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Bermúdez-Barrezueta L, Mayordomo-Colunga J, Miñambres-Rodríguez M, Reyes S, Valencia-Ramos J, Lopez-Fernandez YM, Mendizábal-Diez M, Vivanco-Allende A, Palacios-Cuesta A, Oviedo-Melgares L, Unzueta-Roch JL, López-González J, Jiménez-Villalta MT, Cuervas-Mons Tejedor M, Artacho González L, Jiménez Olmos A, Pons-Òdena M. Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study). Crit Care 2024; 28:235. [PMID: 38992698 PMCID: PMC11241858 DOI: 10.1186/s13054-024-04976-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 05/29/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.
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Affiliation(s)
- Lorena Bermúdez-Barrezueta
- Pediatric and Neonatal Intensive Care, Department of Pediatrics, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain.
- Department of Pediatrics, Faculty of Medicine, Valladolid University, Valladolid, Spain.
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
- Department of Pediatrics, University of Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, RD21/0012/0020, Madrid, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - María Miñambres-Rodríguez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Susana Reyes
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan Valencia-Ramos
- Pediatric Intensive Care Unit, Department of Pediatrics, Complejo Asistencial Universitario de Burgos, Burgos, Spain
- Ciencias de la Salud, University of Burgos, Burgos, Spain
| | - Yolanda Margarita Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario de Cruces, BioBizkaia-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Mikel Mendizábal-Diez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ana Vivanco-Allende
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Alba Palacios-Cuesta
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Lidia Oviedo-Melgares
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - José Luis Unzueta-Roch
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jorge López-González
- Pediatric Intensive Care Unit Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Maite Cuervas-Mons Tejedor
- Pediatric Intensive Care Unit, Department of Pediatrics, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Lourdes Artacho González
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Ainhoa Jiménez Olmos
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Martí Pons-Òdena
- Inmune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate Care Department, Hospital Universitario Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Spain
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Romanelli A, Toigo P, Scarpati G, Caccavale A, Lauro G, Baldassarre D, Oliva F, Lacava G, Pascale G, Piazza O. Predictor factors for non-invasive mechanical ventilation failure in severe COVID-19 patients in the intensive care unit: a single-center retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853166 DOI: 10.1186/s44158-022-00038-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background During the COVID-19 pandemia, non-invasive mechanical ventilation (NIV) has been largely applied. Few data are available about predictors of NIV failure in critical COVID-19 patients admitted to ICU. The aim of this study is to analyze clinical and laboratory features able to predict non-invasive ventilation success in avoiding endotracheal intubation. Methods A retrospective observational study was performed in our COVID-19 ICU during a 6-month period. Demographic, clinical, laboratory, imaging, and outcome data were extracted from electronic and paper medical records and anonymously collected. Results Eighty-two severe COVID-19 patients were supported by NIV at ICU admission. The median PaO2/FiO2 ratio was 125 [98.5–177.7]. NIV failed in 44 cases (53%). Patients who experienced NIV failure had a higher Charlson Comorbidity Index (median value 4) compared to those who were dismissed without endotracheal intubation (median 2, p < 0.0001). At Cox regression analysis, the Charlson Comorbidity Index represented a predictive factor related to NIV failure. PaO2/FiO2, CPK, INR, and AT III at ICU admission showed a significant relationship with the outcome, when single variables were adjusted for the Charlson Comorbidity Index. Conclusion The Charlson Comorbidity Index may be helpful to stratify patients’ risk of NIV failure in a severe COVID-19 population; even if this study, retrospective design does not allow definitive conclusions. Supplementary Information The online version contains supplementary material available at 10.1186/s44158-022-00038-7.
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Altınkaya Çavuş M, Gökbulut Bektaş S, Turan S. Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study. Front Med (Lausanne) 2022; 9:995799. [PMID: 36111123 PMCID: PMC9468549 DOI: 10.3389/fmed.2022.995799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectivesNon-invasive ventilation (NIV) is used in intensive care units (ICUs) to treat of respiratory failure. Sedation and analgesia are effective and safe for improving compliance in patients intolerant to NIV. Our study aimed to evaluate the effects of dexmedetomidine, remifentanil, and propofol on the clinical outcomes in NIV intolerant patients.MethodsThis prospective randomized cohort study was conducted in a tertiary ICU, between December 2018 and December 2019. We divided a total of 120 patients into five groups (DEXL, DEXH, REML, REMH, PRO). IBM SPSS Statistics 20 (IBM Corporation, Armonk, New York, USA) was used to conduct the statistical analyses.ResultsThe DEXL, DEXH, REML, and REMH groups consisted of 23 patients each while the PRO group consisted of 28 patients. Seventy-five patients (62.5%) became tolerant of NIV after starting the drugs. The NIV time, IMV time, ICU LOS, hospital LOS, intubation rate, side effects, and mortality were significantly different among the five groups (P = 0.05). In the groups that were given dexmedetomidine (DEXL, and DEXH), NIV failure, mortality, ICU LOS, and hospital LOS were lower than in the other groups.ConclusionIn this prospective study, we compared the results of three drugs (propofol, dexmedetomidine, and remifentanil) in patients with NIV intolerance. The use of sedation increased NIV success in patients with NIV intolerance. NIV failure, mortality, ICU LOS, IMV time, and hospital LOS were found to be lower with dexmedetomidine.
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Affiliation(s)
- Mine Altınkaya Çavuş
- Kayseri City Hospital, Republic of Turkey Ministry of Health Sciences, Kayseri, Turkey
- *Correspondence: Mine Altınkaya Çavuş
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Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, Gonçalves G, Caldeira V, Cabrita B, Perren A, Fiorentino G, Utku T, Piervincenzi E, El-Khatib M, Alpay N, Ferrari R, Abdelrahim MEA, Saeed H, Madney YM, Harb HS, Vargas N, Demirkiran H, Bhakta P, Papadakos P, Gómez-Ríos MÁ, Abad A, Alqahtani JS, Hadda V, Singha SK, Esquinas AM. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022; 26:938-948. [PMID: 36042773 PMCID: PMC9363803 DOI: 10.5005/jp-journals-10071-23950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.
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Affiliation(s)
- Habib MR Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
- Habib MR Karim, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, Phone: +91 9612372585, e-mail:
| | - Irena Šarc
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Camilla Calandra
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, New York, United States
| | - Bushra Mina
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T Popa”, Iasi, Romania; Consultant in Internal Medicine and Pulmonology, Clinical Hospital of Rehabilitation, Iasi, Romania
| | - Laura D Ciobanu
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gil Gonçalves
- Pulmonology Department, Santa Marta Hospital, Lisbon, Portugal
| | - Vania Caldeira
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruno Cabrita
- Department of Intensive Care Medicine EOC, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Andreas Perren
- Respiratory Unit, AO dei Colli Monaldi Hospital, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Anaesthesiology and Reanimation, General Intensive Care, Yeditepe University Medical Faculty, Istanbul, Turkey
| | - Tughan Utku
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Italy; Anesthesia, Emergency and Intensive Care Medicine, Agostino Gemelli University Policlinic, IRCCS, Italy
| | - Edoardo Piervincenzi
- Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Mohamad El-Khatib
- Department of Anesthesiology and Reanimation, Cukurova University Faculty of Dentistry, Adana, Turkey
| | - Nilgün Alpay
- Emergency Department, Santa Maria della Scaletta Hospital, AUSL Imola, Imola, Italy
| | - Rodolfo Ferrari
- Noninvasive Ventilation Department, University Clinic for Pulmonary and Allergic Diseases, Golnik, Slovenia
| | - Mohamed EA Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Nicola Vargas
- Geriatric and Intensive Geriatric Cares Unit, Medicine Department, “San Giuseppe Moscati” Hospital, Avellino, Italy
| | - Hilmi Demirkiran
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Peter Papadakos
- Department of Anesthesiology, University of Rochester, Rochester, New York, United States
| | - Manuel Á Gómez-Ríos
- Department of Anesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Galicia, Spain
| | - Alfredo Abad
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Jaber S Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Subrata K Singha
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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Hao GW, Luo JC, Xue Y, Ma GG, Su Y, Hou JY, Yu SJ, Liu K, Zheng JL, Tu GW, Luo Z. Remifentanil versus dexmedetomidine for treatment of cardiac surgery patients with moderate to severe noninvasive ventilation intolerance (REDNIVIN): a prospective, cohort study. J Thorac Dis 2020; 12:5857-5868. [PMID: 33209418 PMCID: PMC7656397 DOI: 10.21037/jtd-20-1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of sedation to noninvasive ventilation (NIV) patients remains controversial, however, for intolerant patients who are uncooperative, administration of analgesics and sedatives may be beneficial before resorting to intubation. The aim of this study was to evaluate the efficacy of remifentanil (REM) versus dexmedetomidine (DEX) for treatment of cardiac surgery (CS) patients with moderate to severe NIV intolerance. METHODS This prospective cohort study of CS patients with moderate to severe NIV intolerance was conducted between January 2018 and March 2019. Patients were treated with either REM or DEX, decided by the bedside intensivist. Depending on the treatment regimen, the patients were allocated to one of two groups: the REM group or DEX group. RESULTS A total of 90 patients were enrolled in this study (52 in the REM group and 38 in the DEX group). The mitigation rate, defined as the percentage of patients who were relieved from the initial moderate to severe intolerant status, was greater in the REM group than DEX group at 15 min and 3 h (15 min: 83% vs. 61%, P=0.029; 3 h: 92% vs. 74%, P=0.016), although the mean mitigation rate (81% vs. 85%, P=0.800) was comparable between the two groups. NIV failure, defined as reintubation or death over the course of study, was comparable between the two groups (19.2% vs. 21.1%, respectively, P=0.831). There were no significant differences between the two groups in other clinical outcomes, including tracheostomy (15.4% vs. 15.8%, P=0.958), in-hospital mortality (11.5% vs. 10.5%, P=0.880), ICU length of stay (LOS) (7 vs. 7 days, P=0.802), and in-hospital LOS (17 vs. 19 days, P=0.589). CONCLUSIONS REM was as effective as DEX in CS patients with moderate to severe NIV intolerance. Although the effect of REM was better than that of DEX over the first 3 h, the cumulative effect was similar between the two treatments.
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Affiliation(s)
- Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Xue
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital Fudan University, Xiamen, China
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Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, Khatib KI, Jagiasi BG, Chanchalani G, Mishra RC, Samavedam S, Govil D, Gupta S, Prayag S, Ramasubban S, Dobariya J, Marwah V, Sehgal I, Jog SA, Kulkarni AP. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020; 24:S61-S81. [PMID: 32205957 PMCID: PMC7085817 DOI: 10.5005/jp-journals-10071-g23186] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non-invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61-S81.
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Affiliation(s)
- Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India, , e-mail:
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , 020-25531539 / 25539538, e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India, , e-mail:
| | - G C Khilnani
- Department of PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India, , e-mail:
| | - Yatin Mehta
- Department of Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon-122001, Haryana, India, Extn. 3335, e-mail:
| | - Khalid Ismail Khatib
- Department of Medicine, SKN Medical College, Pune, Maharashtra, India, , e-mail:
| | - Bharat G Jagiasi
- Department of Critical Care, Reliance Hospital, Navi Mumbai, Maharashtra, India, , e-mail:
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, Bhatia Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Shirish Prayag
- Department of Critical Care, Prayag Hospital, Pune, Maharashtra, India, , e-mail:
| | - Suresh Ramasubban
- Department of Critical Care, Apollo Gleneagles Hospital Limited, Kolkata, India, , e-mail:
| | - Jayesh Dobariya
- Department of critical care, Synergy Hospital Rajkot, Rajkot, Gujarat, India, , e-mail:
| | - Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Military Hospital (CTC), Pune, Maharashtra, India, , e-mail:
| | - Inder Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India, , e-mail:
| | - Sameer Arvind Jog
- Department of Critical Care, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India, , 91-9823018178, e-mail:
| | - Atul Prabhakar Kulkarni
- Department of Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, , e-mail:
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Seyfi S, Amri P, Mouodi S. New modalities for non-invasive positive pressure ventilation: A review article. CASPIAN JOURNAL OF INTERNAL MEDICINE 2019; 10:1-6. [PMID: 30858934 PMCID: PMC6386330 DOI: 10.22088/cjim.10.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/20/2018] [Accepted: 05/28/2018] [Indexed: 01/21/2023]
Abstract
Efficiency of non-invasive positive pressure ventilation in the treatment of respiratory failure has been shown in many published studies. In this review article, we introduced new modalities of non-invasive ventilation (NIV), clinical settings in which NIV can be used and a practical summary of the latest official guidelines published by the European Respiratory Clinical Practice. Clinical trials and review articles in four databases up to 25 February 2018 about new modalities of non-invasive positive pressure ventilation were reviewed. Commonly used modalities for treatment of respiratory failure include: CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) or NIPSV (noninvasive pressure support ventilation). The limitations of the BiPAP method are the trigger and cycle asynchrony, inadequate volume delivery and increased respiratory rate. Newer methods, such as adaptive servo-ventilation, have been developed to treat central and complex sleep apnea and the NAVA (neutrally adjusted ventilatory assist) to improve the trigger and cycle asynchrony. In the proportional assist ventilation, unlike the pressure support ventilation, with increased patient effort (flow) the tidal volume increases and it prevents the increase in the respiratory rate and respiratory distress. High-flow nasal cannula is a non-invasive technique that does not provide respiratory support, but provides a mixture of oxygen to the patient. The use of non-invasive pursed-lip breathing ventilation in chronic obstructive pulmonary disease (COPD) patients reduces dyspnea (decreases respiratory rate) and increases blood oxygen saturation. New modalities of NIV improve patient comfort and patient-ventilator interactions, and are recommended in patients with respiratory failure.
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Affiliation(s)
- Shahram Seyfi
- Clinical Research Development Unit of Ayatollah Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Parviz Amri
- Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Simin Mouodi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babal, Iran
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