101
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Frat JP, Coudroy R, Thille AW. Non-invasive ventilation or high-flow oxygen therapy: When to choose one over the other? Respirology 2018; 24:724-731. [PMID: 30406954 DOI: 10.1111/resp.13435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/03/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022]
Abstract
It has been found that high-flow oxygen therapy (HFOT) can reduce mortality of patients admitted to intensive care unit (ICU) for de novo acute respiratory failure (ARF) as compared to non-invasive ventilation (NIV). HFOT might therefore be considered as a first-line strategy of oxygenation in these patients. The beneficial effects of HFOT may be explained by its good tolerance and by physiological characteristics including delivery of high FiO2 , positive end expiratory pressure (PEEP) effect and continuous dead space washout contributing to decreased work of breathing. In contrast, NIV should be used cautiously in patients with de novo ARF due to high tidal volumes promoted by pressure support and that may potentially worsen pre-existing lung injury. Although recent studies have reported no benefit and even deleterious effects of NIV in immunocompromised patients with ARF, the experts have recommended its use as a first-line strategy. In patients with acute-on-chronic respiratory failure and respiratory acidosis, it has been clearly shown that NIV is the best strategy of oxygenation. However, HFOT seems able to reverse respiratory acidosis and further studies are needed to evaluate whether HFOT could represent an alternative to standard oxygen. Although NIV is recommended to treat ARF in post-operative patients or to prevent post-extubation respiratory failure in ICU, recent large-scale randomized studies suggest that HFOT could be equivalent to NIV. While recent recommendations have been established from studies comparing NIV with standard oxygen, new studies are needed to compare NIV versus HFOT in order to better define the appropriate indications for both treatments.
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Affiliation(s)
- Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France.,CIC-1402 ALIVE, INSERM, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
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102
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Petitjeans F, Pichot C, Ghignone M, Quintin L. Building on the Shoulders of Giants: Is the use of Early Spontaneous Ventilation in the Setting of Severe Diffuse Acute Respiratory Distress Syndrome Actually Heretical? Turk J Anaesthesiol Reanim 2018; 46:339-347. [PMID: 30263856 DOI: 10.5152/tjar.2018.01947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/13/2018] [Indexed: 12/14/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is not a failure of the neurological command of the ventilatory muscles or of the ventilatory muscles; it is an oxygenation defect. As positive pressure ventilation impedes the cardiac function, paralysis under general anaesthesia and controlled mandatory ventilation should be restricted to the interval needed to control the acute cardio-ventilatory distress observed upon admission into the critical care unit (CCU; "salvage therapy" during "shock state"). Current management of early severe diffuse ARDS rests on a prolonged interval of controlled mechanical ventilation with low driving pressure, paralysis (48 h, too often overextended), early proning and positive end-expiratory pressure (PEEP). Therefore, the time interval between arrival to the CCU and switching to spontaneous ventilation (SV) is not focused on normalizing the different factors involved in the pathophysiology of ARDS: fever, low cardiac output, systemic acidosis, peripheral shutdown (local acidosis), supine position, hypocapnia (generated by hyperpnea and tachypnea), sympathetic activation, inflammation and agitation. Then, the extended period of controlled mechanical ventilation with paralysis under general anaesthesia leads to CCU-acquired pathology, including low cardiac output, myoneuropathy, emergence delirium and nosocomial infection. The stabilization of the acute cardio-ventilatory distress should primarily itemize the pathophysiological conditions: fever control, improved micro-circulation and normalized local acidosis, 'upright' position, minimized hypercapnia, sympathetic de-activation (normalized sympathetic activity toward baseline levels resulting in improved micro-circulation with alpha-2 agonists administered immediately following optimized circulation and endotracheal intubation), lowered inflammation and 'cooperative' sedation without respiratory depression evoked by alpha-2 agonists. Normalised metabolic, circulatory and ventilatory demands will allow one to single out the oxygenation defect managed with high PEEP (diffuse recruitable ARDS) under early spontaneous ventilation (airway pressure release ventilation+SV or low-pressure support). Assuming an improved overall status, PaO2/FiO2≥150-200 allows for extubation and continuous non-invasive ventilation. Such fast-tracking may avoid most of the CCU-acquired pathologies. Evidence-based demonstration is required.
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103
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Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:355. [PMID: 30370282 DOI: 10.21037/atm.2018.04.39] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiogenic pulmonary edema (CPE) is among the most common causes of acute respiratory failure (ARF) in the acute care setting and often requires ventilatory assistance. In patients with ARF due to CPE, use of non-invasive positive airway pressure can decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema. In these patients, either non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) can improve vital signs and physiological parameters, decreasing the need for endotracheal intubation (ETI) and hospital mortality when compared to conventional oxygen therapy. Results on the use of NIV or CPAP in patients with CPE prior to hospitalization are not homogeneous among studies, hampering any conclusive recommendation regarding their role in the pre-hospital setting.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo De Santis
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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104
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105
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Noninvasive Failure in De Novo Acute Hypoxemic Respiratory Failure: High Positive End-Expiratory Pressure-Low Pressure Support, i.e., "Inverted Settings"? Crit Care Med 2018; 44:e1153-e1154. [PMID: 27755097 DOI: 10.1097/ccm.0000000000001967] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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106
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Dangers L, Montlahuc C, Kouatchet A, Jaber S, Meziani F, Perbet S, Similowski T, Resche-Rigon M, Azoulay E, Demoule A. Dyspnoea in patients receiving noninvasive ventilation for acute respiratory failure: prevalence, risk factors and prognostic impact: A prospective observational study. Eur Respir J 2018; 52:13993003.02637-2017. [PMID: 29976650 DOI: 10.1183/13993003.02637-2017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/21/2018] [Indexed: 11/05/2022]
Abstract
Dyspnoea is a frequent and intense symptom in intubated patients, but little attention has been paid to dyspnoea during noninvasive mechanical ventilation in the intensive care unit (ICU).The objectives of this study were to quantify the prevalence, intensity and prognostic impact of dyspnoea in patients receiving noninvasive ventilation (NIV) for acute respiratory failure (ARF) based on secondary analysis of a prospective observational cohort study in patients who received ventilatory support for ARF in 54 ICUs in France and Belgium. Dyspnoea was measured by a modified Borg scale.Among the 426 patients included, the median (interquartile range) dyspnoea score was 4 (3-5) on admission and 3 (2-4) after the first NIV session (p=0.001). Dyspnoea intensity ≥4 after the first NIV session was associated with the Sequential Organ Failure Assessment Score (odds ratio (OR) 1.12, p=0.001), respiratory rate (OR 1.03, p=0.032), anxiety (OR 1.92, p=0.006), leaks (OR 2.5, p=0.002) and arterial carbon dioxide tension (OR 0.98, p=0.025). Dyspnoea intensity ≥4 was independently associated with NIV failure (OR 2.41, p=0.001) and mortality (OR 2.11, p=0.009), but not with higher post-ICU burden and altered quality of life.Dyspnoea is frequent and intense in patients receiving NIV for ARF and is associated with a higher risk of NIV failure and poorer outcome.
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Affiliation(s)
- Laurence Dangers
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Service de Pneumologie et Réanimation Médicale (Dépt "R3S"), Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Claire Montlahuc
- Service de Biostatistique et Information Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, INSERM, UMR-1153 (CRESS), Epidémiologie Clinique, Statistique pour la Recherche en Santé (ECSTRA), Paris, France
| | - Achille Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Samir Jaber
- Dépt d'Anesthésie et Réanimation, Hôpital Saint-Eloi, Montpellier, France.,Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Ferhat Meziani
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg and EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Sébastien Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France.,R2D2, EA-7281, Université d'Auvergne, Clermont-Ferrand, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Service de Pneumologie et Réanimation Médicale (Dépt "R3S"), Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Matthieu Resche-Rigon
- Service de Biostatistique et Information Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, INSERM, UMR-1153 (CRESS), Epidémiologie Clinique, Statistique pour la Recherche en Santé (ECSTRA), Paris, France
| | - Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint-Louis, Paris, France
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107
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Abstract
Noninvasive ventilation (NIV) has assumed a central role in the treatment of selected patients with acute respiratory failure due to exacerbated chronic obstructive pulmonary disease or acute cardiogenic pulmonary edema. Recent advances in the understanding of physiologic aspects of NIV application through different interfaces and ventilator settings have led to improved patient-machine interaction, enhancing favorable NIV outcome. In recent years, the growing role of NIV in the acute care setting has led to the development of technical innovations to overcome the problems related to gas leakage and dead space, improving the quality of the devices and optimizing ventilation modes.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy.
| | - Alessandra Ionescu Maddalena
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Valentina Giammatteo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
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108
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Schreiber A, Yıldırım F, Ferrari G, Antonelli A, Delis PB, Gündüz M, Karcz M, Papadakos P, Cosentini R, Dikmen Y, Esquinas AM. Non-Invasive Mechanical Ventilation in Critically Ill Trauma Patients: A Systematic Review. Turk J Anaesthesiol Reanim 2018; 46:88-95. [PMID: 29744242 DOI: 10.5152/tjar.2018.46762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 12/20/2017] [Indexed: 12/23/2022] Open
Abstract
There is limited literature on non-invasive mechanical ventilation (NIMV) in patients with polytrauma-related acute respiratory failure (ARF). Despite an increasing worldwide application, there is still scarce evidence of significant NIMV benefits in this specific setting, and no clear recommendations are provided. We performed a systematic review, and a search of clinical databases including MEDLINE and EMBASE was conducted from the beginning of 1990 until today. Although the benefits in reducing the intubation rate, morbidity and mortality are unclear, NIMV may be useful and does not appear to be associated with harm when applied in properly selected patients with moderate ARF at an earlier stage of injury by experienced teams and in appropriate settings under strict monitoring. In the presence of these criteria, NIMV is worth attempting, but only if endotracheal intubation is promptly available because non-responders to NIMV are burdened by an increased mortality when intubation is delayed.
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Affiliation(s)
- Annia Schreiber
- Fondazione Salvatore Maugeri, IRCCS, Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Pavia, Italy
| | - Fatma Yıldırım
- Ankara Dışkapı Yıldırım Beyazıt Research and Education Hospital, Intensive Care Unit, Ankara, Turkey
| | - Giovanni Ferrari
- Ospedale Mauriziano, Department of Respiratory Medicine, Turin Italy
| | - Andrea Antonelli
- Allergologia e Fisiopatologia Respiratoria, ASO S. Croce e Carle Cuneo, Cuneo, Italy
| | | | - Murat Gündüz
- Department of Anaesthesiology and Reanimation, Intensive Care Unit, Çukurova University School of Medicine, Adana, Turkey
| | - Marcin Karcz
- University of Rochester, Department of Anesthesiology, Critical Care Medicine, Rochester, New York, USA
| | - Peter Papadakos
- University of Rochester, Department of Anesthesiology, Surgery and Neurosurgery, Critical Care Medicine, Rochester, New York, USA
| | - Roberto Cosentini
- Emergency Medicine Department, Gruppo NIV, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yalım Dikmen
- Department of Anaesthesiology and Reanimation, Intensive Care Unit, İstanbul University, Cerrahpaşa School of Medicine, İstanbul, Turkey
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109
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Frat JP, Coudroy R, Thille A. Y a-t-il une place pour l’oxygénothérapie nasale à haut débit dans l’insuffisance respiratoire aiguë? Oui. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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110
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Frat JP, Ricard JD, Coudroy R, Robert R, Ragot S, Thille AW. Preoxygenation with non-invasive ventilation versus high-flow nasal cannula oxygen therapy for intubation of patients with acute hypoxaemic respiratory failure in ICU: the prospective randomised controlled FLORALI-2 study protocol. BMJ Open 2017; 7:e018611. [PMID: 29275345 PMCID: PMC5770951 DOI: 10.1136/bmjopen-2017-018611] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Endotracheal intubation in intensive care unit (ICU) is a procedure at high risk of life-threatening complications. Among them, severe oxygen desaturation, usually defined as a drop of pulse oxymetry (SpO2) below 80%, is the most common. Preoxygenation enables delaying oxygen desaturation occurring during apnea induced by anaesthetic drugs. Data suggest that non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) oxygen therapy could further increase PaO2 before intubation procedure and prevent oxygen desaturation episodes as compared with standard oxygen. However, no recommendation favours one technique rather than the other, since they have never been compared. Hence, whether a strategy of preoxygenation with NIV or HFNC is more effective than the other in patients with acute hypoxaemic respiratory failure remains to be established. METHODS AND ANALYSIS The FLORALI-2 study is a multicentre randomised controlled trial comparing a preoxygenation strategy with either NIV or HFNC in patients with acute hypoxaemic respiratory failure needing intubation in ICU. The 320 patients will be randomised with a ratio 1:1 in two groups according to the strategy of preoxygenation. The primary outcome is the occurrence of an episode of severe oxygen desaturation defined by a drop of SpO2 below 80% during the intubation procedure. Secondary outcomes include feasibility of the two strategies, immediate and late complications related to intubation. ETHICS AND DISSEMINATION The study has been approved by the central ethics committee (Ethics Committee Ouest-III, Poitiers, France) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02668458; Pre-results.
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Affiliation(s)
- Jean-Pierre Frat
- Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
- INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
| | - Jean-Damien Ricard
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, Colombes, France
- Université Paris Diderot, UMR IAME 1137, Sorbonne Paris Cité, Paris, France
- INSERM, IAME 1137, Paris, France
| | - Rémi Coudroy
- Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
- INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
| | - René Robert
- Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
- INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
| | - Stéphanie Ragot
- Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
- Department of Biostatistics, INSERM, CIC-1402, Poitiers, France
- CIC-1402, Poitiers, France
| | - Arnaud W Thille
- Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
- INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
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111
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Effects of High-Flow Nasal Cannula on the Work of Breathing in Patients Recovering From Acute Respiratory Failure*. Crit Care Med 2017; 45:1981-1988. [DOI: 10.1097/ccm.0000000000002693] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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112
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017. [PMID: 28860265 DOI: 10.1183/13993003.02426–2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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113
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50:50/2/1602426. [PMID: 28860265 DOI: 10.1183/13993003.02426-2016] [Citation(s) in RCA: 720] [Impact Index Per Article: 102.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/15/2017] [Indexed: 12/13/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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114
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Hukins C, Wong M, Murphy M, Upham J. Management of hypoxaemic respiratory failure in a Respiratory High-dependency Unit. Intern Med J 2017; 47:784-792. [DOI: 10.1111/imj.13403] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Craig Hukins
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Mimi Wong
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Michelle Murphy
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - John Upham
- Department of Respiratory and Sleep Medicine; Princess Alexandra Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
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115
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Frat JP, Coudroy R, Marjanovic N, Thille AW. High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:297. [PMID: 28828372 DOI: 10.21037/atm.2017.06.52] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
High-flow nasal cannula (HFNC) oxygen therapy is a recent technique delivering a high flow of heated and humidified gas. HFNC is simpler to use and apply than noninvasive ventilation (NIV) and appears to be a good alternative treatment for hypoxemic acute respiratory failure (ARF). HFNC is better tolerated than NIV, delivers high fraction of inspired oxygen (FiO2), generates a low level of positive pressure and provides washout of dead space in the upper airways, thereby improving mechanical pulmonary properties and unloading inspiratory muscles during ARF. A recent multicenter randomized controlled trial showed benefits of HFNC concerning mortality and intubation in severe patients with hypoxemic ARF. In management of patients with hypoxemic ARF, NIV results have been conflicting. Despite improved oxygenation, NIV delivered with face mask may generate high tidal volumes and subsequent ventilator-induced lung injury. An approach applying NIV with a helmet, high levels of positive end-expiratory pressure (PEEP) and low pressure support (PS) levels seems to open new opportunities in patients with hypoxemic ARF. However, a large-scale randomized controlled study is needed to assess and compare this approach with HFNC.
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Affiliation(s)
- Jean-Pierre Frat
- CHU de Poitiers, Réanimation Médicale, Poitiers, France.,INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France.,Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Rémi Coudroy
- CHU de Poitiers, Réanimation Médicale, Poitiers, France.,INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France.,Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Nicolas Marjanovic
- INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France.,Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France.,CHU de Poitiers, Services des Urgences, Poitiers, France
| | - Arnaud W Thille
- CHU de Poitiers, Réanimation Médicale, Poitiers, France.,INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France.,Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
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116
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Baudin F, Buisson A, Vanel B, Massenavette B, Pouyau R, Javouhey E. Nasal high flow in management of children with status asthmaticus: a retrospective observational study. Ann Intensive Care 2017; 7:55. [PMID: 28534235 PMCID: PMC5440424 DOI: 10.1186/s13613-017-0278-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/10/2017] [Indexed: 11/30/2022] Open
Abstract
Background Asthma is the most common obstructive airway disease in children and adults. Nasal high flow (NHF) is a recent device that is now used as a primary support for respiratory distress. Several studies have reported use of NHF as a respiratory support in status asthmaticus; however, there are no data to recommend such practice. We therefore conducted this preliminary study to evaluate NHF therapy for children with status asthmaticus admitted to our PICU in order to prepare a multicentre randomized controlled study. Results Between November 2009 and January 2014, 73 patients with status asthmaticus were admitted to the PICU, of whom 39 (53%) were treated with NHF and among these 10 (26%) presented severe acidosis at admission (pH < 7.30). Thirty-four less severe children (41%) were treated with standard oxygen. For one child (2.6%) NHF failed and was then switched to non-invasive ventilation. NHF was discontinued in another patient because of the occurrence of pneumothorax after 31 h with NHF; the patient was then switched to standard oxygen therapy. Mean ± SD heart rate (165 ± 21 vs. 141 ± 25/min, p < 0.01) and respiratory rate (40 ± 13 vs. 31 ± 8/min, p < 0.01) decreased significantly, and blood gas improved in the first 24 h. In the subgroup of patients with acidosis, median [IQR] pH increased significantly between hour 0 and 2 (7.25 [7.21–7.26] vs. 7.30 [7.27–7.33], p = 0.009) and median [IQR] pCO2 decreased significantly (7.27 kPa [6.84–7.91 vs. 5.85 kPa [5.56–6.11], p = 0.007). No patient was intubated. Conclusion This retrospective study showed the feasibility and safety of NHF in children with severe asthma. Blood gas and clinical parameters were significantly improved during the first 24 h. NHF failed in only two patients, and none required invasive ventilation.
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Affiliation(s)
- Florent Baudin
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France. .,UMR T_9405, UMRESTTE, Ifsttar, Université Claude Bernard Lyon1, Univ Lyon, 69373, Lyon, France.
| | - Alexandra Buisson
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Blandine Vanel
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Bruno Massenavette
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Robin Pouyau
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Etienne Javouhey
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France.,UMR T_9405, UMRESTTE, Ifsttar, Université Claude Bernard Lyon1, Univ Lyon, 69373, Lyon, France
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117
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Beloncle F, Piquilloud L, Rittayamai N, Sinderby C, Rozé H, Brochard L. A diaphragmatic electrical activity-based optimization strategy during pressure support ventilation improves synchronization but does not impact work of breathing. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:21. [PMID: 28137269 PMCID: PMC5282691 DOI: 10.1186/s13054-017-1599-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022]
Abstract
Background Poor patient-ventilator synchronization is often observed during pressure support ventilation (PSV) and has been associated with prolonged duration of mechanical ventilation and poor outcome. Diaphragmatic electrical activity (Eadi) recorded using specialized nasogastric tubes is a surrogate of respiratory brain stem output. This study aimed at testing whether adapting ventilator settings during PSV using a protocolized Eadi-based optimization strategy, or Eadi-triggered and -cycled assisted pressure ventilation (or PSVN) could (1) improve patient-ventilator interaction and (2) reduce or normalize patient respiratory effort as estimated by the work of breathing (WOB) and the pressure time product (PTP). Methods This was a prospective cross-over study. Patients with a known chronic pulmonary obstructive or restrictive disease, asynchronies or suspected intrinsic positive end-expiratory pressure (PEEP) who were ventilated using PSV were enrolled in the study. Four different ventilator settings were sequentially applied for 15 minutes (step 1: baseline PSV as set by the clinician, step 2: Eadi-optimized PSV to adjust PS level, inspiratory trigger, and cycling settings, step 3: step 2 + PEEP adjustment, step 4: PSVN). The same settings as step 3 were applied again after step 4 to rule out a potential effect of time. Breathing pattern, trigger delay (Td), inspiratory time in excess (Tiex), pressure-time product (PTP), and work of breathing (WOB) were measured at the end of each step. Results Eleven patients were enrolled in the study. Eadi-optimized PSV reduced Td without altering Tiex in comparison with baseline PSV. PSVN reduced Td and Tiex in comparison with baseline and Eadi-optimized PSV. Respiratory pattern did not change during the four steps. The improvement in patient-ventilator interaction did not lead to changes in WOB or PTP. Conclusions Eadi-optimized PSV allows improving patient ventilator interaction but does not alter patient effort in patients with mild asynchrony. Trial registration Clinicaltrials.gov identifier: NCT 02067403. Registered 7 February 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1599-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francois Beloncle
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France
| | - Lise Piquilloud
- Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France.,Adult Intensive Care and Burn Unit, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Christer Sinderby
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Hadrien Rozé
- CHU de Bordeaux, Service d'Anesthesie-Reanimation 2, Pessac, 33600, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
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118
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Antonelli M. Ventilation-induced lung injury exists in spontaneously breathing patients with acute respiratory failure: No. Intensive Care Med 2017; 43:253-255. [PMID: 28074230 DOI: 10.1007/s00134-016-4488-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Massimo Antonelli
- Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy.
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119
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Duan J, Han X, Bai L, Zhou L, Huang S. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med 2016; 43:192-199. [PMID: 27812731 DOI: 10.1007/s00134-016-4601-3] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/19/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE To develop and validate a scale using variables easily obtained at the bedside for prediction of failure of noninvasive ventilation (NIV) in hypoxemic patients. METHODS The test cohort comprised 449 patients with hypoxemia who were receiving NIV. This cohort was used to develop a scale that considers heart rate, acidosis, consciousness, oxygenation, and respiratory rate (referred to as the HACOR scale) to predict NIV failure, defined as need for intubation after NIV intervention. The highest possible score was 25 points. To validate the scale, a separate group of 358 hypoxemic patients were enrolled in the validation cohort. RESULTS The failure rate of NIV was 47.8 and 39.4% in the test and validation cohorts, respectively. In the test cohort, patients with NIV failure had higher HACOR scores at initiation and after 1, 12, 24, and 48 h of NIV than those with successful NIV. At 1 h of NIV the area under the receiver operating characteristic curve was 0.88, showing good predictive power for NIV failure. Using 5 points as the cutoff value, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for NIV failure were 72.6, 90.2, 87.2, 78.1, and 81.8%, respectively. These results were confirmed in the validation cohort. Moreover, the diagnostic accuracy for NIV failure exceeded 80% in subgroups classified by diagnosis, age, or disease severity and also at 1, 12, 24, and 48 h of NIV. Among patients with NIV failure with a HACOR score of >5 at 1 h of NIV, hospital mortality was lower in those who received intubation at ≤12 h of NIV than in those intubated later [58/88 (66%) vs. 138/175 (79%); p = 0.03). CONCLUSIONS The HACOR scale variables are easily obtained at the bedside. The scale appears to be an effective way of predicting NIV failure in hypoxemic patients. Early intubation in high-risk patients may reduce hospital mortality.
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Affiliation(s)
- Jun Duan
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Xiaoli Han
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Linfu Bai
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Lintong Zhou
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Shicong Huang
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
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120
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Sehgal IS, Agarwal R. Non-invasive ventilation in acute respiratory distress syndrome: helmet use saves lives? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:349. [PMID: 27761453 DOI: 10.21037/atm.2016.08.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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121
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Abstract
High-flow nasal cannula (HFNC) oxygen therapy has several physiological advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure in the pharynx, increasing alveolar recruitment in the lungs, humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. Recently, the use of HFNC in treating adult critical illness patients has significantly increased, and it is now being used in many patients with a range of different disease conditions. However, there are no established guidelines to direct the safe and effective use of HFNC for these patients. This review article summarizes the available published literature on the positive physiological effects, mechanisms of action, and the clinical applications of HFNC, compared with traditional oxygen therapy devices. The available literature suggests that HFNC oxygen therapy is an effective modality for the early treatment of critically adult patients.
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Affiliation(s)
- Jian Zhang
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Ling Lin
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Konghan Pan
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jiancang Zhou
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiaoyin Huang
- 2 Department of Emergency Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
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122
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Abstract
Noninvasive ventilation (NIV) has assumed a prominent role in the treatment of patients with both hypoxemic and hypercapnic acute respiratory failure (ARF). The main theoretic advantages of NIV include avoiding side effects and complications associated with endotracheal intubation, improving patient comfort, and preserving airway defense mechanisms. Factors that affect the success of NIV in patients with ARF are clinicians' expertise, selection of patient, choice of interface, selection of ventilator setting, proper monitoring, and patient motivation. Advances in the understanding of the physiologic aspects of using NIV through different interfaces and ventilator modalities have improved patient-machine interaction, thus enhancing favorable NIV outcome.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Gennaro De Pascale
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Agostino Gemelli Hospital, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy.
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123
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Abstract
Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation. This article will explore the physiological benefits, complications and epidemiology of the different modes of NIV including continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV) and high-flow nasal cannula oxygen (HFNC). The currently available equipment and patient interfaces will be described, and the practical aspects of using NIV clinically will be explored. The current evidence for use of NIV in different clinical settings will be discussed, drawing on adult and neonatal as well as paediatric literature.
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124
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Tucci MR, Costa ELV, Nakamura MAM, Morais CCA. Noninvasive ventilation for acute respiratory distress syndrome: the importance of ventilator settings. J Thorac Dis 2016; 8:E982-E986. [PMID: 27747041 DOI: 10.21037/jtd.2016.09.29] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Noninvasive ventilation (NIV) is commonly used to prevent endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Patients with hypoxemic acute respiratory failure who fail an NIV trial carry a worse prognosis as compared to those who succeed. Additional factors are also knowingly associated with worse outcomes: higher values of ICU severity score, presence of severe sepsis, and lower ratio of arterial oxygen tension to fraction of inspired oxygen. However, it is still unclear whether NIV failure is responsible for the worse prognosis or if it is merely a marker of the underlying disease severity. There is therefore an ongoing debate as to whether and which ARDS patients are good candidates to an NIV trial. In a recent paper published in JAMA, "Effect of Noninvasive Ventilation Delivered by Helmet vs. Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome: A Randomized Clinical Trial", Patel et al. evaluated ARDS patients submitted to NIV and drew attention to the importance of the NIV interface. We discussed their interesting findings focusing also on the ventilator settings and on the current barriers to lung protective ventilation in ARDS patients during NIV.
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Affiliation(s)
- Mauro R Tucci
- Respiratory ICU, Pulmonary Division, Heart Institute (INCOR), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Eduardo L V Costa
- Respiratory ICU, Pulmonary Division, Heart Institute (INCOR), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil; ; Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Maria A M Nakamura
- Respiratory ICU, Pulmonary Division, Heart Institute (INCOR), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Caio C A Morais
- Respiratory ICU, Pulmonary Division, Heart Institute (INCOR), Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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125
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Luo Y, Luo Y, Li Y, Zhou L, Zhu Z, Chen Y, Huang Y, Chen X. Helmet CPAP versus Oxygen Therapy in Hypoxemic Acute Respiratory Failure: A Meta-Analysis of Randomized Controlled Trials. Yonsei Med J 2016; 57:936-41. [PMID: 27189288 PMCID: PMC4951471 DOI: 10.3349/ymj.2016.57.4.936] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/02/2015] [Accepted: 10/05/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The efficacy of helmet continuous positive airway pressure (CPAP) in hypoxemic acute respiratory failure (hARF) remains unclear. The aim of this meta-analysis was to critically review studies that investigated the effect of helmet CPAP on gas exchange, mortality, and intubation rate in comparison with standard oxygen therapy. MATERIALS AND METHODS We performed a meta-analysis of randomized controlled trials (RCTs) by searching the PubMed, Embase, Cochrane library, OVID, and CBM databases, and the bibliographies of the retrieved articles. Studies that enrolled adults with hARF who were treated with helmet CPAP and measured at least one of the following parameters were included: gas exchange, intubation rate, in-hospital mortality rate. RESULTS Four studies with 377 subjects met the inclusion criteria and were analyzed. Compared to the standard oxygen therapy, helmet CPAP significantly increased the PaO₂/FiO₂ [weighted mean difference (WMD)=73.40, 95% confidence interval (95% CI): 43.92 to 102.87, p<0.00001], and decreased the arterial carbon dioxide levels (WMD=-1.92, 95% CI: -3.21 to -0.63, p=0.003), intubation rate [relative risk (RR)=0.21, 95% CI: 0.11 to 0.40, p<0.00001], and in-hospital mortality rate (RR=0.22, 95% CI: 0.09 to 0.50, p=0.0004). CONCLUSION The results of this meta-analysis suggest that helmet CPAP improves oxygenation and reduces mortality and intubation rates in hARF. However, the significant clinical and statistical heterogeneity of the literature implies that large RCTs are needed to determine the role of helmet CPAP in different hypoxemic ARF populations.
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Affiliation(s)
- Yuwen Luo
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Luo
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yun Li
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Luqian Zhou
- The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Zhe Zhu
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yitai Chen
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuxia Huang
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xin Chen
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
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126
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Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure: Role of Tidal Volume. Crit Care Med 2016; 44:282-90. [PMID: 26584191 DOI: 10.1097/ccm.0000000000001379] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A low or moderate expired tidal volume can be difficult to achieve during noninvasive ventilation for de novo acute hypoxemic respiratory failure (i.e., not due to exacerbation of chronic lung disease or cardiac failure). We assessed expired tidal volume and its association with noninvasive ventilation outcome. DESIGN Prospective observational study. SETTING Twenty-four bed university medical ICU. PATIENTS Consecutive patients receiving noninvasive ventilation for acute hypoxemic respiratory failure between August 2010 and February 2013. INTERVENTIONS Noninvasive ventilation was uniformly delivered using a simple algorithm targeting the expired tidal volume between 6 and 8 mL/kg of predicted body weight. MEASUREMENTS Expired tidal volume was averaged and respiratory and hemodynamic variables were systematically recorded at each noninvasive ventilation session. MAIN RESULTS Sixty-two patients were enrolled, including 47 meeting criteria for acute respiratory distress syndrome, and 32 failed noninvasive ventilation (51%). Pneumonia (n = 51, 82%) was the main etiology of acute hypoxemic respiratory failure. The median (interquartile range) expired tidal volume averaged over all noninvasive ventilation sessions (mean expired tidal volume) was 9.8 mL/kg predicted body weight (8.1-11.1 mL/kg predicted body weight). The mean expired tidal volume was significantly higher in patients who failed noninvasive ventilation as compared with those who succeeded (10.6 mL/kg predicted body weight [9.6-12.0] vs 8.5 mL/kg predicted body weight [7.6-10.2]; p = 0.001), and expired tidal volume was independently associated with noninvasive ventilation failure in multivariate analysis. This effect was mainly driven by patients with PaO2/FIO2 up to 200 mm Hg. In these patients, the expired tidal volume above 9.5 mL/kg predicted body weight predicted noninvasive ventilation failure with a sensitivity of 82% and a specificity of 87%. CONCLUSIONS A low expired tidal volume is almost impossible to achieve in the majority of patients receiving noninvasive ventilation for de novo acute hypoxemic respiratory failure, and a high expired tidal volume is independently associated with noninvasive ventilation failure. In patients with moderate-to-severe hypoxemia, the expired tidal volume above 9.5 mL/kg predicted body weight accurately predicts noninvasive ventilation failure.
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127
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Coudroy R, Jamet A, Petua P, Robert R, Frat JP, Thille AW. High-flow nasal cannula oxygen therapy versus noninvasive ventilation in immunocompromised patients with acute respiratory failure: an observational cohort study. Ann Intensive Care 2016; 6:45. [PMID: 27207177 PMCID: PMC4875575 DOI: 10.1186/s13613-016-0151-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/06/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute respiratory failure is the main cause of admission to intensive care unit in immunocompromised patients. In this subset of patients, the beneficial effects of noninvasive ventilation (NIV) as compared to standard oxygen remain debated. High-flow nasal cannula oxygen therapy (HFNC) is an alternative to standard oxygen or NIV, and its use in hypoxemic patients has been growing. Therefore, we aimed to compare outcomes of immunocompromised patients treated using HFNC alone or NIV as a first-line therapy for acute respiratory failure in an observational cohort study over an 8-year period. Patients with acute-on-chronic respiratory failure, those treated with standard oxygen alone or needing immediate intubation, and those with a do-not-intubate order were excluded. RESULTS Among the 115 patients analyzed, 60 (52 %) were treated with HFNC alone and 55 (48 %) with NIV as first-line therapy with 30 patients (55 %) receiving HFNC and 25 patients (45 %) standard oxygen between NIV sessions. The rates of intubation and 28-day mortality were higher in patients treated with NIV than with HFNC (55 vs. 35 %, p = 0.04, and 40 vs. 20 %, p = 0.02 log-rank test, respectively). Using propensity score-matched analysis, NIV was associated with mortality. Using multivariate analysis, NIV was independently associated with intubation and mortality. CONCLUSIONS Based on this observational cohort study including immunocompromised patients admitted to intensive care unit for acute respiratory failure, intubation and mortality rates could be lower in patients treated with HFNC alone than with NIV. The use of NIV remained independently associated with poor outcomes.
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Affiliation(s)
- Rémi Coudroy
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France. .,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France.
| | - Angéline Jamet
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France
| | - Philippe Petua
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France
| | - René Robert
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Service de Réanimation Médicale, CHU de Poitiers, 2, rue de la Milétrie, 86021, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
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128
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Del Sorbo L, Jerath A, Dres M, Parotto M. Non-invasive ventilation in immunocompromised patients with acute hypoxemic respiratory failure. J Thorac Dis 2016; 8:E208-16. [PMID: 27076972 DOI: 10.21037/jtd.2016.02.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The survival rate of immunocompromised patients has improved over the past decades in light of remarkable progress in diagnostic and therapeutic options. Simultaneously, there has been an increase in the number of immunocompromised patients with life threatening complications requiring intensive care unit (ICU) treatment. ICU admission is necessary in up to 15% of patients with acute leukemia and 20% of bone marrow transplantation recipients, and the main reason for ICU referral in this patient population is acute hypoxemic respiratory failure, which is associated with a high mortality rate, particularly in patients requiring endotracheal intubation. The application of non-invasive ventilation (NIV), and thus the avoidance of endotracheal intubation and invasive mechanical ventilation with its side effects, appears therefore of great importance in this patient population. Early trials supported the benefits of NIV in these settings, and the 2011 Canadian guidelines for the use of NIV in critical care settings suggest the use of NIV in immune-compromised patients with a grade 2B recommendation. However, the very encouraging results from initial seminal trials were not confirmed in subsequent observational and randomized clinical studies, questioning the beneficial effect of NIV in immune-compromised patients. Based on these observations, a French group led by Azoulay decided to assess whether early intermittent respiratory support with NIV had a role in reducing the mortality rate of immune-compromised patients with non-hypercapnic hypoxemic respiratory failure developed in less than 72 h, and hence conducted a multicenter randomized controlled trial (RCT) in experienced ICUs in France. This perspective reviews the findings from their RCT in the context of the current critical care landscape, and in light of recent results from other trials focused on the early management of acute hypoxemic respiratory failure.
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Affiliation(s)
- Lorenzo Del Sorbo
- 1 Interdepartmental Division of Critical Care Medicine, 2 Department of Anesthesia, University of Toronto, Toronto, ON, Canada ; 3 Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada ; 4 Keenan Research Center at the Li Ka Shing Knowledge Institute of St, Michael's Hospital, Toronto, ON, Canada
| | - Angela Jerath
- 1 Interdepartmental Division of Critical Care Medicine, 2 Department of Anesthesia, University of Toronto, Toronto, ON, Canada ; 3 Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada ; 4 Keenan Research Center at the Li Ka Shing Knowledge Institute of St, Michael's Hospital, Toronto, ON, Canada
| | - Martin Dres
- 1 Interdepartmental Division of Critical Care Medicine, 2 Department of Anesthesia, University of Toronto, Toronto, ON, Canada ; 3 Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada ; 4 Keenan Research Center at the Li Ka Shing Knowledge Institute of St, Michael's Hospital, Toronto, ON, Canada
| | - Matteo Parotto
- 1 Interdepartmental Division of Critical Care Medicine, 2 Department of Anesthesia, University of Toronto, Toronto, ON, Canada ; 3 Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada ; 4 Keenan Research Center at the Li Ka Shing Knowledge Institute of St, Michael's Hospital, Toronto, ON, Canada
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129
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Beloncle F, Akoumianaki E, Rittayamai N, Lyazidi A, Brochard L. Accuracy of delivered airway pressure and work of breathing estimation during proportional assist ventilation: a bench study. Ann Intensive Care 2016; 6:30. [PMID: 27076185 PMCID: PMC4830790 DOI: 10.1186/s13613-016-0131-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/21/2016] [Indexed: 12/24/2022] Open
Abstract
Background Proportional assist ventilation+ (PAV+) delivers airway pressure (Paw) in proportion to patient effort (Pmus) by using the equation of motion of the respiratory system. PAV+ calculates automatically respiratory mechanics (elastance and resistance); the work of breathing (WOB) is estimated by the ventilator. The accuracy of Pmus estimation and hence accuracy of the delivered Paw and WOB calculation have not been assessed. This study aimed at assessing the accuracy of delivered Paw and calculated WOB by PAV+ and examining the factors influencing this accuracy. Methods Using an active lung model with different respiratory mechanics, we compared (1) the actual delivered Paw by the ventilator to the theoretical Paw as defined by the equation of motion and (2) the WOB value displayed by the ventilator to the WOB measured from a Campbell diagram. Results Irrespective of respiratory mechanics and gain, the ventilator provided a Paw approximately 25 % lower than expected. This underassistance was greatest at the beginning of the inspiration. Intrinsic PEEP (PEEPi), associated with an increase in trigger delay, was a major factor affecting PAV+ accuracy. The absolute value of total WOB displayed by the ventilator was underestimated, but the changes in WOB were accurately detected by the ventilator. Conclusion The assistance provided by PAV+ well follows Pmus but with a constant underassistance. This is associated with an underestimation by the ventilator of the WOB. PEEPi can be a major factor contributing to PAV+ inaccuracy. Clinical recommendations should include using a high trigger sensitivity and a careful PEEP titration. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0131-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francois Beloncle
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Crete, Greece
| | - Nuttapol Rittayamai
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Aissam Lyazidi
- Institut Supérieur des Sciences de la Santé, Université Hassan 1er, Settat, Morocco
| | - Laurent Brochard
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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130
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Brochard L, Hedenstierna G. Ten physiologic advances that improved treatment for ARDS. Intensive Care Med 2016; 42:814-816. [PMID: 27000388 DOI: 10.1007/s00134-016-4320-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 03/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden. .,Hedenstierna Laboratory, entr 40:2, University Hospital, 75185, Uppsala, Sweden.
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131
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132
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Affiliation(s)
- Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P Kress
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
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133
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Lefebvre A, Rabbat A. Ventilation non invasive et patients immunodéprimés. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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134
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Abstract
PURPOSE OF REVIEW This article reviews the use of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF), with a critical review of the most recent literature in this setting. RECENT FINDINGS The efficacy of NIV is variable depending on the cause of the episode of ARF. In community-acquired pneumonia, NIV is often associated with poor response, with better response in patients with preexisting cardiac or respiratory disease. In patients with pandemic influenza H1N1 and severe ARF, NIV has been associated with high failure rates but relatively favorable mortality. In acute respiratory distress syndrome, NIV should be used very cautiously and restricted to patients with mild-moderate acute respiratory distress syndrome without shock or metabolic acidosis due to the high failure rate observed in several reports. Despite limited evidence, NIV may improve the outcomes of patients with chest trauma and severe ARF. In postoperative ARF, both continuous positive airway pressure and NIV are effective to improve clinical outcomes, particularly in those with abdominal, cardiac, and thoracic surgery. SUMMARY Although patients with severe hypoxemic ARF are, in general, less likely to be intubated when NIV is used, the efficacy is different among these heterogeneous populations. Therefore, NIV is not routinely recommended in all patients with severe hypoxemic ARF.
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135
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Gregoretti C, Pisani L, Cortegiani A, Ranieri VM. Noninvasive Ventilation in Critically Ill Patients. Crit Care Clin 2015; 31:435-57. [DOI: 10.1016/j.ccc.2015.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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136
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A centrally acting antihypertensive, clonidine, combined to a venous dilator, nitroglycerin, to handle severe pulmonary edema. Am J Emerg Med 2015; 34:676.e5-7. [PMID: 26152915 DOI: 10.1016/j.ajem.2015.06.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/17/2015] [Indexed: 11/22/2022] Open
Abstract
A patient, with known left ventricular failure presented with severe pulmonary edema, an ejection fraction of 10% to 15%, knee mottling, and lactates of 7 mM L⁻¹. He was treated with unusually high-dose nitroglycerin (NTG) intravenously (IV; NTG ≈ 70 mg for 1 hour). To suppress dyspnea, systolic blood pressure had to be lowered from ≈ 150-160 to ≈ 100-120 mm Hg. To lower NTG requirement, an α-2 agonist, clonidine, was administered (300 μg IV for 2 hours). Dyspnea, tachypnea, and tachycardia subsided for 1 to 2 hours, allowing to reduce NTG infusion to 2 to 4 mg h⁻¹. State-of the-art treatment was superimposed: sitting position with leg down, noninvasive ventilation, positive end-expiratory pressure, bolus of furosemide 250 mg, and administration of 1000 mL of crystalloid for 1 hour under echocardiographic guidance. We ascribed the resistance to NTG to the activation of the sympathetic, vasopressin, and renin-angiotensin systems ("neurohormonal activation"). α-2 agonists reduce the sympathetic activation observed during severe left ventricular failure and overall oxygen consumption, evoke systemic and pulmonary arterial dilation, increase diastolic time, and improve diastolic function and diuresis. Because the α-2 agonist, dexmedetomidine, is available as an IV drug on the North American market, a niche may exist in the setting of emergency medicine/coronary care. This awaits evidence-based documentation.
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137
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Real time noninvasive estimation of work of breathing using facemask leak-corrected tidal volume during noninvasive pressure support: validation study. J Clin Monit Comput 2015; 30:285-94. [DOI: 10.1007/s10877-015-9716-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
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138
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Noninvasive support and ventilation for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S102-10. [PMID: 26035360 DOI: 10.1097/pcc.0000000000000437] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the widespread use of noninvasive ventilation in children and in children with acute lung injury and pediatric acute respiratory distress syndrome, there are few scientific data on the utility of this therapy. In this review, we examine the literature regarding noninvasive positive pressure ventilation and use the Research ANd Development/University of California, Los Angeles appropriateness methodology to provide strong or weak recommendations for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. DATA SOURCES Electronic searches were made in PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus with the following specific keywords: noninvasive ventilation, noninvasive positive pressure ventilation, continuous positive airway pressure, and high-flow nasal cannula. STUDY SELECTION Studies were eligible for inclusion if they included 10 or more children between 1 month and 18 years old. Randomized and nonrandomized controlled trials, controlled before-and-after studies, concurrent cohort studies, interrupted time series studies, historically controlled studies, cohort studies, cross-sectional studies, and uncontrolled longitudinal studies were included for data synthesis. DATA SYNTHESIS The literature provides a solid physiological rationale for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. The addition of noninvasive positive pressure ventilation can improve gas exchange and potentially prevent intubation and mechanical ventilation in some children with mild pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation is not indicated in severe pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation should be performed only in acute care setting with experienced team, and patient-ventilator synchrony is crucial for success. An oronasal interface provides superior support, but close monitoring of children is required due to the risk of progressive respiratory failure and the potential need for intubation. The use of high-flow nasal cannula is a promising treatment for respiratory disease; however, at this time, the efficacy of high-flow nasal cannula compared with noninvasive positive pressure ventilation is unknown. CONCLUSION Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease. However, further research is needed into the use of noninvasive positive pressure ventilation in children.
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139
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Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, Seo HS, Suh HJ, Seo GJ, Kim EY, Hong SB. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med 2015; 41:623-32. [DOI: 10.1007/s00134-015-3693-5] [Citation(s) in RCA: 304] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 02/06/2015] [Indexed: 01/13/2023]
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140
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Karcz MK, Papadakos PJ. Noninvasive ventilation in trauma. World J Crit Care Med 2015; 4:47-54. [PMID: 25685722 PMCID: PMC4326763 DOI: 10.5492/wjccm.v4.i1.47] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/03/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Trauma patients are a diverse population with heterogeneous needs for ventilatory support. This requirement depends mainly on the severity of their ventilatory dysfunction, degree of deterioration in gaseous exchange, any associated injuries, and the individual feasibility of potentially using a noninvasive ventilation approach. Noninvasive ventilation may reduce the need to intubate patients with trauma-related hypoxemia. It is well-known that these patients are at increased risk to develop hypoxemic respiratory failure which may or may not be associated with hypercapnia. Hypoxemia in these patients is due to ventilation perfusion mismatching and right to left shunt because of lung contusion, atelectasis, an inability to clear secretions as well as pneumothorax and/or hemothorax, all of which are common in trauma patients. Noninvasive ventilation has been tried in these patients in order to avoid the complications related to endotracheal intubation, mainly ventilator-associated pneumonia. The potential usefulness of noninvasive ventilation in the ventilatory management of trauma patients, though reported in various studies, has not been sufficiently investigated on a large scale. According to the British Thoracic Society guidelines, the indications and efficacy of noninvasive ventilation treatment in respiratory distress induced by trauma have thus far been inconsistent and merely received a low grade recommendation. In this review paper, we analyse and compare the results of various studies in which noninvasive ventilation was applied and discuss the role and efficacy of this ventilator modality in trauma.
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141
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Mechanical ventilation in critically ill cancer patients. Heart Lung 2014; 44:85-6. [PMID: 25455912 DOI: 10.1016/j.hrtlng.2014.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 02/07/2023]
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142
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Vitaliti G, Wenzel A, Bellia F, Pavone P, Falsaperla R. Noninvasive ventilation in pediatric emergency care: a literature review and description of our experience. Expert Rev Respir Med 2014; 7:545-52. [PMID: 24138696 DOI: 10.1586/17476348.2013.816570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Noninvasive ventilation (NIV) refers to a kind of mechanical respiratory support used in order to avoid the progression of respiratory failure to endotracheal intubation. Even though if this method is widely known in patients affected by chronic diseases and in children admitted in pediatric and neonatal intensive care units, few data are actually available on its use in intermediate care units. The present review focuses on the efficiency of NIV performed in children with acute respiratory failure due to different conditions. Moreover, the authors have described their experience with NIV in pediatric patients admitted to their acute and emergency room where NIV was started, well tolerated and led to an improvement of gas exchanges, decreasing the muscular respiratory work and endotracheal intubation avoidance in most of the patients.
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Affiliation(s)
- Giovanna Vitaliti
- UOC Pediatria e PSP, Azienda O-U Policlinico-Vittorio Emanuele, University of Catania, Italy
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143
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Brambilla AM, Aliberti S, Prina E, Nicoli F, Del Forno M, Nava S, Ferrari G, Corradi F, Pelosi P, Bignamini A, Tarsia P, Cosentini R. Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia. Intensive Care Med 2014; 40:942-9. [PMID: 24817030 DOI: 10.1007/s00134-014-3325-5] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/28/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE The efficacy of noninvasive continuous positive airway pressure (CPAP) to improve outcomes in severe hypoxemic acute respiratory failure (hARF) due to pneumonia has not been clearly established. The aim of this study was to compare CPAP vs. oxygen therapy to reduce the risk of meeting criteria for endotracheal intubation (ETI). METHODS In a multicenter randomized controlled trial conducted in four Italian centers patients with severe hARF due to pneumonia were randomized to receive helmet CPAP (CPAP group) or oxygen delivered with a Venturi mask (control group). The primary endpoint was the percentage of patients meeting criteria for ETI, including either one or more major criteria (respiratory arrest, respiratory pauses with unconsciousness, severe hemodynamic instability, intolerance) or at least two minor criteria (reduction of at least 30% of basal PaO2/FiO2 ratio, increase of 20% of PaCO2, worsening of alertness, respiratory distress, SpO2 less than 90%, exhaustion). RESULTS Between February 2010 and 2013, 40 patients were randomized to CPAP and 41 to Venturi mask. The proportion of patients meeting ETI criteria in the CPAP group was significantly lower compared to those in the control group (6/40 = 15% vs. 26/41 = 63%, respectively, p < 0.001; relative risk 0.24, 95% CI 0.11-0.51; number needed to treat, 2) two patients were intubated in the CPAP group and one in the control group. The CPAP group showed a faster and greater improvement in oxygenation in comparison to controls (p < 0.001). In either study group, no relevant adverse events were detected. CONCLUSIONS Helmet CPAP reduces the risk of meeting ETI criteria compared to oxygen therapy in patients with severe hARF due to pneumonia.
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Affiliation(s)
- Anna Maria Brambilla
- Emergency Medicine Department, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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144
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Zhang J, Cao J, Feng J, Wu Q, Chen BY. A study of noninvasive positive-pressure mechanical ventilation in the treatment of acute lung injury with a complex critical care ventilator. J Int Med Res 2014; 42:788-98. [PMID: 24691455 DOI: 10.1177/0300060514522205] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 01/07/2014] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To test the hypothesis that there would be better clinical outcomes following the treatment of patients with acute lung injury (ALI) using noninvasive positive-pressure mechanical ventilation (NIPPV) delivered via a complex critical care ventilator compared with a conventional mini-ventilator. METHODS Patients with ALI who required NIPPV were prospectively enrolled and randomly divided between three intervention groups: group A was ventilated using a mini-ventilator; groups B and C were ventilated using a complex critical care ventilator using different settings. Clinical parameters were recorded before and after 8 h of mechanical ventilation. RESULTS A total of 51 patients with ALI were enrolled in the study. Clinical parameters in groups B and C underwent greater improvements than those in group A. Group C demonstrated the lowest treatment failure rate (23.5%). Failure rates were highest in group A (58.8%). CONCLUSION The findings of this present study suggest that there were more satisfactory clinical outcomes following the treatment of patients with ALI when NIPPV was delivered using a complex critical care ventilator compared with a conventional mini-ventilator.
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Affiliation(s)
- Jing Zhang
- Department of Respiratory Diseases, General Hospital of Tianjin Medical University, Tianjin, China
| | - Jie Cao
- Department of Respiratory Diseases, General Hospital of Tianjin Medical University, Tianjin, China
| | - Jing Feng
- Department of Respiratory Diseases, General Hospital of Tianjin Medical University, Tianjin, China Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Qi Wu
- Department of Respiratory Diseases, General Hospital of Tianjin Medical University, Tianjin, China
| | - Bao-Yuan Chen
- Department of Respiratory Diseases, General Hospital of Tianjin Medical University, Tianjin, China
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145
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La ventilation non invasive en mode NAVA (neurally adjusted ventilatory assist) en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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146
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Esquinas AM. Noninvasive Positive-Pressure Ventilation in Patients with Acute Hypoxemic Respiratory Failure and HIV/AIDS. NONINVASIVE VENTILATION IN HIGH-RISK INFECTIONS AND MASS CASUALTY EVENTS 2014. [PMCID: PMC7122284 DOI: 10.1007/978-3-7091-1496-4_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pulmonary complications, especially acute respiratory failure (ARF), contribute to morbidity and mortality in immunocompromised patients. The etiology, pathophysiology, and reversibility of lung injury and the severity of ARF are key to the therapeutic response and prognosis for these patients.
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Affiliation(s)
- Antonio M. Esquinas
- Intensive Care & Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
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147
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Abstract
PURPOSE OF REVIEW This critical review discusses the key points that would be of practical help for the clinician who applies noninvasive ventilation (NIV) for treatment of patients with acute respiratory failure (ARF). RECENT FINDINGS In recent years, the growing role of NIV in the acute care setting has led to the development of technical innovations to overcome the problems related to gas leakage and dead space. A considerable amount of research has been conducted to improve the quality of the devices as well as optimize ventilation modes used to administer NIV. As a result, also mechanical ventilators have been implemented with modalities aimed at delivering NIV. SUMMARY The success of NIV in patients with ARF depends on several factors, including the skills of the clinician, selection of patient, choice of interface, selection of ventilation mode and ventilator setting, monitoring, and the motivation of the patient. Recent advances in the understanding of the physiological aspects of using NIV through different interfaces and ventilator settings have led to improve patient-machine interaction, enhancing favorable NIV outcome.
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148
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Frat JP, Goudet V, Girault C. [High flow, humidified-reheated oxygen therapy: a new oxygenation technique for adults]. Rev Mal Respir 2013; 30:627-43. [PMID: 24182650 DOI: 10.1016/j.rmr.2013.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 03/13/2013] [Indexed: 01/07/2023]
Abstract
Currently conventional oxygen therapy is the first choice symptomatic treatment in the management of acute respiratory failure (ARF). However, conventional oxygen therapy has important limitations which have lead to the development of heated and humidified high-flow nasal oxygen therapy (HFNO). HFNO is an innovative technique that can deliver, through special nasal cannulae, up to 100% of the inspired fraction (FiO2) with heated and humidified oxygen at a maximum flow of 70L/min. The characteristics of this technique (overcoming the patient's spontaneous inspiratory flow, heated humidification,) and its physiological effects (no dilution of FiO2, positive end-expiratory pressure, pharyngeal dead-space washout, decrease in airway resistance), allow efficient optimization of oxygenation with better tolerance for patients. Current data, mainly observational, show that HFNO could be used particularly for the management of hypoxemic ARF, notably in the more severe forms. Indications for using HFNO, alone or in association with noninvasive ventilation, are potentially very broad and may involve different types of ARF (post-operative, post-extubation, palliative care) and even the practice of invasive technical procedures (bronchial fibroscopy). However, though current studies are very encouraging and promise a clinical benefit on patient outcomes, randomized trials are still needed to demonstrate that HFNO avoids the need for endotracheal intubation in the management of ARF.
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Affiliation(s)
- J-P Frat
- Service de réanimation médicale, CHRU Jean-Bernard, rue de la Milétrie, BP 577, 86021 Poitiers cedex, France.
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Bertrand PM, Futier E, Coisel Y, Matecki S, Jaber S, Constantin JM. Neurally adjusted ventilatory assist vs pressure support ventilation for noninvasive ventilation during acute respiratory failure: a crossover physiologic study. Chest 2013; 143:30-36. [PMID: 22661448 DOI: 10.1378/chest.12-0424] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patient-ventilator asynchrony is common during noninvasive ventilation (NIV) with pressure support ventilation (PSV). We examined the effect of neurally adjusted ventilatory assist (NAVA) delivered through a facemask on synchronization in patients with acute respiratory failure (ARF). METHODS This was a prospective, physiologic, crossover study of 13 patients with ARF (median Pa(O(2))/F(IO(2)), 196 [interquartile range (IQR), 142-225]) given two 30-min trials of NIV with PSV and NAVA in random order. Diaphragm electrical activity (EAdi), neural inspiratory time (T(In)), trigger delay (Td), asynchrony index (AI), arterial blood gas levels, and patient discomfort were recorded. RESULTS There were significantly fewer asynchrony events during NAVA than during PSV (10 [IQR, 5-14] events vs 17 [IQR, 8-24] events, P = .017), and the occurrence of severe asynchrony (AI > 10%) was also less under NAVA (P = .027). Ineffective efforts and delayed cycling were significantly less with NAVA (P < .05 for both). NAVA was also associated with reduced Td (0 [IQR, 0-30] milliseconds vs 90 [IQR, 30-130] milliseconds, P < .001) and inspiratory time in excess (10 [IQR, 0-28] milliseconds vs 125 [IQR, 20-312] milliseconds, P < .001), but T(In) was similar under PSV and NAVA. The EAdi signal to its maximal value was higher during NAVA than during PSV ( P = .017). There were no significant differences in arterial blood gases or patient discomfort under PSV and NAVA. CONCLUSION In view of specific experimental conditions, our comparison of PSV and NAVA indicated that NAVA significantly reduced severe patient-ventilator asynchrony and resulted in similar improvements in gas exchange during NIV for ARF. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01426178; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Pierre-Marie Bertrand
- Department of Anesthesiology and Critical Care, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand
| | - Emmanuel Futier
- Department of Anesthesiology and Critical Care, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand.
| | - Yannael Coisel
- Department of Anesthesiology and Critical Care (SAR B), Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Stefan Matecki
- Institut National de la Santé et de la Recherche Médicale (INSERM), Unit U1046, University of Montpellier, Montpellier, France
| | - Samir Jaber
- Department of Anesthesiology and Critical Care (SAR B), Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unit U1046, University of Montpellier, Montpellier, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand
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Olivieri C, Costa R, Spinazzola G, Ferrone G, Longhini F, Cammarota G, Conti G, Navalesi P. Bench comparative evaluation of a new generation and standard helmet for delivering non-invasive ventilation. Intensive Care Med 2012; 39:734-8. [PMID: 23223773 DOI: 10.1007/s00134-012-2765-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the performance of a new helmet (NH) recently introduced into clinical use relative to that of the standard helmet (SH) in terms of delivering non-invasive continuous positive airway pressure (nCPAP) and pressure support ventilation (nPSV). DESIGN This was a bench study using a mannequin connected to an active lung simulator. The SH was fastened to the mannequin by armpit braces, which are not needed to secure the NH. MEASUREMENTS The inspiratory and expiratory variations in nCPAP delivered with two different simulated efforts (Pmus), were determined relative to the preset CPAP level. nPSV was applied at two simulated respiratory rates (RR) and two cycling-off flow thresholds. We measured inspiratory trigger delay (Delay trinsp), expiratory trigger delay (Delay trexp), time of synchrony (Time sync), trigger pressure drop (ΔP trigger), airway pressure-time product during the triggering phase (PTPt), the initial 200 ms from the onset of the ventilator pressurization (PTP 200), and the initial 300 and 500 ms from the onset of the simulated effort; this two latter parameters were expressed as the percentage of the area of ideal pressurization (PTP 300-index and PTP 500-index, respectively). RESULTS In nCPAP, at both Pmus, the differences between the two interfaces at both Pmus were small and clinically irrelevant. In nPSV, regardless of the setting, NH resulted in significantly smaller trigger delays, ΔP trigger, and PTPt. Time sync, PTP 200, PTP 300-index, and PTP 500-index were also significantly higher with the NH compared to the SH, irrespective of the setting. CONCLUSIONS Compared to the SH, the NH is equally effective in delivering nCPAP and more effective in delivering nPSV, and it is used to avoid the need for armpit braces.
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Affiliation(s)
- C Olivieri
- Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
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