What is the best approach for airway management in a patient with chronic obstructive pulmonary disease (COPD)?

Airway Management in COPD Patients

For COPD patients requiring airway management, prioritize meticulous pre-oxygenation with a well-fitting mask for 3-5 minutes, use videolaryngoscopy for first-pass success, ensure full neuromuscular blockade before intubation attempts, and employ a two-person two-handed bag-mask technique with VE-grip if ventilation is needed—avoiding multiple attempts that increase risk of hypoxemia and respiratory decompensation. 1

Pre-Intubation Optimization

Oxygenation Strategy

• Perform meticulous pre-oxygenation for 3-5 minutes with a well-fitting mask using a closed circuit (e.g., anesthetic circle breathing circuit), as COPD patients have reduced oxygen reserves and are prone to rapid desaturation 1
• Position the patient with head elevation (ramping if obese) and reverse Trendelenburg to maximize safe apnea time and functional residual capacity 1
• After reliable loss of consciousness, gentle continuous positive airway pressure (CPAP) may be applied if the seal is good to minimize desaturation, but only use minimal oxygen flows and airway pressures 1

Preparation and Personnel

• The most experienced airway manager should perform the intubation, as first-pass success is critical in COPD patients who tolerate hypoxemia poorly 1
• Ensure all necessary equipment is present before starting, including videolaryngoscope, airway trolley, working suction, and rescue devices 1
• Use a tracheal intubation checklist to ensure preparedness 1

Intubation Technique

Pharmacologic Approach

• Administer rocuronium 1.2 mg/kg as early as practical to ensure full neuromuscular blockade before attempting laryngoscopy (or suxamethonium 1.5 mg/kg if used), waiting at least 1 minute to avoid patient coughing which can worsen air trapping 1
• If cardiovascular instability is a concern (common in severe COPD with right heart strain), use ketamine 1-2 mg/kg for induction 1
• Have vasopressor immediately available for managing hypotension, as positive pressure ventilation can further compromise venous return in COPD patients 1

Device Selection and Execution

• Use videolaryngoscopy as the primary device, as it provides the highest likelihood of first-pass success across all patient types including those with difficult airways 1
• Stay as distant from the airway as practical; videolaryngoscopes with separate screens enable optimal positioning 1
• If using a Macintosh blade videolaryngoscope, have a bougie available; if using a hyperangulated blade, use a stylet 1
• Intubate with a single attempt using optimal technique—multiple attempts increase risk of airway trauma, edema, and progressive hypoxemia that COPD patients cannot tolerate 1, 2

Rescue Strategies if Difficulty Encountered

Bag-Mask Ventilation

• If ventilation is needed, use the two-person two-handed technique with VE-grip (not C-grip) to achieve optimal seal, particularly important in COPD patients who may have reduced chest wall compliance 1
• Use a Guedel airway to maintain airway patency 1
• Apply minimal airway pressures consistent with adequate oxygenation to avoid gastric insufflation and barotrauma 1

Supraglottic Airway Device

• A second-generation supraglottic airway device (e.g., i-gel, LMA ProSeal) may be inserted after loss of consciousness to replace bag-mask ventilation or serve as rescue if mask ventilation is difficult 1
• This provides a more secure airway with less aerosol generation than bag-mask ventilation 1

Cognitive Aid for Difficulty

• Use a cognitive aid immediately if difficulty arises, as airway difficulty leads to cognitive overload 1
• Follow established difficult airway algorithms with intentionally reduced scope to encourage prompt, reliable decision-making 1

Post-Intubation Management Specific to COPD

Ventilator Settings

• Use low tidal volume ventilation (4-8 mL/kg predicted body weight) with plateau pressures below 30 cmH2O to avoid dynamic hyperinflation and barotrauma 3
• Allow adequate expiratory time to prevent air trapping, a critical concern in COPD patients 3

Circuit and Tube Management

• Place a heat and moisture exchange (HME) filter between the catheter mount and circuit, but monitor closely for blockage if it becomes wet, which can cause increased airway resistance and be mistaken for patient deterioration 1, 3, 4
• Monitor airway cuff pressure carefully, ensuring it is at least 5 cmH2O above peak inspiratory pressure to prevent air leak (particularly important with high airway pressures in COPD) 1, 3, 4
• Monitor and record tracheal tube depth at every shift to minimize displacement risk 1, 3, 4

Critical Pitfalls to Avoid

• Never make multiple intubation attempts without reassessing and optimizing conditions, as progressive airway edema and hypoxemia develop rapidly in COPD patients with limited respiratory reserve 2, 5
• Avoid non-invasive ventilation or high-flow nasal oxygen as primary strategies in patients requiring definitive airway management, as these delay securing the airway and increase risk of emergency intubation 1, 3
• Do not use techniques you are not trained in or have not used before—this is not the time to test new approaches 1
• Ensure adequate sedation and consider neuromuscular blockade for any procedures requiring circuit disconnection to prevent patient-ventilator dyssynchrony and increased airway pressures 3, 4
• If cricoid pressure is used, promptly remove it if it contributes to intubation difficulty 1