Tuberc Respir Dis.  2018 Apr;81(2):99-105. 10.4046/trd.2017.0094.

What Can We Apply to Manage Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Acute Respiratory Failure?

Affiliations
  • 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea. kimdkmd@gmail.com
  • 2Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.

Abstract

Acute exacerbation(s) of chronic obstructive pulmonary disease (AECOPD) tend to be critical and debilitating events leading to poorer outcomes in relation to chronic obstructive pulmonary disease (COPD) treatment modalities, and contribute to a higher and earlier mortality rate in COPD patients. Besides pro-active preventative measures intended to obviate acquisition of AECOPD, early recovery from severe AECOPD is an important issue in determining the long-term prognosis of patients diagnosed with COPD. Updated GOLD guidelines and recently published American Thoracic Society/European Respiratory Society clinical recommendations emphasize the importance of use of pharmacologic treatment including bronchodilators, systemic steroids and/or antibiotics. As a non-pharmacologic strategy to combat the effects of AECOPD, noninvasive ventilation (NIV) is recommended as the treatment of choice as this therapy is thought to be most effective in reducing intubation risk in patients diagnosed with AECOPD with acute respiratory failure. Recently, a few adjunctive modalities, including NIV with helmet and helium-oxygen mixture, have been tried in cases of AECOPD with respiratory failure. As yet, insufficient documentation exists to permit recommendation of this therapy without qualification. Although there are too few findings, as yet, to allow for regular andr routine application of those modalities in AECOPD, there is anecdotal evidence to indicate both mechanical and physiological benefits connected with this therapy. High-flow nasal cannula oxygen therapy is another supportive strategy which serves to improve the symptoms of hypoxic respiratory failure. The therapy also produced improvement in ventilatory variables, and it may be successfully applied in cases of hypercapnic respiratory failure. Extracorporeal carbon dioxide removal has been successfully attempted in cases of adult respiratory distress syndrome, with protective hypercapnic ventilatory strategy. Nowadays, it is reported that it was also effective in reducing intubation in AECOPD with hypercapnic respiratory failure. Despite the apparent need for more supporting evidence, efforts to improve efficacy of NIV have continued unabated. It is anticipated that these efforts will, over time, serve toprogressively decrease the risk of intubation and invasive mechanical ventilation in cases of AECOPD with acute respiratory failure.

Keyword

Pulmonary Disease, Chronic Obstructive; Respiratory Insufficiency; Noninvasive Ventilation; Oxygen Inhalation Therapy; Carbon Dioxide

MeSH Terms

Anti-Bacterial Agents
Bronchodilator Agents
Carbon Dioxide
Catheters
Head Protective Devices
Humans
Intubation
Mortality
Noninvasive Ventilation
Oxygen
Oxygen Inhalation Therapy
Prognosis
Pulmonary Disease, Chronic Obstructive*
Respiration, Artificial
Respiratory Distress Syndrome, Adult
Respiratory Insufficiency*
Steroids
Anti-Bacterial Agents
Bronchodilator Agents
Carbon Dioxide
Oxygen
Steroids

Figure

  • Figure 1 Trends in initial ventilation. IMV: invasive mechanical ventilation; MV: mechanical ventilation; NIV: noninvasive ventilation. Adapted from Stefan et al. Chest 2015;147:959-68, with permission of Elsevier14.

  • Figure 2 A patient with acute respiratory failure supported by noninvasive ventilation with a helmet (The patient provided written informed consent).

  • Figure 3 The effect of high-flow nasal cannula oxygen therapy on changes in mean airway pressure (A) and tidal volume (B) in patients with stable hypercapnic chronic obstructive pulmonary disease. nCPAP: nasal continuous positive airway pressure; nBiPAP: nasal bi-level positive airway pressure. Adapted from Braunlich et al. Int J Chron Obstruct Pulmon Dis 2016;11:1077-85, according to the Creative Commons license Dove Medical Press30.


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