From the Guidelines
For COPD exacerbation requiring mechanical ventilation, initial ventilator settings should include a low tidal volume of 6-8 mL/kg of ideal body weight, respiratory rate of 8-12 breaths per minute, FiO2 starting at 40-60% (titrated to maintain SpO2 88-92%), and PEEP of 3-5 cmH2O, as recommended by the most recent guidelines 1. The ventilator mode should typically be volume-controlled with pressure support, such as assist-control (AC) or synchronized intermittent mandatory ventilation (SIMV) with pressure support.
- Key considerations for ventilator settings include:
- Low tidal volume to minimize barotrauma risk
- Respiratory rate of 8-12 breaths per minute to accommodate the underlying pathophysiology of COPD
- FiO2 starting at 40-60% to maintain SpO2 88-92% and avoid excessive oxygen use
- PEEP of 3-5 cmH2O to prevent air trapping and dynamic hyperinflation
- Patients with COPD exacerbation require close monitoring for auto-PEEP and permissive hypercapnia may be necessary to avoid worsening air trapping, as suggested by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1.
- Noninvasive ventilation (NIV) should be the first mode of ventilation used in patients with COPD with acute respiratory failure who have no absolute contraindication, as recommended by the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1.
- The use of NIV should not delay escalation to invasive mechanical ventilation (IMV) when this is more appropriate, as stated in the BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults 1.
From the Research
Ventilator Settings for COPD Exacerbation
The ventilator settings for Chronic Obstructive Pulmonary Disease (COPD) exacerbation are crucial for effective management. The following settings are recommended:
- Non-invasive ventilation (NIV) is the first choice therapy in acute exacerbations of chronic hypercapnic respiratory failure (AE-COPD) 2
- NIV should be delivered as assisted positive pressure ventilation with high inspiratory flow and peak pressure 2
- The external positive end expiratory pressure (PEEP) should be adjusted to the intrinsic PEEP 2
- Assisted ventilation modes are preferred over controlled ventilation modes in intubated COPD patients 2
- Settings of respirators should be aimed at a reduction of intrinsic PEEP and dynamic hyperinflation, including sufficient external PEEP, long expiration times, and low respiratory frequencies, even allowing for permissive hypercapnia 2
Patient Selection and Monitoring
Patient selection and monitoring are critical for successful NIV:
- Patients with a pH between 7.25 and 7.35 have demonstrated the most benefit from NIV 2
- Patients with severe acidosis or altered levels of consciousness due to hypercapnic acute respiratory failure are at high risk of NIV failure 3
- NIV should be used in conjunction with usual care, and patients should be closely monitored for signs of treatment failure or complications 4
NIV Settings and Outcomes
The optimal NIV settings and outcomes are:
- High inspiratory positive airway pressures aimed at decreasing CO2 levels can ensure NIV success in stable hypercapnic COPD patients 5
- NIV can lead to improved clinical outcomes, including reduced mortality, need for endotracheal intubation, and hospital length of stay 4
- NIV can also improve symptoms, such as dyspnea, and arterial blood gases, including pH and PaCO2 4