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Yaroshetskiy AI, Merzhoeva ZM, Tsareva NA, Trushenko NV, Nuralieva GS, Konanykhin VD, Krasnoshchekova AP, Avdeev SN. Breathing pattern, accessory respiratory muscles work, and gas exchange evaluation for prediction of NIV failure in moderate-to-severe COVID-19-associated ARDS after deterioration of respiratory failure outside ICU: the COVID-NIV observational study. BMC Anesthesiol 2022; 22:307. [PMID: 36183064 PMCID: PMC9525938 DOI: 10.1186/s12871-022-01847-7] [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: 05/23/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data on the efficacy of non-invasive ventilation (NIV) after progression of respiratory failure in patients who have already received oxygen therapy, or CPAP outside ICU is limited. The study aimed to find predictors of NIV failure based on breathing pattern, gas exchange, and accessory respiratory muscles evaluation in patients who progressed to moderate-to-severe COVID-19 ARDS. METHODS This was a prospective observational study in patients with moderate-to-severe COVID-19-ARDS on NIV (n = 80) admitted to COVID-ICU of Sechenov University. The combined success rate for conventional oxygen and CPAP outside ICU was 78.6% (440 of 560 patients). The primary endpoints were intubation rate and mortality. We measured respiratory rate, exhaled tidal volume (Vte), mean peak inspiratory flow (PIF), inspiratory time (Ti), PaO2, SpO2, end-tidal carbon dioxide (PETCO2), and Patrick score, and calculated ROX index, PaO2/FiO2, ventilatory ratio, and alveolar dead space (Vdalv/Vt) on Days 1, 3, 5, 7, 10, and 14. For all significant differences between NIV success and failure groups in measured data, we performed ROC analysis. RESULTS NIV failure rate in ICU after deterioration of respiratory failure outside ICU was 71.3% (n = 57). Patients with the subsequent NIV failure were older at inclusion, more frail, had longer duration of disease before ICU admission, and higher rate of CPAP use outside ICU. ROC-analysis revealed that the following respiratory parameters after 48 h of NIV can serve as a predictors for NIV failure in moderate-to-severe COVID-19-associated ARDS: PaO2/FiO2 < 112 mmHg (AUROC 0.90 (0.93-0.97), p < 0.0001); PETCO2 < 19.5 mmHg (AUROC 0.84 (0.73-0.94), p < 0.0001); VDalv/VT > 0.43 (AUROC 0.78 (0.68-0.90), p < 0.0001); ROX-index < 5.02 (AUROC 0.89 (0.81-0.97), p < 0.0001); Patrick score > 2 points (AUROC 0.87 (0.78-0.96), p = 0.006). CONCLUSION In patients who progressed to moderate-to-severe COVID-19-ARDS probability of NIV success rate was about 1/3. Prediction of the NIV failure can be made after 48 h based on ROX index < 5.02, PaO2/FiO2 < 112 mmHg, PETCO2 < 19.5 mmHg, and Patrick score > = 2. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04667923 , registered on 16/12/2020.
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Affiliation(s)
- Andrey I Yaroshetskiy
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia. .,Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia.
| | - Zamira M Merzhoeva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia A Tsareva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia V Trushenko
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Galia S Nuralieva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vasily D Konanykhin
- Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia
| | - Anna P Krasnoshchekova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Anesthesiology and Critical Care Department, Research Institution for Clinical Surgery Division, Pirogov Russian National Research Medical University, 8/2 Trubetskaya Str., Moscow, 119991, Russia
| | - Sergey N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Xia J, Gu S, Lei W, Zhang J, Wei H, Liu C, Zhang H, Lu R, Zhang L, Jiang M, Hu C, Cheng Z, Wei C, Chen Y, Lu F, Chen M, Bi H, Liu H, Yan C, Teng H, Yang Y, Liang C, Ge Y, Hou P, Liu J, Gao W, Zhang Y, Feng Y, Tao C, Huang X, Pan P, Luo H, Yun C, Zhan Q. High-flow nasal cannula versus conventional oxygen therapy in acute COPD exacerbation with mild hypercapnia: a multicenter randomized controlled trial. Crit Care 2022; 26:109. [PMID: 35428349 PMCID: PMC9013098 DOI: 10.1186/s13054-022-03973-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background High-flow nasal cannula (HFNC) can improve ventilatory function in patients with acute COPD exacerbation. However, its effect on clinical outcomes remains uncertain. Methods This randomized controlled trial was conducted from July 2017 to December 2020 in 16 tertiary hospitals in China. Patients with acute COPD exacerbation with mild hypercapnia (pH ≥ 7.35 and arterial partial pressure of carbon dioxide > 45 mmHg) were randomly assigned to either HFNC or conventional oxygen therapy. The primary outcome was the proportion of patients who met the criteria for intubation during hospitalization. Secondary outcomes included treatment failure (intolerance and need for non-invasive or invasive ventilation), length of hospital stay, hospital cost, mortality, and readmission at day 90. Results Among 337 randomized patients (median age, 70.0 years; 280 men [83.1%]; median pH 7.399; arterial partial pressure of carbon dioxide 51 mmHg), 330 completed the trial. 4/158 patients on HFNC and 1/172 patient on conventional oxygen therapy met the criteria for intubation (P = 0.198). Patients progressed to NPPV in both groups were comparable (15 [9.5%] in the HFNC group vs. 22 [12.8%] in the conventional oxygen therapy group; P = 0.343). Compared with conventional oxygen therapy, HFNC yielded a significantly longer median length of hospital stay (9.0 [interquartile range, 7.0–13.0] vs. 8.0 [interquartile range, 7.0–11.0] days) and a higher median hospital cost (approximately $2298 [interquartile range, $1613–$3782] vs. $2005 [interquartile range, $1439–$2968]). There were no significant differences in other secondary outcomes between groups. Conclusions In this multi-center randomized controlled study, HFNC compared to conventional oxygen therapy did not reduce need for intubation among acute COPD exacerbation patients with mild hypercapnia. The future studies should focus on patients with acute COPD exacerbation with respiratory acidosis (pH < 7.35). However, because the primary outcome rate was well below expected, the study was underpowered to show a meaningful difference between the two treatment groups. Trial registration: NCT03003559. Registered on December 28, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03973-7.
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Fossat G, Daillet B, Desmalles E, Boulain T. Does diaphragm ultrasound improve the rapid shallow breathing index accuracy for predicting the success of weaning from mechanical ventilation? Aust Crit Care 2021; 35:233-240. [PMID: 34340902 DOI: 10.1016/j.aucc.2021.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This prospective study investigated whether taking into account diaphragmatic excursion (DE) measured by ultrasonography would improve the performance of the rapid shallow breathing index (RSBI) to predict extubation success or failure. OBJECTIVES The aim of the study was to compare the new composite index named the rapid shallow diaphragmatic index (RSDI), and the RSBI measured during a spontaneous breathing trial regarding their ability to predict the need for re-intubation at 72 h. METHODS One hundred mechanically ventilated patients underwent daily 30-min spontaneous breathing trials (SBTs) under pressure support ventilation of 6 cm H2O and end-expiratory pressure of 0 cm H2O until the SBT was considered successful and followed by extubation. The performances of RSBI (respiratory rate/tidal volume) and of the ratio RSBI/DE measured at 5 and 25 min of the successful SBT were compared in terms of area under the receiver operating characteristics curve (AUC), for predicting extubation success at 72 h. As secondary analysis, extubation and weaning success at 7 d were also considered. As exploratory analyses, predictive indices incorporating both clinical characteristics, the DE, and ultrasound diaphragm thickening fraction (DTF) were investigated. RESULTS RSBI and RSBI/DE showed AUCs with 95% confidence intervals consistently extending below 0.50, either at the 5th (0.55 [0.36-0.74] and 0.55 [0.34-0.75], respectively) or at the 25th minute of SBT (0.49 [0.27-0.71] and 0.50 [0.29-0.68], respectively) for predicting weaning success at 72 h or at 7 d (5th min: 0.53 [0.37-0.70] and 0.54 [0.37-0.70], respectively; 25th min: 0.54 [0.37-0.71] and 0.55 [0.39-0.71], respectively). An exploratory index incorporating the accessory respiratory muscle activity, DE, DTF, and respiratory rate at 5th min of SBT showed AUCs for predicting extubation success at 7 d in the 78 patients with DTF measurement (0.77 [0.64-0.90]) that were significantly higher than that of the RSBI (P = 0.017) and RSBI/DE (P < 0.001) in the same respective populations. CONCLUSIONS The RSBI and the ratio RSBI/DE failed to predict weaning success when measured during an SBT performed under minimal pressure support. Predictive indices incorporating ultrasound DE and DTF may merit further investigation.
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Affiliation(s)
- Guillaume Fossat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
| | - Blanche Daillet
- Ecole Universitaire de Kinésithérapie Centre Val de Loire, Orléans, France.
| | - Emmanuelle Desmalles
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
| | - Thierry Boulain
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
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Liu Q, Duan H, Lian A, Zhuang M, Zhao X, Liu X. Rehabilitation Effects of Acupuncture on the Diaphragm Dysfunction in Chronic Obstructive Pulmonary Disease: A Systematic Review. Int J Chron Obstruct Pulmon Dis 2021; 16:2023-2037. [PMID: 34262271 PMCID: PMC8275099 DOI: 10.2147/copd.s313439] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/01/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Diaphragm dysfunction is a significant extrapulmonary effect in chronic obstructive pulmonary disease (COPD), which is manifested by changes in diaphragm structure and reduced diaphragm strength. Acupuncture is a traditional rehabilitation technique in China, which has been used in rehabilitation for COPD. But whether acupuncture can improve the diaphragm function of COPD patients remains to be verified. Objective The objective of this study was to evaluate the rehabilitation effects of acupuncture on diaphragm dysfunction in patients with COPD. Methods The authors retrieved in CNKI, VIP, SinoMed, PubMed, Ebsco, Web of Science, from inception to November 2020, for relevant randomized control trials. Two researchers independently screened the articles and extracted the data. The quality of the included studies was evaluated by Physiotherapy Evidence Database scale. The primary outcome measures were maximal inspiratory pressure and the scale for accessory respiratory muscle mobilization, the secondary outcome measures were pulmonary function-related indicators and arterial blood gas indicators. Results Nine articles were finally obtained. Seven studies added acupuncture to standard treatment for patients with diaphragm dysfunction in COPD and found statistically significant changes in the maximum inspiratory pressure and the scale for accessory respiratory muscle mobilization. Two studies have proved that use acupuncture combined with other Traditional Chinese Medicine methods in the rehabilitation for COPD can effectively improve the diaphragm strength and diaphragmatic motor performance. Seven studies showed that acupuncture has obvious improvement in pulmonary ventilation function. Seven studies reported significant differences in arterial blood gas pre- to post-intervention. Conclusion This systematic review found that acupuncture can effectively enhance the diaphragm strength, relieve respiratory muscle fatigue, it can also play a promoting role in improving lung function, hypoxia, and carbon dioxide retention, as well as preventing and alleviating respiratory failure. The generalizability of these results is limited by the design of the included studies.
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Affiliation(s)
- Qinxin Liu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Hongxia Duan
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Anbei Lian
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Min Zhuang
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Department of Rehabilitation, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Xianli Zhao
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Xiaodan Liu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Engineering Research Center of Intelligent Rehabilitation of Traditional Chinese Medicine, Ministry of Education, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
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Abstract
INTRODUCTION The use of mechanical ventilation is an invaluable tool in caring for critically ill patients. Enhancing our capabilities in mechanical ventilation has been instrumental in the ability to support clinical conditions and diseases which were once associated with high mortality. Areas covered: Within this manuscript, we will look to discuss emerging approaches to improving the care of pediatric patients who require mechanical ventilation. After an extensive literature search, we will provide a brief review of the history and pathophysiology of acute respiratory distress syndrome, an assessment of several ventilator settings, a discussion on assisted ventilation, review of therapy used to rescue in severe respiratory failure, methods of monitoring the effects of mechanical ventilation, and nutrition. Expert opinion: As we have advanced in our care, we are seeing children survive illnesses that would have once claimed their lives. Given this knowledge, we must continue to advance the research in pediatric critical care to understand the means in which we can tailor the therapy to the patient in efforts to efficiently liberate them from mechanical ventilation once their illness has resolved.
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Affiliation(s)
- Duane C Williams
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics , Penn State Hershey Children's Hospital , Hershey , PA , USA
| | - Ira M Cheifetz
- b Division of Pediatric Critical Care Medicine, Department of Pediatrics , Duke Children's Hospital , Durham , NC , USA
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Briones Claudett KH, Grunauer M. Pressure support ventilation vs continuous positive airway pressure for treating of acute cardiogenic pulmonary edema. Comment. Respir Physiol Neurobiol 2019; 259:176-177. [DOI: 10.1016/j.resp.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/11/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
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Luo Z, Wu C, Li Q, Zhu J, Pang B, Shi Y, Ma Y, Cao Z. High-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (HAPPEN): study protocol for a multicenter randomized controlled trial. Trials 2018; 19:645. [PMID: 30463622 PMCID: PMC6249746 DOI: 10.1186/s13063-018-2991-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 10/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite the positive outcomes of the use of noninvasive positive pressure ventilation (NPPV) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), NPPV fails in approximately 15% of patients with AECOPD, possibly because the inspiratory pressure delivered by conventional low-intensity NPPV is insufficient to improve ventilatory status for these patients. High-intensity NPPV, a novel form that delivers high inspiratory pressure, is believed to more efficiently augment alveolar ventilation than low-intensity NPPV, and it has been shown to improve ventilatory status more than low-intensity NPPV in stable AECOPD patients. Whether the application of high-intensity NPPV has therapeutic advantages over low-intensity NPPV in patients with AECOPD remains to be determined. The high-intensity versus low-intensity NPPV in patients with AECOPD (HAPPEN) study will examine whether high-intensity NPPV is more effective for correcting hypercapnia than low-intensity NPPV, hence reducing the need for intubation and improving survival. METHODS/DESIGN The HAPPEN study is a multicenter, two-arm, single-blind, prospective, randomized controlled trial. In total, 600 AECOPD patients with low to moderate hypercapnic respiratory failure will be included and randomized to receive high-intensity or low-intensity NPPV, with randomization stratified by study center. The primary endpoint is NPPV failure rate, defined as the need for endotracheal intubation and invasive ventilation. Secondary endpoints include the decrement of arterial carbon dioxide tension from baseline to 2 h after randomization, in-hospital and 28-day mortality, and 90-day survival. Patients will be followed up for 90 days after randomization. DISCUSSION The HAPPEN study will be the first randomized controlled study to investigate whether high-intensity NPPV better corrects hypercapnia and reduces the need for intubation and mortality in AECOPD patients than low-intensity NPPV. The results will help critical care physicians decide the intensity of NPPV delivery to patients with AECOPD. TRIAL REGISTRATION ClinicalTrials.gov, NCT02985918 . Registered on 7 December 2016.
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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, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Chao Wu
- Department of Respiratory and Critical Care Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, No. 91 Tianchi Road, Tianshan District, Urumqi, 830001 China
| | - Qi Li
- Department of Respiratory and Critical Care Medicine, Army Institute of Respiratory Disease, Chongqing Xin-Qiao Hospital, Army Military Medical University, 183 Xinqiao Main Street, Shapingba District, Chongqing, 400073 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, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Baosen Pang
- 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, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
| | - Yan Shi
- School of Automation Science and Electrical Engineering, Beihang University, No. 37 Xueyuan Road, Haidian District, Beijing, 100191 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, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 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, 5 Jingyuan Road, Shijingshan District, Beijing, 100043 China
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DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure. PLoS One 2017; 12:e0179641. [PMID: 28671972 PMCID: PMC5495207 DOI: 10.1371/journal.pone.0179641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 06/01/2017] [Indexed: 11/19/2022] Open
Abstract
Background The assessment of the work of breathing in the definitions of respiratory failure is vague and variable. Objective Identify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients. Methods We examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis. Results We performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress. Conclusion Most of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.
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Russo A. Expert's comment concerning Grand Rounds case entitled "Subarachnoidal pleural fistula after resection of intradural thoracic disc herniation and multimodal treatment with noninvasive positive pressure ventilation (NPPV)" (H. R. Schlag, S. Muquit, T. B. Hristov, G. Morassi, B. M. Boszczyk, M. Shafafy). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [PMID: 26215178 DOI: 10.1007/s00586-015-4147-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Antonino Russo
- Department of Neurosurgery, University Hospital Birmingham, Birmingham, B15 2TH, UK.
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Park SY, Lim SY, Um SW, Koh WJ, Chung MP, Kim H, Kwon OJ, Park HK, Kim SJ, Im YH, Ahn MJ, Suh GY. Outcome and predictors of mortality in patients requiring invasive mechanical ventilation due to acute respiratory failure while undergoing ambulatory chemotherapy for solid cancers. Support Care Cancer 2013; 21:1647-53. [PMID: 23314602 DOI: 10.1007/s00520-012-1709-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 12/28/2012] [Indexed: 12/27/2022]
Abstract
PURPOSE Acute respiratory failure that requires invasive mechanical ventilation is a leading cause of death in critically ill cancer patients. The aim of this study was to evaluate the outcome and prognostic factors of patients requiring invasive mechanical ventilator for acute respiratory failure, within 1 month of ambulatory chemotherapy for solid cancer. METHODS A retrospective observational study of patients who underwent ambulatory chemotherapy at Samsung Medical Center, between January of 2007 and April of 2009, was employed for this study. RESULTS A total of 51 patients met the inclusion criteria and were included in the study. The median age was 65 years (25-87) and the majority of the patients were male (n = 38, 74.5%). There were 42 patients (82.3%) with lung cancer. The most common cause of acute respiratory failure was pneumonia (n = 24, 47.1%), followed by acute respiratory failure due to extra-pulmonary infection, drug-induced pneumonitis, alveolar hemorrhage, and cancer progression. The intensive care unit (ICU) mortality was 68.6% and the most common cause of death in the ICU was uncorrected cause of acute respiratory failure. Before adjustment for others factors, prechemotherapy Eastern Cooperative Oncology Group (ECOG) Performance Scale (PS) (P = 0.03), Sequential Organ Failure Assessment score (P = 0.01), and anemia (P = 0.04) were significantly associated with ICU mortality. However, when adjusted for age, sex, and Acute Physiologic and Chronic Health Evaluation II score, only poor ECOG PS (≥2) was significantly associated with ICU mortality [OR 6.36 (95% CI (1.02-39.5))]. CONCLUSIONS The outcome of patients with acute respiratory failure needing invasive mechanical ventilation during ambulatory chemotherapy for solid cancer is poor. Prechemotherapy performance status is an independent predictor of mortality.
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Affiliation(s)
- So Young Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Chuncheon, Gangwon-do, Republic of Korea
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Bing D, Jian K, Long-feng S, Wei T, Hong-wen Z. Vibration response imaging: a novel noninvasive tool for evaluating the initial therapeutic effect of noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease. Respir Res 2012; 13:65. [PMID: 22856613 PMCID: PMC3478983 DOI: 10.1186/1465-9921-13-65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 07/24/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The popular methods for evaluating the initial therapeutic effect (ITE) of noninvasive positive pressure ventilation (NPPV) can only roughly reflect the therapeutic outcome of a patient's ventilation because they are subjective, invasive and time-delayed. In contrast, vibration response imaging (VRI) can monitor the function of a patient's ventilation over the NPPV therapy in a non-invasive manner. This study aimed to investigate the value of VRI in evaluating the ITE of NPPV for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS Thirty-six AECOPD patients received VRI at three time points: before NPPV treatment (T1), at 15 min of NPPV treatment (T2), and at 15 min after the end of NPPV treatment (T4). Blood gas analysis was also performed at T1 and at 2 hours of NPPV treatment (T3). Thirty-nine healthy volunteers also received VRI at T1 and T2. VRI examination at the time point T2 in either the patients or volunteers did not require any interruption of the on-going NPPV. The clinical indices at each time point were compared between the two groups. Moreover, correlations between the PaCO2 changes (T3 vs T1) and abnormal VRI scores (AVRIS) changes (T2 vs T1) were analyzed. RESULTS No significant AVRIS differences were found between T1 and T2 in the healthy controls (8.51 ± 3.36 vs. 8.53 ± 3.57, P > 0.05). The AVRIS, dynamic score, MEF score and EVP score showed a significant decrease in AECOPD patients at T2 compared with T1 (P < 0.05), but a significant increase at T4 compared with T2 (P < 0.05). We also found a positive correlation (R2 = 0.6399) between the PaCO2 changes (T3 vs T1) and AVRIS changes (T2 vs T1). CONCLUSIONS VRI is a promising noninvasive tool for evaluating the initial therapeutic effects of NPPV in AECOPD patients and predicting the success of NPPV in the early stage.
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Affiliation(s)
- Dai Bing
- Department of Respiratory Medicine, the First Affiliated Hospital of China Medical University, 155, Nanjing North Street, Heping district, Shenyang 110001, China
| | - Kang Jian
- Department of Respiratory Medicine, the First Affiliated Hospital of China Medical University, 155, Nanjing North Street, Heping district, Shenyang 110001, China
| | - Sun Long-feng
- Department of Respiratory Medicine, the First Affiliated Hospital of China Medical University, 155, Nanjing North Street, Heping district, Shenyang 110001, China
| | - Tan Wei
- Department of Respiratory Medicine, the First Affiliated Hospital of China Medical University, 155, Nanjing North Street, Heping district, Shenyang 110001, China
| | - Zhao Hong-wen
- Department of Respiratory Medicine, the First Affiliated Hospital of China Medical University, 155, Nanjing North Street, Heping district, Shenyang 110001, China
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Allal S, Khedher A, Ben Saida I, Azouzi A, Farjallah A, Chouchen I, Bouchoucha S, Boussarsar M. New severity score of acute respiratory failure. Crit Care 2012. [PMCID: PMC3363833 DOI: 10.1186/cc11022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Affiliation(s)
- Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI 48202, USA
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Cuvelier A, Pujol W, Pramil S, Molano LC, Viacroze C, Muir JF. Cephalic versus oronasal mask for noninvasive ventilation in acute hypercapnic respiratory failure. Intensive Care Med 2008; 35:519-26. [DOI: 10.1007/s00134-008-1327-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 09/16/2008] [Indexed: 11/25/2022]
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Feltracco P, Serra E, Barbieri S, Milevoj M, Salvaterra F, Marulli G, Ori C. Noninvasive ventilation in adult liver transplantation. Transplant Proc 2008; 40:1979-82. [PMID: 18675106 DOI: 10.1016/j.transproceed.2008.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Noninvasive ventilation (NIV) has proven to be a safe and effective technique in the treatment of respiratory failure complicating various medical and surgical diseases. In recent years, a growing interest has emerged in its adoption for ventilatory assistance in immunocompromised patients, such as those undergoing bone marrow, liver, lung, cardiac, and kidney transplantation. Weaning from the ventilator after liver transplantation can take longer because of unsatisfactory gas exchange during various attempts of T-piece trials. Rapid extubation followed by an immediate NIV application should be considered in this setting to shorten and accelerate the weaning process in those recipients who do not completely fulfill the criteria for safe extubation. By adding the pressure support (PS) mode with a continuous positive end expiratory pressure (PEEP), NIV could prevent the loss of vital capacity and impede severe lung derecruitment following extubation. Clinical experience has shown that properly delivered NIV mostly benefits moderately dyspneic recipients in acute respiratory failure, while it appears less promising and efficient in patients ventilated for extended periods of time. It has proven safe and efficient mainly as (1) a tool to promote an early ventilatory discontinuation and extubation; (2) a prophylactic strategy for preventing postoperative pulmonary complications; and (3) a simple method to start with in cases of acute hypoxic and/or hypercapnic respiratory failure. The improvements in arterial hypoxemia, the decreased ventilatory demand provided with an inspiratory support, as well as the scarcity of hemodynamic repercussions are among the major benefits of this method.
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Affiliation(s)
- P Feltracco
- Department of Pharmacology, University Hospital of Padova, Padova, Italy.
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Continuous positive airway pressure vs. proportional assist ventilation for noninvasive ventilation in acute cardiogenic pulmonary edema. Intensive Care Med 2008; 34:840-6. [DOI: 10.1007/s00134-008-0998-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Accepted: 12/29/2007] [Indexed: 11/26/2022]
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Moritz F, Brousse B, Gellée B, Chajara A, L'Her E, Hellot MF, Bénichou J. Continuous positive airway pressure versus bilevel noninvasive ventilation in acute cardiogenic pulmonary edema: a randomized multicenter trial. Ann Emerg Med 2007; 50:666-75, 675.e1. [PMID: 17764785 DOI: 10.1016/j.annemergmed.2007.06.488] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 05/14/2007] [Accepted: 06/25/2007] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Patients with acute cardiogenic pulmonary edema may develop respiratory failure. Noninvasive respiratory support should be initiated rapidly to avoid tracheal intubation. The aim of this study is to compare the efficacy of continuous positive airway pressure (CPAP) delivered by the Boussignac CPAP device and bilevel positive airway pressure (bilevel PAP) in patients with acute respiratory failure caused by acute cardiogenic pulmonary edema. METHODS This prospective multicenter randomized study was conducted in 3 emergency departments. Patients were assigned to Boussignac CPAP through a facemask or to bilevel PAP, in addition to standard therapy. The main outcome was a combined criterion (tracheal intubation, death, or acute myocardial infarction). Complications, durations of ventilation, and hospitalization were also assessed. RESULTS After 1 hour of ventilation and at the end of the ventilation period, clinical parameters of respiratory distress and blood gas exchange significantly improved in each treatment arm. No significant differences were observed between the Boussignac CPAP and bilevel PAP arms for the combined criterion (5% versus 12%, respectively; odds ratio [OR] 0.4; 95% confidence interval [CI] 0.0 to 1.9) and also for severe complications (9% versus 6%; OR 1.5; 95% CI 0.3 to 9.9), duration of ventilation (median for both groups 2 hours; interquartile range [IQR] 1.2 to 3.0 hours), duration of hospitalization (CPAP 8.5 [IQR 6 to 14] days; bilevel PAP 10 [IQR 7 to 16] days), or intrahospital mortality (8% versus 14%; OR 1.8 [IQR 0.4 to 8.8]). Similar results were obtained among hypercapnic patients (PaCO2 >45 mm Hg). Whatever the ventilation support used, the combined criterion and severe complications were more frequently observed among hypercapnic patients. CONCLUSION Both Boussignac CPAP and bilevel PAP appeared effective in rapidly improving respiratory distress even in hypercapnic patients, but they were not different in terms of patient outcome.
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Affiliation(s)
- Fabienne Moritz
- Service d'Accueil et d'Urgences, CHU de Rouen, Hôpital Charles Nicolle, University Hospital, Rouen, France.
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Meguro K, Toyama T, Adachi H, Ohshima S, Taniguchi K, Nagai R. Assessment of central chemosensitivity and cardiac sympathetic nerve activity using I-123 MIBG imaging in central sleep apnea syndrome in patients with dilated cardiomyopathy. Ann Nucl Med 2007; 21:73-8. [PMID: 17373339 DOI: 10.1007/bf03034002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Iodine-123 MIBG imaging has been used to study cardiac sympathetic function in various cardiac diseases. Central sleep apnea syndrome (CSAS) occurs frequently in patients with chronic heart failure (CHF) and is reported to be associated with a poor prognosis. One of the mechanisms of its poor prognosis may be related to impaired cardiac sympathetic activity. However, the relationship between chemosensitivity to carbon dioxide, which is reported to correlate with the severity of CSAS, and cardiac sympathetic activity has not been investigated. Therefore, this study was undertaken to assess cardiac sympathetic function and chemosensitivity to carbon dioxide in CHF patients. METHODS The oxygen desaturation index (ODI) was evaluated in 21 patients with dilated cardiomyopathy (male/female: 19/2, LVEF < 45%, 65 +/- 12 yr). Patients with an ODI > 5 times/h underwent polysomnography. Patients with an apnea hypopnea index > 15/h but without evidence of obstructive apnea were defined as having CSAS. Early (15 min) and delayed (4 hr) planar MIBG images were obtained from these patients. The mean counts in the whole heart and the mediastinum were obtained. The heart-to-mediastinum count ratio of the delayed image (H/M) and the corrected myocardial washout rate (WR) were also calculated. The central chemoreflex was assessed with the rebreathing method using a hypercapnic gas mixture (7% CO2 and 93% O2). RESULTS Ten of the 21 patients had CSAS. The H/M ratio was similar in patients both with and without CSAS (1.57 +/- 0.18 vs. 1.59 +/- 0.14, p = 0.82). However, the WR was higher in patients with CSAS than in patients without CSAS (40 +/- 8% vs. 30 +/- 12%, p < 0.05). ODI significantly correlated with central chemosensitivity to carbon dioxide. Moreover, there was a highly significant correlation between WR and central chemosensitivity (r = 0.65, p < 0.05). However, there was no correlation between ODI and the WR (r = 0.36, p = 0.11). CONCLUSIONS Cardiac sympathetic nerve activity in patients with CHF and CSAS is impaired. However, central sleep apnea might not directly increase cardiac sympathetic nerve activity. We suggest that central chemosensitivity, which is considered to be one of the mechanisms of CSAS, is correlated with cardiac sympathetic nerve activity.
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Affiliation(s)
- Kentaro Meguro
- Department of Cardiovascular Medicine, Tokyo University Graduate School of Medicine, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan.
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Ho RP, Boyle M. Non-invasive positive pressure ventilation in acute respiratory failure: providing competent care. Aust Crit Care 2006; 13:135-7, 139-43. [PMID: 16948204 DOI: 10.1016/s1036-7314(00)70641-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Non-invasive positive pressure ventilation (NPPV) has been used as an alternative strategy to provide ventilatory support for patients with acute respiratory failure. Most studies demonstrate that the use of NPPV in acute respiratory failure results in a reduction in the need for endotracheal intubation and an overall survival advantage. However, current evidence, in the form of randomised controlled trials, suggests that these benefits may be restricted to patients suffering from acute exacerbation of chronic obstructive pulmonary disease (COPD). The clinical application of NPPV involves the development of competence in delivering the particular intervention. Clinical outcomes and thus valid comparisons with alternate methods of ventilatory support can only be made if attention is paid to the clinical indications for the application of NPPV and patient subgroups it is used to treat and the level of competence of care givers in its application and delivery. One essential element of competence is the establishment of an appropriate knowledge base and the development of clinical practice guidelines. This literature review identifies the current indications for NPPV and the relevant information for developing clinical practice guidelines for the management of this form of ventilatory support.
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Affiliation(s)
- R P Ho
- Concord Repatriation General Hospital, Sydney
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Honrubia T, García López FJ, Franco N, Mas M, Guevara M, Daguerre M, Alía I, Algora A, Galdos P. Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial. Chest 2006; 128:3916-24. [PMID: 16354864 DOI: 10.1378/chest.128.6.3916] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. DESIGN A randomized, multicenter, controlled trial. SETTING Seven multipurpose ICUs. PATIENTS Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. INTERVENTION The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. MEASUREMENTS AND RESULTS Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. CONCLUSIONS NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.
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Affiliation(s)
- Teresa Honrubia
- Unidad de Epidemiología Clínica, Hospital Universitario Puerta de Hierro, San Martín de Porres, 4, 28035 Madrid, Spain
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Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2005; 32:2516-23. [PMID: 15599160 DOI: 10.1097/01.ccm.0000148011.51681.e2] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. OBJECTIVE To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. DATA SOURCE We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. STUDY SELECTION We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. DATA EXTRACTION In duplicate and independently, we abstracted data to evaluate methodological quality and results. DATA SYNTHESIS The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10-35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1-3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8-26%). However, trial results were significantly heterogeneous. CONCLUSION Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.
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Affiliation(s)
- Sean P Keenan
- Department of Medicine, Royal Columbian Hospital, New Westminster, British Columbia
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Kleinsasser A, Von Goedecke A, Hoermann C, Maier S, Schaefer A, Keller C, Loeckinger A. Proportional Assist Ventilation Reduces the Work of Breathing during Exercise at Moderate Altitude. High Alt Med Biol 2004; 5:420-8. [PMID: 15671631 DOI: 10.1089/ham.2004.5.420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Reducing the work of breathing (WOB) during exercise and thus the oxygen required solely for ventilation may be an option to increase the oxygen available for nonventilatory physiological tasks at altitude. This study evaluated whether pressure support ventilation (PSV) and proportional assist ventilation (PAV) may partially reduce WOB during exercise at altitude. Seven volunteers breathing with either PSV or PAV or without support (control) were examined for WOB, inspiratory pressure time product (iPTP), and (O(2)) before and during pedaling at 160 W for 4 min on an ergometer at an altitude of 2860 m, where barometric pressure and oxygen partial pressure are approximately 30% less than at sea level. PSV and PAV reduced WOB from 4.5 +/- 0.9 J/L(-1)/min(-1) during unsupported breathing to 3.7 +/- 0.4 (p < 0.05) and 3.2 +/- 0.7 (p < 0.01), respectively. iPTP was reduced during PAV (570 +/- 151 cm H(2)O/sec/min(-1), p < 0.01), but not during PSV (727 +/- 116, p = 0.58) compared with unsupported ventilation during exercise (763 +/- 90). During PSV and PAV breathing, higher arterial oxygen saturations (84 +/- 2%, p < 0.05, and 86 +/- 1%, p < 0.01, respectively) were observed compared with control (80 +/- 3%), indicating that PSV and PAV attenuated hypoxemia during exercise at altitude. Total body (O(2)), however, was not reduced during PSV or PAV. In conclusion, both PSV and PAV reduced the WOB during exercise at altitude, but only PAV reduces iPTP. Both modes reduce hypoxemia, which may be due to higher alveolar ventilation or decreased ventilation-perfusion heterogeneity compared to unsupported breathing.
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Affiliation(s)
- Axel Kleinsasser
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical School, Anichstrasse 35, A-6020 Innsbruck, Tirol, Austria.
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Cuvelier A, Benhamou D, Muir JF. Ventilation non invasive des patients âgés en réanimation. Rev Mal Respir 2004. [DOI: 10.1016/s0761-8425(04)71572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
PURPOSE OF REVIEW To review the changes in mechanical ventilation technology over the past year and identify areas that provide a benefit. RECENT FINDINGS The literature demonstrates a continued effort to improve patient ventilator synchrony though the development of new triggering and cycling methods. These techniques include using new signals and using closed loop techniques to respond to changes in patient breathing pattern. New modes of ventilation continue to be introduced, often without proof of efficacy. Fortunately, clinicians have developed alterations to new modes that improve utility and they continue to study these techniques clinically to determine appropriate use. Monitoring the patient remains an important area of investigation, with a flurry of activity surrounding pressure volume curves of the respiratory system. Finally, new ventilators have been introduced that combine high-end performance with small size and weight, while providing an on-board source of air. SUMMARY Mechanical ventilation is ubiquitous to intensive care. Advances in ventilator technology are rapid, and clinicians must keep abreast of changes in ventilator performance and application.
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Affiliation(s)
- Richard Branson
- Department of Surgery, Division of Trauma & Critical Care, University of Cincinnati, Cincinnati, Ohio, USA.
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Wysocki M, Meshaka P, Richard JC, Similowski T. Proportional-assist ventilation compared with pressure-support ventilation during exercise in volunteers with external thoracic restriction. Crit Care Med 2004; 32:409-14. [PMID: 14758156 DOI: 10.1097/01.ccm.0000108869.12426.51] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Proportional-assist ventilation (PAV) is able to unload respiratory muscles in proportion to the subject's inspiratory effort. However, leak-related alterations in the flow signal, effort-induced modifications in respiratory mechanics, or approximate adjustment of PAV could jeopardize such a theory. The aim of this study was to compare noninvasive PAV and pressure-support ventilation (PSV) in healthy volunteers with external thoracic restriction at rest and during exercise. DESIGN Prospective, crossover, randomized study. SETTING Investigation unit in a nonteaching hospital. PATIENTS Seven volunteers with external thoracic restriction. INTERVENTION After external thoracic restriction to increase elastance (9.00 +/- 1.63 cm H2O/L estimated from the level of elastic assistance), PAV and PSV were compared at rest and during exercise (90 W for 10 mins). MEASUREMENTS AND MAIN RESULTS Flow, airway pressure, and changes in esophageal pressure were measured, and the tidal volume (Vt) and inspiratory muscle effort indexes were calculated. At rest, all variables were comparable during PSV and PAV. Exercise produced a 200% increased in Vt with no change in the breathing frequency and a 400% increased in inspiratory muscle effort indexes. During exercise, peak inspiratory airway pressure was significantly higher with PAV than with PSV (24 +/- 5 vs. 10 +/- 2 cm H2O, p <.05). The Vt and breathing frequency (23 +/- 4 vs. 24 +/- 3 breaths/min) were similar, but the inspiratory muscle effort indexes were significantly lower with PAV than with PSV. A significant linear correlation was found between changes in esophageal pressure and the peak inspiratory airway pressure during PAV (r =.94, p =.0001), whereas, as expected, it was not the case during PSV (r =.27, p =.34). CONCLUSION In volunteers with external thoracic restriction mimicking a patient with increased elastic work of breathing, the breathing pattern at rest and during exercise were comparable with PSV and PAV, whereas inspiratory muscle effort was lower with PAV during exercise because of the significant automatic increase in assistance with PAV.
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Abstract
As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. Such a gain can be accomplished without overuse of valuable resources. Similar prognostic factors that are applied to the younger cancer patients should also be applied to the elderly. These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.
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Affiliation(s)
- Kasra Karamlou
- Division of Hematology & Medical Oncology, Oregon Health & Sciences University, 3181 SW Sam Jackson Park Road, L586, Portland, OR 97201, USA
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Moritz F, Benichou J, Vanheste M, Richard JC, Line S, Hellot MF, Bonmarchand G, Muller JM. Boussignac continuous positive airway pressure device in the emergency care of acute cardiogenic pulmonary oedema: a randomized pilot study. Eur J Emerg Med 2003; 10:204-8. [PMID: 12972896 DOI: 10.1097/00063110-200309000-00009] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study aimed to assess the short-term respiratory effects of a new portable device that delivers a continuous positive airway pressure via a face mask (Boussignac-CPAP) in patients with severe acute cardiogenic pulmonary oedema, and the feasibility of using this technique in an emergency department. We prospectively studied 30 consecutive patients with acute cardiogenic pulmonary oedema. They were randomly assigned either to the Boussignac-CPAP valve, which delivered oxygen, or to standard oxygen delivery for a duration of 30 min. The end-expiratory pressure reached 9.3+/-0.3 cm H2O with the Boussignac-CPAP valve. At the end of the 30 min period, the decreases in respiratory rate and muscular activity were significantly greater among patients assigned to the Boussignac-CPAP valve compared with those on standard oxygen delivery [24+/-1.6 breaths/min, median 24 (15-37) versus 28.5+/-1.9, median 27 (16-38) and 1.3+/-0.2, median 1 (0-4) versus 2.7+/-0.3, median 2 (0-4), respectively]. Moreover, the arterial oxygen tension to inspired oxygen concentration ratio and tidal volume were improved at the end of the 30 min Boussignac-CPAP period compared with baseline. Boussignac-CPAP was easily implemented and no side-effects were reported. Continuous positive pressure delivered using the Boussignac-CPAP device is feasible in an emergency care setting. It can quickly improve respiratory distress in acute cardiogenic pulmonary oedema patients. A larger trial should be initiated in such an emergency care setting to demonstrate the effectiveness of the Boussignac-CPAP device.
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Affiliation(s)
- Fabienne Moritz
- Emergency Department, CHU de Rouen, Hôpital Charles Nicolle, 1 rue de Germont, 76031 Rouen Cedex, France.
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Vitacca M. New things are not always Better: proportional assist ventilation vs. pressure support ventilation. Intensive Care Med 2003; 29:1038-40. [PMID: 12918515 DOI: 10.1007/s00134-003-1707-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Fernández-Vivas M, Caturla-Such J, González de la Rosa J, Acosta-Escribano J, Alvarez-Sánchez B, Cánovas-Robles J. Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure. Intensive Care Med 2003; 29:1126-33. [PMID: 12802487 DOI: 10.1007/s00134-003-1768-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2002] [Accepted: 04/15/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although conventional pressure ventilation (PSV) decreases the rate of intubation in acute respiratory failure, patient-ventilator dyssynchrony is a frequent cause of failure. In proportional assist ventilation (PAV), pressure is applied by the ventilator in proportion to the patient-generated volume and flow; therefore, there is automatic synchrony between the patient's effort and the ventilatory cycle. OBJECTIVE The aim of this study was to compare the effects of PSV and PAV during noninvasive ventilation in the treatment of acute respiratory failure. DESIGN Prospective randomised study. SETTING A multidisciplinary 24-bed intensive care unit of an acute-care teaching hospital in Alicante, Spain. PATIENTS. This study included 117 consecutive adult patients with acute respiratory failure randomised to noninvasive ventilation delivered by PSV ( n = 59) or PAV ( n = 58). MEASUREMENTS AND RESULTS There were no statistically significant differences between patients assigned to each mode of ventilation with regard to baseline parameters and aetiological diagnoses of acute respiratory failure. With regard to outcome data, no significant differences were observed between PSV and PAV in the frequency of intubation (37% vs 34%), mortality rate (29% vs 28%), and mean length of stay. Subjective comfort (0-10 visual analogue scale) was rated higher and intolerance occurred less frequently (3.4% vs 15%, P = 0.03) in the PAV than in the PSV mode. CONCLUSIONS Although PAV seems more comfortable and intolerance occurred less frequently, no major differences exist in terms of physiological improvement or in terms of outcomes when comparing PSV and PAV.
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Affiliation(s)
- Miguel Fernández-Vivas
- Intensive Care Unit, Hospital General Universitario de Alicante, Maestro Alonso 109, 03010, Alicante, Spain.
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Abstract
Noninvasive ventilation refers to any form of ventilatory support applied without the use of an endotracheal tube. It offers the potential to provide primary treatment for acute respiratory failure while avoiding complications associated with mechanical ventilation with endotracheal intubation. Noninvasive ventilation has been most commonly studied in hypercapnic respiratory failure. A review of randomized, controlled studies shows mixed results and methodologic limitations affect the interpretation of current evidence. Patient selection is clearly the most important issue in considering noninvasive ventilation for acute respiratory failure. Unfortunately, patients who benefit from noninvasive ventilation represent only a minority of the total group with any one disease, and thus it is difficult to make broad conclusions concerning applicability of this treatment modality. Future studies are needed to focus on determining the specific patient populations who will benefit the most, evaluating the optimal ventilatory mode and mask for providing noninvasive ventilation, and clarifying its impact on clinical outcomes.
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Affiliation(s)
- R M Jasmer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
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Gehlbach B, Kress JP, Kahn J, DeRuiter C, Pohlman A, Hall J. Correlates of prolonged hospitalization in inner-city ICU patients receiving noninvasive and invasive positive pressure ventilation for status asthmaticus. Chest 2002; 122:1709-14. [PMID: 12426275 DOI: 10.1378/chest.122.5.1709] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To describe the outcome of patients with status asthmaticus (SA) treated in a medical ICU with positive pressure ventilation (PPV), and to identify those factors associated with increased length of hospital stay. DESIGN Retrospective chart review. SETTING University-based hospital in Chicago, IL. PATIENTS All patients admitted with SA and treated with PPV over a 5-year period. RESULTS The first ICU admission for each of 78 patients was analyzed. Fifty-six patients underwent endotracheal intubation (ETI) during the hospitalization, while 22 patients were treated with noninvasive PPV alone. Three patients died. The median hospital length of stay was 5.5 days. Cox regression analysis revealed the following factors to be independently associated with increased length of hospital stay: female gender (p < 0.01), ETI (p < 0.01), the administration of neuromuscular blockers for > 24 h (p < 0.01), inhaled corticosteroid use prior to ICU admission (p = 0.01), and increasing APACHE (acute physiology and chronic health evaluation) II score (p < 0.01). CONCLUSIONS This study suggests that while the mortality associated with SA treated with contemporary methods of PPV is low, certain factors, including female gender, ETI, and the prolonged use of neuromuscular blockade, are associated with an increased length of hospital stay. The development of respiratory failure despite preadmission use of inhaled corticosteroids is also associated with prolonged hospitalization.
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Affiliation(s)
- Robert D Acton
- Department of Surgery, Regions Hospital, St. Paul, Minnesota 55101, USA
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36
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Ambrosino N, Rossi A. Proportional assist ventilation (PAV): a significant advance or a futile struggle between logic and practice? Thorax 2002; 57:272-6. [PMID: 11867835 PMCID: PMC1746276 DOI: 10.1136/thorax.57.3.272] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Proportional assist ventilation is a promising addition to other more conventional modes of mechanical ventilation with the theoretical advantage of improving patient-ventilator interaction. It may also be of use as a diagnostic tool in the control of breathing in mechanically ventilated patients.
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Affiliation(s)
- N Ambrosino
- Salvatore Maugeri Foundation, IRCCS, Pulmonary Rehabilitation and Respiratory Intensive Care Unit, Scientific Institute of Gussago, Italy.
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37
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Wysocki M, Richard JC, Meshaka P. Noninvasive proportional assist ventilation compared with noninvasive pressure support ventilation in hypercapnic acute respiratory failure. Crit Care Med 2002; 30:323-9. [PMID: 11889302 DOI: 10.1097/00003246-200202000-00010] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To compare short-term administration of noninvasive proportional assist ventilation (NIV-PAV) and pressure support ventilation (NIV-PSV). DESIGN Prospective, crossover, randomized study. SETTING Medicosurgical intensive care unit in a nonteaching hospital. PATIENTS Twelve chronic obstructive pulmonary disease patients admitted for hypercapnic acute respiratory failure. INTERVENTION NIV-PSV and NIV-PAV given in a randomized order after baseline evaluation in continuous positive airway pressure. Using a flow-triggering ventilator, NIV-PAV was adjusted using the runaway method and compared with NIV-PSV at similar peak inspiratory airway pressure. MEASUREMENTS AND MAIN RESULTS Flow, airway pressure, and changes in esophageal pressure were measured and the tidal volume, the patient's inspiratory work of breathing, and the esophageal pressure--time product were calculated. Arterial pH and PaCO(2) were measured and breathing comfort was assessed using a visual analogic scale. Peak inspiratory airway pressure (17 +/- 3 cm H(2)O) and tidal volume were similarly increased with the two modalities with no change in respiratory rate. The change in esophageal pressure was similarly decreased (from 20 +/- 8 cm H(2)O in continuous positive airway pressure to 12 +/- 7 in NIV-PSV and 10 +/- 5 cm H(2)O in NIV-PAV) as well as inspiratory muscle effort indexes. Arterial pH and PaCO(2) were similarly improved. Breathing comfort was significantly improved in NIV-PAV (+38 +/- 38%) but not in NIV-PSV (+11 +/- 23%). The tidal volume was more variable in NIV-PAV (89 +/- 18%) than in NIV-PSV (15 +/- 8%) and changes in tidal volume variability were significantly correlated (p =.02) with changes in breathing comfort. CONCLUSIONS In chronic obstructive pulmonary disease patients with hypercapnic acute respiratory failure, NIV-PAV was able to unload inspiratory muscles similarly to NIV-PSV but may be more comfortable than NIV-PSV.
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Affiliation(s)
- Marc Wysocki
- Réanimation Polyvalente, Institut Mutualiste Montsouris, Paris, France.
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Serra A, Polese G, Braggion C, Rossi A. Non-invasive proportional assist and pressure support ventilation in patients with cystic fibrosis and chronic respiratory failure. Thorax 2002; 57:50-4. [PMID: 11809990 PMCID: PMC1746175 DOI: 10.1136/thorax.57.1.50] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with advanced cystic fibrosis can benefit from non-invasive positive pressure ventilation (NPPV) for the treatment of acute decompensation as well as for the management of chronic respiratory failure. This study was undertaken to compare the physiological effects of non-invasive proportional assist ventilation (PAV) and pressure support ventilation (PSV) on ventilatory pattern, transcutaneous blood gas tensions, and diaphragmatic effort in stable patients with cystic fibrosis and chronic CO2 retention. METHODS In 12 patients two periods of spontaneous breathing were followed randomly by PSV (12 (3) cm H2O) and PAV (flow assist 4.9 (1.3) cm H2O/l.s, volume assist 18.9 (5.1) cm H2O/l) set for the patient's comfort and administered for 40 minutes with 2 cm H2O continuous positive airway pressure. Ventilatory pattern, transcutaneous blood gas tensions, and surface diaphragmatic electromyography were measured in the last 10 minutes of each application. RESULTS On average, both PSV and PAV improved ventilation (+30%), tidal volume (+30%), and transcutaneous CO2 (-7%) while reducing diaphragmatic activity (-30% with PSV, -20% with PAV). Mean inspiratory airway pressure was lower during PAV than during PSV (9.7 (1.9) and 12.9 (2.7) cm H2O, respectively; p<0.05). The mean coefficient of variation of tidal volume was about 20% (range 11-39%) during spontaneous breathing and did not change with either PAV or PSV. CONCLUSIONS These results show that short term administration of nasal PAV and PSV to patients with stable cystic fibrosis with chronic respiratory insufficiency is well tolerated, improves ventilation and blood gas tensions, and unloads the diaphragm.
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Affiliation(s)
- A Serra
- Centro Regionale Fibrosi Cistica, Azienda Ospedaliera di Verona, Ospedale Civile Maggiore di Borgo Trento, Verona, Italy
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39
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Gay PC, Hess DR, Hill NS. Noninvasive proportional assist ventilation for acute respiratory insufficiency. Comparison with pressure support ventilation. Am J Respir Crit Care Med 2001; 164:1606-11. [PMID: 11719297 DOI: 10.1164/ajrccm.164.9.2011119] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Noninvasive positive pressure ventilation (NPPV) is usually applied using pressure support ventilation (PSV). Proportional assist ventilation (PAV) is a newer mode that delivers assisted ventilation in proportion to patient effort. We hypothesized that PAV for NPPV would support gas exchange and avoid intubation as well as PSV and be more comfortable and tolerable for patients. Adult patients with acute respiratory insufficiency were randomized to receive NPPV with PAV delivered using the Respironics Vision ventilator or PSV using a Puritan-Bennett 7200ae critical care ventilator. Each mode was adjusted to relieve dyspnea and improve gas exchange until patients met weaning or intubation criteria, died, or refused to continue. Twenty-one and 23 patients were entered into the PAV and PSV groups, respectively, and had similar diagnoses and baseline characteristics, although pH was slightly lower in the PAV group (7.30 versus 7.35, p = 0.02). Mortality and intubation rates were similar, but refusal rate was lower, reduction in respiratory rate was more rapid, and there were fewer complications in the PAV group. We conclude that use of the PAV mode is feasible for noninvasive therapy of acute respiratory insufficiency. Compared with PSV delivered with the Puritan-Bennett 7200ae, PAV is associated with more rapid improvements in some physiologic variables and is better tolerated.
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Affiliation(s)
- P C Gay
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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40
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Farré R, Mancini M, Rotger M, Ferrer M, Roca J, Navajas D. Oscillatory resistance measured during noninvasive proportional assist ventilation. Am J Respir Crit Care Med 2001; 164:790-4. [PMID: 11549534 DOI: 10.1164/ajrccm.164.5.2102049] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Setting proportional assist ventilation (PAV) requires the measurement of patient resistance and elastance. To avoid patient sedation/paralysis or the use of an esophageal balloon, noninvasive PAV is indirectly set by the "runaway" method or in accordance with patient comfort. The aim of this study was to ascertain whether the forced oscillation technique (FOT) applied by the ventilator during noninvasive PAV is useful in assessing patient respiratory resistance. Nasal PAV was applied to 14 patients with severe chronic obstructive pulmonary disease. During PAV a modified ventilator applied a 5-Hz pressure oscillation to noninvasively assess FOT resistance (Rrs). Lung resistance (RL) was measured in seven of the patients by using an esophageal balloon. Moreover, measurements were also performed in five of the patients when PAV was applied through the mouth. Rrs was close to RL both during nasal (Rrs = 8.9 +/- 3.1, RL = 9.0 +/- 2.6; cm H(2)O x s/L; n = 7, p > 0.05) and mouth (Rrs = 5.6 +/- 2.1, RL = 5.8 +/- 1.4; cm H(2)O x s/L; n = 5, p > 0.05) breathing. Rrs was slightly greater than the maximum value of flow assistance applied during the setting of PAV (FAmax): 11.1 +/- 5.4 and 9.5 +/- 2.9 cm H(2)O x s/L, respectively (n = 14, p > 0.05), both variables being significantly correlated (r = 0.72, p < 0.05). FOT applied by the PAV ventilator allowed the assessment of patient resistance. These results suggest that FOT could be useful in setting PAV flow assistance and in automatically and continuously updating this setting in accordance with patient resistance.
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Affiliation(s)
- R Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain.
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41
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Abstract
In acute hypoxaemic respiratory failure (HRF), oxygenation, reduction in the work of breathing and in dyspnoea may be achieved by delivering noninvasive mechanical ventilation (NIMV). Several uncontrolled and 13 randomized controlled studies (RCS) were reviewed. Uncontrolled studies confirmed the feasibility and the possibility to improve arterial blood oxygenation with NIMV. The 13 RCS compared NIMV versus a conventional approach in a total of 720 patients with HRF. Endotracheal intubation was required in 186 of the 358 patients (median (95% confidence interval (CI)) 51%, (40-63%)) assigned to a conventional approach and in 107 of the 362 patients (29% (20-39%)) assigned to NIMV. Eleven of the 13 RCS found a reduction in the rate of endotracheal intubation with NIMV with an absolute risk reduction of 31% (30-33%). Ten of the 13 RCS found a reduction in the mortality rate which was 30% (19-40%) in the control group and 19% (13-26%) in the NIMV group. The mean absolute risk reduction was 15% (10-20%). In conclusion, noninvasive ventilation appears to be a useful method in avoiding endotracheal intubation and probably in reducing the morbidity of patients with hypoxaemic respiratory failure.
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Affiliation(s)
- M Wysocki
- Réanimation Polyvalente, Institut Mutualiste Montsouris, Paris, France
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Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L. Noninvasive versus conventional mechanical ventilation. An epidemiologic survey. Am J Respir Crit Care Med 2001; 163:874-80. [PMID: 11282759 DOI: 10.1164/ajrccm.163.4.2006027] [Citation(s) in RCA: 319] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A prospective survey was performed over a period of 3 wk among 42 intensive care units to assess the incidence of use and effectiveness of noninvasive mechanical ventilation (NIV) in clinical practice. All patients requiring ventilatory support for acute respiratory failure (ARF), either with endotracheal intubation (ETI) or NIV, were included. Ventilatory support was required in 689 patients, 581 with ETI and 108 (16%) with NIV (35% of patients not intubated on admission). Reasons for mechanical ventilation were coma (30%), cardiogenic pulmonary edema (7%), and hypoxemic (48%) and hypercapnic ARF (15%). NIV was never used for patients in coma (who were excluded from further analysis), but was used in 14% of patients with hypoxemic ARF, in 27% of those with pulmonary edema, and in 50% of those with hypercapnic ARF. NIV was followed by ETI in 40% of cases. The incidence of both nosocomial pneumonia (10% versus 19%, p = 0.03), and mortality (22% versus 41%, p < 0.001) was lower in NIV patients than in those with ETI. After adjusting for differences at baseline, Simplified Acute Physiology Score (SAPS) II (odds ratio [OR] = 1.05 per point; confidence interval [CI]: 1.04 to 1.06), McCabe/Jackson score (OR = 2.18; CI: 1.57 to 3.03), and hypoxemic ARF (OR = 2.30; CI: 1.33 to 4.01) were identified as risk factors explaining mortality; success of NIV was associated with a lower risk of pneumonia (OR = 0.06; CI: 0.01 to 0.45) and of death (OR = 0.16; CI: 0.05 to 0.54). In NIV patients, SAPS II and a poor clinical tolerance predicted secondary ETI. Failure of NIV was associated with a longer length of stay. In conclusion, NIV can be successful in selected patients, and is associated with a lower risk of pneumonia and death than is ETI.
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Affiliation(s)
- A Carlucci
- Paris XII Université, Department of Biostatistics, Medical Intensive Care Unit, Institut National de la Recherche et de la Santé Medicale U 492, Henri Mondor Hospital, Créteil, France
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43
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Affiliation(s)
- S Mehta
- Division of Pulmonary and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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44
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Appendini L, Confalonieri M, Rossi A. Clinical relevance of monitoring respiratory mechanics in the ventilator-supported patient: an update (1995–2000). Curr Opin Crit Care 2001; 7:41-8. [PMID: 11373510 DOI: 10.1097/00075198-200102000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The introduction of mechanical ventilation in the intensive care unit environment had the merit of putting a potent life-saving tool in the physicians' hands in a number of situations; however, like most sophisticated technologies, it can cause severe side effects and eventually increase mortality if improperly applied. Assessment of respiratory mechanics serves as an aid in understanding the patient-ventilator interactions with the aim to obtain a better performance of the existing ventilator modalities. It has also provided a better understanding of patients' pathophysiology. Thanks to it, new ventilatory strategies and modalities have been developed. Finally, on-line monitoring of respiratory mechanics parameters is going to be more than a future perspective.
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Affiliation(s)
- L Appendini
- Pulmonary Division, Ospedali Riuniti di Bergamo, Bergamo, Italy
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45
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McIntyre RC, Pulido EJ, Bensard DD, Shames BD, Abraham E. Thirty years of clinical trials in acute respiratory distress syndrome. Crit Care Med 2000; 28:3314-31. [PMID: 11008997 DOI: 10.1097/00003246-200009000-00034] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To systematically review clinical trials in acute respiratory distress syndrome (ARDS). DATA SOURCES Computerized bibliographic search of published research and citation review of relevant articles. STUDY SELECTION All clinical trials of therapies for ARDS were reviewed. Therapies that have been compared in prospective, randomized trials were the focus of this analysis. DATA EXTRACTION Data on population, interventions, and outcomes were obtained by review. Studies were graded for quality of scientific evidence. MAIN RESULTS Lung protective ventilator strategy is supported by improved outcome in a single large, prospective trial and a second smaller trial. Other therapies for ARDS, including noninvasive positive pressure ventilation, inverse ratio ventilation, fluid restriction, inhaled nitric oxide, almitrine, prostacyclin, liquid ventilation, surfactant, and immune-modulating therapies, cannot be recommended at this time. Results of small trials using corticosteroids in late ARDS support the need for confirmatory large clinical trials. CONCLUSIONS Lung protective ventilator strategy is the first therapy found to improve outcome in ARDS. Trials of prone ventilation and fluid restriction in ARDS and corticosteroids in late ARDS support the need for large, prospective, randomized trials.
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Affiliation(s)
- R C McIntyre
- Department of Pediatric Surgery, The Children's Hospital, University of Colorado Health Sciences Center, Denver, USA
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46
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Vitacca M, Clini E, Pagani M, Bianchi L, Rossi A, Ambrosino N. Physiologic effects of early administered mask proportional assist ventilation in patients with chronic obstructive pulmonary disease and acute respiratory failure. Crit Care Med 2000; 28:1791-7. [PMID: 10890621 DOI: 10.1097/00003246-200006000-00016] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the physiologic short-term effects of noninvasive proportional assist ventilation (PAV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN Prospective, physiologic study. SETTING Respiratory intermediate intensive care unit. PATIENTS Seven patients with acute respiratory failure requiring noninvasive mechanical ventilation because of exacerbation of COPD. INTERVENTIONS PAV was administered by nasal mask as first ventilatory intervention. The setting of PAV involved a procedure to adjust volume assist and flow assist to levels corresponding to patient comfort. Volume assist was also set by means of the "run-away" procedure. Continuous positive airway pressure (CPAP) amounting to 2 cm H2O was always set by the ventilator. This setting of assistance (PAV) was applied for 45 mins. Thereafter, CPAP was increased to 5 cm H2O (PAV + CPAP-5) without any change in the PAV setting and was administered for 20 mins. Oxygen was delivered through a port of the mask in the attempt to maintain a target SaO2 >90%. MEASUREMENTS AND MAIN RESULTS Arterial blood gases, breathing pattern, and inspiratory effort were measured during unsupported breathing and at the end of PAV, and breathing pattern and inspiratory effort were measured after 20 mins of PAV + CPAP-5. PAV determined a significant increase in tidal volume and minute ventilation (+64% and +25% on average, respectively) with unchanged breathing frequency and a significant improvement in arterial blood gases (PaO2 with the same oxygen supply, from 65 +/- 15 torr to 97 +/- 36 torr; PaCO2, from 80 +/- 11 torr to 76 +/- 13 torr; pH, from 7.30 +/- 0.02 to 7.32 +/- 0.03). The pressure-time product calculated over a period of 1 min (from 318 +/- 87 to 205 +/- 145 cm H2O x sec x min(-1)) was significantly reduced. PAV + CPAP-5 resulted in a further although not significant decrease in the pressure-time product calculated over a period of 1 min (to 183 +/- 110 cm H2O x sec x min(-1)), without additional changes in the breathing pattern. CONCLUSIONS Noninvasive PAV is able to improve arterial blood gases while unloading inspiratory muscles in patients with acute exacerbation of COPD.
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Affiliation(s)
- M Vitacca
- Salvatore Maugeri Foundation IRCCS, Lung Function Unit, Medical Centre of Gussago, Italy
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47
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Appendini L, Purro A, Gudjonsdottir M, Baderna P, Patessio A, Zanaboni S, Donner CF, Rossi A. Physiologic response of ventilator-dependent patients with chronic obstructive pulmonary disease to proportional assist ventilation and continuous positive airway pressure. Am J Respir Crit Care Med 1999; 159:1510-7. [PMID: 10228119 DOI: 10.1164/ajrccm.159.5.9804130] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To investigate the physiologic effects of proportional assist ventilation (PAV) in difficult-to-wean, mechanically ventilated patients with advanced COPD, we measured in eight ICU patients the breathing pattern, neuromuscular drive (P0.1), lung mechanics, and inspiratory muscle effort (PTPdi and PTPpl) during both spontaneous breathing (SB) and ventilatory support with PAV, CPAP, and CPAP + PAV (in random sequence). PAV (volume assist [VA] and flow assist [FA]) was set as follows: dynamic lung elastance and inspiratory pulmonary resistance were measured during SB; then VA and FA were set to counterbalance the elastic and resistive loads exceeding the normal values, respectively, the inspiratory muscles bearing a normal elastic and resistive workload. CPAP was set close to dynamic intrinsic PEEP (8.3 +/- 3.4 cm H2O). We found significant reductions in P0.1 and PTPdi during both CPAP (-45 and -37%, respectively) and PAV (-50 and -48%, respectively). However, only the combination of PAV and CPAP brought P0.1 (1.69 +/- 0.97 cm H2O) and PTPdi (100 +/- 68 cm H2O. s) within normal values, and ameliorated the breathing pattern compared with SB (tidal volume: 0.69 +/- 0.33 versus 0.33 +/- 0.14 L; breathing frequency, 14.6 +/- 4.6 versus 21.0 +/- 6.5 breaths/min, respectively), without generating ineffective inspiratory efforts. We conclude that in difficult-to-wean COPD patients, (1) PAV improves ventilation and reduces both P0.1 and inspiratory muscle effort; (2) the combination of PAV and CPAP can unload the inspiratory muscles to values close to those found in normal subjects.
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Affiliation(s)
- L Appendini
- Salvatore Maugeri Foundation, IRCCS, Rehabilitation Institute of Veruno, Division of Pulmonary Disease, Veruno (No), Italy.
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48
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Rocker GM, Mackenzie MG, Williams B, Logan PM. Noninvasive positive pressure ventilation: successful outcome in patients with acute lung injury/ARDS. Chest 1999; 115:173-7. [PMID: 9925080 DOI: 10.1378/chest.115.1.173] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is increasing support for the use of noninvasive positive pressure ventilation (NPPV) in the treatment of patients with acute respiratory failure. Highest success rates are recorded in patients with exacerbation of COPD, particularly in patients presenting primarily with hypercarbic respiratory failure. Success has been more limited in patients with acute hypoxemic respiratory failure, and there are few reports of NPPV in patients with acute lung injury (ALI) or ARDS. OBJECTIVES We report the outcome of 12 episodes of ALI/ARDS in 10 patients treated with NPPV. DESIGN Experiential cohort study. SETTING Tertiary referral center and university hospital ICU. INTERVENTION Provision of NPPV in patients with ALI/ARDS. RESULTS Group median (range) APACHE (acute physiology and chronic health evaluation) II score was 16 (11 to 29). Success rate (avoidance of intubation and no further assisted ventilation for 72 h) was achieved on six of nine occasions (66%) when NPPV was used as the initial mode of assisted ventilation. It failed after three episodes of planned (1) or self (2) extubation. Duration of successful NPPV was 64.5 h (23.5 to 80.5 h) with ICU discharge in the next 24 to 48 h for three of six patients. Unsuccessful episodes lasted 7.3 h (0.1 to 116 h) with need for conventional ventilation for an additional 5 days (2.7 to 14 days). Survival (ICU and hospital) for the 10 patients was 70%. CONCLUSIONS In a group of hemodynamically stable patients with severe ALI, NPPV had a high success rate. NPPV should be considered as a treatment option for patients in stable condition in the early phase of ALI/ARDS.
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Affiliation(s)
- G M Rocker
- Division of Respirology, Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
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Hotchkiss JR, Marini JJ. Noninvasive ventilation: an emerging supportive technique for the emergency department. Ann Emerg Med 1998; 32:470-9. [PMID: 9774932 DOI: 10.1016/s0196-0644(98)70177-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Noninvasive ventilation (NIV) is the provision of ventilatory support to a spontaneously breathing patient without endotracheal intubation. In this review, we detail concerns related to endotracheal intubation and summarize the physiologic effects and clinical application of NIV. We then address the use of NIV in 5 conditions of particular interest to the practitioner of emergency medicine: exacerbated chronic obstructive lung disease, severe asthma, patients who are not candidates for endotracheal intubation, pneumonia, and pulmonary edema.
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Affiliation(s)
- J R Hotchkiss
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
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50
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Pang D, Keenan SP, Cook DJ, Sibbald WJ. The effect of positive pressure airway support on mortality and the need for intubation in cardiogenic pulmonary edema: a systematic review. Chest 1998; 114:1185-92. [PMID: 9792593 DOI: 10.1378/chest.114.4.1185] [Citation(s) in RCA: 188] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To critically appraise and summarize the trials examining the addition of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) to standard therapy on hospital mortality, need for endotracheal intubation, and predischarge left ventricular function in patients admitted to the hospital with cardiogenic pulmonary edema with gas exchange abnormalities. DATA SOURCES We searched MEDLINE (1983 to June 1997) and bibliographies of all selected articles and review articles. We also reviewed the abstracts from the proceedings of relevant meetings from 1985 to 1997. STUDY SELECTION (1) POPULATION: patients presenting to hospital with cardiogenic pulmonary edema; (2) intervention: one of the following three: (a) the use of CPAP and standard medical therapy vs standard medical therapy alone; (b) the use of NPPV and standard medical therapy vs standard medical therapy alone; and (c) the use of NPPV and standard therapy vs CPAP and standard therapy; (3) outcome: hospital survival, need for endotracheal intubation, or predischarge left ventricular dysfunction; and (4) study design: randomized controlled trial (RCT); if there were fewer than two RCTs, other study designs were included. DATA EXTRACTION Two authors independently extracted data and evaluated the methodologic quality of the studies. DATA SYNTHESIS CPAP was associated with a decrease in need for intubation (risk difference, -26%, 95% confidence intervals, -13 to -38%) and a trend to a decrease in hospital mortality (risk difference, -6.6%; +3 to -16%) compared with standard therapy alone. There was insufficient evidence to comment on the effectiveness of NPPV either compared with standard therapy or CPAP and standard therapy. Evidence was also lacking on the potential for either intervention to cause harm. CONCLUSIONS A modest amount of favorable experimental evidence exists to support the use of CPAP in patients with cardiogenic pulmonary edema. CPAP appears to decrease intubation rates and data suggest a trend toward a decrease in mortality, although the potential for harm has not been excluded. The role of NPPV in this setting requires further study before it can be widely recommended.
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Affiliation(s)
- D Pang
- Aberdeen Medical School, Scotland
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