Intubation and Ventilators

Chronic obstructive pulmonary disease (COPD) is a term that is used to describe a group of lung conditions that, among other things, make it difficult to breathe well. Typically, COPD refers to chronic bronchitis and emphysema, but can also include refractory asthma and certain types of bronchiectasis.

What is an exacerbation or flare-up?

Exacerbations associated with COPD are an acute worsening of the symptoms. During
these flare-ups, a person will experience symptoms that are much worse than usual.

These symptoms can include:

• Increased breathlessness
• Wheezing
• Tightness in the chest
• Frequent coughing (with and without mucus or sputum production)

When flare-ups deteriorate and become unresponsive to standard treatment and even aggressive
therapies, a person may require immediate intervention in an emergency department setting. A team of professionals will attend to the person, take a history (as feasible), provide a physical exam, conduct diagnostic procedures, (e.g. arterial blood gases (ABG's), x-rays), and possibly even take basic breathing screenings.

What is intubation?

If the results of the medical assessments forecast continued worsening of the condition, a decision may be made to intubate the person. Intubation is the insertion of an artificial airway, called an endotracheal tube (ETT), to help support breathing. The ETT is inserted into the person's airway (trachea). This artificial airway will enable the medical team to support the person's breathing until the exacerbation can be brought under control. Since the ETT is inserted through the vocal cords, this device prevents someone from speaking, coughing and eating. It also makes spontaneously breathing even more difficult than it already was during the exacerbation.

When this occurs it can be a very frightening experience for both the person experiencing it and their family and friends. The health care team should be keeping the person with COPD and family apprised of the situation. Sometimes, during the efforts to stabilize the person, communication from the team to the family is not readily forthcoming. This can briefly complicate the event even further until everyone catches up with the care being delivered. Rest assured the team will be providing the best care for the patient first, and communicate as necessary once the situation is stabilized.

What is a ventilator?

Once the artificial airway (ETT) is established, a ventilator is used which helps the person to breathe.

Patients are usually placed on a ventilator because of a medical condition (for our purposes, COPD) that makes it hard for them to breathe sufficiently on their own.

While on the ventilator, the body is able to rest so that it can heal. The ventilator can assist with breathing or can totally breathe for the person, depending on the specific circumstance.

What to expect?

Since the person has been unable to maintain their own level of normal breathing, the medical team will support the person's breathing with a mechanical ventilator. A ventilator is an electronic device that provides all or part of the breathing for someone who no longer is able to breathe sufficiently on their own. The ventilator is set with parameters (respiratory rate, tidal volume, oxygen level, and other settings) that will be best for the person on it. The respiratory therapist, under the direction of a physician, will make certain the person is provided with the individualized support that is necessary from the ventilator. The objective is to keep the person as comfortable as possible while most of the work of breathing is provided by the mechanical ventilator. This is determined on a case-by-case basis.

Depending on the severity of the medical condition that resulted in respiratory failure, this can range from a brief period of time (sometimes only a few days) to a more lengthy time frame (which can last a few weeks to even months). The time frame varies by individual and is completely dependent on the exacerbation, the condition itself and the comorbidities the person may have.

Some people with COPD adapt very well to being on a ventilator while others need assistance through prescribed medication. Sometimes, people on a ventilator are given medicine that puts them in a coma-like condition so that the ventilator does all the work of breathing.

Emotions

Some people feel frustrated or anxious because they are unable to talk while on the ventilator.
Remember, the endotracheal tube is situated in the vocal cords, preventing speech, but providing the necessary breathing support. There are several ways to help promote communication. The respiratory therapists, nurses, and speech therapists can help to assess if the person will benefit from artificial speaking devices. These devices, when appropriate, may be able to facilitate a kind of mechanical speech.
What about eating and activity? The person on the ventilator will be fed through an intravenous (IV) or feeding tube. If he or she is strong enough, he/she may be able to sit up in a chair while on the ventilator.

Alarms, alerts, and warnings

Even though there may not be a care team member at the bedside all the time, there are a
number of devices that will alert the staff to any problems or changes. There is a monitor located near the bed. It helps keep track of heart rhythm, blood pressure, breathing rate and even oxygen level. Both the monitor and the ventilator are equipped with alarms. Each of the alarms will alert staff members if a change has taken place in the person's condition. Each sound refers to a different condition.

Often when an alarm sounds, there is no great cause for concern. The problem may correct itself, and this can be monitored from the nurses’ station. Other times, a care team member may come to check the alarm. Rest assured the hospital staff is capable of handling all alarm conditions.

Coming off the ventilator

The ventilator brings oxygen into the lungs and helps remove carbon dioxide from a person's body. Sometimes a person may become dependent on a ventilator because of their underlying medical condition(s). This may make it difficult to get the person off the ventilator. However, when the person's medical problems have improved and they are well enough, the process of “weaning” will begin.

Weaning is the process of gradually reducing the person's reliance on the ventilator. He or she is actively assessed to determine when weaning should begin. This assessment includes a regular determination of the person's capacity to be removed from ventilatory support. The goal is to transition from mechanical support to normal spontaneous breathing. The respiratory therapist will evaluate the person's ability to once again breathe on their own by screening with basic spirometry tests at the bedside.

Similar to pulmonary function tests, these will include tidal breathing (the normal breathing volume), respiratory rate, and vital capacity (breathing volume during a deep breath). Muscle strength will also be assessed to gauge the person's ability to take a deep breath and cough. These are all simple maneuvers performed at the bedside. When the assessments go well, the person may be removed from the ventilator. At this point, the breathing tube may be removed from the throat. This is referred to as 'extubation'.

It's a team effort

The care team is a group of professional and support staff who act as a team to provide personal care to the person who has had a serious COPD exacerbation.

The team members include:

• Physicians, including pulmonologists
• Registered nurse
• Respiratory therapist

The support staff members may include:

• Social worker
• Nursing assistant
• Dietitian
• Physical therapist
• Occupational therapist
• Speech therapist

Summary

This article is designed to present the most basic overview of the circumstances which result in the placement of an artificial airway (endotracheal tube) and the use of a ventilator for a serious
exacerbation of COPD. When this occurs and has reached the point where the usual regimen of medications is no longer sufficient, the episode requires more immediate and critical intervention on the part of the medical team. These episodes can be frightening and physically exhausting. The effect on the person with COPD, and their family and friends, will require a lot of emotional support and strength. This support, combined with good medical care, can help to pull a person out of a very difficult time.

We welcome your comments, inquiries, and experiences concerning this serious aspect of COPD.