Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Which patients with acute exacerbation [r]
Trang 1Sherstin T Lommatzsch, MD Assistant Professor of Medicine
National Jewish Health
Denver, CO
Trang 2 Recognize Exacerbations
◦ Non-Invasive Mechanical Ventilation
◦ Invasive Mechanical Ventilation
Trang 3 Increased Frequency of Cough
Out-Patient Management
Hospital Admission Etiology
Trang 6Patient Use
Trang 7Out- Non-Invasive Positive Pressure Ventilation (NPPV)
• Uncompensated Hypercarbic Respiratory Failure
Trang 8 Invasive Positive Pressure Ventilation (IPPV)
• WHEN ?
• Severity of Presenting Respiratory Distress
• Underlying Etiology of Exacerbation
• Failure of BPAP
• Progressive Hypercarbic Encephalopathy
• Worsening Respiratory Acidosis
• Unrelief of Dyspnea
• Hemodynamic Instability
Clinical Judgment
Trang 9 Invasive Positive Pressure Ventilation (IPPV)
• Management
1 Patient Participation
• Triggering Modes
• Assist Control (AC)
• Intermittent Mandatory Ventilation/Pressure Support (IMV/PS)
• [ Pressure Support Ventilation ] (PSV) – Do NOT use acutely
• Wean FIO2 for PaO2 = 60mmH (SpO2 = 88-92%)
• Minimize Sedation – Richland Aggitation Scale Score (RASS): zero - neg one
Trang 10 Invasive Positive Pressure Ventilation (IPPV) – Participation
• Assist Control (AC) – First Choice
• Clinician Controlled Minimal Minute Ventilation
• Clinician Set Tidal Volume ( 5-7ml/Kg IBW )
• Clinician Set Respiratory Rate ( 4 BPM less than Patient Respiratory Rate )
• Patient Rate Above the Set Rate Receives Clinician-Set Tidal Volume
• Intermittent Mandatory Ventilation with Pressure Support
• Clinician Controlled Minimal Minute Ventilation
• Clinician Set Tidal Volume Respiratory Rate
• Patient Rate Above Set Rate Receives Tidal Volume Based on Flow
• Pressure Support Ventilation – NOT Recommended Acutely
• Patient Controlled Minute Ventilation
• Patient Determined Rate and Tidal Volume
• Clinician: Set Pressure Support to Keep RR < 30 BPM
• Associated with Poorer Sleep Architecture than AC
Acute
Sub –
Acute
Suggested Starting Value
Trang 11 Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
Trang 12 Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
• COPD Obstructive Disease Air Cannot Get Out
A Auto-PEEP (Intrinsic PEEP)
• Additional End-Expiratory Pressure
• Perform End-Expiratory Hold
• Auto-PEEP = End-Exp Hold Pressure – Set PEEP
• Applied PEEP Overcomes the added work created by Auto-PEEP
• Additional PEEP added to Set PEEP
• Auto-PEEP (0.80) + Set PEEP
End-Exp Hold 12 cmH2O Set PEEP 5 cmH2O
Auto-PEEP 7 cmH2O
0.80 Applied PEEP 6 cmH2O
Trang 13 Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
OR
Trang 14 Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
C Inspiratory Flow Rate
• Default of 60L/min is often inadequate
• Increase Flow Rate = Increasing Inspiratory Time
Solution
Trang 15 Invasive Positive Pressure Ventilation (IPPV) - Extubation
• Aggressive Extubation
• Spontaneous Breathing Trial (SBT)
• Performed When
• Cause of Respiratory Failure Reversed
• Minimal Ventilator Support ( FIO2 = 0.4, PEEP = 5cmH2O )
• Ventilation via:
• T-Piece,
• Minimal PS/PEEP ( 5 cmH2O/5 cmH2O)
• Automatic Tube Compensation (ATC)
• 30min Rapid Shallow Breathing Index < 104
• With Appropriate Mental Status and Few Secretions
• If SBT Failure Extubate to BPAP
Reduction:
Mortality Ventilator Associated Pneumonia Duration of Mechanical Ventilation Frequency of Tracheostomy Placement
COPD
ONLY!
Burns KE et al Chochrae CatabaseSystm Rev 2010:CD004127
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Organized jointly by the American Thoracic Society, the European Respiratory Society, the EuropeanSociety of Intensive Care Medicine, and the SociÈtÈ
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