People who have chronic obstructive pulmonary disease (COPD) lose elasticity in their lungs, which helps propel air out after they take a deep breath. They have to use a combination of muscles and additional energy to exhale from their “less elastic” lungs.
When there is a worsening of the condition or an exacerbation, the ability to breathe may become inadequate. At this point it may be necessary to intubate the patient, which requires the insertion of a tube through the mouth into the windpipe so that a ventilator can take over the breathing process. This may be life-saving because an individual who has impaired oxygenation may not be able to survive long without help.
Intubation with mechanical ventilation is not something to be taken lightly. It’s clearly not the natural way to breathe. In order for someone to tolerate having a tube in his throat, he must be sedated, which further inhibits the natural drive to breathe. Intubation also means impairing the natural defenses for infection and a patient’s natural ability to clear secretions by coughing.
An alternative treatment
What about a hospitalized COPD patient who has breathing difficulties that are not quite severe enough for intubation? An alternative treatment called noninvasive ventilation is showing great promise, according to clinical trials.
In this scenario, a machine delivers breaths of air to the lungs without a breathing tube. Instead, a mask is strapped tightly onto the mouth and/or nose of the patient. It’s not as effective as the traditional ventilator because of the potential and likelihood of air leaks; the amount of air delivered is also not consistent.
Nevertheless, noninvasive ventilation is a viable option, helping the COPD patient breathe and allowing the taxed lungs to rest.
Evidence for noninvasive ventilation
But how effective is the alternative treatment? This question was posed by a study published in the Cochrane Library in July 2017. Researchers looked at data collected from 17 clinical trials involving 1,264 patients. Up to 20 percent of patients who are hospitalized with respiratory failure die, so the researchers wanted to focus on treatments that offered a reduction in mortality.
The results suggested that with the use of noninvasive ventilation, mortality was reduced by 46 percent and the need for standard intubation was reduced by 65 percent. Both are pretty compelling findings.
The implications have had a profound impact on treating respiratory failure in the COPD patient. Here are some of the advantages of noninvasive ventilation:
It can be given to a patient on a traditional hospital floor. Standard intubation requires admission to the intensive care unit of a hospital, an area that has limited beds saved for the critically ill.
The mask can be removed and replaced again with ease. It can also be used on demand or intermittently during the day. Standard intubation must remain in place until the patient can adequately breathe on his own.
It can help a patient sleep. Some people are more prone to respiratory problems during sleep, and this equipment can be selectively used for this.
For use at home, too
New compact noninvasive ventilation units are being developed that can be adapted for home use. Philips-Respironics, the leading company that makes CPAP machines to treat sleep apnea, has developed a compact unit called the Trilogy Ventilator. It can be used outside the hospital setting for individuals who have a tracheostomy.
It can also be used at home to help a patient in times of need, avoiding an emergency department visit for treatment. The device allows a doctor more flexibility in discharging a COPD patient who is not quite free of symptoms but also not sick enough to meet in-hospital admission criteria.
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Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.