What are the recommended ventilator settings for a 70-year-old patient with a history of Chronic Obstructive Pulmonary Disease (COPD) and COVID-19 requiring pre-hospital intubation?

Pre-Hospital Ventilator Settings for a 70-Year-Old COPD Patient with COVID-19

For a 70-year-old COPD patient with COVID-19 requiring pre-hospital intubation, use low tidal volume ventilation (4-8 mL/kg of predicted body weight), target plateau pressures <30 cmH2O, and implement a higher PEEP strategy (>10 cmH2O) with close monitoring for barotrauma.

Initial Ventilator Settings

Tidal Volume

• Use low tidal volume ventilation: 4-8 mL/kg of predicted body weight 1
• For COPD patients with COVID-19, aim for the lower end of this range (4-6 mL/kg) to minimize risk of barotrauma
• Calculate predicted body weight based on height, not actual weight

Pressure Settings

• Target plateau pressure <30 cmH2O (strong recommendation) 1
• Set initial PEEP at 10-15 cmH2O (higher PEEP strategy) 1
• For COPD patients, be particularly vigilant about monitoring for barotrauma as they are at higher risk 2
• Ensure tracheal tube cuff pressure is at least 5 cmH2O above peak inspiratory pressure 1

Oxygenation

• Initial FiO2: 100% during intubation, then titrate down
• Target SpO2: 90-96% (avoid hyperoxia) 1, 3
• Use an HME filter close to the patient to reduce viral contamination 1

Ventilation Mode

• Volume Control is preferred initially for consistent minute ventilation
• Consider Pressure Control if high airway pressures develop
• Adjust respiratory rate to target normal pH (start with 14-18 breaths/min)

Critical Intubation Considerations

Airway Management

• Inflate the cuff with air to a measured cuff pressure of 20-30 cmH2O immediately after intubation 1
• Secure the tracheal tube firmly and document insertion depth prominently 1
• Confirm tracheal intubation with continuous waveform capnography 1
• Verify bilateral chest expansion visually (auscultation not recommended due to PPE and contamination risk) 1

Circuit Setup

• Use closed tracheal suction system 1
• Place HME filter between patient and circuit 1
• Ensure all connections are secure (push-twist) to prevent accidental disconnections 1

Post-Intubation Management

Sedation and Paralysis

• Ensure adequate sedation before transport
• Consider intermittent boluses of neuromuscular blocking agents rather than continuous infusion 1
• For persistent ventilator dyssynchrony or high plateau pressures, continuous NMBA may be needed 1

Fluid Management

• Implement conservative fluid strategy 1
• Avoid fluid overload which can worsen gas exchange

Special Considerations for COPD

• Monitor closely for auto-PEEP (air trapping)
• Allow for longer expiratory times (lower I:E ratio, 1:3 or 1:4)
• Be prepared to decrease respiratory rate if auto-PEEP develops
• Consider permissive hypercapnia if needed to maintain safe ventilation parameters

Monitoring During Transport

• Continuous SpO2 monitoring
• Continuous waveform capnography
• Monitor plateau pressures and peak inspiratory pressures
• Watch for signs of barotrauma (sudden increase in airway pressure, decreased compliance, hypoxemia)
• Monitor for tube displacement during transport

Pitfalls to Avoid

• Excessive tidal volumes: COVID-19 patients with COPD are at higher risk of barotrauma even with standard ARDSNet protocols 2
• Disconnections: Avoid circuit disconnections; if necessary, follow strict protocol (pause ventilator, clamp tube) 1
• Inadequate sedation: Ensure appropriate sedation to prevent patient-ventilator dyssynchrony and self-extubation
• Failure to recognize auto-PEEP: Watch for incomplete exhalation, rising plateau pressures
• Inadequate cuff inflation: Ensure proper cuff inflation to prevent leaks and reduce aerosolization 1

Remember that patients with COVID-19 who undergo mechanical ventilation develop barotrauma at a higher rate than traditional non-COVID-19 ARDS patients 2, so extra vigilance is required, particularly in those with underlying COPD.