Noninvasive and invasive positive pressure ventilation for acute respiratory failure in critically ill patients: a comparative cohort study

Effectiveness and Outcomes of Noninvasive Positive Pressure Ventilation in Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Endotracheal intubation and mechanical ventilation in individuals experiencing acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with several complications. Therefore, utilizing noninvasive positive pressure ventilation (NIPPV) is the suggested initial management for these individuals. The current study was done to assess and compare the clinical and physiological parameters before and after the application of NIPPV and also to evaluate the outcomes of NIPPV.

METHODOLOGY

A prospective observational study was conducted on 50 patients with COPD experiencing acute exacerbations. These patients were treated with NIPPV. Measurements of blood pressure, respiratory rate (RR), heart rate (HR), dyspnea using the modified Borg scale, and arterial blood gas (ABG) parameters (pH, PaCO2, and PaO2) were recorded at baseline, one hour, six hours, 24 hours, and daily until discharge. The study's outcomes included the subjects who successfully underwent NIPPV and failed during NIPPV.

RESULTS

NIPPV effectively reduced the dyspnea score from 7.24 ± 1.58 at baseline to 5.53 ± 1.82 at one hour, 4.11 ± 1.75 at six hours, 2.60 ± 1.03 at 24 hours, and 1.26 ± 0.44 at the time of discharge. Significant improvements were also observed in HR and RR (P < 0.001). When compared to the baseline, the pH level was significantly maintained, PaCO2 was decreased, and PaO2 was increased at various times. Mortality was observed in four patients.

CONCLUSIONS

NIPPV was successful in 42 (84%) patients, with improvements in ABG and pH for early recovery and reduced hospital stay.

Factors and Outcomes Associated with Failed Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure

Background

The decision guild for non-invasive positive pressure ventilation (NPPV) application in acute respiratory failure (ARF) patients still needs to work out.

Methods

Adult patients with acute hypoxemic or hypercapnic respiratory failure were recruited and treated with NPPV or primary invasive mechanical ventilation (IMV). Patients’ characteristic and clinical outcomes were recorded. Logistic regression models were used to estimate the adjusted odds ratio (aOR) and 95% confidence intervals for baseline characteristics and clinical outcomes. Subgroup analyses by reason behind successful NPPV were conducted to ascertain if any difference could influence the outcome.

Results

A total of 4525 ARF patients were recruited in our facility between year 2015 and 2017. After exclusion, 844 IMV patients, 66 patients with failed NPPV, and 74 patients with successful NPPV were enrolled. Statistical analysis showed APACHE II score (aOR = 0.93), time between admission and start NPPV (aOR = 0.92), and P/F ratio (aOR = 1.04) were associated with successful NPPV. When comparing with IMV patients, failed NPPV patients displayed a significantly lower APACHE II score, higher Glasgow Coma Scale, longer length of stay in hospital, longer duration of invasive ventilation, RCW/Home ventilator, and some comorbidities.

Conclusion

APACHE II score, time between admission and start NPPV, and PaO2 can be predictors for successful NPPV. The decision of NPPV application is critical as ARF patients with failed NPPV have various worse outcomes than patients receiving primary IMV.

Clinical Outcomes of Acute Respiratory Failure Associated With Noninvasive and Invasive Ventilation in a Pediatric ICU

BACKGROUND

It remains unknown if pediatric patients failing initial noninvasive ventilation (NIV) experience worse clinical outcomes than those successfully treated with NIV or those primarily intubated.

METHODS

This was a single-center, retrospective review of patients admitted with acute respiratory failure to the University of Michigan pediatric intensive care or cardiothoracic ICUs and receiving NIV or invasive mechanical ventilation as first-line therapy.

RESULTS

One hundred seventy subjects met inclusion criteria and were enrolled: 65 NIV success, 55 NIV failure, and 50 invasive mechanical ventilation alone. Of those failing NIV, median time to intubation was 1.8 (interquartile range [IQR] < 1-7) h. On multivariable regression, ICU-free days were significantly different between groups (NIV success: 22.9 ± 6.9 d; NIV failure: 13.0 ± 6.6 d; invasive ventilation: 12.5 ± 6.9 d; P < .001 across all groups). Multivariable regression revealed no difference in ventilator-free days between NIV failure and invasive ventilation groups (15.4 ± 10.1 d vs 15.9 ± 9.7 d, P = .71). Of 64 subjects (37.6%) meeting Pediatric Acute Lung Injury Consensus Conference pediatric ARDS criteria, only 14% were successfully treated with NIV. Ventilator-free days were similar between the NIV failure and invasive ventilation groups (11.6 vs 13.2 d, P = .47). On multivariable analysis, ICU-free days were significantly different across pediatric ARDS groups (P < .001): NIV success: 20.8 + 31.7 d; NIV failure: 8.3 + 23.8 d; invasive alone: 8.9 + 23.9 d, yet no significant difference in ventilator-free days between those with NIV failure versus invasive alone (11.6 vs 13.2 d, P = .47).

CONCLUSIONS

We demonstrated that critically ill pediatric subjects unsuccessfully trialed on NIV did not experience increased ICU length of stay or fewer ventilator-free days when compared to those on invasive mechanical ventilation alone, including in the pediatric ARDS subgroup. Our findings are predicated on a median time to intubation of < 2 h in the NIV failure group and the provision of adequate monitoring while on NIV.

Evidence-Based Mechanical Ventilatory Strategies in ARDS

Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO₂ (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.

Noninvasive ventilation failure in patients with hypoxemic respiratory failure: the role of sepsis and septic shock

BACKGROUND

Sepsis and septic shock are common in noninvasive ventilation (NIV) patients. However, studies on the association between sepsis and NIV failure are lacking.

METHODS

A prospective multi-center observational study was performed in 16 Chinese intensive care units (ICUs). Patients who used NIV due to hypoxemic respiratory failure were enrolled. Sepsis and septic shock were diagnosed according to the guideline of sepsis-3.

RESULTS

A total of 519 patients were enrolled. Sepsis developed in 365 patients (70%) and septic shock developed in 79 patients (15%). However, 75 patients (14%) had no sepsis. NIV failure was 23%, 38%, and 61% in patients, with no sepsis, sepsis, and septic shock, respectively. Multivariate analysis found that sepsis [odds ratio (OR) = 1.95, 95% confidence interval (CI): 1.06-3.61] and septic shock (OR = 2.47, 95% CI: 1.12-5.45) were independently associated with NIV failure. In sepsis and septic shock population, the NIV failure was 13%, 31%, 37%, 53%, and 67% in patients with sequential organ failure assessment (SOFA) scores of ⩽2, 3-4, 5-6, 7-8, and ⩾9, respectively. Patients with nonpulmonary induced sepsis had similar NIV failure rate compared with those with pulmonary induced sepsis, but had higher proportion of septic shock (37% versus 10%, p ⩽ 0.01) and lower ICU mortality (10% versus 22%, p ⩽ 0.01).

CONCLUSIONS

Sepsis was associated with NIV failure in patients with hypoxemic respiratory failure, and the association was stronger in septic shock patients. NIV failure increased with the increase of organ dysfunction caused by sepsis. The reviews of this paper are available via the supplemental material section.

Noninvasive Ventilation for Critically Ill Subjects With Acute Respiratory Failure in the Emergency Department

BACKGROUND

We aimed to investigate the association between noninvasive ventilation (NIV) initiated in the emergency department and patient outcomes for those requiring invasive mechanical ventilation so that we could understand the effect of extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation on patient outcomes.

METHODS

We conducted a retrospective single-center cohort study at an academic tertiary care hospital center. All emergency department patients with acute respiratory failure requiring invasive mechanical ventilation and admission to the ICU within 48 h of initial presentation over a 24-month period were included.

RESULTS

Subject characteristics, ventilator parameters, and clinical course were captured via electronic query, respiratory billing data, and standardized chart abstraction. A total of 431 subjects with acute respiratory failure requiring invasive mechanical ventilation within 48 h of arrival were identified, of whom 115 (26.7%) were exposed to NIV prior to invasive mechanical ventilation, with a median duration of 4 h (interquartile range 1.9-9.3). Based on a multivariable model controlling for covariates, any NIV exposure prior to invasive mechanical ventilation was not associated with an increased odds of persistent organ dysfunction or death. However, in the subset of subjects exposed to NIV, extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation was associated with increased odds of persistent organ dysfunction or death (odds ratio 4.11, 95% CI 1.51-11.19). Extended NIV use was also associated with increased odds of in-hospital mortality (odds ratio 4.02, 95% CI 1.51-10.74).

CONCLUSIONS

Although any exposure to NIV prior to invasive mechanical ventilation did not appear to affect morbidity and mortality, extended NIV use prior to invasive mechanical ventilation was associated with worse patient outcomes, suggesting a need for additional study to better understand the ramifications of duration of NIV use prior to failure on outcomes. Given this early timeframe for intervention, future studies should be collaborations between the emergency department and ICU.

Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure Secondary to Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Introduction

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading cause of poor quality of life and mortality in developing countries. Noninvasive positive pressure ventilation (NIPPV) remains the first-line intervention in hospitalized patients with acute respiratory failure (ARF) due to AECOPD. However, NIPPV may fail in some patients. This study was conducted to assess the frequency of NIPPV failure and clinical parameters and outcomes in AECOPD patients with failed NIPPV and their conversion to invasive positive pressure ventilation (IPPV).

Methods

This prospective observational study was conducted in the pulmonology unit of a tertiary care hospital in Pakistan. AECOPD patients with ARF who were candidates of NIPPV were included after securing informed consent. Their demographic characteristics, clinical parameters, and in-hospital outcomes were recorded on a semi-structured proforma. For statistical analysis, SPSS software version 22.0 for Windows (IBM, Armonk, NY) was used.

Results

With 24 hours of NIPPV, 73 (70.2%) patients improved and the remaining 31 (29.8%) were shifted to IPPV. Patients in the IPPV group had higher systolic blood pressure (BP) [133.8 mmHg (±21.2) vs. 121.1 mmHg (±8.3); probability value (p): <0.000] and lower diastolic BP [68.7 mmHg (±13.4) vs. 76.2 mmHg (±10.8); p: 0.003]. Their pH was more acidic [7.20 (±0.13) vs. 7.42 (±0.01); p: <0.000], heart rates were high [131.1 (±10.5) vs. 100.2 (±7.5); p: <0.000], and the percentage of oxygen saturation was low [90.7 (±3.0) vs. 93.4 (±4.5); p: 0.004]. Patients who were managed on NIPPV throughout their hospital stay required respiratory support for fewer days [3.2 (±1.3) vs. 4.1 (±1.8); p: 0.005], and their hospital stay was shorter [3.5 (±1.2) vs. 5.3 (±2.5) days; p: <0.000]. Mortality rate in the NIPPV group was significantly lower (1.4% vs. 12.9%; p: 0.01).

Conclusions

Deranged blood pressure, increased heart rate, acidemia, and a low percentage of oxygen saturation are crucial clinical and biochemical parameters that can predict the success of NIPPV with 24 hours of therapy in patients with AECOPD and secondary ARF. Patients who do not improve with 24 hours of NIPPV therapy usually have poor in-hospital outcomes including mortality.

Outcomes of Noninvasive Positive Pressure Ventilation in Acute Respiratory Distress Syndrome and Their Predictors: A National Cohort

Rationale

Although noninvasive positive pressure ventilation (NIPPV) is increasingly used in acute respiratory distress syndrome (ARDS) to avoid invasive mechanical ventilation (IMV), the data supporting its benefit for this indication are lacking.

Objectives

To analyze the all-cause in-hospital mortality rate and length of stay (LOS) for ARDS patients who received NIPPV in the United States (US) compared to those who were initially intubated. Our secondary outcome of interest was to determine the predicting factors for NIPPV failure.

Methods

We used the 2016 National Inpatient Sample database to identify 4,277 adult records with ARDS who required positive pressure ventilation. We divided the cohort into initial treatment with IMV or NIPPV. Then, the NIPPV group was further subdivided into NIPPV failure or success. We defined NIPPV failure as same-patient use of NIPPV and IMV either on the same day or using IMV at a later date. We analyzed the in-hospital mortality, LOS, and NIPPV failure rate. Linear regression of log-transformed LOS and logistic regression of binary outcomes were used to test for associations.

Results

The NIPPV success group had the lowest mortality rate (4.9% [3.8, 6.4]) and the shortest LOS (7 days [6.6, 7.5]). The NIPPV failure rate was 21%. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure (adjusted OR: 4.47, 2.65, and 2.23, respectively). There was no significant difference between NIPPV failure and IMV groups in-hospital mortality (26.9% [21.8, 32.8] vs. 25.1% [23.5, 26.9], p=0.885) or LOS (16 [14, 18] vs. 15.6 [15, 16.3], p=0.926).

Conclusions

NIPPV success in ARDS exhibits significantly lower hospital mortality rates and shorter LOS compared with IMV, and NIPPV failure exhibits no significant difference in hospital mortality or LOS compared with patients who were initially intubated. Therefore, an initial trial of NIPPV may be considered in ARDS. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure; these factors should be used to stratify patients to the most suitable ventilation modality.

Non-invasive ventilation of patients with acute asthma

A retrospective observational study of 21 patients admitted to the Intensive Care Unit (ICU) of Frankston Hospital with acute asthma between 2011 and 2014 was undertaken. We report the outcomes for three groups of patients; those that did (n = 7) or did not (n = 6) receive initial therapy with non-invasive ventilation (NIV) together with those that received invasive ventilation (n = 8). Patients successfully managed with NIV alone experienced a shorter ICU and hospital stay versus those who required invasive ventilation.

Managing the oncologic patient with suspected pneumonia in the intensive care unit

INTRODUCTION

Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research.

AREAS COVERED

This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

Noninvasive ventilation for acute respiratory distress syndrome: the importance of ventilator settings

Noninvasive ventilation (NIV) is commonly used to prevent endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Patients with hypoxemic acute respiratory failure who fail an NIV trial carry a worse prognosis as compared to those who succeed. Additional factors are also knowingly associated with worse outcomes: higher values of ICU severity score, presence of severe sepsis, and lower ratio of arterial oxygen tension to fraction of inspired oxygen. However, it is still unclear whether NIV failure is responsible for the worse prognosis or if it is merely a marker of the underlying disease severity. There is therefore an ongoing debate as to whether and which ARDS patients are good candidates to an NIV trial. In a recent paper published in JAMA, "Effect of Noninvasive Ventilation Delivered by Helmet vs. Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome: A Randomized Clinical Trial", Patel et al. evaluated ARDS patients submitted to NIV and drew attention to the importance of the NIV interface. We discussed their interesting findings focusing also on the ventilator settings and on the current barriers to lung protective ventilation in ARDS patients during NIV.