ORLANDO, Fla. — Patients with severe COPD exacerbations can present a challenge for any provider, particularly when respiratory failure progresses to the need for mechanical ventilation. While securing the airway may address one immediate problem, ventilating an obstructive patient requires an understanding of what is happening on both sides of the respiratory cycle.
During his 2026 EMS World Expo presentation, “The COPD exacerbation: The nightmare case,” Eric R. Bauer, EdD, MBA, FP-C, CCP-C, C-NPT, NRP, FAASTN(H), CEO of FlightBridgeED, walked attendees through a interfacility transfer case study of a 55-year-old woman with COPD who presented with acute respiratory failure. Using changes in ventilator settings, capnography, blood gases and patient response, Bauer demonstrated how specific adjustments can worsen ventilation when obstructive physiology is not considered.
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Memorable quotes on ventilating COPD patients
Here are some memorable quotes from Bauer on COPD ventilation:
- “The lower the [respiratory] rate, the better off we are because it gives us a longer period overall for inhalation and exhalation.”
- “Make sure that your equipment isn’t hindering you.”
- “We have to focus not only on the expiratory phase, but the inspiratory phase as well.”
- “The key is not to focus on the [EtCO₂] number. It’s about moving that ventilation.”
- “We’ve got to be very, very patient with these patients.”
Top takeaways on COPD ventilation
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1. Understand the obstructive approach
Bauer emphasized that mechanically ventilating a patient with COPD or asthma requires a different approach than ventilating a patient with injured or poorly compliant lungs. Obstructive patients have increased airway resistance and need adequate time to move air through narrowed airways.
Respiratory rate plays an important role. Increasing the rate shortens the total respiratory cycle, leaving less time available for both inspiration and expiration. Bauer identified the patient’s initial respiratory rate of 20 breaths/min as one of the problems in the case and noted that he typically begins an obstructive patient at a lower rate, allowing more time for air movement.
2. Look beyond expiratory flow limitation
COPD is often associated with difficulty exhaling, making prolonged expiratory time a familiar part of ventilator management. Bauer challenged attendees to consider what may be happening during inspiration as well.
Using the case, Bauer demonstrated how a respiratory rate of 22 breaths/min produced a respiratory cycle of only 2.72 seconds. With an I:E ratio of 1:4, approximately half a second remained for inspiration. Even though the setting provided additional expiratory time, there may not have been enough inspiratory time to deliver the desired volume through a highly resistant airway.
Bauer encouraged clinicians to consider both inspiratory and expiratory flow limitations rather than focusing exclusively on giving the patient more time to exhale. He also discussed considering a 1:1 I:E ratio in selected situations when inadequate inspiratory time contributes to difficulty delivering the desired volume.
3. Make sure the ventilator isn’t working against you
Ventilator alarms provide important safety information, but alarm settings can also impact breath delivery. Bauer demonstrated how a high-pressure alarm set too low for a patient with significant airway resistance can limit the breath before the desired tidal volume is delivered.
Rather than simply increasing pressure or respiratory rate when tidal volumes remain low, clinicians should evaluate why the volume is not being delivered. Bauer stressed understanding the ventilator, reviewing alarm settings and determining whether the equipment itself may be contributing to inadequate ventilation.
4. Avoid the “EtCO2 trap”
Capnography provided several pieces of information throughout Bauer’s case. Early in the presentation, the capnogram demonstrated the characteristic obstructive, or “shark-fin,” appearance, supporting the clinical picture of airflow obstruction.
Bauer also cautioned against focusing solely on the EtCO2 number. The patient initially had an EtCO2 of 51 mmHg, while her blood gas and elevated bicarbonate reflected chronic CO2 retention. As the case progressed, Bauer demonstrated why increasing the respiratory rate simply to lower an elevated EtCO₂ may create another problem by shortening the respiratory cycle.
“Don’t ever raise the rate to chase that number,” Bauer told attendees, emphasizing the importance of improving ventilation rather than treating the EtCO2 value in isolation.
5. Reassess and give the patient time to respond
Following changes in the patient’s ventilator management, tidal volume improved into the desired range, static compliance increased and auto-PEEP decreased. Bauer used these changes to reinforce the importance of reassessing the patient after ventilator adjustments, rather than expecting one setting or one number to immediately normalize.
REFERENCES
- Long, B., Koyfman, A., & Vivirito, M. A. (2017). Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations. The Journal of emergency medicine, 53(6), 829–842. https://doi.org/10.1016/j.jemermed.2017.08.026
- See, K. C., & Ng, J. (2022). Management of acute severe asthma and chronic obstructive pulmonary disease. Singapore medical journal, 63(9), 535–541. https://doi.org/10.4103/SINGAPOREMEDJ.SMJ-2022-015
- Walter, J. M., Corbridge, T. C., & Singer, B. D. (2018). Invasive Mechanical Ventilation. Southern medical journal, 111(12), 746–753. https://doi.org/10.14423/SMJ.0000000000000905
