Noninvasive and invasive ventilation in acute respiratory failure associated with bronchiectasis

Effects of high-flow nasal cannula oxygen therapy in bronchiectasis and hypercapnia: a retrospective observational study

BACKGROUND

The effectiveness of high-flow nasal cannula (HFNC) therapy in patients with bronchiectasis experiencing hypercapnia remains unclear. Our aim was to retrospectively analyze the short-term outcomes of HFNC therapy in such patients, and to further explore the predictors of HFNC treatment failure in this particular patient population.

METHODS

A retrospective review was conducted on patients with bronchiectasis who received HFNC (n = 70) for hypercapnia (arterial partial pressure of carbon dioxide, PaCO2 ≥ 45 mmHg) between September 2019 and September 2023.

RESULTS

In the study population, 30% of patients presented with acidemia (arterial pH < 7.35) at baseline. Within 24 h of HFNC treatment, there was a significant reduction in PaCO2 levels by a mean of 4.0 ± 12.7 mmHg (95% CI -7.0 to -1.0 mmHg). Concurrently, arterial pH showed a statistically significant increase with a mean change of 0.03 ± 0.06 (95% CI 0.01 to 0.04). The overall hospital mortality rate in our study was 17.5%. The median length of hospital stay was 11.0 days (interquartile range [IQR] 8.0 to 16.0 days). Sub-analysis revealed no statistically significant differences in hospital mortality (19.0% vs. 20.4%, p = 0.896), length of hospital stay (median 14.0 days [IQR 9.0 to 18.0 days] vs. 10.0 days [IQR 7.0 to 16.0 days], p = 0.117) and duration of HFNC application (median 5.0 days [IQR 2.0 to 8.5 days] vs. 6.0 days [IQR 4.9 to 9.5 days], p = 0.076) between the acidemia group and the non-acidemia group (arterial pH ≥ 7.35). However, more patients in the non-acidemia group had do-not-intubate orders. The overall treatment failure rate for HFNC was 28.6%. Logistic regression analysis identified the APACHE II score (OR 1.24 per point) as the independent predictor of HFNC failure.

CONCLUSIONS

In patients with bronchiectasis and hypercapnia, HFNC as an initial respiratory support can effectively reduce PaCO2 level within 24 h of treatment. A high APACHE II score has emerged as a prognostic indicator for HFNC treatment failure. These observations highlight randomized controlled trials to meticulously evaluate the efficacy of HFNC in this specific population.

Epidemiology and outcomes of multidrug-resistant bacterial infection in non-cystic fibrosis bronchiectasis

PURPOSE

Multidrug-resistant (MDR) bacteria impose a considerable health-care burden and are associated with bronchiectasis exacerbation. This study investigated the clinical outcomes of adult patients with bronchiectasis following MDR bacterial infection.

METHODS

From the Chang Gung Research Database, we identified patients with bronchiectasis and MDR bacterial infection from 2008 to 2017. The control group comprised patients with bronchiectasis who did not have MDR bacterial infection and were propensity-score matched at a 1:2 ratio. The main outcomes were in-hospital and 3-year mortality.

RESULTS

In total, 554 patients with both bronchiectasis and MDR bacterial infection were identified. The types of MDR bacteria that most commonly affected the patients were MDR- Acinetobacter baumannii (38.6%) and methicillin-resistant Staphylococcus aureus (18.4%), Extended-spectrum-beta-lactamases (ESBL)- Klebsiella pneumoniae (17.8%), MDR-Pseudomonas (14.8%), and ESBL-E. coli (7.5%). Compared with the control group, the MDR group exhibited lower body mass index scores, higher rate of chronic bacterial colonization, a higher rate of previous exacerbations, and an increased use of antibiotics. Furthermore, the MDR group exhibited a higher rate of respiratory failure during hospitalization (MDR vs. control, 41.3% vs. 12.4%; p < 0.001). The MDR and control groups exhibited in-hospital mortality rates of 26.7% and 7.6%, respectively (p < 0.001); 3-year respiratory failure rates of 33.5% and 13.5%, respectively (p < 0.001); and 3-year mortality rates of 73.3% and 41.5%, respectively (p < 0.001). After adjustments were made for confounding factors, the infection with MDR and MDR bacteria species were determined to be independent risk factors affecting in-hospital and 3-year mortality.

CONCLUSIONS

MDR bacteria were discovered in patients with more severe bronchiectasis and were independently associated with an increased risk of in-hospital and 3-year mortality. Given our findings, we recommend that clinicians identify patients at risk of MDR bacterial infection and follow the principle of antimicrobial stewardship to prevent the emergence of resistant bacteria among patients with bronchiectasis.

Risk Factors for Influenza-Induced Exacerbations and Mortality in Non-Cystic Fibrosis Bronchiectasis

Influenza infection is a cause of exacerbations in patients with chronic pulmonary diseases. The aim of this study was to investigate the clinical outcomes and identify risk factors associated with hospitalization and mortality following influenza infection in adult patients with bronchiectasis. Using the Chang Gung Research Database, we identified patients with bronchiectasis and influenza-related infection (ICD-9-CM 487 and anti-viral medicine) between 2008 and 2017. The main outcomes were influenza-related hospitalization and in-hospital mortality rate. Eight hundred sixty-five patients with bronchiectasis and influenza infection were identified. Five hundred thirty-six (62%) patients with bronchiectasis were hospitalized for influenza-related infection and 118 (22%) patients had respiratory failure. Compared to the group only seen in clinic, the hospitalization group was older, with more male patients, a lower FEV_1, higher bronchiectasis aetiology comorbidity index (BACI), and more acute exacerbations in the previous year. Co-infections were evident in 55.6% of hospitalized patients, mainly caused by Pseudomonas aeruginosa (15%), fungus (7%), and Klebsiella pneumoniae (6%). The respiratory failure group developed acute kidney injury (36% vs. 16%; p < 0.001), and shock (47% vs. 6%; p < 0.001) more often than influenza patients without respiratory failure. The overall mortality rate was 10.8% and the respiratory failure group exhibited significantly higher in-hospital mortality rates (27.1% vs. 6.2%; p < 0.001). Age, BACI, and previous exacerbations were independently associated with influenza-related hospitalization. Age, presence of shock, and low platelet counts were associated with increased hospital mortality. Influenza virus caused severe exacerbation in bronchiectasis, especially in those who were older and who had high BACI scores and previous exacerbations. A high risk of respiratory failure and mortality were observed in influenza-related hospitalization in bronchiectasis. We highlight the importance of preventing or treating influenza infection in bronchiectasis.

Influence of Comorbidities and Airway Clearance on Mortality and Outcomes of Patients With Severe Bronchiectasis Exacerbations in Taiwan

Bronchiectasis is characterized by systemic inflammation and multiple comorbidities. This study aimed to investigate the clinical outcomes based on the bronchiectasis etiology comorbidity index (BACI) score in patients hospitalized for severe bronchiectasis exacerbations. We included non-cystic fibrosis patients hospitalized for severe bronchiectasis exacerbations between January 2008 and December 2016 from the Chang Gung Research Database (CGRD) cohort. The main outcome was the 1-year mortality rate after severe exacerbations. We used the Cox regression model to assess the risk factors of 1-year mortality. Of 1,235 patients who were hospitalized for severe bronchiectasis exacerbations, 641 were in the BACI < 6 group and 594 in the BACI ≥ 6 group. The BACI ≥ 6 group had more previous exacerbations and a lower FEV₁. Pseudomonas aeruginosa (19.1%) was the most common bacterium, followed by Klebsiella pneumoniae (7.5%). Overall, 11.8% of patients had respiratory failure and the hospital mortality was 3.0%. After discharge, compared to the BACI < 6 group, the BACI ≥ 6 group had a significantly higher cumulative incidence of respiratory failure and mortality in a 1-year follow-up. The risk factors for 1-year mortality in a multivariate analysis include age [hazard ratio (HR) 4.38, p = 0.01], being male (HR 4.38, p = 0.01), and systemic corticosteroid usage (HR 6.35, p = 0.001), while airway clearance therapy (ACT) (HR 0.50, p = 0.010) was associated with a lower mortality risk. An increased risk of respiratory failure and mortality in a 1-year follow-up after severe exacerbations was observed in bronchiectasis patients with multimorbidities, particularly older age patients, male patients, and patients with a history of systemic corticosteroid use. ACT could effectively improve the risk for 1-year mortality.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

A challenging case of hypercapnic respiratory failure during pregnancy

We describe a 40-year-old female who presented with progressive breathlessness and hypercapnic respiratory failure during pregnancy secondary to undiagnosed muscle-specific kinase myasthenia gravis. Her presentation was progressive and protracted, having over five contacts with healthcare professionals over nine months, many of these predating her pregnancy. Her atypical presentation for myasthenia with minimal limb weakness led to consideration of other causes of hypercapnic respiratory failure. Once diagnosed, she was treated with intravenous immunoglobulin and non-invasive ventilation. She gave birth to a pre-term infant by planned caesarean section. Her insidious presentation and the progressive nature of her breathlessness were unusual and our report highlights the predominant involvement of respiratory muscles in muscle-specific kinase myasthenia. Her pregnancy may have further delayed her diagnosis due the attribution of some symptoms to normal pregnancy. Early recognition and treatment of myasthenia gravis are important to prevent life-threatening complications.

Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study

Background

Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors.

Results

Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863.

Conclusion

IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.

Noninvasive ventilation in acute respiratory failure: which recipe for success?

Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.

The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.

Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.

In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.

Noninvasive Ventilation for Acute Respiratory Failure due to Noncystic Fibrosis Bronchiectasis

Purpose of the Study:

Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting.

Methodology:

This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV).

Results:

NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters (n = 15), hypotension (n = 6), worsening of sensorium (n = 3), and intolerance (n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)].

Conclusions:

NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies

Background

Identifying the predictors of noninvasive ventilation (NIV) failure has attracted significant interest because of the strong link between failure and poor outcomes. However, very little attention has been paid to the timing of the failure. This narrative review focuses on the causes of NIV failure and risk factors and potential remedies for NIV failure, based on the timing factor.

Results

The possible causes of immediate failure (within minutes to <1 h) are a weak cough reflex, excessive secretions, hypercapnic encephalopathy, intolerance, agitation, and patient-ventilator asynchrony. The major potential interventions include chest physiotherapeutic techniques, early fiberoptic bronchoscopy, changing ventilator settings, and judicious sedation. The risk factors for early failure (within 1 to 48 h) may differ for hypercapnic and hypoxemic respiratory failure. However, most cases of early failure are due to poor arterial blood gas (ABGs) and an inability to promptly correct them, increased severity of illness, and the persistence of a high respiratory rate. Despite a satisfactory initial response, late failure (48 h after NIV) can occur and may be related to sleep disturbance.

Conclusions

Every clinician dealing with NIV should be aware of these risk factors and the predicted parameters of NIV failure that may change during the application of NIV. Close monitoring is required to detect early and late signs of deterioration, thereby preventing unavoidable delays in intubation.

Efficacy and predictors of success of noninvasive ventilation for prevention of extubation failure in critically ill children with heart disease

The study aimed primarily to evaluate the efficacy of noninvasive ventilation (NIV) and to identify possible predictors for success of NIV therapy in preventing extubation failure in critically ill children with heart disease. The secondary objectives of this study were to assess the efficacy of prophylactic NIV therapy initiated immediately after tracheal extubation and to determine the characteristics, outcomes, and complications associated with NIV therapy in pediatric cardiac patients. A retrospective review examined the medical records of all children between the ages 1 day and 18 years who sustained acute respiratory failure (ARF) that required NIV in the cardiovascular intensive care unit (CVICU) at Lucile Packard Children's Hospital between January 2008 and June 2010. Patients were assigned to a prophylactic group if NIV was started directly after extubation and to a nonprophylactic group if NIV was started after signs and symptoms of ARF developed. Patients were designated as responders if they received NIV and did not require reintubation during their CVICU stay and nonresponders if they failed NIV and reintubation was performed. The data collected included demographic data, preexisting conditions, pre-event characteristics, event characteristics, and outcome data. The outcome data evaluated included success or failure of NIV, duration of NIV, CVICU length of stay (LOS), hospital LOS, and hospital mortality. The two complications of NIV assessed in the study included nasal bridge or forehead skin necrosis and pneumothorax. The 221 eligible events during the study period involved 172 responders (77.8 %) and 49 nonresponders (22.2 %). A total of 201 events experienced by the study cohort received continuous positive airway pressure (CPAP), with 156 responders (78 %), whereas 20 events received bilevel positive airway pressure (BiPAP), with 16 responders (80 %). In the study, 58 events (26.3 %) were assigned to the prophylactic group and 163 events (73.7 %) to the nonprophylactic group. Compared with the nonprophylactic group, the prophylactic group experienced significantly shorter CVICU LOS (median, 49 vs 88 days; p = 0.03) and hospital LOS (median, 60 vs 103 days; p = 0.05). The CVICU LOS and hospital LOS did not differ significantly between the responders (p = 0.56) and nonresponders (p = 0.88). Significant variables identifying a responder included a lower risk-adjusted classification for congenital heart surgery (RACHS-1) score (1-3), a good left ventricular ejection fraction, a normal respiratory rate (RR), normal or appropriate oxygen saturation, prophylactic or therapeutic glucocorticoid therapy within 24 h of NIV initiation, presence of atelectasis, fewer than two organ system dysfunctions, fewer days of intubation before extubation, no clinical or microbiologic evidence of sepsis, and no history of reactive airway disease. As a well-tolerated therapy, NIV can be safely and successfully applied in critically ill children with cardiac disease to prevent extubation failure. The independent predictors of NIV success include lower RACHS-1 classification, presence of atelectasis, steroid therapy received within 24 h after NIV, and normal heart rate and oxygen saturations demonstrated within 24 h after initiation of NIV.

Non-invasive ventilation in immunosuppressed patients with pneumonia and extrapulmonary sepsis

PURPOSE

International guidelines recommend the use of noninvasive ventilation in immunocompromised patients with acute respiratory failure (ARF). We analyzed failure rates and risk factors for NIV failure in immunocompromised patients.

METHODS

We retrospectively analyzed 120 immunodeficient patients treated with NIV in our medical ICU from 2005 to 2011. We compared the clinical course and NIV failure rates. Furthermore, we compared patients with secondary respiratory failure due to those with Systemic Inflammatory Response Syndrome (SIRS) of other than pulmonary origin to those with primary pulmonary infiltrations.

RESULTS

Regression analyses revealed high APACHE II score (p < 0.01), need for catecholamines (p < 0.05) and low paO(2)/FIO(2) ratio (p < 0.05) as risk factors for NIV failure. Regarding the underlying diseases, we could not find differences in NIV duration (p = 0.07) and outcome (p = 0.44). 59.2% suffered from ARF due to lung infiltrations whereas 40.8% had secondary ARF caused by sepsis of extrapulmonary origin. Patients with lung infiltrations had a longer stay on ICU (16.3 vs 13.2 days; p = 0.047) and showed a trend toward longer NIV duration (87 ± 102 h vs 65.6 ± 97.8 h; p = 0.056). The SIRS patients compared to pneumonia patients showed a trend toward higher serum creatinine (1.63 mg/dL to 1.51 mg/dL; p = 0.059), a higher rate of renal failure (p < 0.01), higher APACHE II score (30.6-25.7, p < 0.01) and more frequently needed catecholamines (p < 0.01). NIV failure rate (overall 55%) was not different.

CONCLUSIONS

Almost 50% of the immunocompromised patients treated with NIV did not require intubation independent of the etiology of ARF. High APACHE II scores and severity of oxygenation failure were associated with NIV failure.

Noninvasive mechanical ventilation

PURPOSE OF REVIEW

A critical review of the most recent literature regarding use and clinical indications of noninvasive mechanical ventilation (NIV).

RECENT FINDINGS

According to several randomized controlled trials, NIV has gained acceptance as the preferred ventilatory modality to treat acute respiratory failure (ARF) due to chronic obstructive pulmonary disease exacerbations, cardiogenic pulmonary edema, respiratory failure in immunocompromised patients, and to decrease the intubation length and to improve weaning results in patients recovering from a hypercapnic respiratory failure. Observational studies suggest that NIV may also be used to treat other conditions like severe pneumonia (including H1N1 virus), severe asthma attack, cystic fibrosis, obesity hypoventilation, and to improve the respiratory outcome in postsurgical patients.

SUMMARY

NIV has radically changed the management of ARF. Recently the possible applications of NIV have increased, both in the hospital and extrahospital setting. NIV is no longer confined to the ICU, but has crossed over into the regular ward, Emergency Department and 'out-of-hospital' environment. Current research is focusing on improving the quality and safety of the devices and establishing new ventilatory modes in order to extend even further the indications to NIV as well as its rate of success.