Continuous Positive Airway Pressure Reduces Work of Breathing and Dyspnea during Weaning from Mechanical Ventilation in Severe Chronic Obstructive Pulmonary Disease

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Abstract
Dynamic hyperinflation and the development of intrinsic positive end-expiratory pressure (PEEPi) are commonly observed in patients with severe chronic obstructive pulmonary disease (COPD) and acute respiratory failure. The pressure of intrinsic PEEP acts as an inspiratory threshold load, and contributes significantly to the observed increase in work and oxygen cost of breathing. The present study examined the effects of continuous positive airway pressure (CPAP) (at 5, 10, and 15 cm H2O) and its ability to reduce the mechanical load imposed by PEEPi on breathing pattern, work of breathing, and dyspnea in seven patients with severe COPD during weaning from mechanical ventilation. Tidal volume remained stable at all levels of applied pressure. Breathing frequency was also stable except for a small (12%) decrease during CPAP of 15 cm H2O. Inspiratory pulmonary resistance and elastance were unaltered by the application of CPAP. There were progressive reductions in the inspiratory work of breathing as the level of CPAP increased. At the highest level of CPAP, the amount of inspiratory work performed per minute and per liter of ventilation decreased by 49.8 and 41.8%, respectively. Similar progressive reductions were also obtained in the pressure-time product for the inspiratory muscles and the diaphragm, which amounted to decreases of 42.9 and 42.2%, respectively, at the highest level of CPAP. End-expiratory lung volume remained stable at the lowest level of CPAP, with only modest increases occurring at the higher levels. In addition, all patients reported a reduction in dyspnea during the administration of CPAP. We conclude that CPAP, by reducing the inspiratory mechanical load, decreases the inspiratory work of breathing and sense of breathlessness in patients with severe COPD and acute respiratory failure. This may be of potential therapeutic benefit during weaning from mechanical ventilation as well as during acute exacerbations of severe COPD in the nonintubated patient.