Allison Clemens
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2025 PACUPrep BCCCP Preparatory Course COPD Exacerbation Optimizing Respiratory Support and Sedation in AECOPD

Lesson 3, Topic 4

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Optimizing Respiratory Support and Sedation in AECOPD

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Non-Invasive and Invasive Ventilation Strategies with Targeted Sedation in AECOPD

Learning Objective

Recommend appropriate respiratory support strategies to prevent complications and optimize outcomes in AECOPD-induced acute respiratory failure.

I. Criteria for Initiating Non-Invasive Ventilation (NIV)

Summary: Early NIV in hypercapnic AECOPD reduces intubation rates, complications, and mortality. Candidate selection relies on bedside assessment and arterial blood gases.

Clinical Indicators

Tachypnea >25 breaths/min with use of accessory muscles
Severe dyspnea signs: paradoxical abdominal movement, intercostal retractions, inability to speak full sentences
Agitation or diaphoresis secondary to respiratory distress

Laboratory Indicators

Arterial pH <7.35 and PaCO2 >45 mmHg
Hypoxemia not corrected by low-flow oxygen (PaO2/FiO2 <200)

Contraindications

Respiratory or cardiac arrest, inability to protect airway or clear secretions
Copious secretions, severe encephalopathy, facial trauma/deformity
High aspiration risk, recent upper gastrointestinal surgery

Key Pearl

Initiate NIV promptly in AECOPD with respiratory acidosis to reduce need for intubation and shorten ICU stay.

II. Non-Invasive Ventilation Strategy

Summary: Select the appropriate mode and titrate settings to alleviate work of breathing while avoiding excessive pressures.

Mode Selection

BiPAP in spontaneous/timed (S/T) mode or pressure support ventilation

Initial Settings

IPAP 10–12 cmH2O; EPAP 4–6 cmH2O
FiO2 titrated to SpO2 88–92%
Adjust IPAP to reduce PaCO2 and improve pH; increase EPAP if airway collapse is noted

Monitoring

ABG at baseline and 1 hr after initiation; track pH, PaCO2, PaO2
Respiratory rate, mask fit and leak, patient comfort, hemodynamics

Troubleshooting

Optimize interface fit; switch between nasal, oronasal or helmet mask
Add heated humidification to improve tolerance and secretion clearance

Key Pearl

An early rise in pH and decrease in respiratory rate within the first 1–2 hrs predicts NIV success.

III. Recognizing NIV Failure and Escalation

Summary: Reassess clinical and laboratory response within 1–2 hrs and prepare for IMV if criteria for failure are met.

Clinical Triggers

Worsening encephalopathy (confusion, somnolence), persistent accessory muscle use
Hemodynamic instability: hypotension, new arrhythmias
Inability to tolerate NIV interface

Laboratory Triggers

Persistent pH <7.30 or rising PaCO2 despite maximal NIV settings
Refractory hypoxemia (SpO2 <88% on FiO2 ≥0.6)

Time Frame

Reevaluate at 1–2 hrs; avoid prolonged ineffective NIV (>2 hrs without improvement)

Escalation Criteria

Indications for intubation: NIV intolerance, worsening acidosis/hypoxemia, cardiac or respiratory arrest, severe encephalopathy, hemodynamic compromise

Key Pearl

Delay in switching to IMV after NIV failure increases morbidity and mortality. Aim for timely escalation.

IV. Invasive Mechanical Ventilation (IMV) to Minimize Dynamic Hyperinflation

Summary: IMV settings should prioritize longer expiratory times to prevent auto-PEEP and reduce barotrauma.

Indications for Intubation

NIV failure, PaCO2 >60 mmHg with pH <7.25
Altered mental status, respiratory arrest, refractory hypoxemia, hemodynamic instability

Initial Ventilator Settings

Tidal volume: 6–8 mL/kg ideal body weight
Respiratory rate: ≤12 breaths/min to prolong exhalation
I:E ratio: ≥1:3
Inspiratory flow: 80–100 L/min
External PEEP: 3–5 cmH2O (to offset intrinsic PEEP)
FiO2: titrate to SpO2 88–92%

Monitoring Auto-PEEP

Inspect flow-time waveform for incomplete exhalation
Measure plateau pressure and adjust settings accordingly

Adjustments for Synchrony

Optimize trigger sensitivity and flow delivery
Ensure adequate sedation/analgesia to prevent dyssynchrony

Key Pearl

Minimal external PEEP helps trigger alveolar inflation without worsening hyperinflation in COPD.

V. Pharmacotherapy: Sedation and Analgesia Strategies

Summary: Light, analgesia-first sedation promotes synchrony, reduces delirium risk, and shortens ventilation duration.

Sedation Goals & Protocols

Target RASS –1 to 0; use an analgesia-first approach
Daily sedation interruption and early mobilization

Agent Selection & Profiles

Sedation and Analgesia Agents for Mechanically Ventilated AECOPD Patients
Agent	Mechanism	Dosing	Advantages	Disadvantages	Monitoring
Propofol	GABA-A agonist	5–50 mcg/kg/min infusion; avoid >48 hrs high-dose	Rapid onset/offset, easy titration	Hypotension, hypertriglyceridemia, infusion syndrome	BP, triglycerides, acid-base status
Dexmedetomidine	α2-adrenergic agonist	0.2–1.5 mcg/kg/hr infusion; avoid bolus	Minimal respiratory depression, cooperative sedation	Bradycardia, hypotension, cost	HR, BP
Benzodiazepines (Midazolam, Lorazepam)	GABA-A agonist	Midazolam 0.02–0.1 mg/kg/hr; Lorazepam 0.02–0.06 mg/kg/hr	Anxiolytic, amnestic	Delirium, prolonged sedation, respiratory depression. Reserve for seizures or refractory agitation.	Sedation score, respiratory status
Opioids (Fentanyl, Remifentanil)	μ-opioid receptor agonist	Fentanyl 1–3 mcg/kg/hr; Remifentanil 0.1–0.2 mcg/kg/min	Potent analgesia, remifentanil for rapid weaning	Tolerance, withdrawal, respiratory depression, constipation	Resp rate, sedation scores, pain scores

Weaning & Early Mobilization

Conduct daily sedation holidays and extubation readiness trials
Balance sedation reduction with comfort and synchrony

Controversies

Current Debates in Sedation

Optimal sedative in hypercapnic COPD: propofol vs dexmedetomidine
Role of neuromuscular blockade in severe asynchrony
Impact of sedation depth on long-term cognitive outcomes

Key Pearl

Dexmedetomidine may facilitate earlier extubation due to its minimal respiratory depression and delirium-sparing profile.

References

Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817-22.
Wedzicha JA, Miravitlles M, Hurst JR, Calverley PMA, Albert RK, et al. Management of COPD exacerbations: an ERS/ATS guideline. Eur Respir J. 2017;49(1):1600791.
Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for acute hypercapnic respiratory failure in AECOPD. Cochrane Database Syst Rev. 2017;7(7):CD004104.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for AECOPD on general wards. Lancet. 2000;355(9219):1931-5.
Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation in hospitalized AECOPD. JAMA Intern Med. 2014;174(12):1982-93.
Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs conventional mechanical ventilation after medical treatment failure in COPD. Intensive Care Med. 2002;28(12):1701-7.
Siemieniuk RAC, Chu DK, Kim LH-Y, et al. Oxygen therapy for acutely ill medical patients: clinical practice guideline. BMJ. 2018;363:k4169.
Austin MA, Wills KE, Blizzard L, et al. Effect of high-flow oxygen on mortality in COPD patients: randomised controlled trial. BMJ. 2010;341:c5462.
Celli BR, MacNee W; ATS/ERS Task Force. Standards for diagnosis and treatment of COPD: summary. Eur Respir J. 2004;23(6):932-46.
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of COPD. 2025 report. https://goldcopd.org

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Optimizing Respiratory Support and Sedation in AECOPD

Non-Invasive and Invasive Ventilation Strategies with Targeted Sedation in AECOPD

Learning Objective

I. Criteria for Initiating Non-Invasive Ventilation (NIV)

Clinical Indicators

Laboratory Indicators

Contraindications

II. Non-Invasive Ventilation Strategy

Mode Selection

Initial Settings

Monitoring

Troubleshooting

III. Recognizing NIV Failure and Escalation

Clinical Triggers

Laboratory Triggers

Time Frame

Escalation Criteria

IV. Invasive Mechanical Ventilation (IMV) to Minimize Dynamic Hyperinflation

Indications for Intubation

Initial Ventilator Settings

Monitoring Auto-PEEP

Adjustments for Synchrony

V. Pharmacotherapy: Sedation and Analgesia Strategies

Sedation Goals & Protocols

Agent Selection & Profiles

Weaning & Early Mobilization

Controversies

References