Just breathe. - Emergency Medicine

JUST BREATHE.
OPTIMAL VENTILATION TECHNIQUES FOR ASTHMATICS IN RESPIRATORY FAILURE
Christine B. Davis
Emergency Medicine
Henry Ford Hospital
6 March 2014
GOALS
 Analyze current research in order to learn the best
methods to ventilate asthmatic patients presenting in
respiratory failure with a focus on ventilator settings
 Details on pharmacological management and prevention of future
episodes of severe asthma are beyond the scope of this
presentation
 Details of the types and mechanics of various ventilators are
beyond the scope of this presentation
ACKNOWLEDGEMENTS
Thank you to Doctors:
Gregory Hays
Emmanuel Rivers
Seth Krupp
Michael Mendez
Daniel Ouellete
for their mentorship of this lecture
 Asthma affects 300 million people globally
 2 million emergency department visits for acute asthma per year
 12 million people reporting having had asthma “attacks” in the past year
 Accounts for 1 in every 250 deaths worldwide
 many of which are preventable
ASTHMATIC IN RESPIRATORY FAILURE
 Inability to maintain respiratory effort due to fatigue
 Declining mental status; Agitation
 Cyanosis; Profound diaphoresis
 Accessory muscle use; chest wall retractions
 Brief, fragmented speech (1-2 words)
 Inability to lie supine
 Peak expiratory flow or FEV1 < 35 - 50% of predicted
 Arterial O2 sat < 91%
 Paradoxical pulse exceeding 25 mmHG
 Rapid, shallow breathing (respiratory rate >30 breaths/minute)
 Failure of medical management (i.e. O2, bronchodilators, corticosteroids, Mg,
anticholinergics, heliox, ketamine, leukotriene receptor agonists.)
ASTHMA PATHOPHYSIOLOGY
 airflow obstruction; mucus plugging
 bronchial hyper-responsiveness; bronchoconstriction
 underlying inflammation; airway edema
NONINVASIVE POSITIVE PRESSURE VENTILATION PHYSIOLOGY
 Reduces work of breathing
 Decreases airway resistance
 Relieves the feeling of dyspnea
 Re-expands collapsed alveoli
 Provides rest for the muscles
of respiration
NONINVASIVE POSITIVE PRESSURE VENTILATION SETTINGS
BiPap
 Bilevel positive airway pressure

IPAP: pressure applied during patient triggered breaths

EPAP: pressure applied in between patient triggered
breaths

FiO2: fraction of O2 percentage that is added to the
delivered air

Vf: respiratory rate set as a guarantee for intermittent
bursts of IPAP
CPAP
 Continuous positive airway pressure

unchanged during inspiration and expiration
PSV
 Pressure support ventilation
 provides a small amount of pressure during
inspiration to assist the patient as they draw in a
spontaneous breath
CPAP VS. BIPAP
Continuous positive airway pressure
(CPAP):
Bilevel positive airway pressure (BiPAP)
 bronchodilatory effect in asthma
 unload fatigued inspiratory muscles
 improve gas exchange
 prevent methacholine- and histamine-induced
asthma.
 increases tidal volume
 All that a CPAP does with the added advantage
of adding external positive end-expiratory
pressure (PEEP) to offset the intrinsic PEEP that
builds up during an asthmatic attack
CONTRAINDICATIONS TO NIPPV
Absolute contraindication
 need for urgent intubation (e.g. cardiac or respiratory arrest)
Relative contraindications
 facial trauma or surgery
 upper airway deformity
 inability of patient to cooperate or to maintain cooperation
 copious secretions; risk for aspiration
 recent esophageal anastomosis
ADVERSE EFFECTS OF NONINVASIVE POSITIVE PRESSURE VENTILATION
° local skin trauma secondary to mask
° eye irritation
° gastric distension
ALTHOUGH THERE ARE NO ROBUST RANDOM CONTROL TRIALS FOR NIPPV IN
ASTHMA SHOWING MORTALITY BENEFIT AS THERE ARE FOR PULMONARY
EDEMA, COPD, AND IMMUNOCOMPROMISED PATIENTS; I WILL REVIEW SOME
PROMISING DATA THAT SUGGEST THAT NIPPV CAN BE USEFUL ADJUNCT TO
TREATMENT IN THE ED
A PILOT PROSPECTIVE, RANDOMIZED, PLACEBOCONTROLLED TRIAL OF BILEVEL POSITIVE AIRWAY
PRESSURE IN ACUTE ASTHMATIC ATTACK
Arie Soroksky; David Stav; Isaac Shpirer
Chest. 2003;123(4):1018-1025. doi:10.1378/chest.123.4.1018
 30 patients (18 to 50 years old) with a severe asthma exacerbation, defined as:
 respiratory rate >30 breaths per minute
 FEV1 <60 percent of predicted when measured 30 minutes after inhaled bronchodilator therapy
 Also, with a history of asthma of at least 1 year and duration of current asthma attack of < 7 days.
 Randomly assigned to receive nasal BPAP or sham (subtherapeutic BPAP) for 3 hours in the
emergency department.
BIPAP SETTINGS
 Inspiratory pressure was set at 8 cm H2O then increased gradually by
2 cm H2O every 15 min
 to a maximum of 15 cm H2O
 or until a respiratory rate of < 25 breaths/min was reached
 Expiratory pressure was set at 3 cm H2O then increased gradually by 1 cm H2O every 15 min
 to a maximum of 5 cm H2O
 Rationale for these settings:
 Gradual increase in both the inspiratory and expiratory pressures was aimed at increasing patient comfort and patient
compliance
 Values were set in a rather arbitrary manner, designed to provide what would be considered by most as a mild PEEP
and mild-to-moderate inspiratory pressure support
RESULTS
Primary endpoint:
 BiPAP increased the likelihood of a significant improvement in FEV1

80% vs. 20% (p < 0.004)
Secondary endpoint:
 BiPAP reduced the rate of hospitalization

18% vs. 63% (p = 0.0134)
 Hospitalization was required for:
 3 of 17 patients (17.6%) in the BPV group
 10 of 16 patients (62.5%) in the control group
Conclusion:
In selected patients with a severe asthma attack, the addition of BiPAP to conventional treatment can
improve lung function, alleviate the attack faster, and significantly reduce the need for hospitalization.
CARDIOPULMONARY RESPONSES TO CONTINUOUS POSITIVE AIR
WAY PRESSURE IN ACUTE ASTHMA
Shivaram U, Miro AM, Cash ME, Finch PJ, Heurich AE, Kamholz SL. J Crit Care. 1993 Jun;8(2):87-92.
 In 21 patients with acute asthma, the effects were studied of nasal
continuous positive airway pressure (CPAP) on:
 expiratory flow
 arterial blood gas tensions
 cardiovascular status
 dyspnea
CPAP SETTINGS
 CPAP sequence:
 30 minutes at 5 cm H2O
 20 minutes at 0 cm H2O
 30 minutes at 7.5 cm H2O
 20 minutes at 0 cm H2O
 Six control patients were fitted with a CPAP mask but given no positive-
pressure therapy
RESULTS
 Significant reductions in respiratory rate occurred from a baseline of 22.0 +/- 1.0:
 19.8 +/- 3.8 breaths/min at CPAP 5 cm H2O
 19.4 +/- 4.3 breaths/min at CPAP 7.5 cm H2O (P < .05)
 No significant change occurred in FEV1, heart rate, MAP, or ABG tension with either level of CPAP.
 Dyspnea, as assessed by a breathlessness score, improved during CPAP therapy (P < .05)
 In comparison, the control group showed no change in heart rate, respiratory rate, or breathlessness score
during the study period.
Conclusion:
These data show that application of CPAP in acute asthma reduces respiratory rate and
dyspnea
.
NON-INVASIVE MECHANICAL VENTILATION IN STATUS
ASTHMATICUS
M.M. Fernández, A.Villagrá, L. Blanch, R. Fernández. Intensive Care Medicine. March 2001,
Volume 27, Issue 3, pp 486-492
 Seven-year period retrospective observational study.
58 patients were included in the study.
 25 patients (43%) were not eligible for NIMV:

11 patients (19%) because of respiratory arrest on their arrival
at the Emergency Room

14 patients (24%) because of improvement with medical
management.
 The remaining 33 patients were eligible for NIMV
(57%):
 11 patients (33%) received invasive MV
 22 patients (67%) were treated with NIMV

3 NIMV patients (14%) needed ETI
SETTINGS
Pressure support ventilation (PSV)
 Trigger sensitivity adjusted to 0.5 cm H2O
Continuous positive airway pressure
(CPAP)
 Oxygen levels adjusted to maintain O2 >90%
 PSV was titrated to achieve a minimum expired
tidal volume of 400 mL
 Then increased by steps of 3 cm H2O to
improve patient‟s breathing pattern or ABG
 Positive end expiratory pressure (PEEP) applied
until a substantial improvement in the effort
required to trigger the ventilator was noted
 Fixed CPAP values of:
 5 cmH2O; or
 7.5 cmH2O
RESULTS
 Significant differences were observed in arterial blood gases on
admission to the Emergency Room between MV and NIMV:

PaCO2 (89±29 mmHg vs 53±13 mmHg, p<0.05),

pH (7.05±0.21 vs 7.28±0.008, p<0.05)

HCO3 – level (22±5 mmol/l vs 26±6 mmol/l, p<0.05).
 No differences were found in the median length of ICU stay (4.5 vs
3 days), median hospital stay (15 vs 12 days) and mortality (0 vs 4%).
 Conclusion:
Face mask NIMV appears to be a suitable method for improving
alveolar ventilation and can reduce the need for intubation in a
selected group of patients with SA.
NONINVASIVE POSITIVE PRESSURE VENTILATION IN STATUS
ASTHMATICUS
Gianfranco U. Meduri; et al. Chest. 1996;110(3):767-774.
•
17 episodes of asthma and ARF over a 3-year period in the ICU.
•
Mean age was 35.4±11.3 years; 10 patients were female.
 Initiation of NIPPV:

pH was 7.25±0.01

PaCO2 was 65±2

PaO2 fraction of inspired oxygen was 315±41

respiratory rate was 29.1±1
 less than 2 hours:
 2 to 6 hours:

pH was 7.36±0.02 (p<0.0001)

PaCO2 52±3 (p=0.002)

PaO2 367±47

respiratory rate was 20±1

pH was 7.32±0.02 (p=0.0012)

PaCO2 was 45±3 (p<0.0001)

PaO2 403±47

pH was 7.38±0.02

respiratory rate was 22±1 (p<0.0001)

PaCO2 45±4

PaO2 472±67 (p=0.06)

respiratory rate was 7±1
 12 to 24 hours:
SETTINGS

Initial ventilatory settings included CPAP at 4 +/- 2 cm
H2O to offset intrinsic positive end-expiratory pressure
 Pressure support ventilation (PSV) at 14 +/- 5 cm H2O
aiming at a respiratory rate less than 25 breaths/min and
an exhaled tidal volume of 7 mL/kg or more.
 PSV was then adjusted following arterial blood gas
results.

The mean (+/- SD) peak inspiratory pressure to ventilate in
the NIPPV-treated patients was 18 +/- 5 cm H2O and
always less than 25 cm H2O.
CONCLUSION
In asthmatic patients with ARF, NIPPV via a face mask appears highly effective in correcting gas exchange abnormalities
using a low inspiratory pressure (<25 cm H2O).
NONINVASIVE POSITIVE-PRESSURE VENTILATION IN CHILDREN
WITH LOWER AIRWAY OBSTRUCTION
Thill, Peter J. MD; et al. Pediatric Critical Care Medicine. Issue:Volume 5(4), July 2004, pp 337-342

A prospective, randomized, crossover study.
 20 children admitted to the PICU with acute lower airway
obstruction (increased work of breathing, wheezing, dyspnea)
 Randomized to receive either:

2 hrs of BiPAP followed by crossover to 2 hrs of standard therapy;
or

2 hrs of standard therapy followed by 2 hrs of BiPAP
SETTINGS
 spontaneous mode without a backup rate
 Oxygen supplementation to keep O2 >90%
 inspiratory positive airway pressure (IPAP) of 10 cm H2O
 expiratory positive airway pressure (EPAP) of 5 cm H2O
 settings remained unchanged throughout the course of the study period
RESULTS
Primary end points:
 change in respiratory rate
 Clinical Asthma Score (CAS) – work of breathing, wheezing, dyspnea
 assessment of gas exchange
 BiPAP was associated with a decrease in respiratory rate (49.5 ± 13.9 vs. 32.0 ± 6.2 breaths/min, p <
.0001) for all patients after 2 hrs compared with baseline
 BiPAP was associated with a lower total CAS (5.4 ± 1.2 vs. 2.1 ± 1.0, p < .0001) and lower scores for
each individual component (accessory muscle use, wheeze, and dyspnea; all p < .01)
CROSSOVER GROUPS
 discontinuation of BiPAP in Group 1 at the 2-hr crossover time point was associated with
an increase in both respiratory rate and total CAS by the 4-hr data collection time point
 Group 2 did not improve after 2 hrs of standard therapy but showed improvement in
respiratory rate and total CAS after 2 hrs of BiPAP
CONCLUSION
BiPAP in children with acute lower airway
obstruction can be well tolerated and may
be effective in improving clinical measures
of respiratory distress.
MECHANICAL VENTILATION
 Andreas Vesalius (31 December 1514 – 15
October 1564)
 first person to describe mechanical ventilation
 De humani corporis fabrica (On the fabric of the
human body)
MECHANICAL VENTILATION
 Associated with significant morbidity and mortality
 increased airway resistance, airway injury, barotrauma, hemodynamic instability, nosocomial pneumonia,
increased length of hospital stay (which can lead to DVT, PE, myopathies, malnutrition and infections)
 Last resort –
 when medical management has failed; and noninvasive ventilation is contraindicated or has failed
 mortality rate of only 8%
 but 27% to 45% of patients requiring mechanical ventilatory support experience serious complications
Barry Brenner, Thomas Corbridge, and Antoine Kazzi "Intubation and Mechanical Ventilation of the Asthmatic Patient in
Respiratory Failure", Proceedings of the American Thoracic Society, Vol. 6, No. 4 (2009), pp. 371-379.
INDICATIONS FOR INTUBATION
 Cardiac arrest
 Respiratory arrest
 Altered mental status
 Progressive exhaustion
 Silent chest
 Severe hypoxia with maximal oxygen delivery
 Failure to reverse severe respiratory acidosis despite intensive therapy
 pH < 7.2
 PCO2 increasing by more than 5 mm Hg/h or greater than 55 to 70 mm Hg
 PO2 of less than 60 mm Hg
MECHANICAL VENTILATION
Assist Control Ventilation (AC)
 When patient triggers spontaneous breath, it will
force in either the pressure or volume set, will stack
breaths
Synchronized Intermittent Mandatory
Ventilation (SIMV)
 When patient triggers spontaneous breath, the
pressure or volume will be determined by the patient,
it will not stack breaths
CONTINUOUS MECHANICAL VENTILATION
Volume control
When the ventilator detects the set volume
having been applied, the ventilator cycles to
exhalation.
 Airway pressure increases in response to reduced
compliance, increased resistance, or active exhalation
and may increase the risk of ventilator-induced lung
injury
Pressure Control
Limits the maximum airway pressure delivered to
the lung
 May be difficult to attain adequate tidal volumes
against high airway resistance
TROUBLESHOOTING
 Check plateau pressures by allowing for an inspiratory pause
 If peak pressures are high and plateau pressures are low then you have an obstruction
 If both peak pressures and plateau pressures are high then you have a lung compliance issue
TROUBLESHOOTING
Poor oxygenation in asthmatic patient
Paralysis
ALTHOUGH MECHANICAL VENTILATION IS USED COMMONLY FOR ASTHMATICS,
THERE IS A PAUCITY OF DATA ON THE BEST SETTINGS AND MODES OF VENTILATION.
THE RECOMMENDATIONS FOR SETTINGS COME FROM A FEW SMALL TRIALS AND
RECOMMENDATIONS BASED ON THEORY AND CLINICAL EXPERIENCE.
Severe bronchial asthma requiring ventilation.
A review of 20 cases and advice on management
Webb AK; et al. Postgraduate Medical Journal (March 1979) 55, 16i-170.
 Natural history of 20 asthmatics who required
mechanical ventilation
 Seven of these patients died („steady decline
on the vent,‟ 2 pneumothoraces, etc.)
 14 were male and 6 were female; Age range
was 5-64 years
VENTILATION RECOMMENDATIONS
Webb AK; et al. Postgraduate Medical Journal (March 1979) 55, 16i-170.
 “The
ventilator chosen must be capable of delivering an adequate volume against a high resistance into
a comparatively non-compliant thorax.”
 “A variable I:E ratio is a great advantage…The expiratory time should be sufficiently long…if the
inspiratory phase begins prior (to the end of expiration), further air trapping may occur.”
 “The authors used low volumes with slow respiratory rates.”
THE EFFECTS OF VENTILATORY PATTERN ON HYPERINFLATION, AIRWAY
PRESSURES, AND CIRCULATION IN MECHANICAL VENTILATION OF
PATIENTS WITH SEVERE AIR-FLOW OBSTRUCTION.
Tuxen DV1, Lane S. Am Rev Respir Dis. 1987 Oct;136(4):872-9.
 9 patients with severe air-flow obstruction (5 asthma,
4 chronic air-flow obstruction) requiring mechanical
ventilation were studied while sedated and
therapeutically paralyzed.
 Pulmonary hyperinflation during steady-state
ventilation was quantified by measuring total exhaled
volume during 20- to 40-s apnea (end-inspiratory
lung volume, VEI).
SETTINGS
 3 levels of minute ventilation (10, 16, and 26 L/min)
 And at each minute ventilation, 3 levels of tidal volume (VT) (0.6, 1.0, and 1.6 L)
 3 levels of inspiratory flow (VI) (40, 70, and 100 L/min for VT = 1.0 L)
CONCLUSION
 There were progressive increases in end-expiratory lung volume:
 when tidal volume was increased
 or when expiratory time (TE) was decreased
 either by an increase in rate (and hence minute ventilation) or by a decrease in inspiratory
flow (at a constant minute ventilation)
 Reaching lung volumes as high as 3.6 +/- 0.4 L above functional residual capacity
PRESSURE-CONTROLLED VENTILATION IN
CHILDREN WITH SEVERE STATUS ASTHMATICUS
Sarnaik, Ashok. Pediatric Critical Care Medicine: March 2004 - Volume 5 - Issue 2 - pp 133-138
 Retrospective review at DMC Children‟s Hospital PICU of all patients who received
mechanical ventilation for status asthmaticus
 Pressure-controlled ventilation was used for 40 patients admitted for 51 episodes of
severe status asthmaticus
SETTINGS
 Pressure control
 Rate
 Inspiratory and expiratory time
 All titrated based on blood gas values, flow waveform, and exhaled tidal volume
RESULTS
Before
 Median pH: 7.21 (range, 6.65–7.39)
 Median Pco2: 65 torr (29–264 torr)
4 hours after
 Median pH increased to 7.31 (6.98–7.45, p < .005)
 Median Pco2 decreased to 41 torr (21–118 torr, p < .005).
• Median duration of mechanical ventilation was 29 hrs (4–107 hrs)
• ICU stay was 56 hrs (17–183 hrs)
• Total hospitalization was 5 days (2–20 days)
CONCLUSION
Pressure-controlled ventilation is an effective ventilatory strategy in severe status asthmaticus in children.
INVASIVE AND NONINVASIVE VENTILATION IN PATIENTS WITH
ASTHMA
Benjamin D Medoff. Respiratory Care. June 1, 2008 vol. 53 no. 6 740-750
Recommended Settings
 Pressure or volume control ventilation per individual or institutional preference and patient characteristics
 Avoid air-trapping
 Inspiratory time: 0.8–1.2 s (high flow, constant rather than descending-ramp flow)
 Frequency: 10–15 breaths/min
 Tidal volume: 6–8 mL/kg
 Plateau pressure < 30 cm H2O
 PEEP: 0 cm H2O
 FIO2 adequate to provide SpO2 88–92%
INTUBATION AND MECHANICAL
VENTILATION OF THE ASTHMATIC PATIENT IN
RESPIRATORY FAILURE
Control of hyperinflation and auto-PEEP
 Reduction of respiratory rate
 Reduction of tidal volume
 An initial set-up of 80 L/min with a decelerating waveform configuration might be appropriate in adults.
 Shortening of inspiration with a square wave pattern and an inspiratory flow rate of 60 L/min allows greater time for
exhalation in each respiratory cycle and might help control hyperinflation.
 Auto-PEEP and Plateau pressure should be followed during mechanical ventilation.
Hypercapnia is preferable to hyperinflation
 Hypercapnia should not be used in the presence of increased intracranial pressure
 An acceptable level of hypercapnia and acidosis is a pH as low as 7.15 and a Paco2 of up to 80 mm Hg
Barry Brenner,Thomas Corbridge, and Antoine Kazzi. Proceedings of the American Thoracic
Society,Vol. 6, No. 4 (2009), pp. 371-379.
CLINICAL REVIEW: MECHANICAL VENTILATION
IN SEVERE ASTHMA
David R Stather. Crit Care. 2005; 9(6): 581–587. Published online Sep 8, 2005.
 Low tidal volumes and respiratory rate
 Prolong expiratory time as much as possible
 Shorten inspiratory time as much as possible
 Monitor for the development of dynamic hyperinflation (auto-PEEP, peak plateau pressure)
PROPOSED INITIAL VENTILATOR SETTINGS
Goal:
 pH above 7.2
 Plateau pressure under 30 cmH2O
Pressure control mode
 setting the pressure to achieve a tidal volume of
6–8 ml/kg
 respiratory rate of 11–14 breaths/min
 PEEP at 0–5 cmH2O
INVASIVE MECHANICAL VENTILATION IN ADULTS
WITH ACUTE EXACERBATIONS OF ASTHMA
Carlos A Camargo. UpToDate. Literature review current through: Jan 2014.
SETTINGS
 Respiratory rate 10 to 14 breaths/min
 Tidal volume less than 8 mL/kg
 Minute ventilation less than 115 mL/kg
 Inspiratory flow of 80 to 100 L/min
 Extrinsic positive end-expiratory pressure (extrinsic PEEP) less than 80 percent of the intrinsic PEEP
VENTILATING PATIENTS WITH ACUTE SEVERE
ASTHMA: WHAT DO WE REALLY KNOW?
BURNS, SUZANNE. AACN ADVANCED CRITICAL CARE. ISSUE:VOLUME 17(2),
APRIL/JUNE 2006, P 186–193
Avoiding hyperinflation and associated complications
 Low tidal volumes
 Low respiratory rates
 Short inspiratory times
 Long expiratory times
 PEEP increases lung volumes and aggravates hyperinflation and circulatory compromise
 Use PEEP cautiously and to ensure vigilant monitoring to determine the effect
SUMMARY – NONINVASIVE POSITIVE PRESSURE VENTILATION
 Consensus is that invasive mechanical ventilation should be avoided if noninvasive ventilation is an option
 BiPap preferred over CPAP as can reduce the pressure during exhalation
 Recommended initial settings:
 IPAP 8 - 10
 EPAP 3 - 5
 Titrate for correction of pH, O2 saturation, tachypnea
SUMMARY – INVASIVE MECHANICAL VENTILATION
 Last resort
 Pressure control allows for control of pressure but may not allow for adequate tidal volumes
 Recommended initial settings:

No PEEP

FiO2 for sat > 88 - 92%

Tidal volume 6-8 ml/kg

Keep plateau pressure < 30 mmHG

pH > 7.2; PCO2 < 80

Respiratory rate 10 – 14

Inspiratory flow rate 60 – 100 L/min

Minute ventilation < 115 mL/kg (volume/min)
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the end.