11 - How should exacerbations of COPD be managed in the intensive care unit?

Abstract

Chronic obstructive pulmonary disease (COPD) is increasing in prevalence and accounts for up to 10% of acute emergency medical hospital admissions and 2% of nonsurgical referrals to the intensive care unit (ICU). Acute admission with COPD is associated with as high as an 11% acute mortality and 43% 1-year m ortality, and a 50% readmission rate within 6 months. While it is difficult to predict the acute outcome of ICU admissions in COPD, late failure of ward-based care, comorbidities and severe disease may aid in establishing appropriate ceilings of care. Pharmacologic treatment remains corticosteroids, nebulized bronchodilators, and antibiotics. Oxygen should be titrated in a controlled manner in COPD to oxygen saturation of 88–90%. This has been shown to reduce mortality. Noninvasive ventilation has evolved into the most effective treatment for acute hypercapnic respiratory failure, with better outcome in mortality and length of stay compared with invasive ventilation. Clinicians must be aware of barotrauma and dynamic hyperinflation when using positive pressure ventilation in COPD. High-flow nasal oxygen is evolving as an effective therapy to assist extubation as well as treat acute respiratory failure in COPD. Further studies are required. End-of-life decisions can be assisted by early discussion in those with severe disease, especially with comorbid illness, and in those with prolonged intubation over 72 hours and failed extubation. Some studies have shown that patients with COPD describe same or improved quality of life after invasive ventilation in the ICU; so it can be difficult to predict impact and outcomes.