All these nutritional recommendations should be integrated in a healthy lifestyle. Mandatory tobacco cessation, gradual increase in physical activity, according to cardiorespiratory fitness score, optimal sleep and mindfulness, seen as a harmony between mind, body, thoughts and feelings will be beneficial for COPD patients. Despite a great interest in managing COPD, there is a gap in recommendations for physical activity (PA), the most commonly prescribed PA is: walking, cycling, strength training and nonspecific aerobic training. Physical activity PA should be part of lifestyle, may be performed in groups, social or independently. People with COPD should be active until breathless or as per their capacity. Recommended PA durations are ranging from 20 to 45 min/day, depending on guideline. For severe patients, to add short intervals rather than a continuous activity is mentioned. No specific guidelines are mentioning sedentary behaviors. Despite the fact that no specific sleep recommendations are in COPD guidelines, we

Post COVID 19 pulmonary rehabilitation measures, which start in the hospital for moderate cases, will improve symptoms like dyspnea, anxiety, depression and should continue as part of a healthy lifestyle after recovery, for future. A healthy lifestyle, normalizing body weight by adopting a healthy model adapted to caloric and nutritive requirements daily physical activity and an optimal sleep, mindfulness, will remain key principles for COPD patients after SARS-COV2 infection.

New concept of cardiometabolic disease reflects in a more appropriate way the role of adipose tissue in all comorbidities developed in obesity. Lung function decline associated with obesity, as it is revealed by important studies may be an interesting relation to be considered in COPD obese patients. Moreover, malnutrition, with the worst prognosis on COPD development will influence patients management. The importance of a healthy dietary pattern in COPD, designed in the new COPD pyramid are suggesting the strong correlation between foods, nutrients in order to achieve best therapeutical results. Medical nutrition therapy in COPD, based on Mediterranean model, with a high % of proteins, integrated in a healthy lifestyle should be part of COPD management. Nutritional status play an important role in future COPD prognosis and a multidisciplinary team with pneumologist, nutritionist and kinetotherapist should cooperate in order to achieve best long term

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

role of Mediterranean model in COPD.

**7. Medical nutrition therapy MNT in COPD**

depletion, airway remodeling [28] . But lung function is influenced by dietary factors, too. Detrimental role for lung function of Western type diet, characterized by high energy dense food, red and processed food, added sugar, high salt intake, preservatives, low antioxidants, high glycemic index and saturated fats is already proven. By contrast, fruits, vegetables, whole grains, alcohol, wine, legumes, nuts, coffee, fish, high antioxidants, low glycemic index and unsaturated fats, as part of a mediterranean healthy pattern are a support of a healthy lung function. As dietary patterns, is clearly proved the detrimental role of Western model and the protective

A special pyramid was designed for COPD patients, represented below, in

Daily energy has to be adapted to activities and requirements calculated by bio-

ation in malnutrition is detailed separately). Recommended macronutrients proportion is: 15–25% proteins, 30–45% fats, 40–55% carbohydrates. It has to be underlined that the % of macronutrients is important to maintain (respiratory quotient)RQ, the marker for respiratory tolerance of the pattern recommended. Respiratory quotient, defined as CO2 volume expired/O2 volume consumed is the respiratory parameter that indicates food mix metabolized. RQ is 1 for carbohydrates, 0.85 in mixed diets, 0,82 for proteins and 0.7 for fat. The macronutrient percentage is important, correct diet, but not overconsumption will be critical for COPD patients which have compromised ability for gas exchanges, because excess calories produce CO2 that must be expired and will influence the respiratory process [26]. Considering drug-food interactions, special attention should be considered for salt intake during oral corticosteroid treatment, that should be minimized. Meanwhile, due to increased risk for metabolic disorders,

Muscle mass decrease is a risk factor for mortality from COPD and muscle mass

the objective is to address hypermetabolism in order to prevent weight decrease and lean mass decrease. Practically lean mass/muscular mass maintenance is the key for a good prognosis in COPD [26]. From clinician perspective, MNT should address appetite decrease and improper food intake. Main recommendations are: small meals, frequent, nutritional dense. The main meal should be at the time when the energetic level is the highest. It is recommended to rest before meal. The proper caloric intake will be adjusted in order to maintain a BMI of 20–24 kg/m2

Availability of food which request minimum time to be prepared, eventually preprepared is important. To limit alcohol intake <2 portions/day, 30 g is mandatory.

maintenance is important. Considering these, the recommended daily protein intake is 1,2–1,5 g/kgb/day, combined with physical exercises, much more compared to general population recommendations of 0.75–1 g/kgb/day [53]. General recommendations, specified in the 2019 obesity guidelines [54] should be emphasized: decreasing food energetic density, avoid skipping meals, but also snacking, eating just as response to hunger sensations and stop eating when satiety appears, eating

slowly and mindfully, as an assumed responsibility, not as a restriction.

. (special situ-

.

**Figure 1**, adapted after International Journal of COPD, 2020 [52].

impedance and calorimetry in order to maintain BMI below 30–32 kg/m2

especially high glycaemia, sugar intake should be limited [26].

**7.1 MNT in obesity**

**7.2 MNT in malnutrition**

**74**

### **8. Lifestyle recommendations in COPD**

All these nutritional recommendations should be integrated in a healthy lifestyle. Mandatory tobacco cessation, gradual increase in physical activity, according to cardiorespiratory fitness score, optimal sleep and mindfulness, seen as a harmony between mind, body, thoughts and feelings will be beneficial for COPD patients. Despite a great interest in managing COPD, there is a gap in recommendations for physical activity (PA), the most commonly prescribed PA is: walking, cycling, strength training and nonspecific aerobic training. Physical activity PA should be part of lifestyle, may be performed in groups, social or independently. People with COPD should be active until breathless or as per their capacity. Recommended PA durations are ranging from 20 to 45 min/day, depending on guideline. For severe patients, to add short intervals rather than a continuous activity is mentioned. No specific guidelines are mentioning sedentary behaviors. Despite the fact that no specific sleep recommendations are in COPD guidelines, we encourage a referral to a sleep specialist [55].

### **9. Post-COVID 19**

Post COVID 19 pulmonary rehabilitation measures, which start in the hospital for moderate cases, will improve symptoms like dyspnea, anxiety, depression and should continue as part of a healthy lifestyle after recovery, for future. A healthy lifestyle, normalizing body weight by adopting a healthy model adapted to caloric and nutritive requirements daily physical activity and an optimal sleep, mindfulness, will remain key principles for COPD patients after SARS-COV2 infection.

#### **10. Conclusion**

New concept of cardiometabolic disease reflects in a more appropriate way the role of adipose tissue in all comorbidities developed in obesity. Lung function decline associated with obesity, as it is revealed by important studies may be an interesting relation to be considered in COPD obese patients. Moreover, malnutrition, with the worst prognosis on COPD development will influence patients management. The importance of a healthy dietary pattern in COPD, designed in the new COPD pyramid are suggesting the strong correlation between foods, nutrients in order to achieve best therapeutical results. Medical nutrition therapy in COPD, based on Mediterranean model, with a high % of proteins, integrated in a healthy lifestyle should be part of COPD management. Nutritional status play an important role in future COPD prognosis and a multidisciplinary team with pneumologist, nutritionist and kinetotherapist should cooperate in order to achieve best long term outcomes.

### **Author details**

Anca Mihaela Hâncu1 \*, Florin Mihălțan2 , Mihaela Ionela Vladu3 and Maria Moța3

1 Nutriscience Clinic, Bucharest, Romania

2 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania

3 University of Medicine and Pharmacy, Craiova, Romania

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**77**

*Nutritional Status and COPD*

**References**

edition, 2019

jacc.2019.11.044

s229749

*DOI: http://dx.doi.org/10.5772/intechopen.95600*

Physiol (Oxf) 2014 5;211(1):240-8, doi.

[9] Emiel F. M. Wouters, Transatlantic airway conference, Obesity and Metabolic Abnormalities in Chronic Obstructive Pulmonary Disease Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands, Ann Am Thorac Soc Vol 14, Supplement 5, pp S389–S394, Nov 2017, Copyright © 2017 by the American Thoracic Society, DOI: 10.1513/AnnalsATS.201705-371AW

[10] Prerana Chittal, Abraham Samuel Babu, and Carl J. Lavie. Obesity Paradox: Does Fat Alter Outcomes in Chronic Obstructive Pulmonary Disease? COPD, 00:1-5, 2014, doi.org/10.

3109/15412555.2014.915934

org/10.1093/ajcn/72.6.1415

ajrccm.160.6.9902115

NEJMoa054017

[13] Landbo C, Prescott E, Lange P, et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160:1856-1861. doi.org/10.1164/

[14] Jee SH, Sull JW, Park J, et al. Body-mass index and mortality in Korean men and women. N Engl J Med 2006; 355:779-787. DOI: 10.1056/

[15] Cao C, Wang R, Wang J,

index and mortality in chronic obstructive pulmonary disease: a

Bunjhoo H, Xu Y, Xiong W. Body mass

thx.2007.086827

[11] Franssen FME, O'Donnell DE, Blaak EE, Schols AMWJ. Obesity and the lung: 5. Obesity and COPD. Thorax 2008; 63:1110-1117. doi.org/10.1136/

[12] Jensen LG, Ezzell L. Malnutrition in chronic obstructive pulmonary disease. Am J Clin Nutr 2000; 72:1415-1416 doi.

org/10.1111/apha.12257

[1] www.goldcopd.org/gold-reports

[2] J. Rippe, Lifestyle medicine, 3rd

[3] Jeffrey I. Mechanick, Michael E. Farkouh, Jonathan D. Newman , MPH, W. Timothy Garvey, Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps, JACC STATE-OF-THE-ART REVIEW, Vol. 7 5, No. 5, 2020, doi.org/10.1016/j.

[4] Heng He, Bin Wang, Min Zhou, Limin Cao, Weihong Qiu, Ge Mu, Ailian Chen, Shijie Yang, Weihong Chen, Systemic Inflammation Mediates the Associations Between Abdominal Obesity Indices and Lung Function Decline in a Chinese General Population Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2020:13 141-150 141, doi.org/10.2147/dmso.

[5] Gabriela P. Peralta GP, et al. (2020). Body mass index and weight change are associated with adult lung function trajectories: the prospective ECRHS study Thorax, dx.doi.org/10.1136/

[6] Li J, Zhu L, Wei Y, et al. Association between adiposity measures and COPD risk in Chinese adults. Eur Respir J 2020; 55: 1901899, doi. org/10.1183/13993003.01899-2019

Scharf MT, et al. Impact of interrupted

[8] Bassi M, Furuya WI, Menani JV, et al. Leptin into the ventrolateral medulla facilitates chemorespiratory response in leptin-deficient (ob/ob) mice. Acta

[7] Polotsky VY, Smaldone MC,

leptin pathways on ventilatory control. J Appl Physiol (1985) 2004 3;96(3):991-8. doi.org/10.1152/ japplphysiol.00926.2003

thoraxjnl-2019-213880

### **References**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**76**

**Author details**

Anca Mihaela Hâncu1

\*, Florin Mihălțan2

3 University of Medicine and Pharmacy, Craiova, Romania

\*Address all correspondence to<EMAIL_ADDRESS>
2 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Nutriscience Clinic, Bucharest, Romania

provided the original work is properly cited.

, Mihaela Ionela Vladu3

and Maria Moța3

[1] www.goldcopd.org/gold-reports

[2] J. Rippe, Lifestyle medicine, 3rd edition, 2019

[3] Jeffrey I. Mechanick, Michael E. Farkouh, Jonathan D. Newman , MPH, W. Timothy Garvey, Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps, JACC STATE-OF-THE-ART REVIEW, Vol. 7 5, No. 5, 2020, doi.org/10.1016/j. jacc.2019.11.044

[4] Heng He, Bin Wang, Min Zhou, Limin Cao, Weihong Qiu, Ge Mu, Ailian Chen, Shijie Yang, Weihong Chen, Systemic Inflammation Mediates the Associations Between Abdominal Obesity Indices and Lung Function Decline in a Chinese General Population Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2020:13 141-150 141, doi.org/10.2147/dmso. s229749

[5] Gabriela P. Peralta GP, et al. (2020). Body mass index and weight change are associated with adult lung function trajectories: the prospective ECRHS study Thorax, dx.doi.org/10.1136/ thoraxjnl-2019-213880

[6] Li J, Zhu L, Wei Y, et al. Association between adiposity measures and COPD risk in Chinese adults. Eur Respir J 2020; 55: 1901899, doi. org/10.1183/13993003.01899-2019

[7] Polotsky VY, Smaldone MC, Scharf MT, et al. Impact of interrupted leptin pathways on ventilatory control. J Appl Physiol (1985) 2004 3;96(3):991-8. doi.org/10.1152/ japplphysiol.00926.2003

[8] Bassi M, Furuya WI, Menani JV, et al. Leptin into the ventrolateral medulla facilitates chemorespiratory response in leptin-deficient (ob/ob) mice. Acta

Physiol (Oxf) 2014 5;211(1):240-8, doi. org/10.1111/apha.12257

[9] Emiel F. M. Wouters, Transatlantic airway conference, Obesity and Metabolic Abnormalities in Chronic Obstructive Pulmonary Disease Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands, Ann Am Thorac Soc Vol 14, Supplement 5, pp S389–S394, Nov 2017, Copyright © 2017 by the American Thoracic Society, DOI: 10.1513/AnnalsATS.201705-371AW

[10] Prerana Chittal, Abraham Samuel Babu, and Carl J. Lavie. Obesity Paradox: Does Fat Alter Outcomes in Chronic Obstructive Pulmonary Disease? COPD, 00:1-5, 2014, doi.org/10. 3109/15412555.2014.915934

[11] Franssen FME, O'Donnell DE, Blaak EE, Schols AMWJ. Obesity and the lung: 5. Obesity and COPD. Thorax 2008; 63:1110-1117. doi.org/10.1136/ thx.2007.086827

[12] Jensen LG, Ezzell L. Malnutrition in chronic obstructive pulmonary disease. Am J Clin Nutr 2000; 72:1415-1416 doi. org/10.1093/ajcn/72.6.1415

[13] Landbo C, Prescott E, Lange P, et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160:1856-1861. doi.org/10.1164/ ajrccm.160.6.9902115

[14] Jee SH, Sull JW, Park J, et al. Body-mass index and mortality in Korean men and women. N Engl J Med 2006; 355:779-787. DOI: 10.1056/ NEJMoa054017

[15] Cao C, Wang R, Wang J, Bunjhoo H, Xu Y, Xiong W. Body mass index and mortality in chronic obstructive pulmonary disease: a

meta-analysis. PLoS One. 2012; 7(8):e43892. doi: 10.1371/journal. pone.0043892

[16] M. Fogelholm. Physical activity, fi tness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obesity Rev 2010; 11:202-221. doi. org/10.1111/j.1467-789X.2009.00653.x

[17] Sabino GP, Silva BM, Brunetto AF. Nutritional status is related to fat-free mass, exercise capacity and inspiratory strength in severe chronic obstructive pulmonary disease. Clinics 2010; 65:599-605. doi.org/10.1590/ s1807-59322010000600007

[18] Vanessa M Mc Donald, Lisa G Wood, Anne E Holland, Peter Gibson, "Obesity in COPD: To treat or not to treat? " Expert Review of respiratory medicine 2017 vol 11, NO 2, 81-83, doi. org/10.1080/17476348.2017.1267570

[19] Lian Smulders, Anniek van der Aalst, Erik D. E. T. Neuhaus, Sharona Polman, Frits M. E. Franssen; Decreased Risk of COPD Exacerbations in Obese Patients COPD: Journal of Chronic Obstructive Pulmonary Disease: Vol 17, No 5 (tandfonline.com) 2020. doi.org/1 0.1080/15412555.2020.1799963

[20] Wei YF, Tsai YH, Wang CC, et al. Impact of overweight and obesity on acute exacerbations of COPD - subgroup analysis of the Taiwan Obstructive Lung Disease cohort. Int J Chron Obstruct Pulmon Dis. 2017;12:2723-2729. DOI:10.2147/COPD. S138571

[21] Wu Z, Yang D, Ge Z, et al. Body mass index of patients with chronic obstructive pulmonary disease is associated with pulmonary function and exacerbations: a retrospective real world research. J Thorac Dis. 2018;10(8):5086- 5099. DOI:10.21037/jtd. 2018.08.67

[22] Blum A, Simsolo C, Sirchan R, et al. Obesity paradox" in chronic obstructive pulmonary disease. Isr Med Assoc J. 2011;13(11):672-675.

[23] Pepper DJ, Sun J, Welsh J, et al. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock: a systematic review and meta-analysis. Crit Care. 2016;20(1):181.DOI:10.1186/ s13054-016-1360-z

[24] Zhao Y, Li Z, Yang T, et al. Is body mass index associated with outcomes of mechanically ventilated adult patients in intensive critical units? A systematic review and meta-analysis. PLoS One.2018;13(6):e0198669. DOI:10.1371/ journal.pone.0198669

[25] Carbone S, Lavie CJ, Arena R. Obesity and heart failure: focus on the obesity paradox. Mayo Clin Proc. 2017;92(2):266-279. DOI:10.1016/j. mayocp.2016.11.001

[26] L Kathleen Mahan, Janice L Raymond, "Krause's Food and Nutrition care process" 2020, 15th edition, 689

[27] Gordon L. Jensen, MD, GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. Journal of Parenteral and Enteral Nutrition Volume 43 Number 1 January 2019 32-40, 2018 Elsevier Ltd, the European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and Enteral Nutrition. All rights reserved DOI: 10.1002/jpen.1440 wileyonlinelibrary.com

[28] Egeria Scoditti, Marika Massaro, Sergio Garbarino and Domenico Maurizio Toraldo, Role of Diet in Chronic Obstructive Pulmonary Disease Prevention and Treatment Nutrients 2019, 11, 1357; doi:10.3390/nu11061357

[29] Tabak, C.; Smit, H.A.; Heederik, D.; Ocke, M.C.; Kromhout, D. Diet and chronic obstructive pulmonary

**79**

*Nutritional Status and COPD*

disease: Independent beneficial effects of fruits, whole grains, and alcohol (the MORGEN study). Clin. Exp.Allergy 2001, 31, 747-755. doi: 10.1046/j.1365-2222.2001.01064.x.

[30] Root, M.M.; Houser, S.M.; Anderson, J.J.; Dawson, H.R. Healthy Eating Index 2005 and selected macronutrients are correlated with improved lung function in humans. Nutr. Res. 2014, 34, 277-284. doi. org/10.1016/j.nutres.2014.02.008

[31] Kaluza, J.; Harris, H.; Wallin, A.; Linden, A.; Wolk, A. Dietary Fiber Intake and Risk of Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study of Men. Epidemiology 2018, 29, 254-260. doi: 10.1097/ EDE.0000000000000750.

[32] Varraso, R.;Willett,W.C.; Camargo, C.A., Jr. Prospective study of dietary fiber and risk of chronic obstructive pulmonary disease among US women and men. Am. J. Epidemiol. 2010, 171, 776-784. doi: 10.1093/aje/kwp455. Epub

[33] Kaluza, J.; Larsson, S.C.; Orsini, N.; Linden, A.; Wolk, A. Fruit and vegetable consumption and risk of COPD: A prospective cohort study of men. Thorax 2017, 72, 500-509. doi: 10.1136/thoraxjnl-2015-207851. Epub

[34] Kaluza, J.; Harris, H.R.; Linden, A.; Wolk, A. Long-term consumption of fruits and vegetables and risk of chronic obstructive pulmonary disease: A prospective cohort study of women. Int. J. Epidemiol. 2018, 47, 1897-1909. doi.

[35] Jolli\_e, D.A.; Greenberg, L.; Hooper, R.L.; Mathyssen, C.; Rafiq, R.; de Jongh, R.T.; Camargo, C.A.; Gri\_ths, C.J.; Janssens, W.; Martineau, A.R.; et al. Vitamin D to prevent exacerbations of COPD: Systematic review and meta-analysis of individual participant

2010 Feb 19.

2017 Feb 22.

org/10.1093/ije/dyy178

*DOI: http://dx.doi.org/10.5772/intechopen.95600*

data from randomised controlled trials. Thorax 2019, 74, 337-345. doi.

[36] Janssens, W.; Bouillon, R.; Claes, B.; Carremans, C.; Lehouck, A.; Buysschaert, I.; Coolen, J.; Mathieu, C.; Decramer, M.; Lambrechts, D.; et al. Vitamin D deficiency is highly prevalent in COPD and correlates with variants in the vitamin D-binding gene. Thorax 2010, 65, 215-220. doi: 10.1136/ thx.2009.120659. Epub 2009 Dec 8.

[37] Jollie, D.A.; Greenberg, L.; Hooper, R.L.; Mathyssen, C.; Rafiq, R.; de Jongh, R.T.; Camargo, C.A.; Griths, C.J.; Janssens, W.; Martineau, A.R. et al. Vitamin D to prevent exacerbations of COPD: Systematic review and of individual participant data from randomised controlled trials. Thorax 2019, 74, doi.org/10.1136/

thoraxjnl-2018-212092

nu10070813

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[39] Hirayama, F.; Lee, A.H.; Oura, A.; Mori, M.; Hiramatsu, N.; Taniguchi, H. Dietary intake of six minerals in relation

to the risk of chronic obstructive pulmonary disease. Asia Pac. J. Clin.

[40] McKeever, T.M.; Lewis, S.A.; Smit, H.A.; Burney, P.; Cassano, P.A.; Britton, J. A multivariate analysis of serum nutrient levels and lung function. Respir. Res. 2008, 9, 67. DOI:

[41] Pearson, P.; Britton, J.; McKeever, T.; Lewis, S.A.; Weiss, S.; Pavord, I.; Fogarty, A. Lung function and blood levels of copper, selenium, vitamin C and vitamin E in the general population. Eur. J. Clin. Nutr. 2005, 59, 1043-1048. doi.org/10.1038/sj.ejcn.1602209

Nutr. 2010, 19, 572-577.

10.1186/1465-9921-9-67

org/10.1136/bmj.l1025

#### *Nutritional Status and COPD DOI: http://dx.doi.org/10.5772/intechopen.95600*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

pulmonary disease. Isr Med Assoc J.

[24] Zhao Y, Li Z, Yang T, et al. Is body mass index associated with outcomes of mechanically ventilated adult patients in intensive critical units? A systematic review and meta-analysis. PLoS One.2018;13(6):e0198669. DOI:10.1371/

[25] Carbone S, Lavie CJ, Arena R. Obesity and heart failure: focus on the obesity paradox. Mayo Clin Proc. 2017;92(2):266-279. DOI:10.1016/j.

[26] L Kathleen Mahan, Janice L

[27] Gordon L. Jensen, MD, GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. Journal of Parenteral and Enteral Nutrition Volume 43 Number 1 January 2019 32-40, 2018 Elsevier Ltd, the European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and Enteral Nutrition. All rights reserved DOI: 10.1002/jpen.1440

Raymond, "Krause's Food and Nutrition care process" 2020, 15th edition, 689

[23] Pepper DJ, Sun J, Welsh J, et al. Increased body mass index and adjusted mortality in ICU patients with sepsis or septic shock: a systematic review and meta-analysis. Crit Care. 2016;20(1):181.DOI:10.1186/

2011;13(11):672-675.

s13054-016-1360-z

journal.pone.0198669

mayocp.2016.11.001

wileyonlinelibrary.com

[28] Egeria Scoditti, Marika Massaro, Sergio Garbarino and Domenico Maurizio Toraldo, Role of Diet in

Chronic Obstructive Pulmonary Disease Prevention and Treatment Nutrients 2019, 11, 1357; doi:10.3390/nu11061357

[29] Tabak, C.; Smit, H.A.; Heederik, D.; Ocke, M.C.; Kromhout, D. Diet and chronic obstructive pulmonary

meta-analysis. PLoS One. 2012; 7(8):e43892. doi: 10.1371/journal.

[16] M. Fogelholm. Physical activity, fi tness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obesity Rev 2010; 11:202-221. doi. org/10.1111/j.1467-789X.2009.00653.x

[17] Sabino GP, Silva BM, Brunetto AF. Nutritional status is related to fat-free mass, exercise capacity and inspiratory strength in severe chronic obstructive pulmonary disease. Clinics 2010; 65:599-605. doi.org/10.1590/ s1807-59322010000600007

[18] Vanessa M Mc Donald, Lisa G Wood, Anne E Holland, Peter Gibson, "Obesity in COPD: To treat or not to treat? " Expert Review of respiratory medicine 2017 vol 11, NO 2, 81-83, doi. org/10.1080/17476348.2017.1267570

[19] Lian Smulders, Anniek van der Aalst, Erik D. E. T. Neuhaus, Sharona Polman, Frits M. E. Franssen; Decreased Risk of COPD Exacerbations in Obese Patients COPD: Journal of Chronic Obstructive Pulmonary Disease: Vol 17, No 5 (tandfonline.com) 2020. doi.org/1

0.1080/15412555.2020.1799963

[20] Wei YF, Tsai YH, Wang CC, et al. Impact of overweight and obesity on acute exacerbations of COPD - subgroup analysis of the Taiwan Obstructive Lung Disease cohort. Int J Chron Obstruct Pulmon Dis. 2017;12:2723-2729. DOI:10.2147/COPD.

[21] Wu Z, Yang D, Ge Z, et al. Body mass index of patients with chronic obstructive pulmonary disease is

associated with pulmonary function and exacerbations: a retrospective real world research. J Thorac Dis. 2018;10(8):5086- 5099. DOI:10.21037/jtd. 2018.08.67

[22] Blum A, Simsolo C, Sirchan R, et al. Obesity paradox" in chronic obstructive

pone.0043892

**78**

S138571

disease: Independent beneficial effects of fruits, whole grains, and alcohol (the MORGEN study). Clin. Exp.Allergy 2001, 31, 747-755. doi: 10.1046/j.1365-2222.2001.01064.x.

[30] Root, M.M.; Houser, S.M.; Anderson, J.J.; Dawson, H.R. Healthy Eating Index 2005 and selected macronutrients are correlated with improved lung function in humans. Nutr. Res. 2014, 34, 277-284. doi. org/10.1016/j.nutres.2014.02.008

[31] Kaluza, J.; Harris, H.; Wallin, A.; Linden, A.; Wolk, A. Dietary Fiber Intake and Risk of Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study of Men. Epidemiology 2018, 29, 254-260. doi: 10.1097/ EDE.0000000000000750.

[32] Varraso, R.;Willett,W.C.; Camargo, C.A., Jr. Prospective study of dietary fiber and risk of chronic obstructive pulmonary disease among US women and men. Am. J. Epidemiol. 2010, 171, 776-784. doi: 10.1093/aje/kwp455. Epub 2010 Feb 19.

[33] Kaluza, J.; Larsson, S.C.; Orsini, N.; Linden, A.; Wolk, A. Fruit and vegetable consumption and risk of COPD: A prospective cohort study of men. Thorax 2017, 72, 500-509. doi: 10.1136/thoraxjnl-2015-207851. Epub 2017 Feb 22.

[34] Kaluza, J.; Harris, H.R.; Linden, A.; Wolk, A. Long-term consumption of fruits and vegetables and risk of chronic obstructive pulmonary disease: A prospective cohort study of women. Int. J. Epidemiol. 2018, 47, 1897-1909. doi. org/10.1093/ije/dyy178

[35] Jolli\_e, D.A.; Greenberg, L.; Hooper, R.L.; Mathyssen, C.; Rafiq, R.; de Jongh, R.T.; Camargo, C.A.; Gri\_ths, C.J.; Janssens, W.; Martineau, A.R.; et al. Vitamin D to prevent exacerbations of COPD: Systematic review and meta-analysis of individual participant

data from randomised controlled trials. Thorax 2019, 74, 337-345. doi. org/10.1136/bmj.l1025

[36] Janssens, W.; Bouillon, R.; Claes, B.; Carremans, C.; Lehouck, A.; Buysschaert, I.; Coolen, J.; Mathieu, C.; Decramer, M.; Lambrechts, D.; et al. Vitamin D deficiency is highly prevalent in COPD and correlates with variants in the vitamin D-binding gene. Thorax 2010, 65, 215-220. doi: 10.1136/ thx.2009.120659. Epub 2009 Dec 8.

[37] Jollie, D.A.; Greenberg, L.; Hooper, R.L.; Mathyssen, C.; Rafiq, R.; de Jongh, R.T.; Camargo, C.A.; Griths, C.J.; Janssens, W.; Martineau, A.R. et al. Vitamin D to prevent exacerbations of COPD: Systematic review and of individual participant data from randomised controlled trials. Thorax 2019, 74, doi.org/10.1136/ thoraxjnl-2018-212092

[38] Ting Zhai, Shizhen Li, Wei Hei, Potential micronutrients and phytochemicals against the pathogenesis of COPD and lung cancer, Nutrients, 2018. 337-345. doi.org/10.3390/ nu10070813

[39] Hirayama, F.; Lee, A.H.; Oura, A.; Mori, M.; Hiramatsu, N.; Taniguchi, H. Dietary intake of six minerals in relation to the risk of chronic obstructive pulmonary disease. Asia Pac. J. Clin. Nutr. 2010, 19, 572-577.

[40] McKeever, T.M.; Lewis, S.A.; Smit, H.A.; Burney, P.; Cassano, P.A.; Britton, J. A multivariate analysis of serum nutrient levels and lung function. Respir. Res. 2008, 9, 67. DOI: 10.1186/1465-9921-9-67

[41] Pearson, P.; Britton, J.; McKeever, T.; Lewis, S.A.; Weiss, S.; Pavord, I.; Fogarty, A. Lung function and blood levels of copper, selenium, vitamin C and vitamin E in the general population. Eur. J. Clin. Nutr. 2005, 59, 1043-1048. doi.org/10.1038/sj.ejcn.1602209

[42] Al Alawi, A.M.; Majoni, S.W.; Falhammar, H. Magnesium and Human Health: Perspectives and Research Directions. Int. J. Endocrinol. 2018, 9041694 dx.doi. org/10.1155%2F2018%2F9041694

[43] de Batlle, J.; Sauleda, J.; Balcells, E.; Gomez, F.P.; Mendez, M.; Rodriguez, E.; Barreiro, E.; Ferrer, J.J.; Romieu, I.; Gea, J.; et al. Association between Omega3 and Omega6 fatty acid intakes and serum inflammatory markers in COPD. J. Nutr. Biochem. 2012, 23, 817-821 .doi. org/10.1016/j.jnutbio.2011.04.005

[44] McKeever, T.M.; Lewis, S.A.; Cassano, P.A.; Ocke, M.; Burney, P.; Britton, J.; Smit, H.A. The relation between dietary intake of individual fatty acids, FEV1 and respiratory disease in Dutch adults. Thorax 2008, 63, 208- 214. doi.org/10.1136/thx.2007.090399

[45] Varraso, R.; Barr, R.G.;Willett,W.C.; Speizer, F.E.; Camargo, C.A., Jr. Fish intake and risk of chronic obstructive pulmonary disease in 2 large US cohorts. Am. J. Clin. Nutr. 2015, 101, 354-361. doi.org/10.3945/ajcn.114.094516

[46] Jiang, R.; Paik, D.C.; Hankinson, J.L.; Barr, R.G. Cured meat consumption, lung function, and chronic obstructive pulmonary disease among United States adults. Am. J. Respir. Crit. Care Med. 2007, 175. DOI: 10.1164/rccm.200607-969OC

[47] Varraso, R.; Jiang, R.; Barr, R.G.; Willett, W.C.; Camargo, C.A., Jr. Prospective study of cured meats consumption and risk of chronic obstructive pulmonary disease in men. Am. J. Epidemiol. 2007, 166, doi. org/10.1093/aje/kwm235

[48] Jiang, R.; Camargo, C.A., Jr.; Varraso, R.; Paik, D.C.; Willett,W.C.; Barr, R.G. Consumption of cured meats and prospective risk of chronic obstructive pulmonary disease in women. Am. J. Clin. Nutr. 2008,

87, 1002-1008. doi.org/10.1093/ ajcn/87.4.1002

[49] Kaluza, J.; Larsson, S.C.; Linden, A.; Wolk, A. Consumption of Unprocessed and Processed Red Meat and the Risk of Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study of Men. Am. J. Epidemiol. 2016, 184, 829-836 .doi.org/10.1093/aje/ kww101

[50] de Batlle, J.; Mendez, M.; Romieu, I.; Balcells, E.; Benet, M.; Donaire-Gonzalez, D.; Ferrer, J.J.; Orozco-Levi, M.; Anto, J.M.; Garcia-Aymerich, J.; et al. Cured meat consumption increases risk of readmission in COPD patients. Eur. Respir. J. 2012, 40, 555-560 .doi. org/10.1183/09031936.00116911

[51] Salari-Moghaddam, A.; Milajerdi, A.; Larijani, B.; Esmaillzadeh, A. Processed red meat intake and risk of COPD: A systematic review and dose-response meta-analysis of prospective cohort studies. Clin. Nutr. 2018, 38, 1109-1116 .doi.org/10.1016/j. clnu.2018.05.020

[52] Mariangela Rondanelli, Milena Anna Faliva, Gabriella Peroni, Vittoria Infantino, Clara Gasparri, Giancarlo Iannello, Simone Perna, Tariq AbdulKarim Alalwan, Salwa Al-Thawadi, Angelo Guido, CorsicoFood, Pyramid for Subjects with Chronic Obstructive Pulmonary Diseases, International Journal of Chronic Obstructive Pulmonary Disease, 2020:15 1435-1448

[53] Rebecca F. Mc Loughlin, Vanessa M. McDonald, Peter G. Gibson, Hayley A. Scott, Michael J. Hensley, Lesley MacDonald-Wicks and Lisa G. Wood, The Impact of a Weight Loss Intervention on Diet Quality and Eating Behaviours in People with Obesity and COPD, Nutrients, 2017 Oct 20;9(10):1147. doi.org/10.3390/ nu9101147

**81**

*Nutritional Status and COPD*

*DOI: http://dx.doi.org/10.5772/intechopen.95600*

[54] Durrer Schutz et al, "Management of obesity by GP's" Obesity Facts 2019; 12;40-66, doi.org/10.1159/000496183

[55] Hayley Lewthwaite, Tanja W Effing, Timothy Olds and Marie T Williams, Physical activity, sedentary behaviour and sleep in COPD guidelines: A systematic review, Chronic Respiratory Disease 2017, Vol. 14(3) 231-244. doi.org/

10.1177%2F1479972316687224

*Nutritional Status and COPD DOI: http://dx.doi.org/10.5772/intechopen.95600*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

87, 1002-1008. doi.org/10.1093/

A.; Wolk, A. Consumption of

[49] Kaluza, J.; Larsson, S.C.; Linden,

Unprocessed and Processed Red Meat and the Risk of Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study of Men. Am. J. Epidemiol. 2016, 184, 829-836 .doi.org/10.1093/aje/

[50] de Batlle, J.; Mendez, M.; Romieu, I.; Balcells, E.; Benet, M.; Donaire-Gonzalez, D.; Ferrer, J.J.; Orozco-Levi, M.; Anto, J.M.; Garcia-Aymerich, J.; et al. Cured meat consumption increases risk of readmission in COPD patients. Eur. Respir. J. 2012, 40, 555-560 .doi. org/10.1183/09031936.00116911

[51] Salari-Moghaddam, A.; Milajerdi, A.; Larijani, B.; Esmaillzadeh, A. Processed red meat intake and risk of COPD: A systematic review and dose-response meta-analysis of prospective cohort studies. Clin. Nutr. 2018, 38, 1109-1116 .doi.org/10.1016/j.

[52] Mariangela Rondanelli, Milena Anna Faliva, Gabriella Peroni, Vittoria Infantino, Clara Gasparri, Giancarlo Iannello, Simone Perna, Tariq AbdulKarim Alalwan, Salwa Al-Thawadi, Angelo Guido, CorsicoFood, Pyramid for Subjects with Chronic Obstructive Pulmonary Diseases, International Journal of Chronic Obstructive Pulmonary Disease, 2020:15 1435-1448

[53] Rebecca F. Mc Loughlin,

nu9101147

Vanessa M. McDonald, Peter G. Gibson, Hayley A. Scott, Michael J. Hensley, Lesley MacDonald-Wicks and Lisa G. Wood, The Impact of a Weight Loss Intervention on Diet Quality and Eating Behaviours in People with Obesity and COPD, Nutrients, 2017 Oct 20;9(10):1147. doi.org/10.3390/

clnu.2018.05.020

ajcn/87.4.1002

kww101

[42] Al Alawi, A.M.; Majoni, S.W.; Falhammar, H. Magnesium and Human Health: Perspectives and Research Directions. Int. J. Endocrinol. 2018, 9041694 dx.doi. org/10.1155%2F2018%2F9041694

[43] de Batlle, J.; Sauleda, J.; Balcells, E.; Gomez, F.P.; Mendez, M.; Rodriguez, E.; Barreiro, E.; Ferrer, J.J.; Romieu, I.; Gea, J.; et al. Association between Omega3 and Omega6 fatty acid intakes and serum inflammatory markers in COPD. J. Nutr. Biochem. 2012, 23, 817-821 .doi. org/10.1016/j.jnutbio.2011.04.005

[44] McKeever, T.M.; Lewis, S.A.; Cassano, P.A.; Ocke, M.; Burney, P.; Britton, J.; Smit, H.A. The relation between dietary intake of individual fatty acids, FEV1 and respiratory disease in Dutch adults. Thorax 2008, 63, 208- 214. doi.org/10.1136/thx.2007.090399

[45] Varraso, R.; Barr, R.G.;Willett,W.C.; Speizer, F.E.; Camargo, C.A., Jr. Fish intake and risk of chronic obstructive pulmonary disease in 2 large US cohorts. Am. J. Clin. Nutr. 2015, 101, 354-361. doi.org/10.3945/ajcn.114.094516

[46] Jiang, R.; Paik, D.C.; Hankinson,

[47] Varraso, R.; Jiang, R.; Barr, R.G.; Willett, W.C.; Camargo, C.A., Jr. Prospective study of cured meats consumption and risk of chronic obstructive pulmonary disease in men. Am. J. Epidemiol. 2007, 166, doi.

J.L.; Barr, R.G. Cured meat consumption, lung function, and chronic obstructive pulmonary disease among United States adults. Am. J. Respir. Crit. Care Med. 2007, 175. DOI:

10.1164/rccm.200607-969OC

org/10.1093/aje/kwm235

[48] Jiang, R.; Camargo, C.A., Jr.; Varraso, R.; Paik, D.C.; Willett,W.C.; Barr, R.G. Consumption of cured meats and prospective risk of chronic obstructive pulmonary disease in women. Am. J. Clin. Nutr. 2008,

**80**

[54] Durrer Schutz et al, "Management of obesity by GP's" Obesity Facts 2019; 12;40-66, doi.org/10.1159/000496183

[55] Hayley Lewthwaite, Tanja W Effing, Timothy Olds and Marie T Williams, Physical activity, sedentary behaviour and sleep in COPD guidelines: A systematic review, Chronic Respiratory Disease 2017, Vol. 14(3) 231-244. doi.org/ 10.1177%2F1479972316687224

**83**

**Chapter 7**

**Abstract**

**1. Introduction**

severity of acute exacerbation [1–4].

**2. Non-invasive ventilation**

with COPD

*Ozlem Ediboglu*

Mechanical Ventilation for Patients

Mechanical ventilation is a lifesaving therapy in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD).

**Keywords:** mechanical ventilation, COPD, respiratory failure

Mechanical ventilaton either invasive or non-invasive has an important role in the management of acute exacerbation of COPD (AECOPD). AECOPD required hospitalizaton had increased mortality and poor prognosis. Ventilatory management success related to understanding physiopathology of the disease. Clinicians must be aware of deterioration of clinical signs of COPD patients. The most appropriate treatment should be performed at optimal time. Some COPD patients are at high risk for prolonged mechanical ventilation due to COPD is a progressive disease.

Chronic obstructive pulmonary disease (COPD) is a major global health problem

which has high morbidity and mortality [1]. COPD is characterized by chronic inflammation of the airways and lung parenchyma. The most important physiologic abnormality is worsening of expiratory airflow limitation due to increased airway resistance and decreased elastic recoil [2]. Patients who have fexpiratory airflow limitation cannot breath normally and due to dynamic hyperinflation increase work of breathing. These physiologic changes are deteriorated unless avoid risk factors because of COPD is a progressive disease and can be complicated with different

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is described an acute worsening of the clinical condition of the COPD patient [5]. Clinical features are highly variable and AECOPD has a negative impact of patients' health status and outcomes [1, 6–8]. The reported mortality associated with a AECOPD is variably at 11% to 32% [9]. The mortality rate and costs are much higher in some patients requiring mechanical ventilation [10, 11].  ARF is defined as the inability to maintain the delivery of oxygen and/or removal of carbon dioxide acutely. Worsening gas exchange and consequently hypercapnia and/or hypoxemia occur in arterial blood gas sample (ABG) analysis [12].

Mechanical ventilation either invasive or non- invasive is lifesaving treatment for acute respiratory failure. It is targeted by non - invasive ventilation (NIV)

#### **Chapter 7**

## Mechanical Ventilation for Patients with COPD

*Ozlem Ediboglu*

#### **Abstract**

Mechanical ventilation is a lifesaving therapy in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD). Mechanical ventilaton either invasive or non-invasive has an important role in the management of acute exacerbation of COPD (AECOPD). AECOPD required hospitalizaton had increased mortality and poor prognosis. Ventilatory management success related to understanding physiopathology of the disease. Clinicians must be aware of deterioration of clinical signs of COPD patients. The most appropriate treatment should be performed at optimal time. Some COPD patients are at high risk for prolonged mechanical ventilation due to COPD is a progressive disease.

**Keywords:** mechanical ventilation, COPD, respiratory failure

#### **1. Introduction**

Chronic obstructive pulmonary disease (COPD) is a major global health problem which has high morbidity and mortality [1]. COPD is characterized by chronic inflammation of the airways and lung parenchyma. The most important physiologic abnormality is worsening of expiratory airflow limitation due to increased airway resistance and decreased elastic recoil [2]. Patients who have fexpiratory airflow limitation cannot breath normally and due to dynamic hyperinflation increase work of breathing. These physiologic changes are deteriorated unless avoid risk factors because of COPD is a progressive disease and can be complicated with different severity of acute exacerbation [1–4].

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is described an acute worsening of the clinical condition of the COPD patient [5]. Clinical features are highly variable and AECOPD has a negative impact of patients' health status and outcomes [1, 6–8]. The reported mortality associated with a AECOPD is variably at 11% to 32% [9]. The mortality rate and costs are much higher in some patients requiring mechanical ventilation [10, 11].  ARF is defined as the inability to maintain the delivery of oxygen and/or removal of carbon dioxide acutely. Worsening gas exchange and consequently hypercapnia and/or hypoxemia occur in arterial blood gas sample (ABG) analysis [12].

#### **2. Non-invasive ventilation**

Mechanical ventilation either invasive or non- invasive is lifesaving treatment for acute respiratory failure. It is targeted by non - invasive ventilation (NIV)

to minimize risks of mechanical ventilation and maximize patients' safety and comfort. Hence NIV is successful to provide alveolar ventilation and gas exchange as invasive mechanical ventilation (IMV); NIV accepted widely as the first choice in treating AECOPD patients with ARF [13–24]. NIV therapy success is related to appropriate patient selection and early application [14, 25–27]. The appropriate patient means that is alert, co-operative, compliant and has no contraindications [28].

NIV is applied after initial treatment if the pH remains <7.30 and after exclusion of reversible precipitating causes such as a pneumothorax, the depressant effect of uncontrolled oxygen therapy, or the excessive use of sedatives [29–31]. According to GOLD guide, NIV is considered at least one of these conditions; respiratory acidosis, weakness of respiratory muscles, severe dyspnea, increased work of breathing, accessory muscle using, intercostal retraction, paradoxal breathing and persistant hypoxemia with oxygen therapy [32]. Main determinants are experience of the clinician, place of the NIV therapy, clinical condition and theurapeutic requirement of patient [33, 34].

NIV can be apply with all ventilators used in IMV support [35]. It's important to known technical specialities and settings by clinician. Portable ventilators, intermediate ventilators and ICU ventilators has been used [33, 36]. Portable ventilators are named according to targeted parameter as volume and pressure ventilators. The synonim name is portable device is bilevel or BiPAP (Bilevel positive airway pressure) ventilator. Clinicians must be aware of difference between settings of the two devices: While adjusting IPAP (inspiratory positive airway pressure), EPAP (expiratory positive airway pressure) levels setting in BiPAP device, pressure support (PS = IPAP - EPAP) and EPAP levels in ICU ventilators [33, 37]. Bi-level pressure support ventilators are simpler to use, cheaper, and more flexible than other types of ventilator currently available. ICU ventilators have full monitoring and alarm capability and can be given up to 100% FiO2 when needed [30, 33]. Whole appropriate equipment must be ready to iniciate the NIV therapy as single/double lumen circuit, nasal/oronasal NIV mask by different size [38]. Mask selection is more important than ventilator. In acute setting, oronasal mask is well tolerated and preferred by many clinicians [14, 38, 39].

NIV is contraindicated in these situations; respiratory or cardiac arrest, hemodynamic instability, inability to use mask, excessive secretion, high risk for aspiration, and uncooperative patient.

Initially it is began with low pressure levels as IPAP 8–10 cm H2O and EPAP 4–5 cm H2O. According to patient's clinical status, pressure levels can be increased. Monitorization of clinical signs, parameters of mechanical ventilation and gas exchange at the bedside are very important. Especially clinician must be follow and record subjective symptoms like anxiety, consciousness, delirium, agitation, sedation, analgesia, patient comfort, dyspnea, tolerance of mask. All the time NIV therapy, physiological response like respiratory rate (RR), using accessory muscle, heart rate (HR) and rhythm, blood pressure (BP) must be recorded. After the first 1–2 hours ABG must be done. We must consider intubation, if no improvement in ABG, deterioration in level of consciousness, NIV poorly tolerated, and inadequate secretion clearance [1, 7, 21, 40].

 NIV failure indicators are found as initial pH <7.25, Glascow Coma Scale (GCS) <10, Acute Physiology and Chronic Health Evaluation (APACHE) II score > 25, severe comorbidity, asynchrony, leaks [7, 42], existing pneumonia, and bad initial response (no change RR, pH and paCO2) [14, 43]. The potantial causes NIV failure are defined that poor patient selection, progression of the underlying disease, wrong interface, wrong ventilator, inappropriate ventilator settings

**85**

*Mechanical Ventilation for Patients with COPD DOI: http://dx.doi.org/10.5772/intechopen.96633*

**3. Invasive mechanical ventilation**

experienced clinician [51].

resistance by bronchodilators and steroids [1].

and clinican's inexperience [44]. In a study, HACOR scores (heart rate, acidosis, consciousness, oxygenation, respiratory rate) be defined as a potential tool for clinical physicians to identify NIV failure earlier [45]. Patient tolerance to NIV is a critical factor determining its success in avoiding endotracheal intubation [46]. The most important point of the tolerance to NIV is optimal synchrony between the patient's spontaneous breathing activity and the ventilator's set parameters, known as "patient–ventilator interaction" [47]. Clinician can detected an asynchrony index (AI) (%) via visual inspection of asynchrony events (ineffective triggering, auto-triggering, premature cycling, double triggering and delayed cycling). AI is identified as number of asynchrony events/total RR X 100% and above 10% was accepted as severe asynchrony [44]. In a multicenter study, severe asynchrony was found 43% [48]. The level of pressure support and the existing of leaks were found independent predictive factors of severe asynchronies and severe asynchronies were detected 30% of patients [49]. Patient-ventilator synchrony is related to better success of NIV. For this reason, in case of asynchrony, the most appropriate strategies

Endotracheal intubation should be done any one of the following criteria immediately: respiratory arrest, loss of consciousness, psychomotor agitation requiring sedation, hemodynamic instability with a systolic BP less than 70 or greater than 180 mmHg, HR less than 50 beats/minute with loss of alertness, gasping for air. These criteria are named major criteria. Intubation was suggested any two of the following criteria also named minor criteria; RR >35 breath/min, worsening acidemia or pH < 7.25, paO2 < 40 mmHg or paO2/FiO2 < 200 despite oxygen therapy, decreasing level of consciousness [50]. Before intubation preoxygenation is essential. Intubation with the rapid sequence induction and cricoid

pressure to reduce the risk of aspiration should ideally be performed by an

After intubation, its targeted to improve gas exchange abnormality and to avoid auto-PEEP (PEEPi) [7, 52]. Dynamic hyperinflation(DHI) may exist before intubation or induced by mechanical ventilation. The minute volume (MV) should be adjusted to pH and not to the PaCO2 levels. Clinicians should be avoid overventilation and paCO2 levels should decreased gradually. It is important to provide lower MV (RR x tidal volume (TV)) and higher inspiratory flow rate which has allow longer expiratory time. Any mode can be used, either assist control (AC), synchronized intermittent mandatory ventilation with either volume or pressure target (SIMV-VS, SIMV-PS), or pressure support ventilation(PSV). Clinician's experience is the most important determinant of mode selection. Initial ventilator settings are recommended like that; TV: 6–10 ml/kg, FiO2: 1.0, RR: 10–14 breaths/minute, no PEEP, inspiratory flow rate: 80–100 liter/minute with square waveform [1, 2, 4]. Monitoring the lung mechanics on ventilator graphic screen continously and detecting any sign of DHI or PEEPi are very important. The clinicians should be followed existing any clinical signs to avoid the complications of DHI. The most important complications of DHI are hypotension, hemodynamic collaps, barotrauma and increased work of breathing (WOB) [51, 53]. Therefore, that strategies must be applied by clinicians to reduce auto-PEEP; providing the longest expiratory phase that is possible, reducing patient ventilatory demand and MV, and reducing airflow

Barotrauma is an important risk at the COPD patients. Elevated peak inspiratory pressure (PIP) does not reflect the alveolar pressure in patients with bronchospasm.

should be followed to improve synchronization with NIV [44].

*Mechanical Ventilation for Patients with COPD DOI: http://dx.doi.org/10.5772/intechopen.96633*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

contraindications [28].

of patient [33, 34].

preferred by many clinicians [14, 38, 39].

tion, and uncooperative patient.

secretion clearance [1, 7, 21, 40].

to minimize risks of mechanical ventilation and maximize patients' safety and comfort. Hence NIV is successful to provide alveolar ventilation and gas exchange as invasive mechanical ventilation (IMV); NIV accepted widely as the first choice in treating AECOPD patients with ARF [13–24]. NIV therapy success is related to appropriate patient selection and early application [14, 25–27]. The appropriate patient means that is alert, co-operative, compliant and has no

NIV is applied after initial treatment if the pH remains <7.30 and after exclusion of reversible precipitating causes such as a pneumothorax, the depressant effect of uncontrolled oxygen therapy, or the excessive use of sedatives [29–31]. According to GOLD guide, NIV is considered at least one of these conditions; respiratory acidosis, weakness of respiratory muscles, severe dyspnea, increased work of breathing, accessory muscle using, intercostal retraction, paradoxal breathing and persistant hypoxemia with oxygen therapy [32]. Main determinants are experience of the clinician, place of the NIV therapy, clinical condition and theurapeutic requirement

NIV can be apply with all ventilators used in IMV support [35]. It's important to known technical specialities and settings by clinician. Portable ventilators, intermediate ventilators and ICU ventilators has been used [33, 36]. Portable ventilators are named according to targeted parameter as volume and pressure ventilators. The synonim name is portable device is bilevel or BiPAP (Bilevel positive airway pressure) ventilator. Clinicians must be aware of difference between settings of the two devices: While adjusting IPAP (inspiratory positive airway pressure), EPAP (expiratory positive airway pressure) levels setting in BiPAP device, pressure support (PS = IPAP - EPAP) and EPAP levels in ICU ventilators [33, 37]. Bi-level pressure support ventilators are simpler to use, cheaper, and more flexible than other types of ventilator currently available. ICU ventilators have full monitoring and alarm capability and can be given up to 100% FiO2 when needed [30, 33]. Whole appropriate equipment must be ready to iniciate the NIV therapy as single/double lumen circuit, nasal/oronasal NIV mask by different size [38]. Mask selection is more important than ventilator. In acute setting, oronasal mask is well tolerated and

NIV is contraindicated in these situations; respiratory or cardiac arrest, hemodynamic instability, inability to use mask, excessive secretion, high risk for aspira-

Initially it is began with low pressure levels as IPAP 8–10 cm H2O and EPAP 4–5 cm H2O. According to patient's clinical status, pressure levels can be increased. Monitorization of clinical signs, parameters of mechanical ventilation and gas exchange at the bedside are very important. Especially clinician must be follow and record subjective symptoms like anxiety, consciousness, delirium, agitation, sedation, analgesia, patient comfort, dyspnea, tolerance of mask. All the time NIV therapy, physiological response like respiratory rate (RR), using accessory muscle, heart rate (HR) and rhythm, blood pressure (BP) must be recorded. After the first 1–2 hours ABG must be done. We must consider intubation, if no improvement in ABG, deterioration in level of consciousness, NIV poorly tolerated, and inadequate

NIV failure is associated with hospital mortality, length of hospital and ICU stay [41]. NIV failure indicators are found as initial pH <7.25, Glascow Coma Scale (GCS) <10, Acute Physiology and Chronic Health Evaluation (APACHE) II score > 25, severe comorbidity, asynchrony, leaks [7, 42], existing pneumonia, and bad initial response (no change RR, pH and paCO2) [14, 43]. The potantial causes NIV failure are defined that poor patient selection, progression of the underlying disease, wrong interface, wrong ventilator, inappropriate ventilator settings

**84**

and clinican's inexperience [44]. In a study, HACOR scores (heart rate, acidosis, consciousness, oxygenation, respiratory rate) be defined as a potential tool for clinical physicians to identify NIV failure earlier [45]. Patient tolerance to NIV is a critical factor determining its success in avoiding endotracheal intubation [46]. The most important point of the tolerance to NIV is optimal synchrony between the patient's spontaneous breathing activity and the ventilator's set parameters, known as "patient–ventilator interaction" [47]. Clinician can detected an asynchrony index (AI) (%) via visual inspection of asynchrony events (ineffective triggering, auto-triggering, premature cycling, double triggering and delayed cycling). AI is identified as number of asynchrony events/total RR X 100% and above 10% was accepted as severe asynchrony [44]. In a multicenter study, severe asynchrony was found 43% [48]. The level of pressure support and the existing of leaks were found independent predictive factors of severe asynchronies and severe asynchronies were detected 30% of patients [49]. Patient-ventilator synchrony is related to better success of NIV. For this reason, in case of asynchrony, the most appropriate strategies should be followed to improve synchronization with NIV [44].

#### **3. Invasive mechanical ventilation**

Endotracheal intubation should be done any one of the following criteria immediately: respiratory arrest, loss of consciousness, psychomotor agitation requiring sedation, hemodynamic instability with a systolic BP less than 70 or greater than 180 mmHg, HR less than 50 beats/minute with loss of alertness, gasping for air. These criteria are named major criteria. Intubation was suggested any two of the following criteria also named minor criteria; RR >35 breath/min, worsening acidemia or pH < 7.25, paO2 < 40 mmHg or paO2/FiO2 < 200 despite oxygen therapy, decreasing level of consciousness [50]. Before intubation preoxygenation is essential. Intubation with the rapid sequence induction and cricoid pressure to reduce the risk of aspiration should ideally be performed by an experienced clinician [51].

After intubation, its targeted to improve gas exchange abnormality and to avoid auto-PEEP (PEEPi) [7, 52]. Dynamic hyperinflation(DHI) may exist before intubation or induced by mechanical ventilation. The minute volume (MV) should be adjusted to pH and not to the PaCO2 levels. Clinicians should be avoid overventilation and paCO2 levels should decreased gradually. It is important to provide lower MV (RR x tidal volume (TV)) and higher inspiratory flow rate which has allow longer expiratory time. Any mode can be used, either assist control (AC), synchronized intermittent mandatory ventilation with either volume or pressure target (SIMV-VS, SIMV-PS), or pressure support ventilation(PSV). Clinician's experience is the most important determinant of mode selection. Initial ventilator settings are recommended like that; TV: 6–10 ml/kg, FiO2: 1.0, RR: 10–14 breaths/minute, no PEEP, inspiratory flow rate: 80–100 liter/minute with square waveform [1, 2, 4]. Monitoring the lung mechanics on ventilator graphic screen continously and detecting any sign of DHI or PEEPi are very important. The clinicians should be followed existing any clinical signs to avoid the complications of DHI. The most important complications of DHI are hypotension, hemodynamic collaps, barotrauma and increased work of breathing (WOB) [51, 53]. Therefore, that strategies must be applied by clinicians to reduce auto-PEEP; providing the longest expiratory phase that is possible, reducing patient ventilatory demand and MV, and reducing airflow resistance by bronchodilators and steroids [1].

Barotrauma is an important risk at the COPD patients. Elevated peak inspiratory pressure (PIP) does not reflect the alveolar pressure in patients with bronchospasm.

Alveolar pressure can be detected with plateau pressure (Pplat) and suggested PIP < 50 cmH2O, Pplat < 30 cmH2O to avoid barotrauma [1].

Quantifying PEEPi is a difficult and favored process. PEEPi amount of proportionated with degree of bronchial obstruction. Different techniques can be used to calculate PEEPi. Clinicians can directly measure by occluding the expiratory port for 1–3 seconds at end expiration or by using expiratory hold maneuver on new ventilators. Static PEEPi can be measured in this way only in sedatized patients without active respiratory effort. The PEEPi can then be calculated by subtracting the external PEEP from the total PEEP. If there is spontan respiratory effort of the patient, dynamic PEEPi can be determined by simultanously recording esophageal pressure and airflow tracings. It is measured at end expiration as the negative deflection of esophageal pressure to the point of zero flow. The dynamic PEEPi is usually measured lower than static PEEPi by reason of different longer of time constant [1, 2, 4, 53, 54]. While PEEPi is determined extrinsic PEEP (PEEPe) at 80% of PEEPi should be added to reduce patient triggering effort. Ventilator trigger sensitivity must be justify minimal [1, 4, 6, 51, 55, 56].

Weaning should begin once the cause of the exacerbation is adequately treated and the patient is hemodynamically stable. Physiologic parameters must be followed intensively. It's targeted MV < 15 L, RR < 30 breaths/minute, TV > 325 ml, rapid shallow breathing index (RSBI) <105, maximum inspiratory pressure (MIP) < −15. Although the superiority did not found among each other, different strategies were used to weaning. Daily spontaneous breathing trail (SBT) is one way of identifying patients stable to wean and it may reduce the number of ICU days. While decreasing gradually of PS has not been shown to be superior to SBT, PSV is preferable by many clinicians. Using NIV to facilitate weaning is accepted by multiple RCT [14, 15, 52, 57, 58].

#### **4. High flow oxygen therapy**

Long term oxygen therapy (LTOT), is used mainly in COPD patients with chronic hypoxemia [32]. High flow oxygen therapy (HFOT) is a new technique for delivering oxygen. There are many studies using HFOT instead of conventional oxygen therapy (COT) recently. HFOT was well tolerated and was sensed as comfortable. By using this system, oxygen delivery trends provided to be lower, and paCO2 levels could be measured significant decreased. HFOT could be accepted as an alternative treatment to NIV due to it generates a modest degree of positive pressure almost 5–6 cmH2O. It provides a more physiological humidification and heating of the airways. In this settings, HFOT has been used with different aims, as an alternative to COT, and NIV [59–62].

**87**

**Author details**

Ozlem Ediboglu

University of Health Sciences, Dr Suat Seren Chest Diseases and Surgery Training

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Research Hospital, Intensive Care Unit, Izmir, Turkey

\*Address all correspondence to<EMAIL_ADDRESS>
provided the original work is properly cited.

*Mechanical Ventilation for Patients with COPD DOI: http://dx.doi.org/10.5772/intechopen.96633* *Mechanical Ventilation for Patients with COPD DOI: http://dx.doi.org/10.5772/intechopen.96633*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

PIP < 50 cmH2O, Pplat < 30 cmH2O to avoid barotrauma [1].

trigger sensitivity must be justify minimal [1, 4, 6, 51, 55, 56].

multiple RCT [14, 15, 52, 57, 58].

**4. High flow oxygen therapy**

an alternative to COT, and NIV [59–62].

Alveolar pressure can be detected with plateau pressure (Pplat) and suggested

Quantifying PEEPi is a difficult and favored process. PEEPi amount of proportionated with degree of bronchial obstruction. Different techniques can be used to calculate PEEPi. Clinicians can directly measure by occluding the expiratory port for 1–3 seconds at end expiration or by using expiratory hold maneuver on new ventilators. Static PEEPi can be measured in this way only in sedatized patients without active respiratory effort. The PEEPi can then be calculated by subtracting the external PEEP from the total PEEP. If there is spontan respiratory effort of the patient, dynamic PEEPi can be determined by simultanously recording esophageal pressure and airflow tracings. It is measured at end expiration as the negative deflection of esophageal pressure to the point of zero flow. The dynamic PEEPi is usually measured lower than static PEEPi by reason of different longer of time constant [1, 2, 4, 53, 54]. While PEEPi is determined extrinsic PEEP (PEEPe) at 80% of PEEPi should be added to reduce patient triggering effort. Ventilator

Weaning should begin once the cause of the exacerbation is adequately treated and the patient is hemodynamically stable. Physiologic parameters must be followed intensively. It's targeted MV < 15 L, RR < 30 breaths/minute, TV > 325 ml, rapid shallow breathing index (RSBI) <105, maximum inspiratory pressure (MIP) < −15. Although the superiority did not found among each other, different strategies were used to weaning. Daily spontaneous breathing trail (SBT) is one way of identifying patients stable to wean and it may reduce the number of ICU days. While decreasing gradually of PS has not been shown to be superior to SBT, PSV is preferable by many clinicians. Using NIV to facilitate weaning is accepted by

Long term oxygen therapy (LTOT), is used mainly in COPD patients with chronic hypoxemia [32]. High flow oxygen therapy (HFOT) is a new technique for delivering oxygen. There are many studies using HFOT instead of conventional oxygen therapy (COT) recently. HFOT was well tolerated and was sensed as

comfortable. By using this system, oxygen delivery trends provided to be lower, and paCO2 levels could be measured significant decreased. HFOT could be accepted as an alternative treatment to NIV due to it generates a modest degree of positive pressure almost 5–6 cmH2O. It provides a more physiological humidification and heating of the airways. In this settings, HFOT has been used with different aims, as

**86**

### **Author details**

Ozlem Ediboglu University of Health Sciences, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, Intensive Care Unit, Izmir, Turkey

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Mowery NT. Ventilator Strategies for Chronic Obstructive Pulmonary Disease and Acute Respiratory Syndrome. Surg Clin N Am 2017;97:1381-1397

[3] Levi MO. Structure and function of the respiratory muscles in patients with COPD: impairment or adaptation? Eur Respir J 2003; 22(Suppl 46):41-51s

[4] Ediboglu O. Hasta Tiplerine Gore Mekanik Ventilasyon. Ed. Kunter E, Kıraklı C, Koşar F. Mekanik Ventilasyon. S: 75-89, TÜSAD Eğitim Kitapları Serisi, Probiz Ltd Şti, İstanbul 2013

[5] Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: gold executive summary. Eur Respir J 2017; **49**: 1700214

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[7] Kosar F. Kronik Obstruktif Akciğer Hastalığında Akut Solunum Yetmezliği ve Mekanik Ventilasyon. Turk Klin J Pulm Med Spec Topics 2010; 3 (2): 20-28

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[14] Lieshhing T, Kwok H, Hill N. Acute applications of noninvasive positive pressure ventilation. Chest 2003:124; 699-713

[15] Garpestad E, Brennan J, Hill N. Noninvasive ventilation for critical care. Chest 2007;132: 711-720

[16] Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev 2018;27:180029

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[24] Schönhofer B, Sortor-Leger S. Equipment needs for

Respir J 2002;20:1029-1036

Thorax 2001;56:708-712

2008;53(8):1054-1080

2003;22: Suppl. 47. 31s–37s

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Noninvasive Positive Pressure

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European Society of Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise, and approved by the ATS Board of Directors, December 2000. Intensive Care Med

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[18] Evans TW. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute respiratory failure. Organised jointly by the American Thoracic Society, the European Respiratory Society, the 1394 Mowery European Society of Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise, and approved by the ATS Board of Directors, December 2000. Intensive Care Med 2001;27(1):166-178

[19] Girou E, Brun-Buisson C, Taillé S, et al. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA 2003;290(22):2985-2991

[20] Scala R, Naldi M. Ventilators for Noninvasive Ventilation to Treat Acute Respiratory Failure. Respir Care 2008;53(8):1054-1080

[21] Brochard L. Mechanical ventilation: invasive versus noninvasive. Eur Respir J 2003;22: Suppl. 47. 31s–37s

[22] International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001; 163: 283-291

[23] Crimi C, Noto A. A European Survey of Noninvasive Ventilation Practices. Eur Respir J 2010;36:362-369

[24] Schönhofer B, Sortor-Leger S. Equipment needs for noninvasive mechanical ventilation. Eur Respir J 2002;20:1029-1036

[25] Plant PK, Owen JL, Elliott MW. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001;56:708-712

[26] Celikel T, Sungur M, Ceyhan B, et al. Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest 1998; 114: 1636-1642

[27] Yıldırım F. Kronik Obstrüktif Akciğer Hastalığı Akut Alevlenmede Noninvaziv Mekanik Ventilasyon Kullanımı. Noninvazif Mekanik Ventilasyon Uygulamaları. Ed Ocal S. TÜSAD Eğitim Kitapları Serisi Ekim 2017:119-127

[28] Scala R, Naldi M, Archinucci I, et al. Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness. Chest 2005; 128(3): 1657-1666

[29] Plant P, Owen J, Elliott M. A multi centre randomised control trial of the early use of non invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. Lancet 2000;355:1931-1935

[30] British Thoracic Society Standards of Care Subcommittee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192-211

[31] Brochard L. Non invasive ventilation for acute exacerbations of COPD: a new standard of care. Thorax 2000;55:817-818

[32] Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease GOLD 2019 Report

[33] Ediboglu O. Noninvazif Mekanik Ventilasyonda Cihazlar, Noninvazif Mekanik Ventilasyonda Modlar. Z. Karakurt (Ed) Organizasyondan Tedaviye Yoğun Bakım. Türk Toraks Derneği Toraks Kitapları Bölüm 6, 7, 2014

[34] Penuelas O, Frutos Vivar F, Esteban A. Noninvasive positive

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20-28

(8):1613-24

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

failure requiring mechanical ventilation in severe chronic obstructive pulmonary disease (COPD). Medicine (2018)

Rehmani RS, et al. Chronic obstructive pulmonary disease: hospital and intensive care unit outcomes in the Kingdom of Saudi Arabia. Int J Chron Obstruct Pulmon Dis 2012;7:819-823

[10] Alaithan AM, Memon JI,

[11] Raurich JM, Perez J, Ibanez J, et al. In-hospital and 2-year survival of patients treated with mechanical ventilation for acute exacerbation of COPD. Arch Bronconeumol

[12] Breen D, Churches T, Hawker F, et al. Acute respiratory failure secondary to chronic obstructive pulmonary disease treated in the intensive care unit: a long term follow up study. Thorax

[13] Rochwerg B, Brochard L,

[14] Lieshhing T, Kwok H, Hill N. Acute applications of noninvasive positive pressure ventilation. Chest

[15] Garpestad E, Brennan J, Hill N. Noninvasive ventilation for critical care.

[16] Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev

[17] Hess D. Noninvasive ventilation for acute respiratory failure. Respir Care

Elliott MW, Hess D, et al. Official ERS/ ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;

97:17 (e0487)

2004;40:295-300

2002;57:29-33

50: 1602426

2003:124; 699-713

2018;27:180029

2013;58(6):950-969

Chest 2007;132: 711-720

[1] Reddy RM, Guntupalli KK. Review of ventilatory techniques to optimize mechanical ventilation in acute exacerbation of chronic obstructive pulmonary disease. Int J COPD

[2] Mowery NT. Ventilator Strategies for Chronic Obstructive Pulmonary Disease and Acute Respiratory Syndrome. Surg

[3] Levi MO. Structure and function of the respiratory muscles in patients with COPD: impairment or adaptation? Eur Respir J 2003; 22(Suppl 46):41-51s

[4] Ediboglu O. Hasta Tiplerine Gore Mekanik Ventilasyon. Ed. Kunter E, Kıraklı C, Koşar F. Mekanik Ventilasyon. S: 75-89, TÜSAD Eğitim Kitapları Serisi,

Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: gold executive summary. Eur

Probiz Ltd Şti, İstanbul 2013

[5] Vogelmeier CF, Criner GJ,

Respir J 2017; **49**: 1700214

2008;15 Suppl A:1A-8A

[6] O'Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2008 update highlights for primary care. Can Respir J

[7] Kosar F. Kronik Obstruktif Akciğer Hastalığında Akut Solunum Yetmezliği ve Mekanik Ventilasyon. Turk Klin J Pulm Med Spec Topics 2010; 3 (2):

[8] Ambrosino N, Simonds A. The clinical management in extremely severe COPD. Respir Med 2007; 101

[9] Gadre SK, Duggal A, Mireles-Cabodevila E, et al. Acute respiratory

Clin N Am 2017;97:1381-1397

2007;2(4):441-452

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pressure ventilation in acute respiratory failure. CMAJ 2007;177(10):1211-1218

[35] Hess DR. The Evidence for Noninvasive Positive-Pressure Ventilation in the Care of Patients in Acute Respiratory Failure. A Systematic Review of the Literature. Respir Care 2004;49(7):810-829

[36] Scala R, Naldi M. Ventilators for Noninvasive Ventilation to Treat Acute Respiratory Failure. Respir Care 2008;53(8):1054-1080

[37] Kaya A, Ciledag A. Yoğun Bakım Ventilatörü ve BiPAP İle Noninvaziv Mekanik Ventilasyon Uygulamalarındaki Farklılıklar. Noninvazif Mekanik Ventilasyon Uygulamaları. Ed Ocal S. TÜSAD Eğitim Kitapları Serisi Ekim 2017

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Expiratory Pressure and Dynamic Hyperinflation in Mechanically Ventilated Patients. Respir Care 2005;50(1):110-123

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

Ed Ocal S. TÜSAD Eğitim Kitapları

ventilation for hypercapnic respiratory

Serisi Ekim 2017:28-38

22:1253-1261

[43] Soo Hoo GW, Santiago S, Williams AJ. Nasal mechanical

failure in chronic obstructive pulmonary disease: determinants of success and failure. Crit Care Med 1994;

[44] Hess DR. Patient-ventilator interaction during noninvasive ventilation. Respir Care 2011;56(2):153-165

Intensive Care 2019; 9:108

mechanical ventilation. An

Care Med 2001; 163:874-880

Care Med 2001; 163:1059-1063

840-846

[48] Vignaux L, Vargas F, Roeseler J, et al. Patient–ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 2009; 35:

[49] Carlucci A, Pisani L, Malovini A, Nava S. Patient- ventilator asynchronies: may the respiratory mechanics play a

[50] Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;

[51] Blanch L, Bernabe F. Measurement of air trapping, Intrinsic Positive End

role? Crit Care 2013; 17: R54

333(13): 817-822

[45] Duan J, Wang S, Liu P, et al. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann.

[46] Carlucci A, Richard J, Wysocki M, et al. Noninvasive versus conventional

epidemiologic survey. Am J Respir Crit

[47] Tobin M, Jubran A, Laghi F. Patientventilator interaction. Am J Respir Crit

pressure ventilation in acute respiratory failure. CMAJ 2007;177(10):1211-1218

[35] Hess DR. The Evidence for Noninvasive Positive-Pressure Ventilation in the Care of Patients in Acute Respiratory Failure. A Systematic Review of the Literature. Respir Care

[36] Scala R, Naldi M. Ventilators for Noninvasive Ventilation to Treat Acute Respiratory Failure. Respir Care

[37] Kaya A, Ciledag A. Yoğun Bakım Ventilatörü ve BiPAP İle Noninvaziv Mekanik Ventilasyon Uygulamalarındaki Farklılıklar. Noninvazif Mekanik Ventilasyon

Kitapları Serisi Ekim 2017

Uygulamaları. Ed Ocal S. TÜSAD Eğitim

[38] Navalesi P, Fanfulla F, Frigerio P, et al. Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure. Crit Care Med 2000; 28:1785-1790

[39] Uğurlu AO, Ergan B, Takır HB, İn E, Ozyılmaz E, Edipoğlu O,et al. Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure. Tuberk

Toraks 2015;63(4):213-225

Yayınları/2017, İzmir

[40] Ediboglu O. Yoğun Bakımda Akut Solunum Yetmezliği Olan Hastanın Değerlendirilmesi ve Tedavi İlkeleri. Yoğun Bakim Protokolleri. N. Şenoğlu (Ed). Tepecik Hastanesi

[41] Shah NM, D'Cruz RF, Murphy PB. Update: non-invasive ventilation in chronic obstructive pulmonary disease. T Thorac Dis 2018;10(Suppl 1):S71-S79

[42] Yıldırım F. Noninvaziv Mekanik Ventilasyon Başarısını Etkileyen Fizyolojik Parametreler. Noninvazif Mekanik Ventilasyon Uygulamaları.

2004;49(7):810-829

2008;53(8):1054-1080

**90**

[52] Gladwin MT, Pierson DJ. Mechanical ventilation of the patient with severe chronic obstructive pulmonary disease. Intensive Care Med (1998) 24:898-910

[53] Davidson AC. The pulmonary physician in critical care. Critical care management of respiratory failure resulting from COPD. Thorax 2002;57:1079-1084

[54] Ward NS, Dushay KM. Clinical concise review: Mechanical ventilation of patients with chronic obstructive pulmonary disease. Crit Care Med 2008 Vol. 36, No. 5: 1614-1619

[55] Köhnlein T, Welte T. Ventilation in Obstructive Lung Disease Chapter 3. Eur Respir Mon 2006;36:34-48

[56] Guerin C, Milic-Emili J, Fournier G: Effect of PEEP on work of breathing in mechanically ventilated COPD patients. Intensive Care Med 2000; 26:1207-1214

[57] Esteban A, Frutos F, Tobin NJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Eng J Med 1995; 332:345

[58] Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994;150:896

[59] Vogelsinger H, Kaehler CM. Hihgflow oxygen therapy in COPD patients: Optimised oxygen delivery. European Respiratory Society Annual Congress 2013, Noninvasive Ventilatory Support, 386: 347

[60] Pisani L, Fasano L, Corcione N, et al. Change in pulmonary mechanics and the effect on breathing pattern

of high flow oxygen therapy in stable hypercapnic COPD. Thorax 2017; 51: 373-375

[61] Longhini F, Pisani L, Lungu R, et al. High-flow oxygen therapy after noninvasive ventilation interruption in patients recovering from hypercapnic acute respiratory failure: A physiological Crossover trial. Crit Care Med 2019; 47: e506- e511

[62] Pisani L, Astuto M, Prediletto I, Longhini F. High flow through nasal cannula in exacerbated COPD patients: a systematic review. Pulmonol 2019;25(6):348-354

**93**

**Chapter 8**

*Annie Heiderscheit*

**Abstract**

environment.

**1. Introduction**

Non-Pharmacological

Mechanical Ventilation and

Directed Music Listening

Management of Symptoms during

Chronic Obstructive Pulmonary

Disease in Critical Care: Patient

This chapter provides a review of the literature on nonpharmacological management of symptoms with music listening for critically ill patients during mechanical ventilation and with chronic obstructive pulmonary disease. The critical care environment is high energy, intense, and noisy. These characteristics of the ICU can often exacerbate symptoms and overstimulate patients. Patients may experience increased agitation, anxiety, increased pain or discomfort, and sleep interruptions. Patients are often on various medications unique to their diagnosis and underlying health issues and may need additional medications to address symptoms associated with the hospitalization. Nonpharmacological management, such as music listening provides an intervention that can assist in managing multiple symptoms, can be utilized repeatedly or at various times through the day or evening, be tailored to patient preferences, can be safe and effective, and require minimal energy for patients to use. The chapter reviews the mechanisms of how music listening can help with symptom management and provides guidelines, recommendations, and contraindications for selecting music of patient use. A brief assessment tool is presented to help guide the process of determining patient music preferences and how music listening may be helpful. Lastly, recommendations are provided on how to make music listening accessible in the critical care

**Keywords:** patient directed music listening, critical care, nonpharmacological,

Critical care is the highest level of care provided to the sickest of patients and thus requires and utilizes significant human and financial hospital resources, accounting for nearly 14% of overall hospital costs annually [1–3]. Patients with Chronic obstructive pulmonary disease (COPD) and those requiring mechanical

mechanical ventilation, COPD, symptom management

#### **Chapter 8**

## Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic Obstructive Pulmonary Disease in Critical Care: Patient Directed Music Listening

*Annie Heiderscheit*

### **Abstract**

This chapter provides a review of the literature on nonpharmacological management of symptoms with music listening for critically ill patients during mechanical ventilation and with chronic obstructive pulmonary disease. The critical care environment is high energy, intense, and noisy. These characteristics of the ICU can often exacerbate symptoms and overstimulate patients. Patients may experience increased agitation, anxiety, increased pain or discomfort, and sleep interruptions. Patients are often on various medications unique to their diagnosis and underlying health issues and may need additional medications to address symptoms associated with the hospitalization. Nonpharmacological management, such as music listening provides an intervention that can assist in managing multiple symptoms, can be utilized repeatedly or at various times through the day or evening, be tailored to patient preferences, can be safe and effective, and require minimal energy for patients to use. The chapter reviews the mechanisms of how music listening can help with symptom management and provides guidelines, recommendations, and contraindications for selecting music of patient use. A brief assessment tool is presented to help guide the process of determining patient music preferences and how music listening may be helpful. Lastly, recommendations are provided on how to make music listening accessible in the critical care environment.

**Keywords:** patient directed music listening, critical care, nonpharmacological, mechanical ventilation, COPD, symptom management

#### **1. Introduction**

Critical care is the highest level of care provided to the sickest of patients and thus requires and utilizes significant human and financial hospital resources, accounting for nearly 14% of overall hospital costs annually [1–3]. Patients with Chronic obstructive pulmonary disease (COPD) and those requiring mechanical ventilatory (MV) support are often admitted to intensive care units (ICU). It is estimated that COPD affects 400 million people around the world and by 2030, this number will surpass the annual global economic cost of cardiovascular disease, costing the world \$50 trillion (USD) a year [4, 5]. Further, due to the progressive nature of COPD, severe exacerbation of symptoms often results in an ICU admission, which leads to 26–74% of patients requiring MV [6]. The complexity and severity of the disease led the World Health Organization (WHO) Burden of Disease Project to identify COPD as the fifth leading cause of death and projected that by 2020 it would be the third leading cause of death. ICU occupancy data indicates that between 20 and 39% of beds are filled with patients requiring mechanical ventilation [7].

In the United States alone, more than 1 million people are admitted to intensive care units each year and require MV [8]. Additionally, it is projected that by 2020 over 625,000 adults will required prolonged MV, which includes being ventilated for >96 hours [9]. The ICU environment is an active setting due to the acuity of patients and the need to ICU clinicians to provide constant and prompt care and attend to the changing needs of patients [10]. This critical care environment can be noisy due to the numerous medical devices on the unit and increased number of staff required to provide care [11, 12]. Critically ill patients experience a variety of symptoms that are due to their illness, sedative medications, and stress from noise associated with the ICU environment and that can hinder recovery [13–16]. As a result, critically ill patients experience a wide array of distressing symptoms throughout the course of their hospitalization, which include pain, discomfort, anxiety, stress, agitation, weakness, sleep deprivation, and delirium [17–19].

In recent years, clinicians and researchers have been making concerted efforts to recommend and utilize lighter levels of sedation to promote weaning ventilator support and overall recovery [20] and implementing non-pharmacological interventions such as music listening to manage symptoms associated with care on the ICU [21, 22]. The remainder of the chapter will focus on reviewing the literature regarding the use of music listening with critical ill patients, define patient directed music listening, provide guidelines for best practices in using music listening interventions, how to assess patient music preferences, considerations and contraindications for music listening, and review of economic benefits of music listening.

#### **2. Use of music listening to manage symptoms**

Music listening has emerged as a nonpharmacological approach to manage ICU acquired symptoms such as pain, agitation, anxiety, sleep disturbances, and confusion [23–25]. Due to the fact that these symptoms impact prolonged intensive care, length of hospitalization, morbidity, mortality, and the complexity of interactions with co-morbidities, it is challenging to manage this multiplicity of symptoms [26]. Music listening does not carry the side effects or negative consequences that first line interventions such as sedative and pain medications [25].

Music listening interventions have been implemented to manage a vast array of symptoms, and to manage multiple symptoms simultaneously to support the care and comfort for patients undergoing procedures, as well as those admitted to ICUs. Studies to date have evaluated the use of music listening to reduce discomfort and pain, stress and anxiety, the presence of delirium, sedative exposure, improve selfquality and cognitive functioning [27–42].

**95**

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic…*

**intervention**

Classical Indian music pre-selected by researchers

Slow tempo music preselected by researchers

Patient preferred music as assessed and tailored for patients by a board certified music therapist

Relaxing music pre-selected by researchers

Classical music pre-selected by researchers

Relaxing music pre-selected by researchers

Four pieces of relaxing piano music

**Timing of music intervention**

Patients listened to music for 30 minutes

Patients listened 1 hour 2 times per day

Patients determined when and how long they wanted to listen to music

Patients listened for a single 30 minute session

Patients listened to music for 60 minutes one

time

Patients listened to music 30 minutes one time per day

Patients listened to 45 minutes of music at nocturnal sleep

time

**Outcomes**

RR

Fentanyl

• PDM group had significantly lower anxiety scores • By 5th day anxiety decreased by 36.5% in

PDM group

doses

time

group

and BP

lower HR

• Patients in music group had significant decrease in RR and BP compared to control

• Patients in the music group had demonstrated significantly reduced anxiety, serum cortisol, HR,

• Patients in the music group had shorter N2 stage sleep and longer N3 stage sleep in the first two hours of sleep and improved selfreported sleep quality • Patients in the music group had significantly

• By 5th day PDM group had 2 fewer sedative

• Significant decreases in HR, BP and RR over time in music group • Significant decrease in anxiety in music and headphone group • Significant increase in HR, BP, and RR in control group over

• Significant decreased in both music and PMR groups, however changes were greater in music group on trait and state anxiety, dyspnea, SBP, PR and

• Prolactin and blood cortisol decreased after intervention – Trend toward decreases in

*DOI: http://dx.doi.org/10.5772/intechopen.95889*

72 COPD

Singh V et al. [43]

Beaulieu-Borie et al. [44]

Chlan et al. [28]

Han et al. [45]

Korhan et al. [46]

Lee et al. [47]

Su et al. [48]

**Author Setting & subjects Music**

hospitalized patients randomized to a music or progressive muscle relaxation (PMR) group

49 ICU patients randomized to music or control group (no music) from ICU

373 MV patients randomized to patient directed music listening (PDM), headphones (no music) or usual care group from 12

137 ICU patients randomized to music listening, headphones, or control group

60 ICU patients randomized to music listening or control

85 ICU MV patients randomized to music listening or control

28 MICU patients randomized to music listening or control

group

group

group

ICUs

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic… DOI: http://dx.doi.org/10.5772/intechopen.95889*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

ventilation [7].

and delirium [17–19].

music listening.

**2. Use of music listening to manage symptoms**

line interventions such as sedative and pain medications [25].

quality and cognitive functioning [27–42].

ventilatory (MV) support are often admitted to intensive care units (ICU). It is estimated that COPD affects 400 million people around the world and by 2030, this number will surpass the annual global economic cost of cardiovascular disease, costing the world \$50 trillion (USD) a year [4, 5]. Further, due to the progressive nature of COPD, severe exacerbation of symptoms often results in an ICU admission, which leads to 26–74% of patients requiring MV [6]. The complexity and severity of the disease led the World Health Organization (WHO) Burden of Disease Project to identify COPD as the fifth leading cause of death and projected that by 2020 it would be the third leading cause of death. ICU occupancy data indicates that between 20 and 39% of beds are filled with patients requiring mechanical

In the United States alone, more than 1 million people are admitted to intensive care units each year and require MV [8]. Additionally, it is projected that by 2020 over 625,000 adults will required prolonged MV, which includes being ventilated for >96 hours [9]. The ICU environment is an active setting due to the acuity of patients and the need to ICU clinicians to provide constant and prompt care and attend to the changing needs of patients [10]. This critical care environment can be noisy due to the numerous medical devices on the unit and increased number of staff required to provide care [11, 12]. Critically ill patients experience a variety of symptoms that are due to their illness, sedative medications, and stress from noise associated with the ICU environment and that can hinder recovery [13–16]. As a result, critically ill patients experience a wide array of distressing symptoms throughout the course of their hospitalization, which include pain, discomfort, anxiety, stress, agitation, weakness, sleep deprivation,

In recent years, clinicians and researchers have been making concerted efforts to recommend and utilize lighter levels of sedation to promote weaning ventilator support and overall recovery [20] and implementing non-pharmacological interventions such as music listening to manage symptoms associated with care on the ICU [21, 22]. The remainder of the chapter will focus on reviewing the literature regarding the use of music listening with critical ill patients, define patient directed music listening, provide guidelines for best practices in using music listening interventions, how to assess patient music preferences, considerations and contraindications for music listening, and review of economic benefits of

Music listening has emerged as a nonpharmacological approach to manage ICU acquired symptoms such as pain, agitation, anxiety, sleep disturbances, and confusion [23–25]. Due to the fact that these symptoms impact prolonged intensive care, length of hospitalization, morbidity, mortality, and the complexity of interactions with co-morbidities, it is challenging to manage this multiplicity of symptoms [26]. Music listening does not carry the side effects or negative consequences that first

Music listening interventions have been implemented to manage a vast array of symptoms, and to manage multiple symptoms simultaneously to support the care and comfort for patients undergoing procedures, as well as those admitted to ICUs. Studies to date have evaluated the use of music listening to reduce discomfort and pain, stress and anxiety, the presence of delirium, sedative exposure, improve self-

**94**

**Table 1.**

*Review of music listening research.*

**Table 1** highlights recent research utilizing music listening interventions with critical care, COPD, and MV patients. The table includes details regarding the patient population, the music utilized in the music intervention, the timing of the music intervention and study outcomes. It is important to note the music utilized for the music intervention, the length and frequency of the music listening intervention varies significantly within this body of research.

Protocols regarding the selection of music vary in music listening intervention research. A Cochrane Review of music interventions with mechanically ventilated patients indicated that only 1 of the 14 studies reviewed included a board certified music therapist as a member of the research team [22]. As a result, in many studies the music was selected by the researchers and provided patients only limited options of music to listen to throughout the course of the study [50–53]. While researchers may refer to this as patient-preferred music, in essence patients are choosing what music to listen to, based on a pre-determined and a restrictive list of music, thus choosing what to listen to from limited options. Patient directed music listening is modeled after patient controlled analgesia (PCA), in which the patient makes their own decision regarding when they need to take a dose of pain medication [54]. Patient directed music listening (PDM) empowers the patient to choose the music they want to listen to, when they want to listen to it, and how long they want to listen [28, 54–56].

Implementing a music intervention with patients necessitates understanding the role or function of the music in the intervention. Additionally, implementing a patient directed music listening intervention requires understanding the patient's music preferences. This can be accomplished by completing a music assessment to help determine what the patient likes and does not like related to music listening. In order for a music intervention to be successful, it is vital to have a clear process of delivering the music intervention [21, 57]. These topics will be thoroughly explored in the upcoming sections of this chapter. The first step in this process is to understand how music listening can be helpful to patients in the ICU and the characteristics in music that support and facilitate these processes.

**97**

**Table 2.** *Functions of music.*

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic…*

Music is an accessible tool as critically ill patients can easily engage with music listening even when they are tired and have low energy [21, 54–57]. Music can serve many different functions to critically ill patients and can address multiple symptoms simultaneously [25]. Additionally, music does not hold the negative side effects or consequences that patients may experience from pharmacological interventions such as sedative and pain medications [25]. While a patient may use music listening to address multiple symptoms, it is important to understand the various roles music can play and characteristics in the music that can help address these symptoms [21, 49, 58–60]. **Table 2** identifies the different functions of music,

It is vital to understand the patient need(s) that music can help to address as this helps to determine music that may be most appropriate and effective for the patient. Conducting an assessment is critical to understanding a patient's needs and to determine their music preferences. A music assessment can also provide information on ways a patient may already use music in their day-to-day life, that can be helpful for

There are several reasons why a music listening intervention is a viable option in the critical care environment. Listening to music can help enhance and promote a healing environment. As the patient is able to focus on the music and shift their focus

[21, 28, 49–52].

be overstimulating [21, 49, 51].

**Characteristics and considerations in the music**

Slow rhythms in music foster a relaxation response by slowing the rhythms of the body as the breathing and heart rate entrain or synchronize with the slow rhythms in the music. This is an automatic response and the will body gradually synchronize with the slow rhythm it hears. Music that is 60–80 beats per minute (BPM) is ideal for fostering this relaxation response. Music that is preferred by the listener is more effective in fostering relaxation

Melody and lyrics are the elements in music that capture and hold our attention. Preferred instrumentation can also draw one's attention. Music that is preferred by the patient is most effective in diverting one's focus. It is important to select music that may not overstimulate given the ICU can

The body and mind need to slow down and relax in order to move into a deep sleep state. Very slow rhythms (40–60 bpm) in music help to slow down the rhythms of the body to achieve a deep sleep state (delta sleep). Music that is consistent in dynamics and instrumentation further

Tonality (major or minor), instrumentation and rhythm are the elements that connect to mood. One's familiarity to the music can impact a mood as well. Selecting music that represents (sounds like) the desired mood state can

helps to lull the mind and body [21, 49].

support shifting mood [53].

*DOI: http://dx.doi.org/10.5772/intechopen.95889*

them to use during their hospitalization.

**Function of music Patient need**

**Relaxation:**

**Distraction:** Distraction is a helpful relaxation intervention as it focuses on shifting or directing attention or focus away from, or toward, something.

**Support sleep:** Sleep is designed to be a restorative state in which the body rests and restores in preparation for each day.

**Manage and shift mood:** The state and quality of our feeling impact experiences. Negative mood states can intensify pain, discomfort, impede sleep, and impact healing.

Relaxation response helps the body move from a stress response to a state of rest and calm.

**2.1 The role of music in a music listening intervention**

descriptions, and characteristics in the music that facilitate this.

**addresses**

Anxiety Stress Discomfort Pain Delirium

Anxiety Stress Discomfort Pain

Sleep deprivation Delirium Healing and recovery

Anxiety Stress Discomfort Pain

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic… DOI: http://dx.doi.org/10.5772/intechopen.95889*

#### **2.1 The role of music in a music listening intervention**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**Author Setting & subjects Music**

373 MV patients randomized to patient directed music listening (PDM), headphones (no music) or usual care group from 12

117 ICU patients randomized to personalized music (PM), slow tempo music (STM) and attention control (AC) group

ICUs

Chlan et al. [49]

Khan et al. [42]

**Table 1.**

*Review of music listening research.*

**Table 1** highlights recent research utilizing music listening interventions with critical care, COPD, and MV patients. The table includes details regarding the patient population, the music utilized in the music intervention, the timing of the music intervention and study outcomes. It is important to note the music utilized for the music intervention, the length and frequency of the music listening inter-

**intervention**

Patient preferred music as assessed and tailored for patients by a board certified music therapist

**Timing of music intervention**

Patients determined when and how long they wanted to listen to music

Listening sessions were 1 hour, 2 times a day for up to 7 days

**Outcomes**

• PDM reduced anxiety by 19 points on VAS • PDM resulted in a cost savings of \$2,322 (USD) per patient compared to usual care

• Adherence to study intervention was higher in PM and STM groups (80%) compared to AC group

• Patients in the PM and STM groups had more coma free days than AC group

(30%)

Protocols regarding the selection of music vary in music listening intervention research. A Cochrane Review of music interventions with mechanically ventilated patients indicated that only 1 of the 14 studies reviewed included a board certified music therapist as a member of the research team [22]. As a result, in many studies the music was selected by the researchers and provided patients only limited options of music to listen to throughout the course of the study [50–53]. While researchers may refer to this as patient-preferred music, in essence patients are choosing what music to listen to, based on a pre-determined and a restrictive list of music, thus choosing what to listen to from limited options. Patient directed music listening is modeled after patient controlled analgesia (PCA), in which the patient makes their own decision regarding when they need to take a dose of pain medication [54]. Patient directed music listening (PDM) empowers the patient to choose the music they want to listen to, when they want to listen to it, and how long they want to listen [28, 54–56].

Implementing a music intervention with patients necessitates understanding the role or function of the music in the intervention. Additionally, implementing a patient directed music listening intervention requires understanding the patient's music preferences. This can be accomplished by completing a music assessment to help determine what the patient likes and does not like related to music listening. In order for a music intervention to be successful, it is vital to have a clear process of delivering the music intervention [21, 57]. These topics will be thoroughly explored in the upcoming sections of this chapter. The first step in this process is to understand how music listening can be helpful to patients in the ICU and the characteristics in music that support and facilitate

vention varies significantly within this body of research.

**96**

these processes.

Music is an accessible tool as critically ill patients can easily engage with music listening even when they are tired and have low energy [21, 54–57]. Music can serve many different functions to critically ill patients and can address multiple symptoms simultaneously [25]. Additionally, music does not hold the negative side effects or consequences that patients may experience from pharmacological interventions such as sedative and pain medications [25]. While a patient may use music listening to address multiple symptoms, it is important to understand the various roles music can play and characteristics in the music that can help address these symptoms [21, 49, 58–60]. **Table 2** identifies the different functions of music, descriptions, and characteristics in the music that facilitate this.

It is vital to understand the patient need(s) that music can help to address as this helps to determine music that may be most appropriate and effective for the patient. Conducting an assessment is critical to understanding a patient's needs and to determine their music preferences. A music assessment can also provide information on ways a patient may already use music in their day-to-day life, that can be helpful for them to use during their hospitalization.

There are several reasons why a music listening intervention is a viable option in the critical care environment. Listening to music can help enhance and promote a healing environment. As the patient is able to focus on the music and shift their focus

**Table 2.** *Functions of music.*

away from the noisy or over stimulating environment of the ICU, this can foster a sense of relaxation and calm. Music can provide a sense of comfort as well. When a patient listens to soothing or familiar music, this can reduce stress and anxiety associated with their hospitalization. A music listening intervention provides the opportunity for the patient to exert control. Providing patients with the power to choose the music they want to listen to fosters feelings of empowerment, which is important when so many aspects of their care in the ICU is outside of their control [21, 55–58].

#### **2.2 Assessing music preferences**

Conducting an assessment is a key part of any treatment process. Implementing a music intervention is no exception. A music assessment allows the clinician to gather information that impacts a patient's music preferences, such as education, cultural background, and religious and faith affiliations. It provides insight into ways the patient may currently use music in their daily life that may be effective during the course of their treatment. The music assessment provides information on music preferences and music the patient does not like. Gathering this information helps to ensure the clinician can provide the music that can be more effective for the patient because it is their preferred music and to avoid music the patient does not like [21, 55, 58].

Music is often thought to be innocuous and does not have any negative impact. Listening to music one does not like can cause agitation and negatively impact mood [21, 55]. Music can also be connected to significant life experiences and hearing songs that remind a patient of those experiences can foster a strong emotional response. As a result, it is important to understand which music may not be appropriate or helpful for the patient [55, 57].

The Brief Music Assessment Tool (BMAT) that follows can be utilized to effectively and efficiently assess a patient's music preferences. The BMAT is an abbreviated version of a music assessment tool (MAT) utilized in patient directed music listening research [28, 55, 57]. Recent research indicates that patients did not find the gathering of assessment data burdensome, as it could be collected quickly and easily [25] (**Table 3**).

**99**

**Table 3.**

*Brief music assessment tool (BMAT).*

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic…*

When the music assessment is complete and the clinician has a clear understanding of what patient needs that music can help to address, as well as what music the patient prefers and will be most effective, the next step is determining the delivery method of the music listening intervention. The method of delivery should be accessible at all times to enable the patient to utilize music listening when they want

10. Are there any cultural considerations important for you when selecting music? (Please specify)

Music is easily accessible through many different platforms and various devices. Patients may have their preferred music available on their personal mobile devices

or need, and for their desired length of time [21, 56, 58].

**2.3 Considerations of delivery of a music listening intervention**

*DOI: http://dx.doi.org/10.5772/intechopen.95889*

\_\_\_\_ Other (please specify)

4. What types of music do you enjoy? (Check all that apply) \_\_\_\_ Classical \_\_\_\_ Religious/Sacred \_\_\_\_ Classic rock \_\_\_\_ Hard rock \_\_\_\_ Rhythm & blues \_\_\_\_ Country \_\_\_\_ Hip hop \_\_\_\_ Reggae \_\_\_\_ Jazz \_\_\_\_ Rap \_\_\_\_ New age \_\_\_\_ World music \_\_\_\_ Alternative \_\_\_\_ Heavy metal \_\_\_\_ Oldies (1950–1970) \_\_\_\_ Pop music

5. Are there any particular groups or artists you prefer?

\_\_\_\_ Orchestral \_\_\_\_ Harp \_\_\_\_ Vocal \_\_\_\_ Flute \_\_\_\_ Folk/acoustic guitar \_\_\_\_ Piano

\_\_\_\_ Electric guitar \_\_\_\_ Bass

\_\_\_\_ Others (please specify)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 6. What instruments or instrumental sounds do you like? (Check all that apply)

\_\_\_\_ Synthesizer \_\_\_\_ Strings (violin, viola, cello)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8. Are there any genres of music you DO NOT like? (Please specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9. Are there any groups or artists you DO NOT like? (Please specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7. Are there any instruments or instrumental sounds that you DO NOT like? (Please specify)

\_\_\_\_ Saxophone \_\_\_\_ Percussion/drumming \_\_\_\_ Brass or horns \_\_\_\_ Clarinet or oboe \_\_\_\_ Ocean waves \_\_\_\_ Environmental sounds *Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic… DOI: http://dx.doi.org/10.5772/intechopen.95889*

9. Are there any groups or artists you DO NOT like? (Please specify)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10. Are there any cultural considerations important for you when selecting music? (Please specify)

#### **Table 3.**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**2.2 Assessing music preferences**

priate or helpful for the patient [55, 57].

**Patient demographic information**

If yes, what do you play?

1. Do you like to listen to music? Yes No 2. Do you play an instrument(s)? Yes No

3. When do you like to listen to music? (Check all that apply) \_\_\_\_Relaxation \_\_\_ Stress reduction \_\_\_\_ Pure enjoyment \_\_\_\_ To pass time \_\_\_\_ During exercise \_\_\_\_ During meals \_\_\_\_ With friends & family \_\_\_\_ For prayer

\_\_\_\_ While working \_\_\_\_ Other (please specify)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Patient name: Date: Education: Vocation:

Cultural background: Religion or faith background: Current mood state: Hearing impairment: Specify: **Music preferences assessment**

away from the noisy or over stimulating environment of the ICU, this can foster a sense of relaxation and calm. Music can provide a sense of comfort as well. When a patient listens to soothing or familiar music, this can reduce stress and anxiety associated with their hospitalization. A music listening intervention provides the opportunity for the patient to exert control. Providing patients with the power to choose the music they want to listen to fosters feelings of empowerment, which is important when so many aspects of their care in the ICU is outside of their control [21, 55–58].

Conducting an assessment is a key part of any treatment process. Implementing a music intervention is no exception. A music assessment allows the clinician to gather information that impacts a patient's music preferences, such as education, cultural background, and religious and faith affiliations. It provides insight into ways the patient may currently use music in their daily life that may be effective during the course of their treatment. The music assessment provides information on music preferences and music the patient does not like. Gathering this information helps to ensure the clinician can provide the music that can be more effective for the patient because it is their preferred music and to avoid music the patient does not like [21, 55, 58].

Music is often thought to be innocuous and does not have any negative impact. Listening to music one does not like can cause agitation and negatively impact mood [21, 55]. Music can also be connected to significant life experiences and hearing songs that remind a patient of those experiences can foster a strong emotional response. As a result, it is important to understand which music may not be appro-

The Brief Music Assessment Tool (BMAT) that follows can be utilized to effectively and efficiently assess a patient's music preferences. The BMAT is an abbreviated version of a music assessment tool (MAT) utilized in patient directed music listening research [28, 55, 57]. Recent research indicates that patients did not find the gathering of assessment data burdensome, as it could be collected quickly and easily [25] (**Table 3**).

**98**

*Brief music assessment tool (BMAT).*

When the music assessment is complete and the clinician has a clear understanding of what patient needs that music can help to address, as well as what music the patient prefers and will be most effective, the next step is determining the delivery method of the music listening intervention. The method of delivery should be accessible at all times to enable the patient to utilize music listening when they want or need, and for their desired length of time [21, 56, 58].

#### **2.3 Considerations of delivery of a music listening intervention**

Music is easily accessible through many different platforms and various devices. Patients may have their preferred music available on their personal mobile devices

(iPhone, Smartphone, iPad, laptop, etc.) which they have available during their hospitalization. If so, it can be helpful to talk with the patient about the music they have available and how they can use it to manage symptoms. An intensive care unit may choose to make music available through a platform or device on the unit. There are several considerations when making music available for patient use.

It is imperative that the delivery process be accessible to patients whenever they may want or need to engage in music listening. Accessibility is a vital consideration when creating a delivery system, as well as one that does not burden ICU staff. Patients need to be able to access the music and any equipment needed to engage in music listening with as little assistance as possible. This will empower them to use the music listening for their own care, if they are not dependent upon family or staff to help them access it. It is important to provide music that is tailored to patients' music preferences. This can require having a diverse and extensive collection of music or access to music streaming. Providing limited genres of music for patients does not allow them to select their preferred music and can discourage use of the intervention. Additionally, given the noisy nature of the ICU it can be helpful for patients to use headphones or ear buds when listening to music. These devices can help block out environmental noise and to further enhance the listening experience, as well as to help avoid over stimulation [21, 56, 58]. **Table 4** provides more detailed information and considerations for the music listening delivery process.

**101**

*Non-Pharmacological Management of Symptoms during Mechanical Ventilation and Chronic…*

Literature is available to help inform staff about implementing a patient directed music listening intervention

Institutions and critical care units may choose to consult a board certified music therapist (MT-BC) to utilize their expertise about the use of music and music listening with patients. Organizations can contact state or local music therapy organizations or contact the American Music Therapy Association to get assistance in locating

a music therapist in the area.

[21, 25, 55, 56].

**Delivery process Considerations Suggestions**

Staff can benefit from some education and training to ensure they are able to properly educate and inform patients regarding the use of

It also empowers staff to know when it may be appropriate to suggest or recommend a patient try music

Most people listen to music and understand it is an enjoyable and relaxing. It is helpful to provide patients some simple information and education to help them understand the many different ways that listening to music can manage symptoms. This information and knowledge will encourage their use of music listening and empower them in their own care.

**Educating patients**

**Staff**

music listening.

listening [61].