Remifentanil versus dexmedetomidine for treatment of cardiac surgery patients with moderate to severe noninvasive ventilation intolerance (REDNIVIN): a prospective, cohort study

Analgo-sedation in Patients on Non-invasive Mechanical Ventilation: Need for Guideline Recommendation

Shrinath V, Marwah V, Jyothis MC. Analgo-sedation in Patients on Non-invasive Mechanical Ventilation: Need for Guideline Recommendation. Indian J Crit Care Med 2024;28(3):309-310.

Sedation and analgesia strategies for non-invasive mechanical ventilation: A systematic review and meta-analysis

BACKGROUND

The use of sedative and analgesic drugs during non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is controversial.

OBJECTIVES

To assess the clinical effectiveness of sedative and analgesic medications used during NIV for patients with ARF to no sedation or analgesia. In addition, to investigate the characteristics of dexmedetomidine in comparison to other medications.

METHODS

PubMed, Embase, Web of Science, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched. Mean differences (MDs) or pooled risk ratios (RRs) were computed using random-effects models. We applied the Cochrane risk-of-bias assessment tool 2.0 to assess the methodological quality of eligible studies and the GRADE approach to evaluate the evidence certainty.

RESULTS

Twenty-one studies were selected. Whether in Group A (using sedative and analgesic drugs vs. nonuse) or Group B (using dexmedetomidine vs. other drugs), the rates of tracheal intubation and delirium, the length of NIV, and the length of stay in the intensive care unit (ICU LOS) all decreased in both experimental groups (P < 0.05). And there were no significant differences in all-cause mortality and the incidence of hypotension between the two groups (P > 0.05), while both Group A and Group B's experimental groups had greater incidences of bradycardia.

CONCLUSIONS

Administering sedative and analgesic medications during NIV can reduce the risk of tracheal intubation and delirium. Additionally, dexmedetomidine outperformed other sedative medications in terms of these clinical outcomes, making it the better option when closely monitoring patients' vital signs.

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

Background and objectives

Non-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.

Methods

This 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.

Results

The 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.

Conclusion

In 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.

Comfort During Non-invasive Ventilation

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.