351
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Patient-ventilator Interaction During Non-invasive Ventilation with the Helmet Interface. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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352
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Abstract
Noninvasive ventilation (NIV), the provision of ventilatory assistance without an artificial airway, has emerged as an important ventilatory modality in critical care. This has been fueled by evidence demonstrating improved outcomes in patients with respiratory failure due to COPD exacerbations, acute cardiogenic pulmonary edema, or immunocompromised states, and when NIV is used to facilitate extubation in COPD patients with failed spontaneous breathing trials. Numerous other applications are supported by weaker evidence. A trial of NIV is justified in patients with acute respiratory failure due to asthma exacerbations and postoperative states, extubation failure, hypoxemic respiratory failure, or a do-not-intubate status. Patients must be carefully selected according to available guidelines and clinical judgment, taking into account risk factors for NIV failure. Patients begun on NIV should be monitored closely in an ICU or other suitable setting until adequately stabilized, paying attention not only to vital signs and gas exchange, but also to comfort and tolerance. Patients not having a favorable initial response to NIV should be considered for intubation without delay. NIV is currently used in only a select minority of patients with acute respiratory failure, but with technical advances and new evidence on its proper application, this role is likely to further expand.
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Affiliation(s)
- Erik Garpestad
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts-New England Medical Center, 750 Washington St, Boston, MA 02111, USA
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353
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Sungur M, Layon AJ, Gabrielli A. Treatment of postoperative respiratory insufficiency in the obese patient--who makes the call? Obes Surg 2007; 17:457-9. [PMID: 17608256 DOI: 10.1007/s11695-007-9081-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Murat Sungur
- Division of Critical Care Medicine, Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA
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354
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Abstract
PURPOSE OF REVIEW To discuss the recent literature concerning the use of noninvasive ventilation for hypoxemic acute respiratory failure. RECENT FINDINGS The benefits of noninvasive ventilation for patients with hypoxemic acute respiratory failure are unclear. In immunocompromised patients and following thoracic surgery, there is a strong rationale for using noninvasive ventilation to treat acute respiratory failure. Prophylactic continuous positive airway pressure after abdominal or thoracic surgery and prophylactic noninvasive ventilation in patients at risk of extubation failure have proved beneficial. Recent studies show that noninvasive ventilation has a favourable impact in immunocompetent patients with acute lung injury/acute respiratory distress syndrome, but caution is required. In hypoxemic acute respiratory failure after extubation, one study reported excess mortality in patients treated with noninvasive ventilation, possibly related to the delay for intubation. A major issue is avoiding undue noninvasive ventilation prolongation and staying alert for predictors of early noninvasive ventilation failure. Caution, close monitoring, and broad experience are required. SUMMARY Hypoxemic acute respiratory failure may benefit from noninvasive ventilation or continuous positive airway pressure, but undue prolongation should be avoided. In postextubation respiratory failure there is no evidence for routine use of noninvasive ventilation.
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Affiliation(s)
- François Lellouche
- Centre de Recherche de l'Hôpital Laval, Soins Intensifs de Chirurgie Cardiaque, Hôpital Laval, Quebec City, Canada.
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355
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Vignaux L, Tassaux D, Jolliet P. Performance of noninvasive ventilation modes on ICU ventilators during pressure support: a bench model study. Intensive Care Med 2007; 33:1444-51. [PMID: 17563875 DOI: 10.1007/s00134-007-0713-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 05/02/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Noninvasive ventilation (NIV) is often applied with ICU ventilators. However, leaks at the patient-ventilator interface interfere with several key ventilator functions. Many ICU ventilators feature an NIV-specific mode dedicated to preventing these problems. The present bench model study aimed to evaluate the performance of these modes. DESIGN AND SETTING Bench model study in an intensive care research laboratory of a university hospital. METHODS Eight ICU ventilators, widely available in Europe and featuring an NIV mode, were connected by an NIV mask to a lung model featuring a plastic head to mimic NIV conditions, driven by an ICU ventilator imitating patient effort. Tests were conducted in the absence and presence of leaks, the latter condition with and without activation of the NIV mode. Trigger delay, trigger-associated inspiratory workload, and pressurization were tested in conditions of normal respiratory mechanics, and cycling was also assessed in obstructive and restrictive conditions. RESULTS On most ventilators leaks led to an increase in trigger delay and workload, a decrease in pressurization, and delayed cycling. On most ventilators the NIV mode partly or totally corrected these problems, but with large variations between machines. Furthermore, on some ventilators the NIV mode worsened the leak-induced dysfunction. CONCLUSIONS The results of this bench-model NIV study confirm that leaks interfere with several key functions of ICU ventilators. Overall, NIV modes can correct part or all of this interference, but with wide variations between machines in terms of efficiency. Clinicians should be aware of these differences when applying NIV with an ICU ventilator.
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Affiliation(s)
- Laurence Vignaux
- Intensive Care, University Hospital, 1211 Geneva 14, Switzerland.
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356
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Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27-72. [PMID: 17278083 PMCID: PMC7107997 DOI: 10.1086/511159] [Citation(s) in RCA: 4113] [Impact Index Per Article: 241.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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357
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Battisti A, Tassaux D, Bassin D, Jolliet P. Automatic adjustment of noninvasive pressure support with a bilevel home ventilator in patients with acute respiratory failure: a feasibility study. Intensive Care Med 2007; 33:632-8. [PMID: 17323049 DOI: 10.1007/s00134-007-0550-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 01/19/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To test the feasibility of applying noninvasive ventilation (NIV) using a prototype algorithm implemented in a bilevel ventilation device designed to adjust pressure support (PS) to maintain a clinician-set alveolar ventilation in patients with acute respiratory failure after initial stabilization. DESIGN AND SETTING Prospective crossover interventional study in an intensive care unit, university hospital. PATIENTS 19 patients receiving NIV for acute hypercapnic respiratory failure (13 men, 6 women; mean age 70+/-11 years). METHODS The same bilevel ventilator was used with manually adjusted PS and with the automated algorithm (autoPS), set to maintain the same alveolar ventilation as in PS. Sequence (measurements at end of each period): (a) prior to initiating NIV (baseline 1); (b) 45 min with manually set PS; (c) 60 min without NIV; (d) 45 min with autoPS; (e) 60 min without NIV; (f) 45 min with manually set PS. RESULTS The magnitude of decrease in PaCO(2) and increase in pH with autoPS was comparable to that of conventional PS, with the same alveolar ventilation and level of PS. No technical problem occurred in autoPS mode, and no NIV trial had to be discontinued because of patient discomfort. CONCLUSIONS These results suggest that the alveolar ventilation based automatic control of PS during NIV with a bilevel device is feasible and leads to beneficial effects in patients with acute respiratory failure comparable to those of manually set PS. Further studies should now explore the potential of this system over longer periods in patients with acute and chronic respiratory failure.
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Affiliation(s)
- Anne Battisti
- Department of Intensive Care, University Hospital, 1211, Geneva 14, Switzerland
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358
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Garpestad E, Schumaker G, Hill NS. Noninvasive ventilation for acute respiratory distress syndrome: breaking down the final frontier? Crit Care Med 2007; 35:288-90. [PMID: 17197766 DOI: 10.1097/01.ccm.0000251637.35325.f5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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359
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Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, Rocco M, Maviglia R, Pennisi MA, Gonzalez-Diaz G, Meduri GU. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007; 35:18-25. [PMID: 17133177 DOI: 10.1097/01.ccm.0000251821.44259.f3] [Citation(s) in RCA: 270] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In randomized studies of heterogeneous patients with hypoxemic acute respiratory failure, noninvasive positive pressure ventilation (NPPV) was associated with a significant reduction in endotracheal intubation. The role of NPPV in patients with acute respiratory distress syndrome (ARDS) is still unclear. The objective was to investigate the application of NPPV as a first-line intervention in patients with early ARDS, describing what happens in everyday clinical practice in centers having expertise with NPPV. DESIGN Prospective, multiple-center cohort study. SETTING Three European intensive care units having expertise with NPPV. PATIENTS Between March 2002 and April 2004, 479 patients with ARDS were admitted to the intensive care units. Three hundred and thirty-two ARDS patients were already intubated, so 147 were eligible for the study. INTERVENTIONS Application of NPPV. MEASUREMENTS AND MAIN RESULTS NPPV improved gas exchange and avoided intubation in 79 patients (54%). Avoidance of intubation was associated with less ventilator-associated pneumonia (2% vs. 20%; p < .001) and a lower intensive care unit mortality rate (6% vs. 53%; p < .001). Intubation was more likely in patients who were older (p = .02), had a higher Simplified Acute Physiology Score (SAPS) II (p < .001), or needed a higher level of positive end-expiratory pressure (p = .03) and pressure support ventilation (p = .02). Only SAPS II >34 and a Pao2/Fio2 < or =175 after 1 hr of NPPV were independently associated with NPPV failure and need for endotracheal intubation. CONCLUSIONS In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients. A SAPS II >34 and the inability to improve Pao2/Fio2 after 1 hr of NPPV were predictors of failure.
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Affiliation(s)
- Massimo Antonelli
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy.
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360
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Nagarkar S. The role of noninvasive ventilation in cancer patients with acute respiratory failure. Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.32433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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361
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Abstract
Older adults comprise 48% of the critically ill population in intensive care units and will continue to represent a substantial proportion of patients requiring intensive care for decades to come. Aging both decreases the reserve capacity of vital organs and increases the risk of concurrent illnesses that challenge the respiratory system, such as pneumonia, renal failure, or heart diseases. Because respiratory failure is one of the leading causes of death in intensive care units, implementation of strategies to prevent the need for reintubation should be considered early in the course of respiratory decompensation. For those who require mechanical ventilation, protocols to identify patients who are ready to wean should facilitate liberation from respiratory support and reduce complications of mechanical ventilation. Finally, allocation of potentially limited health care resources necessitates knowing about the risk-benefit of mechanical ventilation and other treatment for respiratory failure in this population.
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Affiliation(s)
- Ali A El Solh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14215, USA.
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362
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Abstract
Bronchial obstruction due to one of the major pulmonary diseases asthma, COPD, or emphysema are a common problem in intensive care medicine as the leading cause or as comorbidity. While in pharmacological therapy no major changes have occurred during the last few years, two major advances have been reached in ventilation therapy which are in the focus of this review. First the non invasive ventilation (NIV) has been shown to prove efficient in treating acute on chronic respiratory failure in COPD patients and is capable of shortening the duration of hospital stay. In addition NIV can be used successfully in weaning after long time ventilator therapy and improve prognosis in COPD patients. Secondly the strategy of invasive ventilation therapy has changed significantly. "Permissive hypercapnia" is unequivocally established in severe bronchial obstruction in situations of limited ventilation. When intrinsic PEEP and elevated airway resistance are present PEEP may be useful and the upper limit of airways peak pressure that we are used to in "protective ventilation" of ARDS patients can be necessary and useful to exceed.
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Affiliation(s)
- T Wagner
- Pneumologie/Allergologie, Klinikum der Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
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363
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Patroniti N, Saini M, Zanella A, Isgrò S, Pesenti A. Danger of helmet continuous positive airway pressure during failure of fresh gas source supply. Intensive Care Med 2006; 33:153-7. [PMID: 17115133 DOI: 10.1007/s00134-006-0446-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 10/09/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the behavior of different helmets after discontinuation of fresh gas flow by disconnection at the helmet inlet, flow generator, or gas source. DESIGN AND SETTING Randomized physiological study in a university research laboratory. PATIENTS Five healthy volunteers. INTERVENTION CPAP (FIO2 50%, PEEP 5 cmH2O) delivered in random sequence with three different helmets: 4Vent (Rüsch), PN500 (Harol), CaStar (StarMed) with antisuffocation valve open or locked. For each helmet all three disconnections were randomly employed up to 4 min. MEASUREMENTS AND RESULTS During flow disconnection we measured: respiratory rate and tidal volume by respitrace; inspiratory and expiratory CO2 concentration, and FIO2 from a nostril; SpO2 by pulse oxymetry. Independently of the site of disconnection we observed a fast increase in CO2 rebreathing and minute ventilation, associated with a decrease in inspired O2 concentration. In the absence of an operational safety valve, larger helmet size and lower resistance of the inlet hose resulted in slower increase in CO2 rebreathing. The presence of the safety valve limited the rebreathing of CO2, and the increase in minute ventilation but did not protect from a decrease in FIO2 and loss of PEEP. CONCLUSIONS While the use of a safety valve proved effective in limiting CO2 rebreathing, it did not protect from the risk of hypoxia related to decrease in FIO2 and loss of PEEP. In addition to a safety antisuffocation valve, a dedicated monitoring and alarming systems are needed to employ helmet CPAP safely.
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Affiliation(s)
- Nicolò Patroniti
- Department of Surgical Sciences and Intensive Care, University of Milan-Bicocca, Ospedale San Gerardo Nuovo dei Tintori, via Donizetti 106, 20052, Monza, Italy.
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364
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Garpestad E, Hill NS. Noninvasive ventilation for acute lung injury: how often should we try, how often should we fail? Crit Care 2006; 10:147. [PMID: 16879722 PMCID: PMC1750989 DOI: 10.1186/cc4960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The selection of patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) to receive noninvasive ventilation (NIV) is challenging, partly because there are few reliable selection criteria. The study by Rana and colleagues in the previous issue of Critical Care identifies metabolic acidosis and a lower oxygenation index as predictors of NIV failure, although it is unable to identify threshold values. It also demonstrates that treating patients with NIV for ALI/ARDS and shock is an exercise in futility. Future studies need to focus on criteria that will enable selection of patients for whom NIV will have a high likelihood of success.
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Affiliation(s)
- Erik Garpestad
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts-New England Medical Center, Washington St, Boston, MA 02111, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts-New England Medical Center, Washington St, Boston, MA 02111, USA
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365
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Demoule A, Girou E, Richard JC, Taille S, Brochard L. Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med 2006; 32:1756-65. [PMID: 17019559 DOI: 10.1007/s00134-006-0324-1] [Citation(s) in RCA: 189] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Accepted: 07/20/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Noninvasive ventilation (NIV) fails more frequently for de novo acute respiratory failure (de novo) than for cardiogenic pulmonary edema (CPE) or acute-on-chronic respiratory failure (AOC). The impact of NIV failure and success was compared between de novo and CPE or AOC after adjustment for disease severity. SETTINGS Patients requiring ventilatory support were enrolled in a prospective survey in 70 French ICUs. Of 1076 patients requiring ventilatory support, 524 were eligible, including 299 de novo (NIV use, 30%) and 225 CPE-AOC (NIV use, 55%). DESIGN AND ANALYSIS Independent risk factors associated with mortality and length of stay were identified by logistic regression analysis. The adjusted outcome of NIV success or failure was compared to that with endotracheal intubation without NIV. RESULTS NIV success was independently associated with survival in both de novo, adjusted OR 0.05 (95% CI 0.01-0.42), and CPE-AOC OR 0.03 (CI 0.01-0.24). NIV failure was associated with ICU mortality in the de novo group (OR 3.24, CI 1.61-6.53) but not in the CPE-AOC group. Nosocomial pneumonia was less common in patients successful with NIV. NIV failure was associated with a longer ICU stay in CPE-AOC only. The overall use of NIV was independently associated with a better outcome only in CPE-AOC patients (OR 0.33, CI 0.15-0.73). CONCLUSION The effect of NIV differs between de novo and CPE-AOC patients because NIV failure is associated with increased mortality for de novo patients. This finding should raise a note of caution when applying NIV in this indication.
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Affiliation(s)
- Alexandre Demoule
- Service de Réanimation Médicale, AP-HP, Hôpital Henri Mondor, 51 av du Mal de Lattre de Tassigny, 94000, Créteil, France
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366
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Ikeda H, Asato R, Chin K, Kojima T, Tanaka S, Omori KI, Hiratsuka Y, Ito J. Negative-pressure pulmonary edema after resection of mediastinum thyroid goiter. Acta Otolaryngol 2006; 126:886-8. [PMID: 16846936 DOI: 10.1080/00016480500527235] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Negative-pressure pulmonary edema (NPPE) is an uncommon but life-threatening complication of acute or chronic upper airway obstruction; however, there are few reports of NPPE after giant goiter resection. We report a case with severe NPPE induced by the resection of a mediastinum thyroid goiter. The patient was successfully treated by non-invasive positive airway ventilation (NPPV).
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Affiliation(s)
- Haruto Ikeda
- Kyoto University Hospital, Kyoto University, Kyoto, Japan
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367
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Chakrabarti B, Calverley PMA. Management of acute ventilatory failure. Postgrad Med J 2006; 82:438-45. [PMID: 16822920 PMCID: PMC2563765 DOI: 10.1136/pgmj.2005.043208] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 12/03/2005] [Indexed: 01/09/2023]
Abstract
Acute ventilatory failure is a challenging yet increasingly common medical emergency reflecting the growing burden of respiratory disease. It is not a diagnosis in itself but the end result of a diversity of disease processes culminating in arterial hypoxaemia and hypercapnia. This review focuses on key management issues including giving appropriate oxygen therapy, treatment of the underlying aetiology as well as any precipitant factors and provision of assisted ventilation if required. Ventilatory assistance can be provided both invasively and non-invasively and the indications for either or both forms of assisted ventilation are discussed. Further emphasis is needed regarding advanced directives of care and clinicians should be aware of ethical issues regarding assisted ventilation.
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Affiliation(s)
- B Chakrabarti
- Aintree Chest Centre, University Hospital Aintree, Liverpool, UK.
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368
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Battisti A, Roeseler J, Tassaux D, Jolliet P. Automatic adjustment of pressure support by a computer-driven knowledge-based system during noninvasive ventilation: a feasibility study. Intensive Care Med 2006; 32:1523-8. [PMID: 16804727 DOI: 10.1007/s00134-006-0267-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2006] [Accepted: 06/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the feasibility of using a knowledge-based system designed to automatically titrate pressure support (PS) to maintain the patient in a "respiratory comfort zone" during noninvasive ventilation (NIV) in patients with acute respiratory failure. DESIGN AND SETTING Prospective crossover interventional study in an intensive care unit of a university hospital. PATIENTS Twenty patients. INTERVENTIONS After initial NIV setting and startup in conventional PS by the chest physiotherapist NIV was continued for 45 min with the automated PS activated. MEASUREMENTS AND RESULTS During automated PS minute-volume was maintained constant while respiratory rate decreased significantly from its pre-NIV value (20+/-3 vs. 25+/-3 bpm). There was a trend towards a progressive lowering of dyspnea. In hypercapnic patients PaCO(2) decreased significantly from 61+/-9 to 51+/-2 mmHg, and pH increased significantly from 7.31+/-0.05 to 7.35+/-0.03. Automated PS was well tolerated. Two system malfunctions occurred prompting physiotherapist intervention. CONCLUSIONS The results of this feasibility study suggest that the system can be used during NIV in patients with acute respiratory failure. Further studies should now determine whether it can improve patient-ventilator interaction and reduce caregiver workload.
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Affiliation(s)
- Anne Battisti
- University Hospital, Intensive Care, 1211 Geneva 14, Switzerland
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369
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Demoule A, Girou E, Richard JC, Taillé S, Brochard L. Increased use of noninvasive ventilation in French intensive care units. Intensive Care Med 2006; 32:1747-55. [PMID: 16799775 DOI: 10.1007/s00134-006-0229-z] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Accepted: 05/11/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A prospective survey of French intensive care units (ICUs) in 1997 showed moderate and variable use of noninvasive ventilation (NIV). This study examined changes in NIV use in French ICUs after the intervening 5years. SETTINGS Patients were enrolled in a prospective survey in 70 French ICUs. METHODS Three-week survey, with prospective inclusion of all patients requiring ventilatory support. MEASUREMENTS AND RESULTS Overall 1,076 patients received ventilatory support (55% of admissions). First-line NIV was significantly more common than 5years earlier, overall (23% vs. 16%) and especially in patients not intubated before ICU admission (52% vs. 35%). Reasons for respiratory failure were coma (33%), cardiogenic pulmonary edema (8%), acute-on-chronic respiratory failure (17%), and de novo respiratory failure (41%). Significant increases in NIV use were noted for acute-on-chronic respiratory failure (64% vs. 50%) and de novo respiratory failure (22% vs. 14%). Among patients given NIV, 38% subsequently required endotracheal intubation (not significantly different). Independent risk factors for NIV failure were high SAPS II and de novo respiratory failure, whereas factors associated with success were good NIV tolerance and high body mass index. CONCLUSIONS NIV use has significantly increased in French ICUs during the past 5years, and the success rate has remained unchanged. In patients not previously intubated, NIV is the leading first-line ventilation modality. The proportion of patients successfully treated with NIV increased significantly over the 5-year period (13% vs. 9% of all patients receiving ventilatory support).
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Affiliation(s)
- Alexandre Demoule
- Service de Réanimation Médicale, AP-HP, Hôpital Henri Mondor, 51 av du Mal de Lattre de Tassigny, 94000, Créteil, France
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370
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Rana S, Jenad H, Gay PC, Buck CF, Hubmayr RD, Gajic O. Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R79. [PMID: 16696863 PMCID: PMC1550938 DOI: 10.1186/cc4923] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 02/15/2006] [Accepted: 04/19/2006] [Indexed: 11/30/2022]
Abstract
Introduction The role of non-invasive positive pressure ventilation (NIPPV) in the treatment of acute lung injury (ALI) is controversial. We sought to assess the outcome of ALI that was initially treated with NIPPV and to identify specific risk factors for NIPPV failure. Methods In this observational cohort study at the two intensive care units of a tertiary center, we identified consecutive patients with ALI who were initially treated with NIPPV. Data on demographics, APACHE III scores, degree of hypoxemia, ALI risk factors and NIPPV respiratory parameters were recorded. Univariate and multivariate regression analyses were performed to identify risk factors for NIPPV failure. Results Of 79 consecutive patients who met the inclusion criteria, 23 were excluded because of a do not resuscitate order and two did not give research authorization. Of the remaining 54 patients, 38 (70.3%) failed NIPPV, among them all 19 patients with shock. In a stepwise logistic regression restricted to patients without shock, metabolic acidosis (odds ratio 1.27, 95% confidence interval (CI) 1.03 to 0.07 per unit of base deficit) and severe hypoxemia (odds ratio 1.03, 95%CI 1.01 to 1.05 per unit decrease in ratio of arterial partial pressure of O2 and inspired O2 concentration – PaO2/FiO2) predicted NIPPV failure. In patients who failed NIPPV, the observed mortality was higher than APACHE predicted mortality (68% versus 39%, p < 0.01). Conclusion NIPPV should be tried very cautiously or not at all in patients with ALI who have shock, metabolic acidosis or profound hypoxemia.
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Affiliation(s)
- Sameer Rana
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota USA
| | - Hussam Jenad
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota USA
| | - Peter C Gay
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota USA
| | - Curtis F Buck
- Department of Anesthesiology, Division of Intensive Care and Respiratory Care, Mayo Clinic, Rochester, Minnesota USA
| | - Rolf D Hubmayr
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota USA
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota USA
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371
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Agarwal R, Reddy C, Aggarwal AN, Gupta D. Is there a role for noninvasive ventilation in acute respiratory distress syndrome? A meta-analysis. Respir Med 2006; 100:2235-8. [PMID: 16678394 DOI: 10.1016/j.rmed.2006.03.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2005] [Accepted: 03/18/2006] [Indexed: 11/24/2022]
Abstract
The role of noninvasive ventilation (NIV) in the management of acute respiratory distress syndrome (ARDS) is controversial. The aim of this study was to assess the effect of NIV on the rate of endotracheal intubation and intensive care unit (ICU) mortality in patients with ARDS. We searched the MEDLINE database for relevant studies published from 1980 to September 2005, and included studies if (a) the design was a randomized controlled trial; (b) patients had ARDS irrespective of the underlying etiology; (c) the interventions compared NIV and medical therapy with medical therapy alone; and (d) outcomes included need for endotracheal intubation and/or ICU survival. The addition of NIV to standard care in the setting of ARDS did not reduce the rate of endotracheal intubation (absolute risk reduction (RR) 13.5%, 95% confidence interval (CI) -5.2% to 31.3%), and had no effect on ICU survival (absolute RR 4.8%, 95% CI -12.8% to 22.1%). However, the trial results were significantly heterogeneous. Thus, current evidence suggests that patients with ARDS are unlikely to have any significant benefits on outcome when NIV is added to standard therapy. However, this analysis is limited by the presence of significant heterogeneity; hence large randomized controlled trials are required to settle this issue.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India.
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372
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Rabitsch W, Staudinger T, Locker GJ, Köstler WJ, Laczika K, Frass M, Knoebl P, Greinix HT, Kalhs P, Keil F. Respiratory failure after stem cell transplantation: improved outcome with non-invasive ventilation. Leuk Lymphoma 2006; 46:1151-7. [PMID: 16085555 DOI: 10.1080/10428190500097649] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
We retrospectively analyzed the efficacy of non-invasive ventilation in 35 patients with acute hypoxemic respiratory failure after autologous or allogeneic stem cell transplantation (SCT). Non-invasive ventilation was delivered by a standard face mask or helmet. Decisions to intubate were made according to standard criteria. Between 1993 and 2003, 836 patients underwent an autologous or allogeneic bone marrow or SCT. Eighty-two patients developed respiratory failure. Of these, 47 patients were initially intubated and mechanically ventilated. None of these patients survived. Thirty-five patients initially underwent non-invasive ventilation at the bone marrow transplant unit. Seven of these patients survived and were discharged from the hospital (20%). Eleven of the 35 (31%) patients improved within the first 4 h of non-invasive ventilation with respect to oxygenation and were regarded as responders. Seven of these patients survived to hospital discharge (64%), while all non-responders died (P<0.001). In all survivors, the partial pressure of arterial oxygen (PaO2) improved after the initiation of non-invasive ventilation. In non-survivors, PaO2 improved in only 4 of 28 patients (17%) (P<0.0001). Non-invasive ventilation in patients with acute respiratory failure after SCT could improve prognosis in a carefully selected group of patients.
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Affiliation(s)
- Werner Rabitsch
- Bone Marrow Transplantation Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.
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373
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Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, Cohen Y, Eledjam JJ, Adnet F, Jaber S. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 2006; 174:171-7. [PMID: 16627862 DOI: 10.1164/rccm.200509-1507oc] [Citation(s) in RCA: 251] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Critically ill patients are predisposed to oxyhemoglobin desaturation during intubation. OBJECTIVES To find out whether noninvasive ventilation (NIV), as a preoxygenation method, is more effective at reducing arterial oxyhemoglobin desaturation than usual preoxygenation during orotracheal intubation in hypoxemic, critically ill patients. METHODS Prospective randomized study performed in two surgical/medical intensive care units (ICUs). Preoxygenation was performed, before a rapid sequence intubation, for a 3-min period using a nonrebreather bag-valve mask (control group) or pressure support ventilation delivered by an ICU ventilator through a face mask (NIV group) according to the randomization. MEASUREMENTS AND MAIN RESULTS The control (n = 26) and NIV (n = 27) groups were similar in terms of age, disease severity, diagnosis at admission, and pulse oxymetry values (Sp(O(2))) before preoxygenation. At the end of preoxygenation, Sp(O(2)) was higher in the NIV group as compared with the control group (98 +/- 2 vs. 93 +/- 6%, p < 0.001). During the intubation procedure, the lower Sp(O(2)) values were observed in the control group (81 +/- 15 vs. 93 +/- 8%, p < 0.001). Twelve (46%) patients in the control group and two (7%) in the NIV group had an Sp(O(2)) below 80% (p < 0.01). Five minutes after intubation, Sp(O(2)) values were still better in the NIV group as compared with the control group (98 +/- 2 vs. 94 +/- 6%, p < 0.01). Regurgitations (n = 3; 6%) and new infiltrates on post-procedure chest X ray (n = 4; 8%) were observed with no significant difference between groups. CONCLUSION For the intubation of hypoxemic patients, preoxygenation using NIV is more effective at reducing arterial oxyhemoglobin desaturation than the usual method.
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Affiliation(s)
- Christophe Baillard
- Intensive Care Unit, Department of Anesthesiology, DAR B CHU de Montpellier, Hôpital Saint Eloi, 80 avenue Augustin Fliche, 34295 Montpellier Cedex 5, France
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374
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Gruber PC, Gomersall CD, Joynt GM. Avian influenza (H5N1): implications for intensive care. Intensive Care Med 2006; 32:823-9. [PMID: 16568274 PMCID: PMC7095211 DOI: 10.1007/s00134-006-0148-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 03/08/2006] [Indexed: 11/25/2022]
Abstract
Background As influenza A/H5N1 spreads around the globe the risk of an epidemic
increases. Discussion Review of the cases of influenza A/H5N1 reported to date demonstrates that
it causes a severe illness, with a high proportion of patients (63%)
requiring advanced organ support. Of these approx. 68% develop multiorgan
failure, at least 54% develop acute respiratory distress syndrome, and
90% die. Disease progression is rapid, with a median time from
presentation to hospital to requirement for advanced organ support of only
2 days. Conclusion The infectious nature, severity and clinical manifestations of the disease
and its potential for pandemic spread have considerable implications for
intensive care in terms of infection control, patient management, staff
morale and intensive care expansion.
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Affiliation(s)
- Pascale C. Gruber
- Department of Anaesthesia and intensive care, Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Charles D. Gomersall
- Department of Anaesthesia and intensive care, Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Gavin M. Joynt
- Department of Anaesthesia and intensive care, Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, Hong Kong
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375
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Jaber S, Chanques G, Sebbane M, Salhi F, Delay JM, Perrigault PF, Eledjam JJ. Noninvasive Positive Pressure Ventilation in Patients with Respiratory Failure due to Severe Acute Pancreatitis. Respiration 2006; 73:166-72. [PMID: 16432295 DOI: 10.1159/000088897] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 06/06/2005] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients with acute pancreatitis (AP) who require mechanical ventilation have high morbidity and mortality rates. Noninvasive positive pressure ventilation (NPPV) delivered through a mask has become increasingly popular for the treatment of acute respiratory failure (ARF) and may limit some mechanical ventilation complications. OBJECTIVES The purpose of this retrospective, observational study was to evaluate our clinical experience with the use of NPPV in AP patients with ARF. METHODS From 1997 to 2003, we documented clinical data, gas exchange and outcome of the 62 AP patients admitted to our intensive care unit. Patients who benefited from NPPV (success) were compared with those who failed (intubated). RESULTS Twenty-nine patients were intubated at admission and 5 did not develop ARF. Of the 28 patients treated with NPPV, 15 were not intubated (54%). Both groups had a similar PaO(2)/FiO(2) ratio (142 +/- 21 vs. 133 +/- 20; p = 0.127) and severity of illness (Ranson and Balthazar scores). Presence of atelectasis, bilateral alveolar infiltrates and abdominal distension were associated with failure of NPPV. Oxygenation improved and respiratory rate decreased significantly only in the success group. Additionally, the length of stay at the intensive care unit was significantly lower in the success group. CONCLUSION NPPV is feasible and safe to treat ARF in selected patients with AP who require ventilatory support.
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Affiliation(s)
- Samir Jaber
- Critical Care and Anesthesiology Department, DAR B, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France.
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376
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Antro C, Merico F, Urbino R, Gai V. Non-invasive ventilation as a first-line treatment for acute respiratory failure: "real life" experience in the emergency department. Emerg Med J 2006; 22:772-7. [PMID: 16244332 PMCID: PMC1726611 DOI: 10.1136/emj.2004.018309] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe our experience with non-invasive ventilation (NIV) for patients with acute respiratory failure (ARF) in the emergency department (ED). METHODS A prospective/retrospective, observational study on 190 patients with ARF (mean +/-SD age 72.2+/-12.9 years, mean APACHE II score 18.9+/-5.9), who received 200 NIV trials in an ED. We analysed the NIV register data (prospectively collected) and medical records (retrospective data abstraction) and evaluated clinical indications for NIV, patient outcomes, and predictive factors for success and death. NIV success was defined as tolerance of the procedure and no need for endotracheal intubation (ETI). RESULTS Main indications to NIV were cardiogenic pulmonary oedema (CPE) (70 trials), acute exacerbation of COPD (39), both CPE and acute exacerbation of COPD (11), pneumonia (48), decompensation of obesity/hypoventilation (6), other conditions (26). The procedure was successful in 60.5% of trials. Global mortality was 34.5%, similar to the APACHE II predicted mortality of 32%. ETI rates were 6.5% and tracheostomy rates 1%. The improvement of pH within six hours after NIV initiation was predictive of survival in the hypercapnic group. CONCLUSIONS Our results confirm the global efficacy of NIV in an ED setting, and show that, in spite of lower success rate in "real practice" in comparison with RCTs, an intermediate care unit can represent an appropriate and less expensive setting to perform this technique. The low rate of ETI seems to be because of the high number of patients for whom NIV was used as "ceiling" treatment.
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Affiliation(s)
- C Antro
- Dipartimento di Emergenza e Accettazione, Ospedale San Giovanni Battista, Turin, Italy.
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377
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378
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379
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Suri JC, Ramakrishnan N, Mani RK, Khilnani GC, Sidhu US, Nagarkar S. Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med 2006. [DOI: 10.4103/0972-5229.25926] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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380
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Jaber S, Delay JM, Chanques G, Sebbane M, Jacquet E, Souche B, Perrigault PF, Eledjam JJ. Outcomes of Patients With Acute Respiratory Failure After Abdominal Surgery Treated With Noninvasive Positive Pressure Ventilation. Chest 2005; 128:2688-95. [PMID: 16236943 DOI: 10.1378/chest.128.4.2688] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Little is known about the physiologic and clinical effects of noninvasive positive pressure ventilation (NPPV) in patients who have acute respiratory failure (ARF) after abdominal surgery. We evaluated our clinical experience with the use of NPPV in the treatment of ARF after abdominal surgery. METHODS We prospectively evaluated NPPV use during a 2-year period in a medical-surgical ICU of a university hospital. We documented demographic and diagnostic data, gas exchange, and clinical outcomes. We compared patients who were not intubated to those who were intubated after a trial of NPPV. RESULTS Of 72 patients with ARF after abdominal surgery who were treated with NPPV, 48 patients avoided intubation (67%). Patients in the intubated and nonintubated groups had similar demographic characteristics, and similar American Society of Anesthesiologists physical status and simplified acute physiology score II scores at admission. The intubated group had a significantly lower Pa(O2)/fraction of inspired oxygen (Fi(O2)) ratio (123 +/- 62 mm Hg vs 194 +/- 76 mm Hg, p < 0.01) and more extended bilateral alveolar infiltrates (67% vs 31%, p < 0.01) than the non-intubated group. Within the first NPPV observation period, the Pa(O2)/Fi(O2) increased (+ 36 +/- 29% [+/- SD], p = 0.04) and the respiratory rate decreased (28.2 +/- 3.4 breaths/min vs 23.1 +/- 3.8 breaths/min, p < 0.01) significantly only in the non-intubated group. The non-intubated group had significantly lower length of ICU stay (17.3 +/- 10.9 days vs 34.1 +/- 28.5 days, p < 0.01) and mortality rate (6% vs 29%, p < 0.01). CONCLUSION NPPV may be an alternative to conventional ventilation in selected patients with ARF after abdominal surgery who require ventilatory support.
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Affiliation(s)
- Samir Jaber
- Department of Anesthesiology, Intensive Care and Transplantation Unit, Saint Eloi Hospital, University Hospital of Montpellier, France.
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381
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Meduri GU, Umberger R, Confalonieri M. Hydrocortisone Infusion for Severe Community-acquired Pneumonia. Am J Respir Crit Care Med 2005. [DOI: 10.1164/ajrccm.172.6.952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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382
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Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. Crit Care Med 2005; 33:1976-82. [PMID: 16148468 DOI: 10.1097/01.ccm.0000178176.51024.82] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the outcome from the use of noninvasive positive pressure ventilation (NPPV) in "do-not-intubate" (DNI) patients in acute respiratory failure. DESIGN Prospective observational study. SETTING University-affiliated large medical center. PATIENTS All patients with DNI status who received NPPV for a 1-yr period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic, physiologic, and laboratory data were collected before initiation, 2 hrs after initiation, and each morning and evening for as long as NPPV was provided. Data were recorded on 137 episodes of acute respiratory failure in 131 DNI patients. Hospital mortality rate was 37.5% in 24 patients with an exacerbation of chronic obstructive pulmonary disease (COPD), 39% in 28 patients with acute cardiogenic pulmonary edema, 68% in nine patients with non-COPD hypercapnic ventilatory failure, 77% in 13 post-extubation respiratory failure patients, and 86% in 57 patients with hypoxemic respiratory failure. Advanced cancer was present in 40 patients and was associated with increased risk of death (85% mortality rate, p = .002). A score based on the Simplified Acute Physiology Score (SAPS) II and serum albumin level calculated before NPPV was predictive of hospital outcome. CONCLUSIONS NPPV is successful in reversing acute respiratory failure and preventing hospital mortality in DNI patients with COPD and cardiogenic pulmonary edema but not in patients with post-extubation failure, hypoxemic respiratory failure, or end-stage cancer. An easy-to-calculate score combining SAPS II and serum albumin level is a good prediction of outcome in DNI patients receiving NPPV.
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383
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L'Her E, Deye N, Lellouche F, Taille S, Demoule A, Fraticelli A, Mancebo J, Brochard L. Physiologic effects of noninvasive ventilation during acute lung injury. Am J Respir Crit Care Med 2005; 172:1112-8. [PMID: 16081548 DOI: 10.1164/rccm.200402-226oc] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A prospective, crossover, physiologic study was performed in 10 patients with acute lung injury to assess the respective short-term effects of noninvasive pressure-support ventilation and continuous positive airway pressure. We measured breathing pattern, neuromuscular drive, inspiratory muscle effort, arterial blood gases, and dyspnea while breathing with minimal support and the equipment for measurements, with two combinations of pressure-support ventilation above positive end-expiratory pressure (10-10 and 15-5 cm H2O), and with continuous positive airway pressure (10 cm H2O). Tidal volume was increased with pressure support, and not with continuous positive airway pressure. Neuromuscular drive and inspiratory muscle effort were lower with the two pressure-support ventilation levels than with other situations (p < 0.05). Dyspnea relief was significantly better with high-level pressure-support ventilation (15-5 cm H2O; p < 0.001). Oxygenation improved when 10 cm H2O positive end-expiratory pressure was applied, alone or in combination. We conclude that, in patients with acute lung injury (1) noninvasive pressure-support ventilation combined with positive end-expiratory pressure is needed to reduce inspiratory muscle effort; (2) continuous positive airway pressure, in this setting, improves oxygenation but fails to unload the respiratory muscles; and (3) pressure-support levels of 10 and 15 cm H2O provide similar unloading but differ in their effects on dyspnea.
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Affiliation(s)
- Erwan L'Her
- Réanimation Médicale, CHU de la Cavale Blanche, 29609 Brest Cedex, France.
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384
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Xirouchaki N, Kondoudaki E, Anastasaki M, Alexopoulou C, Koumiotaki S, Georgopoulos D. Noninvasive bilevel positive pressure ventilation in patients with blunt thoracic trauma. Respiration 2005; 72:517-22. [PMID: 16210892 DOI: 10.1159/000086501] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 12/14/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Noninvasive bilevel positive pressure ventilation (N-BiPAP) has an established role in providing respiratory support in patients with acute respiratory failure. The significant advantage of N-BiPAP is to avoid endotracheal intubation and its complications. Currently there are no data that support N-BiPAP as first-line treatment in patients with blunt thoracic trauma. OBJECTIVE To evaluate the safety and efficacy of N-BiPAP in patients with acute respiratory failure due to blunt thoracic trauma. METHODS Prospective observational study. Twenty-two patients with blunt chest trauma (mean injury severity score 26 +/- 9) were studied. N-BiPAP was applied via a tight-fitting full or total-face mask, combined with regional anesthesia in all patients. RESULTS N-BiPAP resulted in significant changes in blood gasses, heart rate and breathing frequency at 1 h. Eighteen out of 22 patients avoided intubation and were discharged from the ICU (success group). Four patients met predefined criteria and required intubation (failure group) within 24 h after N-BiPAP. Three of the patients in the failure group survived while 1 developed septic shock and died. The acute response of oxygenation to N-BiPAP differed significantly between groups, being higher in the success group. Complications related to N-BiPAP were minor, consisting of nose bridge injury (1 patient) and gastric distention (1 patient). CONCLUSIONS N-BiPAP administration could be a safe and effective method to improve the gas exchange in patients with acute respiratory failure due to blunt thoracic trauma.
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Affiliation(s)
- N Xirouchaki
- Intensive Care Medicine Department, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
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385
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Phua J, Kong K, Lee KH, Shen L, Lim TK. Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure. Intensive Care Med 2005; 31:533-9. [PMID: 15742175 DOI: 10.1007/s00134-005-2582-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2004] [Accepted: 02/03/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study compared the effectiveness of noninvasive ventilation (NIV) and the risk factors for NIV failure in hypercapnic acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) vs. non-COPD conditions. DESIGN AND SETTING Prospective cohort study in the medical intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS 111 patients with hypercapnic ARF, 43 of whom had COPD exacerbations and 68 other conditions. Baseline characteristics of the two groups were similar. MEASUREMENTS AND RESULTS The risk of NIV failure, defined as the need for endotracheal intubation, was significantly lower in COPD than in other conditions (19% vs. 47%). High APACHE II score was an independent predictor of NIV failure in COPD (OR 5.38 per 5 points). The presence of pneumonia (OR 5.63), high APACHE II score (OR 2.59 per 5 points), rapid heart rate (OR 1.22 per 5 beats/min), and high PaCO(2) 1 h after NIV (OR 1.22 per 5 mmHg) were independent predictors of NIV failure in the non-COPD group. Failure of NIV independently predicted mortality (OR 10.53). CONCLUSIONS Noninvasive ventilation was more effective in preventing endotracheal intubation in hypercapnic ARF due to COPD than non-COPD conditions. High APACHE II score predicted NIV failure in both groups. Noninvasive ventilation was least effective in patients with hypercapnic ARF due to pneumonia.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore.
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386
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Díaz GG, Alcaraz AC, Talavera JCP, Pérez PJ, Rodriguez AE, Cordoba FG, Hill NS. Noninvasive Positive-Pressure Ventilation To Treat Hypercapnic Coma Secondary to Respiratory Failure. Chest 2005; 127:952-60. [PMID: 15764781 DOI: 10.1378/chest.127.3.952] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Hypercapnic coma secondary to acute respiratory failure (ARF) is considered to be a contraindication to the use of treatment with noninvasive positive-pressure ventilation (NPPV). However, intubation exposes these patients to the risk of complications such as nosocomial pneumonia, sepsis, and even death. PATIENTS AND METHODS We performed a prospective, open, noncontrolled study to assess the outcomes of NPPV therapy in patients with a Glasgow coma scale (GCS) score of </= 8 points due to ARF. The primary goal of the study was to determine the success of NPPV therapy (defined as a response to therapy allowing the patient to avoid endotracheal intubation, and to survive a stay in the ICU and at least 24 h on a medical ward) in patients with hypercapnic coma, compared to those who started NPPV therapy while awake. The secondary goal of the study was to identify the variables that can predict a failure of NPPV therapy in these patients. RESULTS A total of 76 coma patients (80%) responded to NPPV therapy, and 605 patients with GCS scores > 8 responded to therapy (70%; p = 0.04). A total of 25 coma patients died in the hospital (26.3%), and 287 noncoma patients died in the hospital (33.2%; p = 0.17). The variables related to the success of NPPV therapy were GCS score 1 h posttherapy (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.53 to 3.53) and higher levels of multiorgan dysfunction, as measured by the maximum sequential organ failure assessment index score reached during NPPV therapy (OR, 0.72; 95% CI, 0.55 to 0.92). CONCLUSIONS We concluded that selected patients with hypercapnic coma secondary to ARF can be treated as successfully with NPPV as awake patients with ARF.
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Affiliation(s)
- Gumersindo Gónzalez Díaz
- Intensive Care Unit, Hospital Morales Meseguer, C/Marqués de los Velez s/n, 30008 Murcia, Spain.
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387
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Rodríguez Mulero L, Carrillo Alcaraz A, Melgarejo Moreno A, Renedo Villarroya A, Párraga Ramírez M, Jara Pérez P, Millán MJ, González Díaz G. Factores de predicción del éxito de la ventilación no invasiva en el tratamiento del edema agudo de pulmón cardiogénico. Med Clin (Barc) 2005; 124:126-31. [PMID: 15713241 DOI: 10.1157/13071006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Recent studies support the use of non invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). We aimed to evaluate the factors related to the success of the technique in patients admitted to an intensive care unit (ICU) with ACPE. PATIENTS AND METHOD An observational prospective study was performed in ICU.199 consecutive patients were enrolled with ACPE at admission who received treatment with NIV and standardized pharmacological treatment. The success of the NIV was achieved when endotracheal intubation was avoided and patients were alive without dyspnea within and 24 hours after discharge from the ICU. Clinical, physiological and gasometric parameters were analyzed at admission and one hour after starting NIV. RESULTS Patient's age was 74 years. 43% were male. The SAPS II was 45. 74.4% of the patients were successfully treated with NIV. 12.6% required endotracheal intubation. In a multivariate analysis, the success of the technique (values expressed as odds ratio [95% confidence interval]) was related to: SAPS II (0.95 [0.91-0.99]); the place of admission (6.78 [1.85-24.79]); value of PCO2 at admission (1.05 [1.01-1.09]); PO2/FiO2 index (1.03 [1.01-1.06]) and respiratory frequency (0.91 [0.84-0.99]) within the first hour; SOFA (acute failure organics score) (0.62 [0.49-0.78]); concomittant acute myocardial infarction (AMI) (0.05 [0.01-0.22]) and number of complications (0.17 [0.47-0.65]). The hospital mortality rate was 32.7%. The non intubation order (0.12 [0.04-0.32]) and the success of the technique (100.03 [28.71-348.47]) were related to the hospital mortality. CONCLUSIONS The success of NIV in the treatment of ACPE is related to a lower SAPS II, admission at the emergency department, elevated PCO2 at admission, improvement of the PO2/FiO2 index and the respiratory rate within the first hour. The non intubation order and the success of the technique were related to the hospital mortality.
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388
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Nava S, Cuomo AM. Acute respiratory failure in the cancer patient: the role of non-invasive mechanical ventilation. Crit Rev Oncol Hematol 2005; 51:91-103. [PMID: 15276174 DOI: 10.1016/j.critrevonc.2004.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2004] [Indexed: 10/26/2022] Open
Abstract
The most common cause of ICU admission in patients affected by a hematologic or solid cancer is acute respiratory failure, often associated with a respiratory infection. The prognosis of these critically ill patients is disappointingly low especially if they require endotracheal intubation. In the last 10 years, non-invasive mechanical ventilation (NIV), delivered through a face or nose mask, has been increasingly used as an alternative to invasive ventilation. There is good evidence that, compared to the standard medical therapy alone or with invasive mechanical ventilation, NIV may improve survival and reduce the rate of infectious complications in patients affected by hematologic cancers. Patients with a solid tumor and "reversible" acute respiratory failure are also likely to benefit from NIV, while the use of NIV in palliative care of terminally ill patients still needs to be elucidated. The success of NIV is strictly dependent on its "early" use and on the experience of the staff involved.
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Affiliation(s)
- Stefano Nava
- Respiratory Unit, Istituto Scientifico di Pavia, Fondazione S. Maugeri, I.R.C.C.S., Via Ferrata 8, 27100 Pavia, Italy.
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389
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Abstract
PURPOSE OF REVIEW To provide some practical and clinical considerations that may guide users through the decision process when choosing mechanical ventilators RECENT FINDINGS Although the complexity of mechanical ventilators is steadily increasing, the importance of many devices developed over the course of the technical evolution is still a matter of discussion. Recent data demonstrate that the technical performance of equivalent ventilators (ie, machines of the same generation and category) is pretty similar, suggesting that the different manufacturers keep in step with new developments. Thus, other factors than technical limitations will probably influence the choice of ventilators. Among them the ability of the staff to understand the rationale of the different devices and controls as well as deal with the complexity of the ventilator may be particularly important. SUMMARY Choosing mechanical ventilators should begin by defining the algorithms of how to ventilate a patient. Once this is done, a ventilator should allow the transformation of specific strategies into practice and the adaptation of the mechanical support to the needs of the individual patient. This procedure is crucially important, because ventilator therapy should always be determined by the physician and based on solid physiologic rationales rather than by the technical features of the machine.
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Affiliation(s)
- Zsolt Iványi
- Semmelweis Egyetem, Aneszteziológiai és Intenzív Terápiás Klinika, Budapest, Hungary
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390
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Affiliation(s)
- Younsuck Koh
- Department of Anesthesia, University of Cincinnati Medical Center, OH 45267-0531, USA
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391
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Rocco M, Dell'Utri D, Morelli A, Spadetta G, Conti G, Antonelli M, Pietropaoli P. Noninvasive Ventilation by Helmet or Face Mask in Immunocompromised Patients. Chest 2004; 126:1508-15. [PMID: 15539720 DOI: 10.1378/chest.126.5.1508] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To compare the efficacy of noninvasive positive pressure ventilation (NPPV) by helmet and face mask in immunocompromised patients with hypoxemic acute respiratory failure (ARF). DESIGN Case-control study. SETTING The general ICU of a university hospital. PATIENTS Nineteen immunocompromised patients (hematologic malignancies [n = 8], solid-organ recipients [n = 8], AIDS [n = 3]) with hypoxemic ARF, fever, and lung infiltrates were treated with NPPV delivered by a helmet. Nineteen immunocompromised patients matched for diagnosis, age, simplified acute physiology score II, and Pao(2)/fraction of inspired oxygen (Fio(2)) receiving NPPV through a facial mask served as case-control subjects. RESULTS The use of NPPV delivered via helmet was as effective as NPPV delivered via face mask in avoiding endotracheal intubations (intubation rate, 37% vs 47%, respectively; p = 0.37) and improving gas exchange; 14 patients (74%) in the helmet group showed a sustained improvement in Pao(2)/Fio(2) ratio (ability to increase Pao(2)/Fio(2) ratio > 200, or an increase > 100 from the baseline) in comparison with 7 patients (34%) in the mask group (p = 0.02), whose Pao(2)/Fio(2) at treatment discontinuation was higher (p = 0.02) and had fewer complications related to NPPV (ie, skin necrosis, p = 0.01). Moreover, the patients receiving ventilation via helmet required significantly less NPPV discontinuations in the first 24 h of application (p < 0.001) than patients receiving ventilation via face mask. CONCLUSIONS The helmet may represent a valid alternative to a face mask in immunocompromised patients with lung infiltrates and hypoxemic ARF, increasing the patient's tolerance (ie, the number of hours of continuous NPPV use without interruptions) and decreasing the rate of complications directly related to the administration of NPPV.
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Affiliation(s)
- Monica Rocco
- Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
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392
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Cuomo A, Delmastro M, Ceriana P, Nava S, Conti G, Antonelli M, Iacobone E. Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer. Palliat Med 2004; 18:602-10. [PMID: 15540668 DOI: 10.1191/0269216304pm933oa] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Noninvasive ventilation (NIV) is widely used in the treatment of acute respiratory failure (ARF), but not in patients with end-stage solid cancer in whom any form of mechanical ventilation tends to be avoided. In a prospective study, we investigated the use of NIV in 23 patients with solid malignancies receiving palliative care and who were affected by severe hypoxic or hypercapnic ARF. The most frequent causes of ARF were exacerbations of pre-existing pulmonary diseases and pneumonia. After one hour, NIV significantly improved PaO2/FiO2 (from 154+/-48 to 187+/-55) and the Borg dyspnoea score (from 5.5+/-1.2 to 2.3+/-0.3). NIV also improved pH, but only in the subset of hypercapnic patients. Thirteen of 23 (57%) patients were successfully ventilated and discharged alive, while 10/23 patients (43%) met the criteria for intubation or died after an initial trial of NIV. Only two of these patients accepted invasive ventilation. The mortality rate in this subgroup was 9/10 (90%). A higher Simplified Acute Physiology Score (SAPS II) and a lower PaO2/FiO2 on admission were associated with a lower probability of survival. Patients with ARF and end-stage solid malignancies have an overall ICU and 1-year mortality rate of 39% and 87%, respectively, but despite this, a consistent subset of patients may still be successfully treated with NIV, if the cause of ARF is reversible.
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Affiliation(s)
- Annamaria Cuomo
- Fondazione S Maugeri, IRCCS, Istituto Scientifico di Pavia, Pavia, Italy
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393
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Antonelli M, Pennisi MA, Montini L. Clinical review: Noninvasive ventilation in the clinical setting--experience from the past 10 years. Crit Care 2004; 9:98-103. [PMID: 15693991 PMCID: PMC1065090 DOI: 10.1186/cc2933] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This brief review analyses the progress of noninvasive ventilation (NIV) over the last decade. NIV has gained the dignity of first line intervention for acute exacerbation of chronic obstructive pulmonary disease, assuring reduction of the intubation rate, rate of infection and mortality. Despite positive results, NIV still remains controversial as a treatment for acute hypoxemic respiratory failure, largely due to the different pathophysiology of hypoxemia. The infection rate reduction effect achieved by NIV application is crucial for immunocompromised patients for whom the endotracheal intubation represents a high risk. Improvements in skills acquired with experience over time progressively allowed successful treatment of more severe patients.
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Affiliation(s)
- Massimo Antonelli
- Unità Operativa di Rianimazione e Terapia Intensiva, Istituto di Anestesia e Rianimazione, Policlinico Universitario A Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy.
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394
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Paus-Jenssen ES, Reid JK, Cockcroft DW, Laframboise K, Ward HA. The use of noninvasive ventilation in acute respiratory failure at a tertiary care center. Chest 2004; 126:165-72. [PMID: 15249458 DOI: 10.1378/chest.126.1.165] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Financial constraints and bed limitations frequently prevent admission of ill patients to a critical care setting. We surveyed the use of treatment with noninvasive ventilation (NIV) in clinical practice by physicians in a tertiary care, university-based teaching hospital and compared our findings with published recommendations for the use of NIV. METHODS Data were collected prospectively on all patients with acute respiratory failure (ARF) for whom NIV was ordered over a 5-month period. The respiratory therapy department was responsible for administering NIV on written order by a physician. The respiratory therapist completed a survey form with patient tracking data for each initiation of NIV. The investigators then surveyed the clinical chart for clinical data. RESULTS NIV was utilized for the treatment of ARF on 75 occasions during the 5-month period. Fourteen patients (18%) received NIV for a COPD exacerbation, and 61 patients (82%) received it for respiratory failure of other etiologies. NIV was initiated in the emergency department in 32% of patients, in a critical care setting in 27% of patients, in a ward observation unit in 23% of patients, and on a general medical or surgical ward in 18% of patients. Arterial blood gases (ABGs) were measured on 68 occasions prior to the initiation of NIV, and 51 patients had an ABG measurement within the first 6 h of treatment. The mean pH at baseline was 7.29, and 33% of patients had a baseline pH of < 7.25. Seven patients required endotracheal intubation (ETI) [13%], and there were 18 deaths (24%) with patients having do-not-resuscitate orders, accounting for 12 deaths. CONCLUSION NIV is commonly used outside of a critical care setting. Our outcomes of ETI and death were similar to those cited in the literature despite less aggressive monitoring of these patients.
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395
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Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168:1438-44. [PMID: 14500259 DOI: 10.1164/rccm.200301-072oc] [Citation(s) in RCA: 333] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficacy of noninvasive ventilation (NIV) to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O2 tension or saturation persistently 60 mm Hg or less or 90% or less, respectively; breathing conventional Venturi oxygen at a maximal concentration [50%]), excluding hypercapnia, admitted into intensive care units of three hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive NIV (n=51) or high-concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, NIV decreased the need for intubation (13, 25% vs. 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs. 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs. 21, 39%, p=0.028) and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the noninvasive ventilation group with time (p=0.029 each). Multivariate analyses showed NIV to be independently associated with decreased risks of intubation (odds ratio, 0.20; p=0.003) and 90-day mortality (odds ratio, 0.39; p=0.017). The use of noninvasive ventilation prevented intubation, reduced the incidence of septic shock, and improved survival in these patients compared with high-concentration oxygen therapy.
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Affiliation(s)
- Miquel Ferrer
- Unitat de Vigilància Intensiva Respiratòria, Institut Clinic de Pneumologia i Cirurgia Toracica, Universitat de Barcelona, Barcelona, Spain.
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396
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Gabrielli A, Caruso LJ, Layon AJ, Antonelli M. Yet another look at noninvasive positive-pressure ventilation. Chest 2003; 124:428-31. [PMID: 12907525 DOI: 10.1378/chest.124.2.428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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397
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Fernández-Vivas M, Caturla-Such J, González de la Rosa J, Acosta-Escribano J, Alvarez-Sánchez B, Cánovas-Robles J. Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure. Intensive Care Med 2003; 29:1126-33. [PMID: 12802487 DOI: 10.1007/s00134-003-1768-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2002] [Accepted: 04/15/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although conventional pressure ventilation (PSV) decreases the rate of intubation in acute respiratory failure, patient-ventilator dyssynchrony is a frequent cause of failure. In proportional assist ventilation (PAV), pressure is applied by the ventilator in proportion to the patient-generated volume and flow; therefore, there is automatic synchrony between the patient's effort and the ventilatory cycle. OBJECTIVE The aim of this study was to compare the effects of PSV and PAV during noninvasive ventilation in the treatment of acute respiratory failure. DESIGN Prospective randomised study. SETTING A multidisciplinary 24-bed intensive care unit of an acute-care teaching hospital in Alicante, Spain. PATIENTS. This study included 117 consecutive adult patients with acute respiratory failure randomised to noninvasive ventilation delivered by PSV ( n = 59) or PAV ( n = 58). MEASUREMENTS AND RESULTS There were no statistically significant differences between patients assigned to each mode of ventilation with regard to baseline parameters and aetiological diagnoses of acute respiratory failure. With regard to outcome data, no significant differences were observed between PSV and PAV in the frequency of intubation (37% vs 34%), mortality rate (29% vs 28%), and mean length of stay. Subjective comfort (0-10 visual analogue scale) was rated higher and intolerance occurred less frequently (3.4% vs 15%, P = 0.03) in the PAV than in the PSV mode. CONCLUSIONS Although PAV seems more comfortable and intolerance occurred less frequently, no major differences exist in terms of physiological improvement or in terms of outcomes when comparing PSV and PAV.
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Affiliation(s)
- Miguel Fernández-Vivas
- Intensive Care Unit, Hospital General Universitario de Alicante, Maestro Alonso 109, 03010, Alicante, Spain.
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398
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Giacomini M, Iapichino G, Cigada M, Minuto A, Facchini R, Noto A, Assi E. Short-term noninvasive pressure support ventilation prevents ICU admittance in patients with acute cardiogenic pulmonary edema. Chest 2003; 123:2057-61. [PMID: 12796189 DOI: 10.1378/chest.123.6.2057] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Noninvasive ventilation, although effective as treatment for patients with acute cardiogenic pulmonary edema when prolonged for hours, is of limited use in the emergency department (ED). The aim of the study was to determine whether a short attempt at noninvasive pressure support ventilation avoids ICU admittance and to identify lack of response prediction variables. DESIGN Prospective inception cohort study. SETTING ED of a university hospital. PATIENTS Fifty-eight consecutive patients with cardiogenic pulmonary edema who had been unresponsive to medical treatment and were admitted between January 1999 and December 2000. INTERVENTIONS Pressure support ventilation was instituted through a full-face mask until the resolution of respiratory failure. A 15-min "weaning test" was performed to evaluate clinical stability. Responder patients were transferred to a medical ward. Nonresponding patients were intubated and were admitted to the ICU. MAIN OUTCOME MEASURES The included optimal length of intervention, the avoidance of ICU admittance, the incidence of myocardial infarction, and predictive lack of response criteria. RESULTS Patients completed the trial (mean [+/- SD] duration, 96 +/- 40 min). None of the responders (43 patients; 74%) was subsequently ventilated or was admitted to the ICU. Two new episodes of myocardial infarction were observed. Thirteen of 58 patients died. A mean arterial pressure of < 95 mm Hg (odds ratio [OR], 10.6; 95% confidence interval [CI], 1.8 to 60.8; p < 0.01) and COPD (OR, 9.4; 95% CI, 1.6 to 54.0; p < 0.05) at baseline predicted the lack of response to noninvasive ventilation. CONCLUSIONS A short attempt at noninvasive ventilation is effective in preventing invasive assistance. A 15-min weaning test can identify patients who will not need further invasive ventilatory support. COPD and hypotension at baseline are negative predictive criteria.
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Affiliation(s)
- Matteo Giacomini
- Istituto di Anestesiologia e Rianimazione dell'Università degli Studi di Milano, Azienda Ospedaliera, Polo Universitario Ospedale San Paolo, Milan, Italy
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399
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Abstract
Pulmonary edema is differentiated into two categories--cardiogenic and noncardiogenic. Noncardiogenic pulmonary edema is due to changes in permeability of the pulmonary capillary membrane as a result of either a direct or an indirect pathologic process. It is a spectrum of illness ranging from the less severe form of ALI to the severe ARDS. The mainstay of treatment is mechanical ventilation with maximization of ventilation and oxygenation through the judicious use of PEEP. Newer ventilation techniques, such as high-frequency oscillatory ventilation and partial fluid ventilation, are promising but are in the early stages of clinical testing. Mortality rates remain high despite increasing intensive care unit care.
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Affiliation(s)
- Debra G Perina
- Department of Emergency Medicine, University of Virginia Health Systems, PO Box 800699, Charlottesville, VA 22908, USA.
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400
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Welte T. [Noninvasive ventilation in the intensive care unit -- is it still negligible?]. Wien Klin Wochenschr 2003; 115:89-98. [PMID: 12674684 DOI: 10.1007/bf03040286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Non-invasive positive pressure ventilation (NIPPV) has been discussed comprehensively in the last years, but usage of non-invasive ventilation in Intensive Care Units is rare. The reasons may be uncertainty in indications and difficulties in handling the masks and ventilators. In the last years the introduction of full face masks and respiratory helmets has made it possible to ventilate patients with unusual facial forms and to avoid problems of pressure necrosis. Software components designed for NIPPV are available for standard respirators. Indications for NIPPV (neuromuscular diseases, spinal abnormalities, chest wall malformations, COPD, cardiogenic pulmonary edema) have been ensured in clinical trials. No sufficient data are available for the application of NIPPV in weaning and respiratory failure following extubation. Indication for NIPPV becomes apparent when therapy starts in early stage with sufficient ventilation pressure. Compared to standard therapy, no reliable advantage has been seen for NIPPV in hypoxic hypercapnia respiratory failure except for malignant diseases. However, prophylactic use in patients with high risk might be conceivable. For these patients strict criteria of termination are required to avoid missing the time point for intubation. Gas exchange disturbances in advanced lung fibrosis, pneumonia and ARDS are not amenable to NIPPV. Contraindications for NIPPV are non-compliant patients, absence of cough- and pharyngeal reflexes as well as retention of secretions and malignant ventricular arrhythmia. Relative contraindications are catecholamine-dependent circulatory collapse and acute myocardial infarction, since sufficient data for NIPPV are missing.
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Affiliation(s)
- Tobias Welte
- Otto von Guericke-Universität, Magdeburg, Deutschland.
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