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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
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.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Volpato E, Banfi PI, Pagnini F. Acceptance and adherence to non-invasive positive pressure ventilation in people with chronic obstructive pulmonary disease: a grounded theory study. Front Psychol 2023; 14:1134718. [PMID: 37599749 PMCID: PMC10435845 DOI: 10.3389/fpsyg.2023.1134718] [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: 12/30/2022] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Non-Invasive Positive Pressure Ventilation (NPPV) is an established treatment for people with Chronic Obstructive Pulmonary Disease (COPD), but it is often improperly used or rejected. The patterns of acceptance and adherence to NPPV, conceiving constraints, and strengths related to its adaptation have not been explored from a qualitative perspective yet. Objectives This study aims to qualitatively explore patterns of adaptation to NPPV in people affected by COPD and to identify the core characteristics and the specific adaptive challenges during the adaptation process. Methods Forty-two people with moderate or severe COPD were recruited and 336 unstructured interviews were conducted. A Constructivist Grounded Theory was used to gather and analyze data: the transcriptions were mutually gathered in open, selective, and theoretical phases, with open, selective, and theoretical coding, respectively. Results The analysis resulted in a non-linear and dynamic process, characterized by three phases: deciding, trying NPPV, and using NPPV. The patterns revealed that positive and negative NPPV experiences, together with beliefs, emotions, stressful mental states, and behaviors result in different acceptance and adherence rates. Discussions These findings may be helpful to implement new care strategies to promote acceptance and adherence to NPPV.
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Affiliation(s)
- Eleonora Volpato
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | | | - Francesco Pagnini
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
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Elsayed AA, Neanaa EHM, Beshey BN. Diaphragmatic impairment as a predictor of invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2085975] [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] Open
Affiliation(s)
- Amr Abdalla Elsayed
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Bassem Nashaat Beshey
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Azzi M, Aboab J, Alviset S, Ushmorova D, Ferreira L, Ioos V, Memain N, Issoufaly T, Lermuzeaux M, Laine L, Serbouti R, Silva D. Extracorporeal CO 2 removal in acute exacerbation of COPD unresponsive to non-invasive ventilation. BMJ Open Respir Res 2021; 8:8/1/e001089. [PMID: 34893522 PMCID: PMC8666884 DOI: 10.1136/bmjresp-2021-001089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO₂ removal (ECCO₂R) devices can be an alternative to intubation. The aim of the study was to assess ECCO₂R effectiveness and safety. Methods Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO₂R device implementation in our ICU in 2015 (Xenios AG). Results Both groups (ECCO₂R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO₂R group (30 kg/m² vs 25 kg/m²). pH and PaCO₂ significantly improved in both groups. The mean time on ECCO₂R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO₂R group, of whom three received IMV after ECCO₂R weaning. Seven major bleeding events were observed with ECCO₂R, but only three led to premature discontinuation of ECCO₂R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO₂R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%. Conclusions ECCO₂R was associated with significant improvement of pH and PaCO₂ in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates. Trial registration number ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered. https://www.clinicaltrials.gov/ct2/show/NCT04882410.
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Affiliation(s)
- Mathilde Azzi
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Jerome Aboab
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Sophie Alviset
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Daria Ushmorova
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Luis Ferreira
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Vincent Ioos
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Nathalie Memain
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Tazime Issoufaly
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Mathilde Lermuzeaux
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Laurent Laine
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Rita Serbouti
- Medical Affairs, Fresenius Medical Care France SAS, Fresnes, Île-de-France, France
| | - Daniel Silva
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
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Feng X, Pan S, Yan M, Shen Y, Liu X, Cai G, Ning G. Dynamic prediction of late noninvasive ventilation failure in intensive care unit using a time adaptive machine model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106290. [PMID: 34298473 DOI: 10.1016/j.cmpb.2021.106290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Noninvasive ventilation (NIV) failure is strongly associated with poor prognosis. Nowadays, plenty of mature studies have been proposed to predict early NIV failure (within 48 hours of NIV), however, the prediction for late NIV failure (after 48 hours of NIV) lacks sufficient research. Late NIV failure delays intubation resulting in the increasing mortality of the patients. Therefore, it is of great significance to expeditiously predict the late NIV failure. In order to dynamically predict late NIV failure, we proposed a Time Updated Light Gradient Boosting Machine (TULightGBM) model. MATERIAL AND METHODS In this work, 5653 patients undergoing NIV over 48 hours were extracted from the database of Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) for model construction. The TULightGBM model consists of a series of sub-models which learn clinical information from updating data within 48 hours of NIV and integrates the outputs of the sub-models by the dynamic attention mechanism to predict late NIV failure. The performance of the proposed TULightGBM model was assessed by comparison with common models of logistic regression (LR), random forest (RF), LightGBM, eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and long short-term memory (LSTM). RESULTS The TULightGBM model yielded prediction results at 8, 16, 24, 36, and 48 hours after the start of the NIV with dynamic AUC values of 0.8323, 0.8435, 0.8576, 0.8886, and 0.9123, respectively. Furthermore, the sensitivity, specificity, and accuracy of the TULightGBM model were 0.8207, 0.8164, and 0.8184, respectively. The proposed model achieved superior performance over other tested models. CONCLUSIONS The TULightGBM model is able to dynamically predict the late NIV failure with high accuracy and offer potential decision support for clinical practice.
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Affiliation(s)
- Xue Feng
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
| | - Su Pan
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China
| | - Molei Yan
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Yanfei Shen
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Xiaoqing Liu
- Deepwise AI LAB, 8 Haidian Road, Beijng 100089, China
| | - Guolong Cai
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China.
| | - Gangmin Ning
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
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Risk Factors Associated with Late Failure of Noninvasive Ventilation in Patients with Chronic Obstructive Pulmonary Disease. Can Respir J 2020; 2020:8885464. [PMID: 33123301 PMCID: PMC7582075 DOI: 10.1155/2020/8885464] [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: 08/19/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022] Open
Abstract
Background Risk factors for noninvasive ventilation (NIV) failure after initial success are not fully clear in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Methods Patients who received NIV beyond 48 h due to acute exacerbation of COPD were enrolled. However, we excluded those whose pH was higher than 7.35 or PaCO2 was less than 45 mmHg which was measured before NIV. Late failure of NIV was defined as patients required intubation or died during NIV after initial success. Results We enrolled 291 patients in this study. Of them, 48 (16%) patients experienced late NIV failure (45 received intubation and 3 died during NIV). The median time from initiation of NIV to intubation was 4.8 days (IQR: 3.4–8.1). Compared with the data collected at initiation of NIV, the heart rate, respiratory rate, pH, and PaCO2 significantly improved after 1–2 h of NIV both in the NIV success and late failure of NIV groups. Nosocomial pneumonia (odds ratio (OR) = 75, 95% confidence interval (CI): 11–537), heart rate at initiation of NIV (1.04, 1.01–1.06 beat per min), and pH at 1–2 h of NIV (2.06, 1.41–3.00 per decrease of 0.05 from 7.35) were independent risk factors for late failure of NIV. In addition, the Glasgow coma scale (OR = 0.50, 95% CI: 0.34–0.73 per one unit increase) and PaO2/FiO2 (0.992, 0.986–0.998 per one unit increase) were independent protective factors for late failure of NIV. In addition, patients with late failure of NIV had longer ICU stay (median 9.5 vs. 6.6 days) and higher hospital mortality (92% vs. 3%) compared with those with NIV success. Conclusions Nosocomial pneumonia; heart rate at initiation of NIV; and consciousness, acidosis, and oxygenation at 1–2 h of NIV were associated with late failure of NIV in patients with COPD exacerbation. And, late failure of NIV was associated with increased hospital mortality.
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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Navarra SM, Congedo MT, Pennisi MA. Indications for Non-Invasive Ventilation in Respiratory Failure. Rev Recent Clin Trials 2020; 15:251-257. [PMID: 32493199 DOI: 10.2174/1574887115666200603151838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 04/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Non-invasive ventilation (NIV) is increasingly being used to treat episodes of acute respiratory failure not only in critical care and respiratory wards, but also in emergency departments. AIM Aim of this review is to summarize the current indications for the management of NIV for respiratory failure. METHODS Current literature about the topic was reviewed and critically reported to describe the rationale and physiologic advantages of NIV in various situations of respiratory failure. RESULTS Early NIV use is commonly associated with the significant decrease in endotracheal intubation rate, the incidence of infective complications (especially ventilatory associated pneumonia), Intensive Care Units and the length of hospital stay and, in selected conditions, also in mortality rates. Severe acute exacerbation of chronic obstructive pulmonary disease (pH<7.35 and relative hypercarbia) and acute cardiogenic pulmonary oedema are the most common NIV indications; in these conditions NIV advantages are clearly documented. Not so evident are the NIV benefits in hypoxaemic respiratory failure occurring without prior chronic respiratory disease (De novo respiratory failure). One recent randomized control trial reported in hypoxaemic respiratory failure a survival benefit of high-flow nasal cannulae over standard oxygen therapy and bilevel NIV. Evidence suggests the advantages of NIV also in respiratory failure in immunocompromised patients or chest trauma patients. Use during a pandemic event has been assessed in several observational studies but remains controversial; there also is not sufficient evidence to support the use of NIV treatment in acute asthma exacerbation. CONCLUSION NIV eliminates morbidity related to the endotracheal tube (loss of airway defense mechanism with increased risk of pneumonia) and in selected conditions (COPD exacerbation, acute cardiogenic pulmonary edema, immunosuppressed patients with pulmonary infiltrates and hypoxia) is clearly associated with a better outcome in comparison to conventional invasive ventilation. However, NIV is associated with complications, especially minor complications related to interface. Major complications like aspiration pneumonia, barotrauma and hypotension are infrequent.
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Affiliation(s)
- Simone Maria Navarra
- Department of Emergency Medicine, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Teresa Congedo
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS - Universita Cattolica del Sacro Cuore, Rome, Italy
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Barrett NA, Hart N, Camporota L. Assessment of Work of Breathing in Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. COPD 2019; 16:418-428. [PMID: 31694406 DOI: 10.1080/15412555.2019.1681390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The assessment of the work of breathing (WOB) of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) is difficult, particularly when the patient first presents with acute hypercapnia and respiratory acidosis. Acute exacerbations of COPD patients are in significant respiratory distress and noninvasive measurements of WOB are easier for the patient to tolerate. Given the interest in using alternative therapies to noninvasive ventilation, such as high flow nasal oxygen therapy or extracorporeal carbon dioxide removal, understanding the physiological changes are key and this includes assessment of WOB. This narrative review considers the role of three different methods of assessing WOB in patients with acute exacerbations of COPD. Esophageal pressure is a very well validated measure of WOB, however the ability of patients with acute exacerbations of COPD to tolerate esophageal tubes is poor. Noninvasive alternative measurements include parasternal electromyography (EMG) and electrical impedance tomography (EIT). EMG is easily applied and is a well validated measure of neural drive but is more likely to be degraded by the electrical environment in intensive care or high dependency. EIT is less well validated as a tool for WOB in COPD but extremely well tolerated by patients. Each of the different methods assess WOB in a different way and have different advantages and disadvantages. For research into therapies treating acute exacerbations of COPD, combinations of EIT, EMG and esophageal pressure are likely to be better than only one of these.
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Affiliation(s)
- N A Barrett
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - N Hart
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - L Camporota
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Barrett NA, Kostakou E, Hart N, Douiri A, Camporota L. Extracorporeal carbon dioxide removal for acute hypercapnic exacerbations of chronic obstructive pulmonary disease: study protocol for a randomised controlled trial. Trials 2019; 20:465. [PMID: 31362776 PMCID: PMC6664508 DOI: 10.1186/s13063-019-3548-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/29/2019] [Indexed: 01/14/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a common cause of chronic respiratory failure and its course is punctuated by a series of acute exacerbations which commonly lead to hospital admission. Exacerbations are managed through the application of non-invasive ventilation and, when this fails, tracheal intubation and mechanical ventilation. The need for mechanical ventilation significantly increases the risk of death. An alternative therapy, extracorporeal carbon dioxide removal (ECCO2R), has been shown to be efficacious in removing carbon dioxide from the blood; however, its impact on respiratory physiology and patient outcomes has not been explored. Methods/design A randomised controlled open label trial of patients (12 in each arm) with acute exacerbations of COPD at risk of failing conventional therapy (NIV) randomised to either remaining on NIV or having ECCO2R added to NIV with a primary endpoint of time to cessation of NIV. The change in respiratory physiology following the application of ECCO2R and/or NIV will be measured using electrical impedance tomography, oesophageal pressure and parasternal electromyography. Additional outcomes, including patient tolerance, outcomes, need for readmission, changes in blood gases and biochemistry and procedural complications, will be measured. Physiological changes will be compared within one patient over time and between the two groups. Healthcare costs in the UK system will also be compared between the two groups. Discussion COPD is a common disease and exacerbations are a leading cause of hospital admission in the UK and worldwide, with a sizeable mortality. The management of patients with COPD consumes significant hospital and financial resources. This study seeks to understand the feasibility of a novel approach to the management of patients with acute exacerbations of COPD as well as to understand the underlying physiological changes to explain why the approach does or does not assist this patient cohort. Detailed respiratory physiology has not been previously undertaken using this technique and there are no other randomised controlled trials currently in the literature. Trial registration ClinicalTrials.gov, NCT02086084. Electronic supplementary material The online version of this article (10.1186/s13063-019-3548-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK. .,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Eirini Kostakou
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Nicholas Hart
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.,Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, WC2R 2LS, UK.,National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Trust and King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK.,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Steriade AT, Johari S, Sargarovschi N, Necula D, Tudose CE, Ionita D, Bogdan MA, Bumbacea D. Predictors of outcome of noninvasive ventilation in severe COPD exacerbation. BMC Pulm Med 2019; 19:131. [PMID: 31319839 PMCID: PMC6639947 DOI: 10.1186/s12890-019-0892-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 07/09/2019] [Indexed: 12/24/2022] Open
Abstract
Background Noninvasive ventilation (NIV) reduces the rate of endotracheal intubation (ETI) and overall mortality in severe acute exacerbation of COPD (AECOPD) with acute respiratory failure and is increasingly applied in respiratory intermediate care units. However, inadequate patient selection and incorrect management of NIV increase mortality. We aimed to identify factors that predict the outcome of NIV in AECOPD. Also, we looked for factors that influence ventilator settings and duration. Methods A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2016 and 2017. Age, BMI, lung function, arterial pH and pCO2 at admission (t0), at 1–2 h (t1) and 4–6 h (t2) after admission, creatinine clearance, echocardiographic data (that defined left heart dysfunction), mean inspiratory pressure during the first 72 h (mIPAP-72 h) and hours of NIV during the first 72 h (dNIV-72 h) were recorded. Main outcome was NIV failure (i.e., ETI or in-hospital death). Secondary outcomes were in-hospital mortality, length of stay (LOS), duration of NIV (days), mIPAP-72 h, and dNIV-72 h. Results We included 89 patients (45 male, mean age 67.6 years) with AECOPD that required NIV. NIV failure was 12.4%, and in-hospital mortality was 11.2%. NIV failure was correlated with days of NIV, LOS, in-hospital mortality (p < 0.01), and kidney dysfunction (p < 0.05). In-hospital mortality was strongly associated with days of NIV (OR 1.27, 95%CI: 1.07–1.5, p < 0.01) and with FEV1 (p < 0.05). All other investigated parameters (including left heart dysfunction, dNIV-72 h, mIPAP-72 h, pH, etc.) did not influence NIV failure or mortality. dNIV-72 h and days of NIV were independent predictors of LOS (p < 0.01). Regarding the secondary outcomes, left heart dysfunction and pH at 1-2 h independently predicted NIV duration (dNIV-72 h, p < 0.01), while BMI and baseline pCO2 predicted NIV settings (mIPAP-72 h, p < 0.01). Conclusion In-hospital mortality and NIV failure were not influenced by BMI, left heart dysfunction, age, nor by arterial blood gas values in the first 6 h of NIV. Patients with severe acidosis and left heart dysfunction required prolonged use of NIV. BMI and pCO2 levels influence the NIV settings in AECOPD regardless of lung function.
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Affiliation(s)
- Alexandru T Steriade
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania. .,"Carol Davila" University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania.
| | - Shirin Johari
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania
| | - Nicoleta Sargarovschi
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania
| | - Daniela Necula
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania
| | - Cornelia E Tudose
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania
| | - Diana Ionita
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania
| | - Miron A Bogdan
- "Carol Davila" University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania.,"Marius Nasta" Institute of Pneumology, 90 Viilor St., București, 050152, Bucharest, Romania
| | - Dragos Bumbacea
- Department of Pneumology & Acute Respiratory Care, "Elias" Emergency University Hospital, 17 Marasti Blvd, 011461, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474, Bucharest, Romania
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12
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Corsonello A, Aucella F, Pedone C, Antonelli-Incalzi R. Chronic kidney disease: A likely underestimated component of multimorbidity in older patients with chronic obstructive pulmonary disease. Geriatr Gerontol Int 2017; 17:1770-1788. [DOI: 10.1111/ggi.13054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/28/2017] [Accepted: 02/20/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology; Italian National Research Center on Aging (INRCA); Cosenza Italy
| | - Filippo Aucella
- Department of Nephrology and Dialysis; Scientific Institute for Research and Health Care "Casa Sollievo della Sofferenza" IRCCS; San Giovanni Rotondo Foggia Italy
| | - Claudio Pedone
- Unit of Geriatric and Respiratory Medicine; University Campus BioMedico; Rome Italy
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13
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Kreppein U, Litterst P, Westhoff M. [Hypercapnic respiratory failure. Pathophysiology, indications for mechanical ventilation and management]. Med Klin Intensivmed Notfmed 2016; 111:196-201. [PMID: 26902369 DOI: 10.1007/s00063-016-0143-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/13/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute hypercapnic respiratory failure is mostly seen in patients with chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). Depending on the underlying cause it may be associated with hypoxemic respiratory failure and places high demands on mechanical ventilation. OBJECTIVE Presentation of the current knowledge on indications and management of mechanical ventilation in patients with hypercapnic respiratory failure. MATERIAL AND METHODS Review of the literature. RESULTS Important by the selection of mechanical ventilation procedures is recognition of the predominant pathophysiological component. In hypercapnic respiratory failure with a pH < 7.35 non-invasive ventilation (NIV) is primarily indicated unless there are contraindications. In patients with severe respiratory acidosis NIV requires a skilled and experienced team and close monitoring in order to perceive a failure of NIV. In acute exacerbation of COPD ventilator settings need a long expiration and short inspiration time to avoid further hyperinflation and an increase in intrinsic positive end-expiratory pressure (PEEP). Ventilation must be adapted to the pathophysiological situation in patients with OHS or overlap syndrome. If severe respiratory acidosis and hypercapnia cannot be managed by mechanical ventilation therapy alone extracorporeal venous CO2 removal may be necessary. Reports on this approach in awake patients are available. CONCLUSION The use of NIV is the predominant treatment in patients with hypercapnic respiratory failure but close monitoring is necessary in order not to miss the indications for intubation and invasive ventilation. Methods of extracorporeal CO2 removal especially in awake patients need further evaluation.
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Affiliation(s)
- U Kreppein
- Abteilung für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland
| | - P Litterst
- Abteilung für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland
| | - M Westhoff
- Abteilung für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland. .,Universität Witten/Herdecke, 58448, Witten, Deutschland.
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Ko BS, Ahn S, Lim KS, Kim WY, Lee YS, Lee JH. Early failure of noninvasive ventilation in chronic obstructive pulmonary disease with acute hypercapnic respiratory failure. Intern Emerg Med 2015; 10:855-60. [PMID: 26341216 DOI: 10.1007/s11739-015-1293-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 08/08/2015] [Indexed: 11/24/2022]
Abstract
Noninvasive ventilation (NIV) in the management of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure is considered a first-line therapy. However, patients who fail NIV and then require invasive mechanical ventilation have been found to have higher mortality than patients initially treated with invasive mechanical ventilation. We tried to find parameters associated with early NIV failure (need for intubation or death <24 h of starting NIV) in patients presenting to the ED with acute exacerbation of COPD. A retrospective analysis was conducted of the medical records of 218 patients with acute exacerbation of COPD visiting Asan Medical Center and managed with NIV during their stay in the ED from January 2007 to December 2013. NIV was successful in 200 (91.7%) and 18 (8.3%) had early NIV failure. Of the variables obtained before NIV treatment, heart rate (≥120/min: OR 2.5, 95% CI 1.2-7.0) and pH (7.25-7.29: OR 2.1, 95% CI 1.0-8.8; <7.25: OR 11.7, 95% CI 3.5-38.6) were significant factors associated with early NIV failure. Of the variables obtained after 1 h of NIV treatment, heart rate (≥120/min: OR 7.5, 95% CI 2.3-24.3) and pH (7.25-7.29: OR 4.7, 95% CI 1.5-15.1; <7.25: OR 20.9, 95% CI 5.4-61.2) were still significant. The presence of tachycardia and severe acidosis before NIV treatment and persistence of tachycardia and severe acidosis after 1 h of NIV treatment were associated with early NIV failure.
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Affiliation(s)
- Byuk Sung Ko
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea.
| | - Kyung Soo Lim
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
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Zamzam MA, Abd El Aziz AA, Elhefnawy MY, Shaheen NA. Study of the characteristics and outcomes of patients on mechanical ventilation in the intensive care unit of EL-Mahalla Chest Hospital. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2015.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Hajizadeh N, Crothers K, Braithwaite RS. Using modeling to inform patient-centered care choices at the end of life. J Comp Eff Res 2014; 2:497-508. [PMID: 24236746 DOI: 10.2217/cer.13.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Advance directives are often under-informed due to a lack of disease-specific prognostic information. Without well-informed advance directives patients may receive default care that is incongruent with their preferences. We aimed to further inform advance care planning in patients with severe chronic obstructive pulmonary disease by estimating outcomes with alternative advance directives. METHODS We designed a Markov microsimulation model estimating outcomes for patients choosing between the Full Code advance directive (permitting invasive mechanical ventilation), and the Do Not Intubate directive (only permitting noninvasive ventilation). RESULTS Our model estimates Full Code patients have marginally increased one-year survival after admission for severe respiratory failure, but are more likely to be residing in a nursing home and have frequent rehospitalizations for respiratory failure. CONCLUSION Patients with severe chronic obstructive pulmonary disease may consider these potential tradeoffs between survival, rehospitalizations and institutionalization when making informed advance care plans and end-of-life decisions. We highlight outcomes research needs for variables most influential to the model's outcomes, including the risk of complications of invasive mechanical ventilation and failing noninvasive mechanical ventilation.
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Affiliation(s)
- Negin Hajizadeh
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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17
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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.
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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.
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18
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Sørensen D, Frederiksen K, Groefte T, Lomborg K. Striving for habitual well-being in noninvasive ventilation: a grounded theory study of chronic obstructive pulmonary disease patients with acute respiratory failure. J Clin Nurs 2013; 23:1726-35. [DOI: 10.1111/jocn.12322] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Dorthe Sørensen
- Section for Nursing Health; Aarhus University; Aarhus Denmark
| | | | - Thorbjoern Groefte
- Department of Anaesthesiology; Randers Regional Hospital; Randers Denmark
| | - Kirsten Lomborg
- Section for Nursing Health; Aarhus University; Aarhus Denmark
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Brulotte CA, Lang ES. Acute exacerbations of chronic obstructive pulmonary disease in the emergency department. Emerg Med Clin North Am 2012; 30:223-47, vii. [PMID: 22487106 DOI: 10.1016/j.emc.2011.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPDs) are a common presentation to emergency departments and are an important cause of respiratory failure. This article discusses the disease process and diagnosis of COPD and AECOPD. A further in-depth discussion is undertaken of evidence-based treatments, palliation, and disposition of patients who present to emergency departments with AECOPD.
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Affiliation(s)
- Cory A Brulotte
- Department of Emergency Medicine, Alberta Health Services: Calgary Zone, Foothills Medical Center, 1403 29th Street Northwest, Room C231, Calgary, Alberta, Canada T2N 2T9.
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20
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Hajizadeh N, Crothers K, Braithwaite RS. Informing shared decisions about advance directives for patients with severe chronic obstructive pulmonary disease: a modeling approach. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:357-366. [PMID: 22433768 DOI: 10.1016/j.jval.2011.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 09/19/2011] [Accepted: 10/25/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To estimate the survival and quality-adjusted life-years (QALYs) of Full Code versus Do Not Intubate (DNI) advance directives in patients with severe chronic obstructive pulmonary disease and to evaluate how patient preferences and place of residence influence these outcomes. METHODS A Markov decision model using published data for COPD exacerbation outcomes. The advance directives that were modeled were as follows: DNI, allowing only noninvasive mechanical ventilation, or Full Code, allowing all forms of mechanical ventilation including invasive mechanical ventilation with endotracheal tube (ETT) insertion. RESULTS In community-dwellers, Full Code resulted in a greater likelihood of survival and higher QALYs (4-year survival: 23% Full Code, 18% DNI; QALYs: 1.34 Full Code, 1.24 DNI). When considering patient preferences regarding complications, however, if patients were willing to give up >3 months of life expectancy to avoid ETT complications, or >1 month of life expectancy to avoid long-term institutionalization, DNI resulted in higher QALYs. For patients in long-term institutions, DNI resulted in a greater likelihood of survival and higher QALYs (4-year survival: 2% DNI, 1% Full Code; QALYs: 0.29 DNI, 0.24 Full Code). In sensitivity analyses, the model was sensitive to the probabilities of ETT complication and noninvasive mechanical ventilation failure and to patient preferences about ETT complications and long-term institutionalization. CONCLUSION Our model demonstrates that patient preferences regarding ETT complications and long-term institutionalization, as well as baseline place of residence, affect the advance directive recommendation when considered in terms of both survival and QALYs. Decision modeling can demonstrate the potential trade-off between survival and quality of life, using patient preferences and disease-specific data, to inform the shared advance directive decision.
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Affiliation(s)
- Negin Hajizadeh
- Division of General Internal Medicine, New York University, New York, NY 10010, USA.
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21
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Corral-Gudino L, Jorge-Sánchez RJ, García-Aparicio J, Herrero-Herrero JI, López-Bernús A, Borao-Cengotita-Bengoa M, Martín-González JI, Moreiro-Barroso MT. Use of noninvasive ventilation on internal wards for elderly patients with limitations to respiratory care: a cohort study. Eur J Clin Invest 2011; 41:59-69. [PMID: 20868369 DOI: 10.1111/j.1365-2362.2010.02380.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of noninvasive positive pressure ventilation (NPPV) outside the intensive wards has been evaluated in patients with no limitation on life-sustaining support. Our aim was to evaluate its usefulness in general wards for patients with NPPV as the ceiling of ventilator care when admission to the intensive care unit (ICU) has been withheld. MATERIALS AND METHODS Noninvasive positive pressure ventilation was used in 44 patients with acute respiratory failure (ARF) and limitations to respiratory care- 22 with chronic obstructive pulmonary disease (COPD) exacerbations and 22 with acute cardiogenic pulmonary oedema (CPE). Survival at hospital discharge, and survival and readmission rate at 12 months were assessed. RESULTS Sixty-three per cent of COPD and 55% of CPE patients survived hospital discharge; and 50% and 37% respectively, were alive after 1 year. The cause of the in-hospital mortality was related to the admission diagnosis in 88% of cases. Cancer in COPD patients [P = 0·040, odds ratio (OR) = 15, 95% CI = 1·14-198] and the completion of NPPV treatment in both diseases (P = 0·008, OR = 0·03, 95% CI = 0·00-0·39 for COPD and P = 0·010, OR = 0·04, 95% CI = 0·00-0·45 for CPE) were related to in-hospital mortality. Fifty-six per cent of COPD and 33% of CPE patients that survived hospital admission were readmitted. CONCLUSIONS Our study suggests that the use of NPPV in general wards could be a safe and effective option, as a last choice treatment, in patients with NPPV as the ceiling of ventilator care when admission to ICU has been withheld.
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Affiliation(s)
- Luis Corral-Gudino
- Servicio de Medicina Interna, Hospital de los Montalvos, Hospital Universitario de Salamanca, Spain.
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A theoretical decision model to help inform advance directive discussions for patients with COPD. BMC Med Inform Decis Mak 2010; 10:75. [PMID: 21172022 PMCID: PMC3020153 DOI: 10.1186/1472-6947-10-75] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 12/20/2010] [Indexed: 11/19/2022] Open
Abstract
Background Advance directives (AD) may promote preference-concordant care yet are absent in many patients with Chronic Obstructive Pulmonary Disease (COPD). In order to begin to inform AD discussions between clinicians and COPD patients, we constructed a decision tree to estimate the impact of alternative AD decisions on both quality and quantity of life (quality adjusted life years, QALYs). Methods Two aspects of the AD were considered, Do Not Intubate (DNI; i.e., no invasive mechanical ventilation) and Full Code (i.e., may use invasive mechanical ventilation). Model parameters were based on published estimates. Our model follows hypothetical patients with COPD to evaluate the effect of underlying COPD severity and of hypothetical patient-specific preferences (about long-term institutionalization and complications from invasive mechanical ventilation) on the recommended AD. Results Our theoretical model recommends endorsing the Full Code advance directive for patients who do not have strong preferences against having a potential complication from intubation (ETT complications) or being discharged to a long-term ECF. However, our model recommends endorsing the DNI advance directive for patients who do have strong preferences against having potential complications of intubation and are were willing to tradeoff substantial amounts of time alive to avoid ETT complications or permanent institutionalization. Our theoretical model also recommends endorsing the DNI advance directive for patients who have a higher probability of having complications from invasive ventilation (ETT). Conclusions Our model suggests that AD decisions are sensitive to patient preferences about long-term institutionalization and potential complications of therapy, particularly in patients with severe COPD. Future work will elicit actual patient preferences about complications of invasive mechanical ventilation, and incorporate our model into a clinical decision support to be used for actual COPD patients facing AD decisions.
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Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a frequent cause of hospital admission and are associated with significant morbidity, mortality, high readmission rates and high resource utilization. More accurate prediction of survival and readmission in patients hospitalized with AECOPD should help to optimize clinical management and allocation of resources, including targeting of palliative care and strategies to reduce readmissions. We have reviewed the published retrospective and prospective studies in this field to identify the factors most likely to be of value in predicting in-hospital and post-discharge mortality, and readmission of patients hospitalized for AECOPD. The prognostic factors which appear most important vary with the particular outcome under consideration. In-hospital mortality is related most clearly to the patient's acute physiological state and to the development of acute comorbidity, while post-discharge mortality particularly reflects the severity of the underlying COPD, as well as specific comorbidities, especially cardiac disease. Important factors influencing the frequency of readmission include functional limitation and poor health-related quality of life. Large prospective studies which incorporate all the potentially relevant variables are required to refine prediction of the important outcomes of AECOPD and thus to inform clinical decision making, for example on escalation of care, facilitated discharge and provision of palliative care.
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Affiliation(s)
- J Steer
- North Tyneside General Hospital, Northumbria Health NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear, NE29 8NH, UK.
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Factors associated with noninvasive ventilation failure in postoperative acute respiratory insufficiency: an observational study. Eur J Anaesthesiol 2010; 27:270-4. [PMID: 20182089 DOI: 10.1097/eja.0b013e32832dbd49] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Few data are available on the efficacy of noninvasive ventilation (NIV) in postoperative patients with acute respiratory failure (ARF). METHODS Seventy-two patients coming from the surgical wards with postoperative ARF were retrospectively evaluated. The major characteristics of patients who were intubated were compared with the characteristics of those who were not after a trial of NIV. Predictive factors for failure of NIV were analysed. RESULTS Out of 72 patients with ARF after surgery who were treated with NIV, 42 avoided intubation (58%). On a univariate analysis, a decrease in the paO2/FiO2 ratio after 1 h of NIV (223 +/- 84 to 160 +/- 68 mmHg, P < 0.05) was associated with NIV failure and need for tracheal intubation because of nosocomial pneumonia and an increased simplified acute physiology score (SAPS) 2. In a multivariate analysis, nosocomial pneumonia [odds ratio (OR) 4.189; 95% confidence interval (CI) 1.383-12.687] and SAPS 2 higher than 35 (OR 4.969; 95% CI 1.627-15.172) were independent predictive factors of NIV failure. NIV success was associated with a reduced ICU stay (16.8 vs. 26.1 days, P < 0.001). CONCLUSION NIV could be considered in postoperative patients who presented with ARF. Nosocomial pneumonia is predictive of NIV failure.
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Chronic obstructive pulmonary disease exacerbations in emergency departments: predictors of outcome. Curr Opin Pulm Med 2010; 16:112-7. [PMID: 20019614 DOI: 10.1097/mcp.0b013e328335f039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Exacerbations have a major short-term and long-term impact on patients with chronic obstructive pulmonary disease (COPD). Risk stratification of patients presenting to the emergency department for an exacerbation of COPD is of utmost importance to help in deciding patients' orientation and treatment and in improving outcomes. RECENT FINDINGS Studies on predictors of outcomes of COPD exacerbations are markedly heterogeneous in terms of assessed variables, outcomes of interest and timeframe (short-term vs. long-term outcomes). Age, severity of underlying disease, clinical signs of immediate severity, and comorbidities are among the most frequently identified prognostic factors of in-hospital outcome. In the most severe patients, ICU scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) also have a prognostic value. Several biomarkers have also been studied, but their additional value for risk stratification is not clarified. SUMMARY Scores predicting the risk of poor outcome could prove useful in the management of COPD exacerbations. Some have been suggested but remain to be further validated before their use can be generalized.
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Poor sleep quality is associated with late noninvasive ventilation failure in patients with acute hypercapnic respiratory failure*. Crit Care Med 2010; 38:477-85. [DOI: 10.1097/ccm.0b013e3181bc8243] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Domínguez-Cherit G, Posadas-Calleja JG, Borunda D. Chronic Obstructive Pulmonary Disease. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50042-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Agarwal R, Gupta R, Aggarwal AN, Gupta D. Noninvasive positive pressure ventilation in acute respiratory failure due to COPD vs other causes: effectiveness and predictors of failure in a respiratory ICU in North India. Int J Chron Obstruct Pulmon Dis 2008; 3:737-43. [PMID: 19281088 PMCID: PMC2650588 DOI: 10.2147/copd.s3454] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To determine the effectiveness of noninvasive positive pressure ventilation (NIPPV), and the factors predicting failure of NIPPV in acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) versus other causes of ARF. PATIENTS AND METHODS This was a prospective observational study and all patients with ARF requiring NIPPV over a one-and-a-half year period were enrolled in the study. We recorded the etiology of ARF and prospectively collected the data for heart rate, respiratory rate, arterial blood gases (pH, partial pressure of oxygen in the arterial blood [PaO2], partial pressure of carbon dioxide in arterial blood [PaCO2]) at baseline, one and four hours. The patients were further classified into two groups based on the etiology of ARF as COPD-ARF and ARF due to other causes. The primary outcome was the need for endotracheal intubation during the intensive care unit (ICU) stay. RESULTS During the study period, 248 patients were admitted in the ICU and of these 63 (25.4%; 24, COPD-ARF, 39, ARF due to other causes; 40 male and 23 female patients; mean [standard deviation] age of 45.7 [16.6] years) patients were initiated on NIPPV. Patients with ARF secondary to COPD were older, had higher APACHE II scores, lower respiratory rates, lower pH and higher PaCO2 levels compared to other causes of ARF. After one hour there was a significant decrease in respiratory rate and heart rate and decline in PaCO2 levels with increase in pH and PaO2 levels in patients successfully managed with NIPPV. However, there was no difference in improvement of clinical and blood gas parameters between the two groups except the rate of decline of pH at one and four hours and PaCO2 at one hour which was significantly faster in the COPD group. NIPPV failures were significantly higher in ARF due to other causes (15/39) than in ARF-COPD (3/24) (p = 0.03). The mean ICU and hospital stay and the hospital mortality were similar in the two groups. In the multivariate logistic regression model (after adjusting for gender, APACHE II scores and improvement in respiratory rate, pH, PaO2 and PaCO2 at one hour) only the etiology of ARF, ie, ARF-COPD, was associated with a decreased risk of NIPPV failure (odds ratio 0.23; 95% confidence interval, 0.58-0.9). CONCLUSIONS NIPPV is more effective in preventing endotracheal intubation in ARF due to COPD than other causes, and the etiology of ARF is an important predictor of NIPPV failure.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Khilnani GC, Banga A. Noninvasive ventilation in patients with chronic obstructive airway disease. Int J Chron Obstruct Pulmon Dis 2008; 3:351-7. [PMID: 18990962 PMCID: PMC2629986 DOI: 10.2147/copd.s946] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Recent years have seen the emergence of noninvasive ventilation (NIV) as an important tool for management of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Several well conducted studies in the recent years have established its role in the initial, as well as later management of these patients. However, some grey areas remain. Moreover, data is emerging on the role of long term nocturnal NIV use in patients with very severe stable COPD. This review summarizes the evidence supporting the use of NIV in various stages of COPD, discuss the merits as well as demerits of this novel ventilatory strategy and highlight the grey areas in the current body of knowledge.
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Affiliation(s)
- Gopi C Khilnani
- Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
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Suri JC, Ramakrishnan N, Mani RK, Khilnani GC, Sidhu US, Nagarkar S. Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med 2006. [DOI: 10.4103/0972-5229.25926] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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