1
|
Spinazzola G, Spadaro S, Ferrone G, Grasso S, Maggiore SM, Cinnella G, Cabrini L, Cammarota G, Maugeri JG, Simonte R, Patroniti N, Ball L, Conti G, De Luca D, Cortegiani A, Giarratano A, Gregoretti C. Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:68. [PMID: 39350290 PMCID: PMC11441104 DOI: 10.1186/s44158-024-00203-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 09/16/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Discomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS. METHODS The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus. RESULTS The use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting. CONCLUSIONS The use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.
Collapse
Affiliation(s)
- G Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - S Spadaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - G Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - S Grasso
- Department of Emergency and Organ Transplantation (DETO), Section of Anesthesiology and Intensive Care, University of Bari "Aldo Moro'', Bari, Italy
| | - S M Maggiore
- Department of Anesthesia, Intensive Care and Emergency, SS Annunziata Chieti Hospital, G. D'Annunzio Chieti University Pescara, Pescara, Italy
| | - G Cinnella
- Department of Anesthesia and Intensive Care of University of Foggia, Foggia, Italy
| | - L Cabrini
- Department of Biotechnology and Life Sciences, University of Pennsylvania Studies of Insubria, Varese, Italy
| | - G Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - J G Maugeri
- Anesthesia and Intensive Care Unit, ARNAS Garibaldi Catania, PO "Garibaldi Centro, Catania, Italy
| | - R Simonte
- Department of Medicine and Surgery, Università Degli Studi Di Perugia, Perugia, Italy
| | - N Patroniti
- Anesthesia and Intensive Care San Martino Di Genova, Department of Surgical Sciences and Integrated Diagnosis, University of Genoa, Genoa, Italy
| | - L Ball
- Anesthesia and Intensive Care San Martino Di Genova, Department of Surgical Sciences and Integrated Diagnosis, University of Genoa, Genoa, Italy
| | - G Conti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of Sacred Heart, Rome, Italy
| | - D De Luca
- Division of Paediatrics and Neonatal Critical Care, "A. Béclère" Hospital, APHP-Paris Saclay University, Paris, France
| | - A Cortegiani
- Department of Precision Medicine in Area Medical, Surgical and Critical Care. Anesthesia Unit, Resuscitation, and Intensive Care, AOU Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - A Giarratano
- Department of Precision Medicine in Area Medical, Surgical and Critical Care. Anesthesia Unit, Resuscitation, and Intensive Care, AOU Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - C Gregoretti
- Intensive Care Unit, Fondazione G. Giglio, Cefalù, Unicamillus International University, Roma, Cefalù, Italy
| |
Collapse
|
2
|
Hao GW, Wu JQ, Yu SJ, Liu K, Xue Y, Gong Q, Xie RC, Ma GG, Su Y, Hou JY, Zhang YJ, Liu WJ, Li W, Tu GW, Luo Z. Remifentanil vs. dexmedetomidine for cardiac surgery patients with noninvasive ventilation intolerance: a multicenter randomized controlled trial. J Intensive Care 2024; 12:35. [PMID: 39294818 PMCID: PMC11409483 DOI: 10.1186/s40560-024-00750-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 09/07/2024] [Indexed: 09/21/2024] Open
Abstract
BACKGROUND The optimal sedative regime for noninvasive ventilation (NIV) intolerance remains uncertain. The present study aimed to assess the efficacy and safety of remifentanil (REM) compared to dexmedetomidine (DEX) in cardiac surgery patients with moderate-to-severe intolerance to NIV. METHODS In this multicenter, prospective, single-blind, randomized controlled study, adult cardiac surgery patients with moderate-to-severe intolerance to NIV were enrolled and randomly assigned to be treated with either REM or DEX for sedation. The status of NIV intolerance was evaluated using a four-point NIV intolerance score at different timepoints within a 72-h period. The primary outcome was the mitigation rate of NIV intolerance following sedation. RESULTS A total of 179 patients were enrolled, with 89 assigned to the REM group and 90 to the DEX group. Baseline characteristics were comparable between the two groups, including NIV intolerance score [3, interquartile range (IQR) 3-3 vs. 3, IQR 3-4, p = 0.180]. The chi-squared test showed that mitigation rate, defined as the proportion of patients who were relieved from their initial intolerance status, was not significant at most timepoints, except for the 15-min timepoint (42% vs. 20%, p = 0.002). However, after considering the time factor, generalized estimating equations showed that the difference was statistically significant, and REM outperformed DEX (odds ratio = 3.31, 95% confidence interval: 1.35-8.12, p = 0.009). Adverse effects, which were not reported in the REM group, were encountered by nine patients in the DEX group, with three instances of bradycardia and six cases of severe hypotension. Secondary outcomes, including NIV failure (5.6% vs. 7.8%, p = 0.564), tracheostomy (1.12% vs. 0%, p = 0.313), ICU LOS (7.7 days, IQR 5.8-12 days vs. 7.0 days, IQR 5-10.6 days, p = 0.219), and in-hospital mortality (1.12% vs. 2.22%, p = 0.567), demonstrated comparability between the two groups. CONCLUSIONS In summary, our study demonstrated no significant difference between REM and DEX in the percentage of patients who achieved mitigation among cardiac surgery patients with moderate-to-severe NIV intolerance. However, after considering the time factor, REM was significantly superior to DEX. Trial registration ClinicalTrials.gov (NCT04734418), registered on January 22, 2021. URL of the trial registry record: https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AM4S&selectaction=Edit&uid=U00038YX&ts=3&cx=eqn1z0 .
Collapse
Affiliation(s)
- Guang-Wei Hao
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jia-Qing Wu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yan Xue
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Qian Gong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, Anhui, China
| | - Rong-Cheng Xie
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, 361015, Fujian, China
| | - Guo-Guang Ma
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Ying Su
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun-Yi Hou
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Zhang
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Jun Liu
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wei Li
- Department of Intensive Care Unit, The People's Hospital of Fujian Traditional Medical University, Fuzhou, 350004, Fujian, China.
| | - Guo-Wei Tu
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| | - Zhe Luo
- Department of Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Department of Critical Care Medicine, Shanghai Xuhui Central Hospital, Zhongshan Xuhui Hospital, Fudan University, Shanghai, 200020, China.
- Shanghai Key Lab of Pulmonary Inflammation and Injury, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| |
Collapse
|
3
|
Spinazzola G, Ferrone G, Michi T, Torrini F, Postorino S, Sbaraglia F, Gulmini L, Antonelli M, Conti G, Spadaro S. Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease. J Clin Med 2024; 13:5165. [PMID: 39274381 PMCID: PMC11396473 DOI: 10.3390/jcm13175165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/24/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024] Open
Abstract
The management of patients with life-threatening respiratory disease in the ICU and at home has become increasingly of interest over the past decades. Growing knowledge supports the use of NRS, aimed at improving patient comfort and improving quality of life. However, its role during palliative care is not well defined, and evidence of support remains limited. The aim of this narrative review is to examine the recent evidence relating to the use of non-invasive respiratory support at the end of life, in order to clarify who benefits and when. The literature research was conducted on PubMed, using MeSH words. A review of the relevant literature showed that non-invasive respiratory support techniques for patients with life-limiting respiratory disease vary (from high-flow oxygen therapy to conventional oxygen therapy, from CPAP to NPPV) and each has precise indications. To date, from the hospital to the home setting, the monitoring and application of these respiratory support techniques have varied widely. In conclusion, the choice of respiratory support in this category of patients should be based on the technique that will optimize the comfort of the patient and improve the quality of their life. On the other hand, regarding monitoring, both telemedicine and ultrasound diagnostics help to satisfy the patient's wish to spend the last period of his life in the home environment, to avoid inappropriately aggressive diagnostic interventions, and to reduce the high costs of hospitalized procedures in this category of patients.
Collapse
Affiliation(s)
- Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giuliano Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Teresa Michi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavia Torrini
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Stefania Postorino
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Loretta Gulmini
- Palliative Care/Hospice, University of Ferrara, 44100 Ferrara, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
- Department of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
- Department of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliera-Universitaria di Ferrara, 44100 Ferrara, Italy
| |
Collapse
|
4
|
Mocellin A, Guidotti F, Rizzato S, Tacconi M, Bruzzi G, Messina J, Puggioni D, Patsoura A, Fantini R, Tabbì L, Castaniere I, Marchioni A, Clini E, Tonelli R. Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing. Intern Emerg Med 2024:10.1007/s11739-024-03715-3. [PMID: 39207721 DOI: 10.1007/s11739-024-03715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024]
Abstract
Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.
Collapse
Affiliation(s)
- Anna Mocellin
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Federico Guidotti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Simone Rizzato
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Tacconi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Jacopo Messina
- Internal Medicine Unit, University of Rome, Roma 1, Rome, Italy
| | - Daniele Puggioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Athina Patsoura
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy.
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| |
Collapse
|
5
|
Dunbar PJ, Peterson R, McGrath M, Pomponio R, Kiser TH, Ho PM, Vandivier RW, Burnham EL, Moss M, Sottile PD. Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure. Crit Care Med 2024; 52:1043-1053. [PMID: 38506571 DOI: 10.1097/ccm.0000000000006253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death. DESIGN A retrospective multicenter cohort study. SETTING A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States. PATIENTS Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40). CONCLUSIONS The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.
Collapse
Affiliation(s)
- Peter J Dunbar
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Max McGrath
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Raymond Pomponio
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| |
Collapse
|
6
|
Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
Collapse
Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
| |
Collapse
|
7
|
Osterkamp JTF, Strandby RB, Henningsen L, Marcussen KV, Thomsen T, Mortensen CR, Achiam MP, Jans Ø. Comparing the effects of continuous positive airway pressure via mask or helmet interface on oxygenation and pulmonary complications after major abdominal surgery: a randomized trial. J Clin Monit Comput 2023; 37:63-70. [PMID: 35429325 PMCID: PMC9013185 DOI: 10.1007/s10877-022-00857-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/29/2022] [Indexed: 01/25/2023]
Abstract
The risk of pulmonary complications is high after major abdominal surgery but may be reduced by prophylactic postoperative noninvasive ventilation using continuous positive airway pressure (CPAP). This study compared the effects of intermittent mask CPAP (ICPAP) and continuous helmet CPAP (HCPAP) on oxygenation and the risk of pulmonary complications following major abdominal surgery. Patients undergoing open abdominal aortic aneurysm repair or pancreaticoduodenectomy were randomized (1:1) to either postoperative ICPAP or HCPAP. Oxygenation was evaluated as the partial pressure of oxygen in arterial blood fraction of inspired oxygen ratio (PaO2/FIO2) at 6 h, 12 h, and 18 h postoperatively. Pulmonary complications were defined as X-ray verified pneumonia/atelectasis, clinical signs of pneumonia, or supplementary oxygen beyond postoperative day 3. Patient-reported comfort during CPAP treatment was also evaluated. In total, 96 patients (ICPAP, n = 48; HCPAP, n = 48) were included, and the type of surgical procedure were evenly distributed between the groups. Oxygenation did not differ between the groups by 6 h, 12 h, or 18 h postoperatively (p = 0.1, 0.08, and 0.67, respectively). Nor was there any difference in X-ray verified pneumonia/atelectasis (p = 0.40) or supplementary oxygen beyond postoperative day 3 (p = 0.53). Clinical signs of pneumonia tended to be more frequent in the ICPAP group (p = 0.06), yet the difference was not statistically significant. Comfort scores were similar in both groups (p = 0.43), although a sensation of claustrophobia during treatment was only experienced in the HCPAP group (11% vs. 0%, p = 0.03). Compared with ICPAP, using HCPAP was associated with similar oxygenation (i.e., PaO2/FIO2 ratio) and a similar risk of pulmonary complications. However, HCPAP treatment was associated with a higher sensation of claustrophobia.
Collapse
Affiliation(s)
- Jens T F Osterkamp
- Department of Surgical Gastroenterology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Rune B Strandby
- Department of Surgical Gastroenterology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lara Henningsen
- Department of Anaesthesia, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Klaus V Marcussen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, University of Zeeland, Slagelse, Denmark
| | - Thordis Thomsen
- Department of Clinical Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian R Mortensen
- Department of Anaesthesia, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Surgical Gastroenterology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Øivind Jans
- Department of Anaesthesia, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Muacevic A, Adler JR, Tauheed N, Khan D. Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series. Cureus 2023; 15:e33981. [PMID: 36811041 PMCID: PMC9938913 DOI: 10.7759/cureus.33981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2023] [Indexed: 01/22/2023] Open
Abstract
Non-compliance to the non-invasive ventilation (NIV) mask in a distressed hypoxemic patient is not an unusual finding, especially in desaturated coronavirus disease (COVID-19) or chronic obstructive pulmonary disease (COPD) patients with respiratory distress who require ventilatory support to improve oxygenation. Failure to achieve success with the non-invasive ventilatory support with the tight-fitting mask led to emergent endotracheal intubation. This was in view to avert consequences such as severe hypoxemia and subsequent cardiac arrest. Sedation is an important component of ICU management for noninvasive mechanical ventilation to improve NIV compliance/tolerance. Including the various sedatives used, such as fentanyl, propofol, or midazolam, the most suitable agent to be used as a primary/sole sedative still remains unclear. Dexmedetomidine providing analgosedation without significant respiratory depression facilitates better tolerance of NIV mask application. This case series is a retrospective analysis of patients in whom dexmedetomidine bolus followed by infusion was observed to facilitate compliance to NIV with the tight-fitting mask. Herein, a case summary of six patients with acute respiratory distress who were dyspnoic, agitated have severe hypoxemia were put on NIV with dexmedetomidine infusion is being reported. They were extremely uncooperative as their RASS score (Richmond Agitation-Sedation score) was + 1 to +3, not allowing the application of the NIV mask. Due to their poor compliance with to use of the NIV mask, proper ventilation could not be achieved. Dexmedetomidine infusion (0.3 to 0.4 mcg/kg/hr) was used after a bolus dose (0.2-0.3 mcg/kg). The RASS Score of our patients was +2 or +3 before this intervention which became -1 or -2 after including dexmedetomidine in the treatment protocol. The low dose dexmedetomidine bolus and infusion thereafter showed to improve the patient's acceptance of the device. Oxygen therapy with this was shown to improve patient oxygenation by allowing the acceptance of the tight-fitting NIV face mask. In conclusion, this case series serves as evidence of the use of dexmedetomidine as an effective therapy to calm the agitated desaturated patient, thereby facilitating non-invasive ventilation in COVID-19 and COPD patients and promoting better oxygenation. This may, in turn, avoid endotracheal intubation for invasive ventilation and the associated complications.
Collapse
|
9
|
Bongiovanni F, Michi T, Natalini D, Grieco DL, Antonelli M. Advantages and drawbacks of helmet noninvasive support in acute respiratory failure. Expert Rev Respir Med 2023; 17:27-39. [PMID: 36710082 DOI: 10.1080/17476348.2023.2174974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Non-invasive ventilation (NIV) represents an effective strategy for managing acute respiratory failure. Facemask NIV is strongly recommended in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnia and acute cardiogenic pulmonary edema (ACPE). Its role in managing acute hypoxemic respiratory failure (AHRF) remains a debated issue. NIV and continuous positive airway pressure (CPAP) delivered through the helmet are recently receiving growing interest for AHRF management. AREAS COVERED In this narrative review, we discuss the clinical applications of helmet support compared to the other available noninvasive strategies in the different phenotypes of acute respiratory failure. EXPERT OPINION Helmets enable the use of high positive end-expiratory pressure, which may protect from self-inflicted lung injury: in AHRF, the possible superiority of helmet support over other noninvasive strategies in terms of clinical outcome has been hypothesized in a network metanalysis and a randomized trial, but has not been confirmed by other investigations and warrants confirmation. In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO2 rebreathing. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.
Collapse
Affiliation(s)
- Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Daniele Natalini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| |
Collapse
|
10
|
Quality Improvement Initiative to Improve Initiation and Acceptability of Noninvasive Ventilation in Critically Ill Children. Indian J Pediatr 2022; 89:1209-1215. [PMID: 35612686 DOI: 10.1007/s12098-022-04164-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 01/11/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate if the use of a quality improvement (QI) initiative improves initiation and acceptability of noninvasive ventilation (NIV) in critically ill children with respiratory distress. METHODS The study was carried out in 3 phases over a period of 6 mo in the pediatric intensive care unit of a tertiary care hospital in children aged 2 mo to 14 y of age. In phase 1, data were collected for 1 mo and reasons for NIV failure were identified. In phase 2, process changes like adherence to checklist, monitoring, and one-day orientation program were instituted. The plan-do-study-act (PDSA) cycle was carried out in each phase. In phase 3, which was for 2 mo, the acceptance of NIV was measured and results were compared with phase 1. RESULTS A total of 37 patients were included, 12 in phase 1 and 25 in phase 3. NIV failure was recorded in 5 (42%) and 2 (8%) patients in phase 1 and phase 3 (p = 0.025), respectively. The cause of NIV failure was intolerance to the interface in both phases. Sedation was used in 18 (72%) patients in phase 3, as compared to 2 patients in phase 1. CONCLUSIONS The use of a quality improvement initiative in the form of a protocol, checklist, and training of the treating team resulted in improved tolerance to NIV, and thereby, its success. Use of sedation may help improve tolerance to the interface and contribute to its success.
Collapse
|
11
|
Altınkaya Çavuş M, Gökbulut Bektaş S, Turan S. Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study. Front Med (Lausanne) 2022; 9:995799. [PMID: 36111123 PMCID: PMC9468549 DOI: 10.3389/fmed.2022.995799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectivesNon-invasive ventilation (NIV) is used in intensive care units (ICUs) to treat of respiratory failure. Sedation and analgesia are effective and safe for improving compliance in patients intolerant to NIV. Our study aimed to evaluate the effects of dexmedetomidine, remifentanil, and propofol on the clinical outcomes in NIV intolerant patients.MethodsThis prospective randomized cohort study was conducted in a tertiary ICU, between December 2018 and December 2019. We divided a total of 120 patients into five groups (DEXL, DEXH, REML, REMH, PRO). IBM SPSS Statistics 20 (IBM Corporation, Armonk, New York, USA) was used to conduct the statistical analyses.ResultsThe DEXL, DEXH, REML, and REMH groups consisted of 23 patients each while the PRO group consisted of 28 patients. Seventy-five patients (62.5%) became tolerant of NIV after starting the drugs. The NIV time, IMV time, ICU LOS, hospital LOS, intubation rate, side effects, and mortality were significantly different among the five groups (P = 0.05). In the groups that were given dexmedetomidine (DEXL, and DEXH), NIV failure, mortality, ICU LOS, and hospital LOS were lower than in the other groups.ConclusionIn this prospective study, we compared the results of three drugs (propofol, dexmedetomidine, and remifentanil) in patients with NIV intolerance. The use of sedation increased NIV success in patients with NIV intolerance. NIV failure, mortality, ICU LOS, IMV time, and hospital LOS were found to be lower with dexmedetomidine.
Collapse
Affiliation(s)
- Mine Altınkaya Çavuş
- Kayseri City Hospital, Republic of Turkey Ministry of Health Sciences, Kayseri, Turkey
- *Correspondence: Mine Altınkaya Çavuş
| | | | | |
Collapse
|
12
|
Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
Collapse
|
13
|
Coppadoro A, Zago E, Pavan F, Foti G, Bellani G. The use of head helmets to deliver noninvasive ventilatory support: a comprehensive review of technical aspects and clinical findings. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:327. [PMID: 34496927 PMCID: PMC8424168 DOI: 10.1186/s13054-021-03746-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/20/2021] [Indexed: 11/14/2022]
Abstract
A helmet, comprising a transparent hood and a soft collar, surrounding the patient’s head can be used to deliver noninvasive ventilatory support, both as continuous positive airway pressure and noninvasive positive pressure ventilation (NPPV), the latter providing active support for inspiration. In this review, we summarize the technical aspects relevant to this device, particularly how to prevent CO2 rebreathing and improve patient–ventilator synchrony during NPPV. Clinical studies describe the application of helmets in cardiogenic pulmonary oedema, pneumonia, COVID-19, postextubation and immune suppression. A section is dedicated to paediatric use. In summary, helmet therapy can be used safely and effectively to provide NIV during hypoxemic respiratory failure, improving oxygenation and possibly leading to better patient-centred outcomes than other interfaces.
Collapse
Affiliation(s)
| | - Elisabetta Zago
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Fabio Pavan
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Giuseppe Foti
- ASST Monza, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Giacomo Bellani
- ASST Monza, San Gerardo Hospital, Monza, Italy. .,Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy.
| |
Collapse
|
14
|
Wang X, Meng J. Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study. Int J Gen Med 2021; 14:983-992. [PMID: 33790627 PMCID: PMC7997559 DOI: 10.2147/ijgm.s297356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background The present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV). Patients and Methods We divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly. Results Patients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol. Conclusion Butorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV. Trial Registration Registered at http://www.chictr.org.cn/ (ChiCTR1800015534).
Collapse
Affiliation(s)
- Xiaohong Wang
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, 310003, People's Republic of China
| | - Jianbiao Meng
- Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, 310012, People's Republic of China
| |
Collapse
|
15
|
Kim T, Kim JS, Choi EY, Chang Y, Choi WI, Hwang JJ, Moon JY, Lee K, Kim SW, Kang HK, Sim YS, Park TS, Park SY, Park S, Cho JH. Utilization of pain and sedation therapy on noninvasive mechanical ventilation in Korean intensive care units: a multi-center prospective observational study. Acute Crit Care 2020; 35:255-262. [PMID: 33161687 PMCID: PMC7808848 DOI: 10.4266/acc.2020.00164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022] Open
Abstract
Background The use of sedative drugs may be an important therapeutic intervention during noninvasive ventilation (NIV) in intensive care units (ICUs). The purpose of this study was to assess the current application of analgosedation in NIV and its impact on clinical outcomes in Korean ICUs. Methods Twenty Korean ICUs participated in the study, and data was collected on NIV use during the period between June 2017 and February 2018. Demographic data from all adult patients, NIV clinical parameters, and hospital mortality were included. Results A total of 155 patients treated with NIV in the ICUs were included, of whom 26 received pain and sedation therapy (sedation group) and 129 did not (control group). The primary cause of ICU admission was due to acute exacerbation of obstructed lung disease (45.7%) in the control group and pneumonia treatment (53.8%) in the sedation group. In addition, causes of NIV application included acute hypercapnic respiratory failure in the control group (62.8%) and post-extubation respiratory failure in the sedation group (57.7%). Arterial partial pressure of carbon dioxide (PaCO2) levels before and after 2 hours of NIV treatment were significantly decreased in both groups: from 61.9±23.8 mm Hg to 54.9±17.6 mm Hg in the control group (P<0.001) and from 54.9±15.1 mm Hg to 51.1±15.1 mm Hg in the sedation group (P=0.048). No significant differences were observed in the success rate of NIV weaning, complications, length of ICU stay, ICU survival rate, or hospital survival rate between the groups. Conclusions In NIV patients, analgosedation therapy may have no harmful effects on complications, NIV weaning success, and mortality compared to the control group. Therefore, sedation during NIV may not be unsafe and can be used in patients for pain control when indicated.
Collapse
Affiliation(s)
- Taehee Kim
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jung Soo Kim
- Department of Pulmonary and Critical Care Medicine, Inha University College of Medicine, Incheon, Korea
| | - Eun Young Choi
- Department of Pulmonary and Critical Care Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Youjin Chang
- Department of Pulmonary and Critical Care Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Myongji Hospital, Goyang, Korea
| | - Jae-Joon Hwang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jae Young Moon
- Department of Pulmonary and Critical Care Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Sei Won Kim
- Department of Pulmonary, Critical Care and Sleep Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yun Su Sim
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Seung Yong Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Hwa Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | |
Collapse
|
16
|
Hao GW, Luo JC, Xue Y, Ma GG, Su Y, Hou JY, Yu SJ, Liu K, Zheng JL, Tu GW, Luo Z. Remifentanil versus dexmedetomidine for treatment of cardiac surgery patients with moderate to severe noninvasive ventilation intolerance (REDNIVIN): a prospective, cohort study. J Thorac Dis 2020; 12:5857-5868. [PMID: 33209418 PMCID: PMC7656397 DOI: 10.21037/jtd-20-1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of sedation to noninvasive ventilation (NIV) patients remains controversial, however, for intolerant patients who are uncooperative, administration of analgesics and sedatives may be beneficial before resorting to intubation. The aim of this study was to evaluate the efficacy of remifentanil (REM) versus dexmedetomidine (DEX) for treatment of cardiac surgery (CS) patients with moderate to severe NIV intolerance. METHODS This prospective cohort study of CS patients with moderate to severe NIV intolerance was conducted between January 2018 and March 2019. Patients were treated with either REM or DEX, decided by the bedside intensivist. Depending on the treatment regimen, the patients were allocated to one of two groups: the REM group or DEX group. RESULTS A total of 90 patients were enrolled in this study (52 in the REM group and 38 in the DEX group). The mitigation rate, defined as the percentage of patients who were relieved from the initial moderate to severe intolerant status, was greater in the REM group than DEX group at 15 min and 3 h (15 min: 83% vs. 61%, P=0.029; 3 h: 92% vs. 74%, P=0.016), although the mean mitigation rate (81% vs. 85%, P=0.800) was comparable between the two groups. NIV failure, defined as reintubation or death over the course of study, was comparable between the two groups (19.2% vs. 21.1%, respectively, P=0.831). There were no significant differences between the two groups in other clinical outcomes, including tracheostomy (15.4% vs. 15.8%, P=0.958), in-hospital mortality (11.5% vs. 10.5%, P=0.880), ICU length of stay (LOS) (7 vs. 7 days, P=0.802), and in-hospital LOS (17 vs. 19 days, P=0.589). CONCLUSIONS REM was as effective as DEX in CS patients with moderate to severe NIV intolerance. Although the effect of REM was better than that of DEX over the first 3 h, the cumulative effect was similar between the two treatments.
Collapse
Affiliation(s)
- Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Xue
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital Fudan University, Xiamen, China
| |
Collapse
|
17
|
Consequences and Solutions for the Impact of Communication Impairment on Noninvasive Ventilation Therapy for Acute Respiratory Failure: A Focused Review. Crit Care Explor 2020; 2:e0121. [PMID: 32695990 PMCID: PMC7314319 DOI: 10.1097/cce.0000000000000121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objectives: With over 2 million cases of acute respiratory failure in the United States per year, noninvasive ventilation has become a leading treatment modality, often supplanting invasive mechanical ventilation as the initial treatment of choice. Most acute respiratory failure patients use a full face (oronasal) mask with noninvasive ventilation, which is known to impair communication, but its popularity and benefit has led many providers to accept the communication impairment. Medical staff periodically remove masks to communicate with patients, but patients are often limited to short utterances and risk lung derecruitment upon removal of positive pressure. These problems can lead to noninvasive ventilation failure, which is often linked to worse outcomes than first initiating invasive mechanical ventilation and can lead to increased hospitalization costs. Data Sources: We searched MEDLINE and Google Scholar for “speech,” “communication,” “impairment,” “failure,” “complications,” “NIPPV,” “NIV,” and “noninvasive ventilation.” Study Selection: We included articles with patients in acute respiratory failure. We excluded articles for patients using noninvasive ventilation therapy for obstructive sleep apnea. Data Synthesis: Communication impairment has been associated with increasing noninvasive ventilation anxiety (odds ratio, 1.25). Of patients using noninvasive ventilation, 48% require early discontinuation, 22% refuse noninvasive ventilation, and 9% are ultimately intubated. Improvements to communication have been shown to reduce fear and anxiety in invasive mechanical ventilation patients. Analogous communication problems exist with effective solutions in other fields, such as fighter pilot masks, that can be easily implemented to enhance noninvasive ventilation patient care, increase adherence to noninvasive ventilation treatment, and improve patient outcomes. Conclusions: Communication impairment is an underappreciated cause of noninvasive ventilation complications and failure and requires further characterization. Analogous solutions—such as throat microphones and mask-based microphones—that can be easily implemented show potential as cost-effective methods to reduce noninvasive ventilation failure.
Collapse
|
18
|
Luo Z, Yang L, Liu S, Hu Y, Cao Z, Zhu J, Wang J, Ma Y. Mechanical ventilation for acute respiratory failure due to idiopathic pulmonary fibrosis versus connective tissue disease-associated interstitial lung disease: Effectiveness and risk factors for death. CLINICAL RESPIRATORY JOURNAL 2020; 14:918-932. [PMID: 32460444 DOI: 10.1111/crj.13223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/18/2020] [Accepted: 05/21/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Relatively little is known about the effects of mechanical ventilation (MV; including invasive MV [IMV] and noninvasive ventilation) on clinical outcomes of patients with idiopathic pulmonary fibrosis (IPF) and connective tissue disease-associated interstitial lung disease (CTD-ILD) in the intensive care unit (ICU) and risk factors for ICU death remain to be determined. OBJECTIVES Our objective was to determine and compare mortality rates between IPF and CTD-ILD patients receiving MV and to identify risk factors for ICU death in these patients. METHODS We conducted a retrospective cohort study in respiratory ICUs of three university hospitals in China during a 7-year period. We compared clinical data and outcomes between patients with IPF and those with CTD-ILD and performed logistic regression analyses to identify risk factors for ICU death. RESULTS Of the 94 patients in the analyses, 63 were diagnosed with IPF and 31 were diagnosed with CTD-ILD. ICU mortality was significantly higher in the IPF group than in the CTD-ILD group (86% vs 68%; P = 0.041) and was significantly lower in patients receiving noninvasive ventilation than in those receiving IMV (62% vs 88%; P = 0.004). Risk factors for ICU death were disease progression as the principal cause of acute respiratory failure and IMV. CONCLUSION Based on current clinical practice in three ICUs, the mortality rate in IPF patients receiving MV might reach 86% and is higher than in CTD-ILD patients. IMV might be initiated cautiously, especially in patients with disease progression as the principal cause of acute respiratory failure.
Collapse
Affiliation(s)
- Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Liu Yang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Sijie Liu
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuhan Hu
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jian Zhu
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yingmin Ma
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
19
|
|
20
|
Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, Khatib KI, Jagiasi BG, Chanchalani G, Mishra RC, Samavedam S, Govil D, Gupta S, Prayag S, Ramasubban S, Dobariya J, Marwah V, Sehgal I, Jog SA, Kulkarni AP. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020; 24:S61-S81. [PMID: 32205957 PMCID: PMC7085817 DOI: 10.5005/jp-journals-10071-g23186] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non-invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61-S81.
Collapse
Affiliation(s)
- Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India, , e-mail:
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , 020-25531539 / 25539538, e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India, , e-mail:
| | - G C Khilnani
- Department of PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India, , e-mail:
| | - Yatin Mehta
- Department of Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon-122001, Haryana, India, Extn. 3335, e-mail:
| | - Khalid Ismail Khatib
- Department of Medicine, SKN Medical College, Pune, Maharashtra, India, , e-mail:
| | - Bharat G Jagiasi
- Department of Critical Care, Reliance Hospital, Navi Mumbai, Maharashtra, India, , e-mail:
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, Bhatia Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Shirish Prayag
- Department of Critical Care, Prayag Hospital, Pune, Maharashtra, India, , e-mail:
| | - Suresh Ramasubban
- Department of Critical Care, Apollo Gleneagles Hospital Limited, Kolkata, India, , e-mail:
| | - Jayesh Dobariya
- Department of critical care, Synergy Hospital Rajkot, Rajkot, Gujarat, India, , e-mail:
| | - Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Military Hospital (CTC), Pune, Maharashtra, India, , e-mail:
| | - Inder Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India, , e-mail:
| | - Sameer Arvind Jog
- Department of Critical Care, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India, , 91-9823018178, e-mail:
| | - Atul Prabhakar Kulkarni
- Department of Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, , e-mail:
| |
Collapse
|
21
|
Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
Collapse
Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
22
|
Messika J, Martin Y, Maquigneau N, Puechberty C, Henry-Lagarrigue M, Stoclin A, Panneckouke N, Villard S, Dechanet A, Lafourcade A, Dreyfuss D, Hajage D, Ricard JD. A musical intervention for respiratory comfort during noninvasive ventilation in the ICU. Eur Respir J 2018; 53:13993003.01873-2018. [DOI: 10.1183/13993003.01873-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 10/31/2018] [Indexed: 01/29/2023]
Abstract
Discomfort associated with noninvasive ventilation (NIV) may participate in its failure. We aimed to determine the effect of a musical intervention on respiratory discomfort during NIV in patients with acute respiratory failure (ARF).An open-label, controlled trial was performed over three centres. Patients requiring NIV for ARF were randomised to either a musical intervention group (where they received a musical intervention and were subjected to visual deprivation during the first 30 min of each NIV session), a sensory deprivation group (where they wore insulating headphones and were subjected to visual deprivation during the first 30 min of each NIV session), or a control group (where they received NIV as routinely performed). The primary outcome was the change in respiratory discomfort before and after 30 min of the first NIV session.A total of 113 patients were randomised (36 in the musical intervention group, 38 in the sensory deprivation group and 39 in the control group). Median (interquartile range (IQR)) change in respiratory discomfort was 0 (−1; 1) between the musical intervention and control groups (p=0.7). Between groups comparison did not evidence any significant variation of respiratory parameters across time or health-related quality of life (HRQoL) at day-90. The Peri-traumatic Distress Inventory (PDI) at intensive care unit (ICU) discharge was reduced in musical intervention group patients. However, a 30 min musical intervention did not reduce respiratory discomfort during NIV for ARF in comparison to conventional care or sensory deprivation.
Collapse
|
23
|
Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. THE LANCET RESPIRATORY MEDICINE 2018; 6:935-947. [DOI: 10.1016/s2213-2600(18)30388-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022]
|
24
|
Piastra M, Pizza A, Gaddi S, Luca E, Genovese O, Picconi E, De Luca D, Conti G. Dexmedetomidine is effective and safe during NIV in infants and young children with acute respiratory failure. BMC Pediatr 2018; 18:282. [PMID: 30144795 PMCID: PMC6109351 DOI: 10.1186/s12887-018-1256-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 08/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is increasingly utilized in infants and young children, though associated with high failure rates due to agitation and poor compliance, mostly if patient-ventilator synchronization is required. METHODS A retrospective cohort study was carried out in an academic pediatric intensive care unit (PICU). Dexmedetomidine (DEX) was infused as unique sedative in 40 consecutive pediatric patients (median age 16 months) previously showing intolerance and agitation during NIV application. RESULTS During NIV clinical application both COMFORT-B Score and Richmond Agitation-Sedation Scale (RASS) were serially evaluated. Four patients experiencing NIV failure, all due to pulmonary condition worsening, required intubation and invasive ventilation. 36 patients were successfully weaned from NIV under DEX sedation and discharged from PICU. All patients survived until home discharge. CONCLUSION Our data suggest that DEX may represent an effective sedative agent in infants and children showing agitation during NIV. Early use of DEX in infants/children receiving NIV for acute respiratory failure (ARF) should be considered safe and capable of improving NIV, thus permitting both lung recruitment and patient-ventilator synchronization.
Collapse
Affiliation(s)
- M Piastra
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - A Pizza
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy.
| | - S Gaddi
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - E Luca
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - O Genovese
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - E Picconi
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - D De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, Paris, France
| | - G Conti
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| |
Collapse
|
25
|
Cai XF, Zhang FR, Zhang L, Sun JM, Li WB. [Efficacy of analgesic and sedative treatments in children with mechanical ventilation in the pediatric intensive care unit]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1138-1144. [PMID: 29132458 PMCID: PMC7389320 DOI: 10.7499/j.issn.1008-8830.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of different analgesic and sedative treatments in children with mechanical ventilation in the pediatric intensive care unit (PICU). METHODS Eighty children with mechanical ventilation in the PICU who needed analgesic and sedative treatments were equally and randomly divided into midazolam group and remifentanil+midazolam group. The sedative and analgesic effects were assessed using the Ramsay Scale and the Face, Legs, Activity, Cry and Consolability (FLACC) Scale. The following indices were recorded for the two groups: vital signs, ventilator parameters, organ function, total doses of remifentanil and midazolam, duration of mechanical ventilation, length of PICU stay, PICU cost, and incidence of adverse events. RESULTS Satisfactory sedation was achieved in the two groups, but the remifentanil+midazolam group had a significantly shorter time to analgesia and sedation than the midazolam group. The remifentanil+midazolam group had a significantly higher percentage of patients with grade 3-4 on the Ramsay Scale and a significantly lower dose of midazolam than the midazolam group (P<0.05). Both groups showed decreases in heart rate (HR), mean arterial pressure (MAP), and spontaneous breathing frequency (RRs) after treatment. However, the remifentanil+midazolam group had significantly greater decreases in HR at 3-24 hours after treatment and MAP and RRs at 3-12 hours after treatment than the midazolam group (P<0.05). Compared with the midazolam group, the remifentanil+midazolam group had significantly higher ventilator tidal volume and transcutaneous oxygen saturation at 6 and 12 hours after treatment and significantly lower end-tidal carbon dioxide partial pressure at 6 and 12 hours after treatment (P<0.05). The remifentanil+midazolam group had significantly shorter time to awake, extubation time, duration of mechanical ventilation, and length of PICU stay than the midazolam group (P<0.05). There were no significant differences in PICU cost, incidence of adverse events, and hepatic and renal functions before and after treatment between the two groups (P>0.05). Both groups showed a significant decrease in fasting blood glucose level after treatment (P<0.05). CONCLUSIONS For children with mechanical ventilation in the PICU, remifentanil+midazolam treatment can rapidly achieve analgesia and sedation, improve the effect of mechanical ventilation, and reduce the dose of sedative compared with midazolam alone, and is well tolerated.
Collapse
Affiliation(s)
- Xiao-Fang Cai
- Intensive Care Unit, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430016, China.
| | | | | | | | | |
Collapse
|
26
|
Ni YN, Wang T, Yu H, Liang BM, Liang ZA. The effect of sedation and/or analgesia as rescue treatment during noninvasive positive pressure ventilation in the patients with Interface intolerance after Extubation. BMC Pulm Med 2017; 17:125. [PMID: 28915879 PMCID: PMC5602861 DOI: 10.1186/s12890-017-0469-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 09/06/2017] [Indexed: 02/05/2023] Open
Abstract
Background Sedation and/or analgesia can relieve the patient-ventilator asynchrony. However, whether sedation and/or analgesia can benefit the clinical outcome of the patients with interface intolerance is still unclear. Methods A retrospective study was performed on patients with interface intolerance who received noninvasive positive pressure ventilation (NIPPV) after extubation in seven intensive care units (ICU) of West China Hospital, Sichuan University. The primary outcome was rate of NIPPV failure (defined as need for reintubation and mechanical ventilation); Secondary outcomes were hospital mortality rate and length of ICU stay after extubation. Results A total of 80 patients with oral-nasal mask (90%) and facial mask (10%) were included in the analysis. 41 out of 80 patients received sedation and/or analgesia treatment (17 used analgesia, 11 used sedation and 13 used both) at some time during NIPPV. They showed a decrease of NIPPV failure rate, (15% vs. 38%, P = 0.015; adjusted odd ratio [OR] 0.29, 95% confidence interval [CI] 0.10–0.86, P = 0.025), mortality rate (7% vs. 33%, P = 0.004; adjusted OR 0.14, 95% CI 0.03–0.60, P = 0.008), and the length of ICU stay after extubation. Conclusion This clinical study suggests that sedation and/or analgesia treatment can decrease the rate of NIPPV failure, hospital mortality rate and ICU LOS in patients with interface intolerance after extubution during NIPPV. Electronic supplementary material The online version of this article (10.1186/s12890-017-0469-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Ting Wang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China
| | - He Yu
- Department of Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China.
| | - Zong-An Liang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China.
| |
Collapse
|
27
|
Longhini F, Abdalla K, Navalesi P. Non-invasive ventilation in hypoxemic patients: does the interface make a difference? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:359. [PMID: 27761463 DOI: 10.21037/atm.2016.09.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy
| | - Karim Abdalla
- Anesthesia and Intensive Care, A.O.U. Mater Domini, Catanzaro, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy;; Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy;; CRRF Mons. L. Novarese, Moncrivello, VC, Italy
| |
Collapse
|
28
|
Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure: Role of Tidal Volume. Crit Care Med 2016; 44:282-90. [PMID: 26584191 DOI: 10.1097/ccm.0000000000001379] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A low or moderate expired tidal volume can be difficult to achieve during noninvasive ventilation for de novo acute hypoxemic respiratory failure (i.e., not due to exacerbation of chronic lung disease or cardiac failure). We assessed expired tidal volume and its association with noninvasive ventilation outcome. DESIGN Prospective observational study. SETTING Twenty-four bed university medical ICU. PATIENTS Consecutive patients receiving noninvasive ventilation for acute hypoxemic respiratory failure between August 2010 and February 2013. INTERVENTIONS Noninvasive ventilation was uniformly delivered using a simple algorithm targeting the expired tidal volume between 6 and 8 mL/kg of predicted body weight. MEASUREMENTS Expired tidal volume was averaged and respiratory and hemodynamic variables were systematically recorded at each noninvasive ventilation session. MAIN RESULTS Sixty-two patients were enrolled, including 47 meeting criteria for acute respiratory distress syndrome, and 32 failed noninvasive ventilation (51%). Pneumonia (n = 51, 82%) was the main etiology of acute hypoxemic respiratory failure. The median (interquartile range) expired tidal volume averaged over all noninvasive ventilation sessions (mean expired tidal volume) was 9.8 mL/kg predicted body weight (8.1-11.1 mL/kg predicted body weight). The mean expired tidal volume was significantly higher in patients who failed noninvasive ventilation as compared with those who succeeded (10.6 mL/kg predicted body weight [9.6-12.0] vs 8.5 mL/kg predicted body weight [7.6-10.2]; p = 0.001), and expired tidal volume was independently associated with noninvasive ventilation failure in multivariate analysis. This effect was mainly driven by patients with PaO2/FIO2 up to 200 mm Hg. In these patients, the expired tidal volume above 9.5 mL/kg predicted body weight predicted noninvasive ventilation failure with a sensitivity of 82% and a specificity of 87%. CONCLUSIONS A low expired tidal volume is almost impossible to achieve in the majority of patients receiving noninvasive ventilation for de novo acute hypoxemic respiratory failure, and a high expired tidal volume is independently associated with noninvasive ventilation failure. In patients with moderate-to-severe hypoxemia, the expired tidal volume above 9.5 mL/kg predicted body weight accurately predicts noninvasive ventilation failure.
Collapse
|
29
|
Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foëx B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 Suppl 2:ii1-35. [DOI: 10.1136/thoraxjnl-2015-208209] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
30
|
Bhatti H, Ramdass A, Cury JD, Jones LM, Shujaat A, Louis M, Seeram V, Bajwa AA. Operator dependent factors implicated in failure of non-invasive positive pressure ventilation (NIPPV) for respiratory failure. CLINICAL RESPIRATORY JOURNAL 2016; 11:901-905. [PMID: 26663322 DOI: 10.1111/crj.12434] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/13/2015] [Accepted: 12/04/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Non-invasive Positive Pressure Ventilation (NIPPV) is employed for the management of acute respiratory failure and studies have shown that it can prevent the need for endotracheal intubation, mechanical ventilation and associated complications. Given limited studies evaluating the factors, other than those related patient or underlying disease severity, that may lead to NIPPV failure, we performed this study to gain insight into current practices in terms of utilization of NIPPV and operator dependent factors that may possibly contribute to failure of NIPPV. METHOD After institutional board review approval a retrospective chart review was performed of consecutive patients who were initiated on and failed NIPPV between January 2009 and December 2009. Data was recorded regarding baseline demographics, admission diagnosis, indications for NIPPV, presence of contraindications, type of NIPPV and initial settings, ABG analysis before and after initiation, whether a titration of the settings was performed or not, operator related factors that may have contributed to failure of NIPPV and clinical outcomes. RESULTS Among 1095 patients screened, 111 failed NIPPV. The mean age was 60 years with 59% males. The most frequent indication for initiating NIPPV was COPD exacerbation (N = 27) followed by pneumonia (N = 26). CPAP was used in 5(6%) patients. Median inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) setting were 10 and 5 cm of H2 O respectively. Three most common reasons for failure were an inappropriate indication (33%), Progression of underlying disease (30%) and lack of titration (23%). Overall mortality was 22%. Mortality was higher when NIPPV failure was seen among patients with an inappropriate indication or an overlooked contraindication compared to those with an appropriate indication (27% vs 17%). CONCLUSIONS Excluding progression of underlying disease, operator dependent factors linked to NIPPV failure are; inappropriate indication, lack of adequate titration and an overlooked contraindication. Inappropriate utilization of NIPPV in respiratory failure is associated with higher mortality.
Collapse
Affiliation(s)
- Hammad Bhatti
- Orlando Veterans Affairs Medical Center, Orlando, FL, USA
| | - Avinash Ramdass
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - James D Cury
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Lisa M Jones
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Adil Shujaat
- University of Buffalo at State University of New York, Buffalo, NY, USA
| | - Mariam Louis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Vandana Seeram
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Abubakr A Bajwa
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| |
Collapse
|
31
|
Quelles mesures pour améliorer la tolérance de la ventilation non invasive. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1149-4] [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]
|
32
|
Sédation légère chez les patients en insuffisance respiratoire aiguë. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1147-2] [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]
|
33
|
Matsumoto T, Tomii K, Tachikawa R, Otsuka K, Nagata K, Otsuka K, Nakagawa A, Mishima M, Chin K. Role of sedation for agitated patients undergoing noninvasive ventilation: clinical practice in a tertiary referral hospital. BMC Pulm Med 2015; 15:71. [PMID: 26164393 PMCID: PMC4499444 DOI: 10.1186/s12890-015-0072-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 07/06/2015] [Indexed: 11/23/2022] Open
Abstract
Background Although sedation is often required for agitated patients undergoing noninvasive ventilation (NIV), reports on its practical use have been few. This study aimed to evaluate the efficacy and safety of sedation for agitated patients undergoing NIV in clinical practice in a single hospital. Methods We retrospectively reviewed sedated patients who received NIV due to acute respiratory failure from May 2007 to May 2012. Sedation level was controlled according to the Richmond Agitation Sedation Scale (RASS). Clinical background, sedatives, failure rate of sedation, and complications were evaluated by 1) sedative methods (intermittent only, switched to continuous, or initially continuous) and 2) code status (do-not-intubate [DNI] or non-DNI). Results Of 3506 patients who received NIV, 120 (3.4 %) consecutive patients were analyzed. Sedation was performed only intermittently in 72 (60 %) patients, was switched to continuously in 37 (31 %) and was applied only continuously in 11 (9 %). Underlying diseases in 48 % were acute respiratory distress syndrome/acute lung injury/severe pneumonia or acute exacerbation of interstitial pneumonia. In non-DNI patients (n = 39), no patient required intubation due to agitation with continuous sedation, and in DNI patients (n = 81), 96 % of patients could continue NIV treatment. PaCO2 level changes (6.7 ± 15.1 mmHg vs. -2.0 ± 7.7 mmHg, P = 0.028) and mortality in DNI patients (81 % vs. 57 %, P = 0.020) were significantly greater in the continuous use group than in the intermittent use group. Conclusions According to RASS scores, sedation during NIV in proficient hospitals may be favorably used to potentially avoid NIV failure in agitated patients, even in those having diseases with poor evidence of the usefulness of NIV. However, with continuous use, we must be aware of an increased hypercapnic state and the possibility of increased mortality. Larger controlled studies are needed to better clarify the role of sedation in improving NIV outcomes in intolerant patients. Electronic supplementary material The online version of this article (doi:10.1186/s12890-015-0072-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Takeshi Matsumoto
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan. .,Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto, 606-8507, Japan.
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Ryo Tachikawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan. .,Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto, 606-8507, Japan.
| | - Kojiro Otsuka
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Kazuma Nagata
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Kyoko Otsuka
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Atsushi Nakagawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto, 606-8507, Japan.
| | - Kazuo Chin
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto, 606-8507, Japan.
| |
Collapse
|
34
|
Conti G, Hill NS, Nava S. Is sedation safe and beneficial in patients receiving NIV? No. Intensive Care Med 2015; 41:1692-5. [PMID: 26149298 DOI: 10.1007/s00134-015-3915-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/08/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Giorgio Conti
- Department of Intensive Care and Anesthesia, Catholic University of Rome, Largo A Gemelli 1, 00168, Rome, Italy
| | | | | |
Collapse
|
35
|
Hilbert G, Navalesi P, Girault C. Is sedation safe and beneficial in patients receiving NIV? Yes. Intensive Care Med 2015; 41:1688-91. [DOI: 10.1007/s00134-015-3935-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/17/2015] [Indexed: 01/27/2023]
|
36
|
Muriel A, Peñuelas O, Frutos-Vivar F, Arroliga AC, Abraira V, Thille AW, Brochard L, Nin N, Davies AR, Amin P, Du B, Raymondos K, Rios F, Violi DA, Maggiore SM, Soares MA, González M, Abroug F, Bülow HH, Hurtado J, Kuiper MA, Moreno RP, Zeggwagh AA, Villagómez AJ, Jibaja M, Soto L, D’Empaire G, Matamis D, Koh Y, Anzueto A, Ferguson ND, Esteban A. Impact of sedation and analgesia during noninvasive positive pressure ventilation on outcome: a marginal structural model causal analysis. Intensive Care Med 2015; 41:1586-600. [DOI: 10.1007/s00134-015-3854-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
|
37
|
Sedation in non-invasive ventilation: do we know what to do (and why)? Multidiscip Respir Med 2014; 9:56. [PMID: 25699177 PMCID: PMC4333891 DOI: 10.1186/2049-6958-9-56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/06/2014] [Indexed: 01/01/2023] Open
Abstract
This review examines some of the issues encountered in the use of sedation in patients receiving respiratory support from non-invasive ventilation (NIV). This is an area of critical and intensive care medicine where there are limited (if any) robust data to guide the development of best practice and where local custom appears to exert a strong influence on patterns of care. We examine aspects of sedation for NIV where the current lack of structure may be contributing to missed opportunities to improve standards of care and examine the existing sedative armamentarium. No single sedative agent is currently available that fulfils the criteria for an ideal agent but we offer some observations on the relative merits of different agents as they relate to considerations such as effects on respiratory drive and timing, and airways patency. The significance of agitation and delirium and the affective aspect(s) of dyspnoea are also considered. We outline an agenda for placing the use of sedation in NIV on a more systematic footing, including clearly expressed criteria and conditions for terminating NIV and structural and organizational conditions for prospective multicentre trials.
Collapse
|
38
|
Devlin JW, Al-Qadheeb NS, Chi A, Roberts RJ, Qawi I, Garpestad E, Hill NS. Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebo-controlled pilot study. Chest 2014; 145:1204-1212. [PMID: 24577019 DOI: 10.1378/chest.13-1448] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Successful application of noninvasive ventilation (NIV) for acute respiratory failure (ARF) requires patient cooperation and comfort. The efficacy and safety of early IV dexmedetomidine when added to protocolized, as-needed IV midazolam and fentanyl remain unclear. METHODS Adults with ARF and within 8 h of starting NIV were randomized to receive IV dexmedetomidine (0.2 μg/kg/h titrated every 30 min to 0.7 μg/kg/h to maintain a Sedation-Agitation Scale [SAS] score of 3 to 4) or placebo in a double-blind fashion up to 72 h, until NIV was stopped for ≥ 2 h, or until intubation. Patients with agitation (SAS ≥ 5) or pain (visual analog scale ≥ 5 of 10 cm) 15 min after each dexmedetomidine and placebo increase could receive IV midazolam 0.5 to 1.0 mg or IV fentanyl 25 to 50 μg, respectively, at a minimum interval of every 3 h. RESULTS The dexmedetomidine (n = 16) and placebo (n = 17) groups were similar at baseline. Use of early dexmedetomidine did not improve NIV tolerance (score, 1 of 4; OR, 1.44; 95% CI, 0.44-4.70; P = .54) nor, vs. placebo, led to a greater median (interquartile range) percent time either tolerating NIV (99% [61%-100%] vs. 67% [40%-100%], P = .56) or remaining at the desired sedation level (SAS score = 3 or 4, 100% [86%-100%] vs. 100% [100%-100%], P = .28], or fewer intubations (P = .79). Although use of dexmedetomidine was associated with a greater duration of NIV vs placebo (37 [16-72] vs. 12 [4-22] h, P = .03), the total ventilation duration (NIV + invasive) was similar (3.3 [2-4] days vs. 3.8 [2-5] days, P = .52). More patients receiving dexmedetomidine had one or more episodes of deep sedation vs placebo (SAS ≤ 2, 25% vs. 0%, P = .04). Use of midazolam (P = .40) and episodes of either severe bradycardia (heart rate ≤ 50 beats/min, P = .18) or hypotension (systolic BP ≤ 90 mm Hg, P = .64) were similar. CONCLUSIONS Initiating dexmedetomidine soon after NIV initiation in patients with ARF neither improves NIV tolerance nor helps to maintain sedation at a desired goal. Randomized, multicenter trials targeting patients with initial intolerance are needed to further elucidate the role for dexmedetomidine in this population.
Collapse
Affiliation(s)
- John W Devlin
- School of Pharmacy, Northeastern University; Division of Pulmonary, Critical Care and Sleep Medicine.
| | | | - Amy Chi
- Division of Pulmonary, Critical Care and Sleep Medicine
| | | | - Imrana Qawi
- Division of Pulmonary, Critical Care and Sleep Medicine
| | | | | |
Collapse
|
39
|
Ozyilmaz E, Ugurlu AO, Nava S. Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies. BMC Pulm Med 2014; 14:19. [PMID: 24520952 PMCID: PMC3925956 DOI: 10.1186/1471-2466-14-19] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 01/29/2014] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | - Stefano Nava
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Respiratory and Critical Care, University of Bologna, Sant'Orsola Malpighi Hospital building #15, Alma Mater Studiorum, via Massarenti n,15, Bologna 40185, Italy.
| |
Collapse
|
40
|
Suzuki T, Kurazumi T, Toyonaga S, Masuda Y, Morita Y, Masuda J, Kosugi S, Katori N, Morisaki H. Evaluation of noninvasive positive pressure ventilation after extubation from moderate positive end-expiratory pressure level in patients undergoing cardiovascular surgery: a prospective observational study. J Intensive Care 2014; 2:5. [PMID: 25520822 PMCID: PMC4267591 DOI: 10.1186/2052-0492-2-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 01/08/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND It remains to be clarified if the application of noninvasive positive pressure ventilation (NPPV) is effective after extubation in patients with hypoxemic respiratory failure who require the sufficient level of positive end-expiratory pressure (PEEP). This study was aimed at examining the effect and the safety of NPPV application following extubation in patients requiring moderate PEEP level for sufficient oxygenation after cardiovascular surgery. METHODS With institutional ethic committee approval, the patients ventilated invasively for over 48 h after cardiovascular surgery were enrolled in this study. The patients who failed the first spontaneous breathing trial (SBT) at 5 cmH2O of PEEP, but passed the second SBT at 8 cmH2O of PEEP, received NPPV immediately after extubation following our weaning protocol. Respiratory parameters (partial pressure of arterial oxygen tension to inspiratory oxygen fraction ratio: P/F ratio, respiratory ratio, and partial pressure of arterial carbon dioxide: PaCO2) 2 h after extubation were evaluated with those just before extubation as the primary outcome. The rate of re-intubation, the frequency of respiratory failure and intolerance of NPPV, the duration of NPPV, and the length of intensive care unit (ICU) stay were also recorded. RESULTS While 51 postcardiovascular surgery patients were screened, 6 patients who met the criteria received NPPV after extubation. P/F ratio was increased significantly after extubation compared with that before extubation (325 ± 85 versus 245 ± 55 mmHg, p < 0.05). The other respiratory parameters did not change significantly. Re-intubation, respiratory failure, and intolerance of NPPV never occurred. The duration of NPPV and the length of ICU stay were 2.7 ± 0.7 (SD) and 7.5 (6 to 10) (interquartile range) days, respectively. CONCLUSIONS While further investigation should be warranted, NPPV could be applied effectively and safely after extubation in patients requiring the moderate PEEP level after cardiovascular surgery.
Collapse
Affiliation(s)
- Takeshi Suzuki
- />Department of Anesthesiology and General Intensive Care Unit, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan
| | - Takuya Kurazumi
- />Department of Anesthesia, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa 210-0013 Japan
| | - Shinya Toyonaga
- />Department of Anesthesia, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa 210-0013 Japan
| | - Yuya Masuda
- />Department of Anesthesia, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa 210-0013 Japan
| | - Yoshihisa Morita
- />Department of Anesthesia, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa 210-0013 Japan
| | - Junichi Masuda
- />Department of Anesthesia, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa 210-0013 Japan
| | - Shizuko Kosugi
- />Department of Anesthesiology and General Intensive Care Unit, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan
| | - Nobuyuki Katori
- />Department of Anesthesiology and General Intensive Care Unit, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan
| | - Hiroshi Morisaki
- />Department of Anesthesiology and General Intensive Care Unit, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan
| |
Collapse
|
41
|
Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
42
|
Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
|
43
|
Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:223. [PMID: 23680299 PMCID: PMC3672531 DOI: 10.1186/cc11875] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO₂ rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure.
Collapse
|
44
|
Carron M, Freo U, BaHammam AS, Dellweg D, Guarracino F, Cosentini R, Feltracco P, Vianello A, Ori C, Esquinas A. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth 2013; 110:896-914. [PMID: 23562934 DOI: 10.1093/bja/aet070] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.
Collapse
Affiliation(s)
- M Carron
- Department of Pharmacology and Anesthesiology, University of Padua, Padua, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Lemyze M, Mallat J, Gasan G, Van Grunderbeeck N, Tronchon L, Thevenin D. NIV should be delivered in do-not-intubate patients in acute respiratory failure, but how? Intensive Care Med 2013; 39:983. [PMID: 23417205 DOI: 10.1007/s00134-013-2859-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2013] [Indexed: 11/28/2022]
|
46
|
Vaschetto R, Turucz E, Dellapiazza F, Guido S, Colombo D, Cammarota G, Della Corte F, Antonelli M, Navalesi P. Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study. Intensive Care Med 2012; 38:1599-606. [PMID: 22825283 DOI: 10.1007/s00134-012-2652-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 06/27/2012] [Indexed: 01/27/2023]
Abstract
PURPOSE The use of noninvasive ventilation (NIV) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure (hypoxemic ARF) has never been explored. This pilot study aims to assess the feasibility of early extubation followed by immediate NIV, compared conventional weaning, in patients with resolving hypoxemic ARF. METHODS Twenty consecutive hypoxemic patients were randomly assigned to receive either conventional weaning or NIV. The changes in arterial blood gases and respiratory rate were compared between the two groups at 1, 12, 24 and 48 h. Differences in the rate of extubation failure, ICU and hospital mortality, number of invasive-ventilation-free-days at day 28, septic complications, number of tracheotomies, days and rates of continuous intravenous sedation, and ICU length of stay were also determined. RESULTS No patient interrupted the study protocol. Arterial blood gases were similar during invasive mechanical ventilation, 1 h after NIV application following extubation, and after 12, 24 and 48 h. Respiratory rate was higher after 1 h in the NIV group, but no different after 12, 24 and 48 h. The number of invasive-ventilation-free-days at day 28 was 20 ± 8 (min = 0, max = 25) days in the treatment group and 10 ± 9 (min = 0, max = 25) days in the control group (p = 0.014). The rate of extubation failure, ICU and hospital mortality, tracheotomies, septic complications, days and rates of continuous sedation, and ICU length of stay were not significantly different between the two groups. CONCLUSIONS In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF.
Collapse
Affiliation(s)
- Rosanna Vaschetto
- Anesthesia and Intensive Care Medicine, Maggiore della Carità Hospital, Novara, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Archambault PM, St-Onge M. Invasive and Noninvasive Ventilation in the Emergency Department. Emerg Med Clin North Am 2012; 30:421-49, ix. [DOI: 10.1016/j.emc.2011.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Clouzeau B, Vargas F, Boyer A, Bui HN, Gruson D, Hilbert G. Place et modalités de la sédation au cours de la ventilation non invasive. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
49
|
Scala R. Hypercapnic encephalopathy syndrome: a new frontier for non-invasive ventilation? Respir Med 2011; 105:1109-17. [PMID: 21354774 DOI: 10.1016/j.rmed.2011.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 02/01/2011] [Accepted: 02/07/2011] [Indexed: 02/07/2023]
Abstract
According to the classical international guidelines, non-invasive ventilation is contraindicated in hypercapnic encephalopathy syndrome (HES) due to the poor compliance to ventilatory treatment of confused/agitated patients and the risk of aspirative pneumonia related to lack of airways protection. As a matter of fact, conventional mechanical ventilation has been recommended as "golden standard" in these patients. However, up to now there are not controlled data that have demonstrated in HES the advantage of conventional mechanical ventilation vs non-invasive ventilation. In fact, patients with altered mental status have been systematically excluded from the randomised and controlled trials performed with non-invasive ventilation in hypercapnic acute respiratory failure. Recent studies have clearly demonstrated that an initial cautious NPPV trial in selected HES patients may be attempt as long as there are no other contraindications and the technique is provided by experienced caregivers in a closely monitored setting where ETI is always readily available. The purpose of this review is to report the physiologic rationale, the clinical feasibility and the still open questions about the careful use of non-invasive ventilation in HES as first-line ventilatory strategy in place of conventional mechanical ventilation via endotracheal intubation.
Collapse
Affiliation(s)
- Raffaele Scala
- U.O. Pneumologia e Unità di Terapia Semi-Intensiva Respiratoria, Campo di Marte Hospital, Lucca, Italy.
| |
Collapse
|
50
|
Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2010: III. ARDS and ALI, mechanical ventilation, noninvasive ventilation, weaning, endotracheal intubation, lung ultrasound and paediatrics. Intensive Care Med 2011; 37:394-410. [PMID: 21290103 PMCID: PMC3042109 DOI: 10.1007/s00134-011-2136-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 01/19/2011] [Indexed: 01/10/2023]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|