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Ventilatory strategies in obstructive lung disease

机译：阻塞性肺疾病的通气策略

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Chronic obstructive pulmonary disease (COPD) is characterized by expiratory flow limitation (EFL) due to progressive airflow obstruction. The various mechanisms that cause EFL are central to understanding the physiopathology of COPD. At the end of expiration, dynamic inflation may occur due to incomplete emptying the lungs. This extra volume increases the alveolar pressure at the end of the expiration, resulting in auto-positive end-expiratory pressure (PEEP) or PEEPi. Acute exacerbations of COPD may result in increased airway resistance and inspiratory effort, further leading to dynamic hyperinflation. COPD exacerbations may be triggered by environmental exposures, infections (viral and bacterial), or bronchial inflammation, and may result in worsening respiratory failure requiring mechanical ventilation (MV). Acute exacerbations of COPD need to be distinguished from other events such as cardiac failure or pulmonary emboli. Strategies to treat acute respiratory failure (ARF) in COPD patients include noninvasive ventilation (NIV), pressure support ventilation, and tracheal intubation with MV. In this review, we discuss invasive and noninvasive techniques to address ARF in this patient population. When invasive MV is used, settings should be adjusted in a way that minimizes hyperinflation, while providing reasonable gas exchange, respiratory muscle rest, and proper patient-ventilator interaction. Further, weaning from MV may be difficult in these patients, and factors amenable to pharmacological correction (such as increased bronchial resistance, tracheobronchial infections, and heart failure) are to be systematically searched and treated. In selected patients, early use of NIV may hasten the process of weaning from MV and improve outcomes.
机译：慢性阻塞性肺疾病（COPD）的特征是由于进行性气流阻塞引起的呼气流量受限（EFL）。导致EFL的各种机制对于理解COPD的病理生理至关重要。呼气末，由于不完全排空肺部，可能会发生动态膨胀。在呼气末，该额外的体积会增加肺泡压力，从而导致自呼气末正压（PEEP）或PEEPi。 COPD的急性加重可能导致呼吸道阻力增加和吸气强度增加，进而导致动态过度充气。 COPD恶化可能由环境暴露，感染（病毒和细菌）或支气管炎症引起，并可能导致需要机械通气（MV）的呼吸衰竭加重。需要将COPD的急性加重与其他事件（例如心力衰竭或肺栓塞）区分开来。治疗COPD患者的急性呼吸衰竭（ARF）的策略包括无创通气（NIV），压力支持通气和MV气管插管。在这篇综述中，我们讨论了有创和无创技术来解决该患者人群中的ARF。使用侵入性MV时，应调整设置，以最大程度地减少过度充气，同时提供合理的气体交换，呼吸肌休息和适当的患者-呼吸机互动。此外，在这些患者中从MV断奶可能很困难，需要系统地搜索和治疗适合药理校正的因素（例如，支气管阻力增加，气管支气管感染和心力衰竭）。在选定的患者中，早期使用NIV可能会加快MV的断奶过程并改善结局。

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