. tumor,
hematoma)
Benefits of NIV
Symptomatic relief of dyspnea
Correction of gas exchange
Improve lung mechanics
Decrease mortality associated with resp failure
Prevent intubation and associated
complications:
Tracheal stenosis, VAP, tracheostomy need, GI
bleed, DVT, mopathy
Benefits of NIV
Unload respiratory muscle inspiratory cycle:
Hyperinflation >> resp muscle shortening
Decrease compliance of respiratory system
Overcome intrinsic PEEP
Stent open lower airway expiratory cycle
Overcome the dynamic airway collapse in the
expiratory phase and coughing episodes
Stent open upper airway
Associated OSA
Non-invasive ventilation for acute
exacerbation of COPD
INCLUSION CRITERIA
COPD with exacerbation of dyspnea > two days and at least two of the
following:
RR>30
PaO2 < 45 mm Hg
pH < 7.35 after > 10 min on RA
EXCLUSION CRITERIA
RR< 12 breaths, sedative drugs within the previous 12 hours
CNS disorder unrelated to hypercapnic encephalopathy or hypoxemia
Cardiac arrest (within the previous five days)
Cardiogenic pulmonary edema
Asthma
Noninvasive ventilation in acute exacerbations of COPD M.W. Elliott, Eur Respir Rev 2005
Rapid Shallow Breathing index
RBSI = respiratory frequency/Vt
Berg KM, et al. The rapid shallow breathing index as a predictor of failure on non-invasive ventilation
Invasive Mechanical Ventilation
COPD Exacerbation
Invasive mechanical ventilation
Indications
Accessory muscle use
Showing signs of retaining pCO2
Assess the pCO2 with the respiratory rate, not what a normal
value is
Does not meet criteria for NIPPV
RR> 35
Case Presentation
Vent settings:
Use a slow respiratory rate to reduce the risk of air-
trapping
Auto-PEEP: consider matching extrinsic PEEP if the
patient appears to have difficulty triggering the
ventilator
Mechanical Ventilation
Vent settings:
Mode A/C, PC
FiO2 21%-100%
Vt (6-10cc/kg) or Pressure setting (15-20 cmH2O)
RR (10-30/min)
PEEP 0-24 cmH2O
Patient monitors:
Difference between inspiratory and expiratory Vt
leaks
PIP, Plateau, I:E ratio
Waveforms
Byrd RP, et al. Mechanical Ventilation. Medscape
Airway Pressures
Resistance vs. Compliance
Peak Pressures
Airway resistance AND compliance
Keep below 40-45 cm H2O
Plateau Pressures (EIP)
Lung and chest wall compliance
Keep below 30 cm H2O
Effusion
Mechanical over-
distension or shearing
Ventilator Associate Lung Injury (VALI)
Vt
RR
PEEP
I:E
Problem of this heterogeneity
Finding the right balance of Vt, RR and PEEP to
keep the lungs open without generating high
pressure is the goal
This may be a challenge when these are at a
constant setting without a dynamic response to
the lungs signals being provided
e.g. waveforms, compliance trends
Upper inflection point
Improves ventilation
An increase in airway
pressure at the end
of inspiration without
a significant increase
in delivery of tidal
volume beaking at
the end of inspiration
Optimal PEEP
PEEP should be high enough
to shift the end-expiratory
pressure above the lower
inflection point by 2-3 cm H2O
(usually 12-15 cm H2O)
Upper inflection point
Allows maximal alveolar
recruitment
To fix it,
Decrease minute vent
(either frequency or Vt)
Prolong I:E
Complications associated with PEEP
Barotrauma
Regional hypoperfusion
Paradoxical hypoxemia
Hypercapnea and respiratory acidosis
Diminished cardiac output
Augmentation of ICP
Pulmonary edema
High PEEP
In rats ventilated with PEEP
10 and a peak Pressure 45,
no injury was present
Rats with PEEP 0 and a
peak Pressure 45, severe
pulmonary edema was
present within 20 minutes
Subsequent study showed a
preservation of the structure
of the alveolar epithelium by
using PEEP 10, which was
accompanied by the lack of
alveolar flooding
Pneumothorax associated with
COPD
Case Presentation
Hsu CW, Sun SF. Iatrogenic pneumothorax related to mechanical ventilation. World J Crit Care Med 2014; 3: 8-14
Pneumothorax in COPD
Cerfolio RJ. Advances in thoracostomy tube management. Surg Clin N Am 2002; 82:833-848
Bullae vs PTX
?
Cryptogenic hemoptysis in COPD
Cryptogenic hemoptysis in COPD
Delage A, et al. cryptogenic hemoptysis in COPD: Characteristics and Outcome. Respiration 2010: 80:387-392
Cryptogenic hemoptysis in COPD
Delage A, et al. cryptogenic hemoptysis in COPD: Characteristics and Outcome. Respiration 2010: 80:387-392
Cryptogenic hemoptysis in COPD
No difference between
CT and bronch to
determine the site of
bleed
Arterial embolization
succeeded in controlling
bleeding in all patients
who underwent the
procedure
34 pts followed for 5 yrs;
only 2 had recurrent
hemoptysis. None died
Delage A, et al. cryptogenic hemoptysis in COPD: Characteristics and Outcome. Respiration 2010: 80:387-392
Important fact about the lungs
The lungs are heterogeous in nature
Non-physiological ventilation in healthy lungs
induce lung injury
Summary