Use of noninvasive ventilation at the pulmonary infection control window for acute respiratory failure in AECOPD patients: A systematic review and meta-analysis based on GRADE approach

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Effect of spontaneous breathing trial on extubation in patients with acute exacerbation of chronic obstructive pulmonary disease under mechanical ventilation

Objective

To evaluate how spontaneous breathing trial (SBT) affects successful extubation and prognosis in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients under mechanical ventilation.

Methods

AECOPD patients under invasive mechanical ventilation were recruited into the study and divided into the SBT and non-SBT groups. SBT patients received SBT for 60 min before extubation, while non-SBT patients that met weaning criteria were immediately extubated without SBT.

Results

A total of 64 patients were enrolled in analysis, including 32 in SBT group and 32 in non-SBT group. Patients in the two groups had similar baseline demographics and clinical characteristics (all parameters: p =  > 0.05). Four (12.5%) patients in the SBT group and 5 (15.6%) in the non-SBT group were reintubated in 48 h of extubation (p = 0.821). During the 28-day follow-up after extubation, 3 patients died, 1 (3.1%) in the SBT group and 2 (6.3%) in the non-SBT group (p = 0.554).

Conclusion

Our findings indicate that SBT did not affect extubation success, in-hospital mortality, and 28-day survival in AECOPD patients under mechanical ventilation.

Procalcitonin kinetics to guide sequential invasive-noninvasive mechanical ventilation weaning in patients with acute exacerbation of chronic obstructive pulmonary disease and respiratory failure: procalcitonin's adjunct role

How to identify the optimum switch point of sequential invasive and noninvasive ventilation is the focus of clinical attention on the patients suffering from acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated by acute respiratory failure (ARF). This study aims to explore the clinical significance of taking the change rate of procalcitonin (PCT) as identifying the timing of weaning on the mechanical ventilation for the patients of AECOPD followed by ARF as a complication. There were altogether 140 patients of AECOPD complicated with ARF, who were randomly selected and divided into a study group and a control group respectively. A change rate of serum PCT level exceeding 50% was taken as the switch point selection of tracheal intubation removal for the patients of the study group, while the ‘pulmonary infection control (PIC) window’ was done for those in the control group. With CRP, IL-6, TNF-a, PaCO_2, PaO_2, and Lac having been detected before and after treatment to them all, clinical indexes were obtained and compared between these two groups. The CRP, TNF-a, and IL-6 levels of the patients in the study group after treatment (p < 0.05) were lower than those in the control group. There was no significant difference in PaCO_2, PaO_2, and Lac between these two groups before and after treatment (p > 0.05). Even so, some other indexes available for the study group of patients were found to be lower than those for the control group (p < 0.05) in the following aspects: duration of invasive ventilation support, total time of mechanical ventilation support, incidence rate of ventilator-associated pneumonia, 48-hour reintubation rate, incidence rate of upper gastrointestinal bleeding, hospitalization time of critical respiratory illness, total hospitalization time, RICU treatment cost, total treatment cost, and mortality. It is preferable to take the change rate of PCT level exceeding 50% as the switch point of weaning time in sequential mechanical ventilation rather than the PIC window.

Abbreviations

AECOPD: acute exacerbation of chronic obstructive pulmonary disease; ARF: acute respiratory failure; PCT: procalcitonin; PaO₂: the oxygen partial pressure; PaCO₂: the partial pressure of carbon dioxide; TNF-a: serum tumor necrosis factor-a; IL-6: interleukin-6; CRP: serum C-reactive protein; PIC window: pulmonary infection control window; RICU: respiration and intensive care unit

Invasive-noninvasive Sequential Ventilation for the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

BACKGROUND

The study aimed to evaluate the efficacy and safety of invasivenoninvasive sequential ventilation versus invasive ventilation in the treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD).

METHODS

PubMed, Cochrane, Embase, Wanfang, CNKI, VIP database were searched by the index words to identify the qualified RCTs, and relevant literature sources were also searched. The latest research was conducted in June 2017. Relative Risks (RR), and Mean Difference (MD) along with 95% confidence interval (95% CI) were used to analyze the main outcomes.

RESULTS

Twenty-nine RCTs were involved in this analysis of 1061 patients in the invasivenoninvasive sequential ventilation group (In-non group) and 1074 patients in the invasive ventilation group (In group). The results indicated that compared with the invasive ventilation, invasive-noninvasive sequential ventilation would significantly decrease the incidence of VAP (RR:0.20, 95%CI: 0.16-0.26), mortality (RR:0.38, 95%CI: 0.26-0.55), reintubation (RR:0.39, 95%CI: 0.27-0.55); and statistically reduced the duration of invasive ventilation (MD:-9.23, 95%CI: -10.65, -7.82), the total duration of mechanical ventilation (MD:-4.91, 95%CI: -5.99, -3.83), and the length of stay in the ICU (MD:-5.10, 95%CI: -5.43, -4.76).

CONCLUSION

The results demonstrated that the application of noninvasive sequential ventilation after invasive ventilation at the pulmonary infection control window has a significant influence on VAP incidence, mortality, and the length of stay in the ICU, but further well-designed, adequately powered RCTs are required to validate the conclusion.

Comparison of high flow nasal cannula with noninvasive ventilation in chronic obstructive pulmonary disease patients with hypercapnia in preventing postextubation respiratory failure: A pilot randomized controlled trial

High flow nasal cannula (HFNC) has been shown to improve extubation outcomes in patients with hypoxemia, but the role of HFNC in weaning patients with chronic obstructive pulmonary disease (COPD) with hypercapnia from invasive ventilation is unclear. We compared the effects of HFNC to noninvasive ventilation (NIV) on postextubation vital signs and arterial blood gases (ABGs) among patients with COPD. Other outcomes included comfort scores, need for bronchoscopy, use of pulmonary medications, and chest physiotherapy. Forty-two COPD patients who had persistent hypercapnia at extubation were assigned randomly to receive HFNC (22) or NIV (20). Twenty patients in each group were enrolled for per-protocol analysis with regard to primary outcomes. Vital signs and ABGs before extubation were similar between groups. At 3 hr after extubation, pH in the NIV group was lower than HFNC group (7.42 ± 0.06 vs. 7.45 ± 0.05, p = 0.01). At 24 hr after extubation, patients' mean arterial pressure (82.97 ± 9.04 vs. 92.06 ± 11.11 mmHg, p = 0.05) and pH (7.42 ± 0.05 vs. 7.46 ± 0.03, p = 0.05) in the NIV group were lower than in the HFNC group. No significant differences were found at 48 hr after extubation. In the HFNC group, comfort scores were better (3.55 ± 2.01 vs. 5.15 ± 2.28, p = 0.02) and fewer patients needed bronchoscopy for secretion management within 48 hr after extubation (2/22 vs. 9/20, p = 0.03). HFNC is a potential alternative to NIV to wean hypercapnic COPD patients with regard to vital signs and ABGs, HFNC improved patients' comfort and secretion clearance.

Effects of Budesonide Combined with Noninvasive Ventilation on PCT, sTREM-1, Chest Lung Compliance, Humoral Immune Function and Quality of Life in Patients with AECOPD Complicated with Type II Respiratory Failure

Objective

Our objective is to explore the effects of budesonide combined with noninvasive ventilation on procalcitonin (PCT), soluble myeloid cell triggering receptor-1 (sTREM-1), thoracic and lung compliance, humoral immune function, and quality of life in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with type II respiratory failure.

Methods

There were 82 patients with AECOPD complicated with type II respiratory failure admitted into our hospital between March, 2016-September, 2017. They were selected and randomly divided into observation group (n=41) and control group (n=41). The patients in the control group received noninvasive mechanical ventilation and the patients in the observation group received budesonide based on the control group. The treatment courses were both 10 days.

Results

The total effective rate in the observation group (90.25%) was higher than the control group (65.85%) (P<0.05). The scores of cough, expectoration, and dyspnea were decreased after treatment (Observation group: t=18.7498, 23.2195, 26.0043, control group: t=19.9456, 11.6261, 14.2881, P<0.05); the scores of cough, expectoration, and dyspnea in the observation group were lower than the control group after treatment (t=11.6205, 17.4139, 11.6484, P<0.05). PaO2 was increased and PaCO2 was decreased in both groups after treatment (Observation group: t=24.1385, 20.7360, control group: t=11.6606, 9.2268, P<0.05); PaO2 was higher and PaCO2 was lower in the observation group than the control group after treatment (t=10.3209, 12.0115, P<0.05). Serum PCT and sTREM-1 in both groups were decreased after treatment (Observation group: t=16.2174, 12.6698, control group: t=7.2283, 6.1634, P<0.05); serum PCT and sTREM-1 in the observation group were lower than the control group after treatment (t=10.1017, 7.8227, P<0.05). The thoracic and lung compliance in both groups were increased after treatment (Observation group: t=30.5359, 17.8471, control group: t=21.2426, 13.0007, P<0.05); the thoracic and lung compliance in the observation group were higher than the control group after treatment (t=10.8079, 5.9464, P<0.05). IgA and IgG in both groups were increased after treatment (Observation group: t=9.5794, 25.3274, control group: t=5.5000, 4.7943, P<0.05), however IgM was not statistically different after treatment (Observation group: t=0.7845, control group: t=0.1767, P>0.05); IgA and IgG in the observation group were higher than the control group (t=4.9190, 4.7943, P<0.05), however IgM was not statistically different between two groups after treatment (t=0.6168, P>0.05). COPD assessment test (CAT) scores were decreased in both groups after treatment (Observation group: t=20.6781, control group: t=9.0235, P<0.05); CAT score in the observation group was lower than the control group after treatment (t=12.9515, P<0.05). Forced expiratory volume in one second (FEV1%) and forced expiratory volume in one second/ forced expiratory volume in one second (FEV1/FVC) were increased in both groups after treatment (Observation group: t=15.3684, 15.9404, control group: t=10.6640, 12.8979, P<0.05); FEV1% and FEV1/FVC in the observation group were higher than the control group (t=6.9528, 7.3527,P<0.05). The rates of complication were not statistically different between two groups (P>0.05).

Conclusion

Budesonide combined with noninvasive mechanical ventilation has good curative effects in treating AECOPE patients complicated with type II respiratory failure. It can decrease serum PCT and sTREM-1, increase thoracic lung compliance, and improve the humoral immune function and life quality.

The benefit of daily sputum suction via bronchoscopy in patients of chronic obstructive pulmonary disease with ventilators: A randomized controlled trial

BACKGROUND

To compare the clinical values of bronchoscopic sputum suction and general sputum suction in respiratory failure patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) combined with sequential invasive-noninvasive mechanical ventilation at the pulmonary infection control (PIC) window (period of lower sputum production, with thinner viscosity and lighter color, and alleviated clinical signs of infection).

METHODS

Patients with AECOPD-induced respiratory failure received orotracheal intubation mechanical ventilation and were randomly divided into bronchoscopic sputum suction group or general sputum suction group, and who were then treated with sequential invasive-noninvasive mechanical ventilation at PIC window (both groups). Baseline data, postoperative blood gas conditions, and postoperative clinical parameters of the patients such as appearance of PIC window, time of invasive ventilation, total time of ventilation, hospital stay, weaning success rate, reintubation rate, ventilator-associated pneumonia (VAP) incidence, and fatality rate were measured to compare the effect of 2 different ways of sputum suction.

RESULTS

There was no significant difference in baseline characteristics, postoperative blood gas conditions, between 2 groups (all P > .05). Nevertheless, the bronchoscopic sputum suction group showed earlier appearance of PIC window, shorter time of invasive ventilation, total time of ventilation and hospital stay, lower reintubation rate, VAP incidence and fatality rate, and higher weaning success rate than the general sputum suction group (all P < .05).

CONCLUSION

Bronchoscopic sputum suction combined with sequential invasive-noninvasive mechanical ventilation at PIC window showed clinical effects in treating respiratory failure patients with AECOPD.

Erratum: Medicine, Volume 95, Issue 24: Erratum

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