How To Manage Ventilator

In Asthma / COPD

JCCA-Perdatin Jaya
Jakarta 2018
 INTRODUCTION

• Resp. Fail. severe asthma/COPD is life-

threatening condition  Reversible

• Estimated about 10% admitted to hospital for

asthma go to the intensive care unit, with 2%
patients being intubated

• COPD 5-10% emergency medical admision

to hospital
 INTRODUCTION

• Poor outcome in this setting is frequently a

result of the development of gas-trapping

• These complications include barotrauma,

hypotension and refractory respiratory
acidosis
 Asthma/COPD exacerbations
Pathophysiology
• Occlusion of the bronchial lumen by mucus,
cells, thickened/contracted smooth muscle,
bronchial wall inflammation and edema.
• Leads to:
– low V/Q ratios
– increased work of breathing
– dynamic hyperinflation
 Differences from Asthma
• Have chronic small airway disease and
emphysema
• Are older, weaker, have more comorbid
conditions
• More likely to have bacterial infection
ASTHMA vs COPD
Chest X Ray normal vs COPD
 Asthma/COPD Exacerbations
Therapeutic options
• Oxygen
• Bronchodilators
– Aerosolized albuterol
– Ipratropium
– Methylxanthines
– Long acting bronchodilators
• Corticosteroids for (<14 day total course)
• Antibiotics
• Non-invasive ventilation
• Invasive ventilation
 PPV

• Severe asthma/COPD not respond adequately to

medical therapy, provide adequate oxygenation
and ventilation

• Noninvasive positive pressure ventilation (NPPV)

or Invasive positive pressure mechanical
ventilation is frequently life saving
 NPPV
• Indications
- Accessory muscle use/abdominal paradox
- Acidosis (pH<7.35) and PCO2 (>45mmHg)
- RR>25

• Contraindications
- Cardiac/respiratory arrest
- Haemodynamic instability
- High risk for aspiration
- Unstable arrhythmia
- Severe encephalopathy
- Facial surgery/deformity
- Gastrointestinal bleeding
- Upper airway obstruction
 The Decision to Intubate
• The decision to intubate should be on clinical
judgement.

• Because many patients presenting with hypercapnia do

not require intubation, and thus the decision should
not be based solely on blood gases

• Markers of deterioration:
- Rising CO2 levels - Exhaustion
- Mental status depression - CV instability
- Refractory hypoxaemia
 Development of Gas-Trapping
• Severe airflow limitation is always associated
with severe asthma/COPD exacerbation as a
result of bronchoconstriction, airway oedema
and/or mucous plugging

• Increased work because the normally passive

process of expiration  active in an attempt
by the patient to force the inspired gas out of
their lungs
 Development of Gas-Trapping
• Increased inspiratory work caused by high
airway resistance and hyperinflation

• Hyperinflation causes the lungs and chest wall

to operate on a suboptimal portion of their
pressure–volume curves (overstretched),
resulting in increased work to stretch them
further in an attempt to ventilate adequately
 Development of Gas-Trapping
• Gas-trapping because the low expiratory flow
rates mandate long expiratory times if the
entire inspired volume is to be exhaled

• Gas is trapped in the lungs there is additional

pressure at the end of expiration (auto-PEEP
or intrinsic PEEP) above applied PEEP, which
leads to dynamic hyperinflation
 Measuring gas-trapping
• Gas-trapping can be measured a variety of
ways involving volume, pressure, or flow of
gas
1. Estimating gas-trapping using volume
measures can be done by collecting the total
exhaled volume (VEI) during 20–60 s of
apnoea in a paralyzed patient
VEI above 20 ml/kg predicted complications of
hypotension and barotrauma
 Measuring gas-trapping
2. Measure end-expiratory pressure  estimate
gas trapping
occluded the expiratory port of the ventilator
at end-expiration, then the proximal airway
pressure will equilibrate with alveolar pressure
and permit measurement of auto-PEEP (end
expiratory pressure above applied PEEP) at the
airway opening
 Measuring Gas-Trapping

3. Observe the flow versus time graphics on the

ventilator. If inspiratory flow begins before
expiratory flow ends  gas must be trapped
 Measuring Gas-Trapping
4. volume-cycled ventilation Increasing
plateau airway pressure (Pplat) 
decreases in respiratory system compliance 

5. pressure cycled ventilation  Decreasing tidal

volumes may indicate gas trapping
 Limiting Gas-Trapping
1. Most effective method is reduce the Min.Vol.
Reduced tidal volumes (less gas to exhale)
Reduced respiratory rates (longer expiratory time)

2. Relieving expiratory flow resistance

Frequent airway suctioning , BT if necessary
Bronchodilators
Steroids
Large-bore endotracheal tube
 Limiting Gas-Trapping
3. Reducing inspiratory time
Increasing the inspiratory flow rate (60-100l/min) /
Modifying I:E ratio (1:3-5)

4. Controlled CO2 use of ‘permissive hypercapnia’

Maintains a pH above 7.20 or an arterial carbon
dioxide tension below 90 mmHg
Decreasing carbon dioxide production (e.g.
sedation/paralysis, controlling fever/pain)
 Initial Ventilator Settings
1. Controlled Mode (pres/vol)
Tidal volume of 6–8 ml/kg
Respiratory rate of 11–14 breaths/min (Increase
exp time – slow RR)
PEEP at 0–5 cmH2O
high FiO2 is not required

2. Permissive hypercapnia Goal pH above 7.2

 Initial Ventilator Settings
3. Pplat under 30 cmH2O
If a Pplat under 30 cmH2O cannot be maintained,
evaluated for causes of decreased respiratory
system compliance (i.e. pneumothorax, misplaced
endotracheal tube, pulmonary oedema, etc.)

4. Sedation/paralysis
 WEANING
• An aggressive weaning  inability to wean is
associated with a worse prognosis and
prolonged ventilation

• Factors that increase resistance such as size,

secretions, kinking of the tube and the
presence of elbow-shaped parts or a heat and
moisture exchanger in the circuit have to be
optimised to promote early weaning
 WEANING
• Patients of cor pulmonale may require small
dose of inotrope, diuretics and low fluid strategy
during weaning

• Weaning can be done with PS mode along with

spontaneous breathing trials (SBTs)
• Rapid Shallow Breathing Index (RR/VT in L)
• ≤105  80% success extubasi
 WEANING
• Sequential weaning (early extubation followed
by NPPV) is found to be good alternative in
patients showing failed SBTs

• Tracheostomy is also expected to help in

weaning
 KESIMPULAN
• PPV bisa non/invasif. Merupakan life saving
• Intubasi berdasar clinical judgement
• Mengetahui cara mendiagnosa (auto peep,
Pplat, Flow exp) dan mencegah gas trapping
( low MV, airway resistence, permisive
hipercapni, prod CO2)
• Jika perlu trakeostomi untuk weaning
TERIMA KASIH