From the Guidelines
Ventilator settings for COPD patients should prioritize noninvasive ventilation (NIV) as the first mode of ventilation, with a focus on preventing dynamic hyperinflation and auto-PEEP, as recommended by the 2020 American Thoracic Society clinical practice guideline 1. The initial settings should include a low tidal volume of 6-8 mL/kg ideal body weight, respiratory rate of 10-14 breaths per minute, and longer expiratory times with an I:E ratio of 1:3 or greater.
- Use low PEEP (typically 3-5 cmH2O) to counterbalance auto-PEEP without worsening hyperinflation.
- FiO2 should be titrated to maintain SpO2 between 88-92%, as higher oxygen levels may suppress respiratory drive in COPD patients with chronic hypercapnia, as suggested by the 2017 BTS guideline for oxygen use in adults 1 and the 2017 BTS guideline for initial hospital management of patients with exacerbation of COPD 1.
- Pressure-controlled ventilation may be preferred over volume-controlled to limit peak airway pressures.
- Permissive hypercapnia is often acceptable, targeting pH > 7.25 rather than normal CO2 levels.
- Bronchodilators like albuterol and ipratropium should be administered via in-line nebulizer. These settings help prevent barotrauma, volutrauma, and ventilator-induced lung injury while accommodating the obstructive physiology of COPD with its prolonged expiratory phase and air trapping tendencies. Regular assessment of auto-PEEP and patient-ventilator synchrony is essential for optimizing these settings, and NIV should be used with targeted normalization of PaCO2 in patients with hypercapnic COPD on long-term NIV, as recommended by the 2020 American Thoracic Society clinical practice guideline 1.
From the Research
Ventilator Settings for COPD Patients
- The appropriate ventilator settings for a patient with Chronic Obstructive Pulmonary Disease (COPD) depend on various factors, including the severity of the disease and the patient's individual needs 2, 3.
- Noninvasive ventilation (NIV) is often used to treat respiratory acidosis due to exacerbation of COPD, with settings adjusted to minimize hyperinflation while providing reasonable gas exchange, respiratory muscle rest, and proper patient-ventilator interaction 3.
- Positive end-expiratory pressure (PEEP) should be set at 3-5 cmH2O, with inspiratory support to obtain a tidal volume between 6 and 8 ml/kg of ideal body weight 2.
- High-flow nasal therapy (HFNT) can also be used, initially set at a temperature of 37°C and a flow of 60 L/min 2.
Comparison of NIV and Invasive Mechanical Ventilation (IMV)
- NIV has been shown to be effective in reducing the need for endotracheal intubation, inhospital mortality, and hospital length of stay in COPD patients with acute hypercapnic respiratory failure 4.
- However, the evidence is inconsistent and of low to very low quality when comparing NIV to IMV for patients who have failed usual medical care 4.
- NIV has been shown to be effective in weaning COPD patients from IMV, with significant reductions in mortality, nosocomial pneumonia, and weaning failure 4.
Pharmacological Therapy
- Short-acting inhaled bronchodilators, such as salbutamol and ipratropium, are commonly used in the treatment of acute exacerbations of COPD 5.
- Long-acting dual bronchodilator therapy, such as indacaterol/glycopyrronium, has been shown to be effective in improving lung function in COPD patients, but its effectiveness compared to nebulized short-acting dual bronchodilator therapy is still being studied 6.