Trends in the Use and Outcomes of Mechanical Ventilation among Patients Hospitalized with Acute Exacerbations of COPD in Spain, 2001 to 2015

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

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.

The Association between Non-Invasive Ventilation and the Rate of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) has significant effects on patient outcomes, including prolonging the duration of both mechanical ventilation and stay in the intensive care unit (ICU). The aim of this study was to assess the association between non-invasive ventilation/oxygenation (NIVO) prior to intubation and the rate of subsequent VAP. This was a multicenter retrospective cohort study of adult patients who were admitted to the medical ICU from three tertiary care academic centers in three distinct regions. NIVO was defined as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or high-flow nasal cannula (HFNC) for any duration during the hospitalization prior to intubation. The primary outcome variable was VAP association with NIVO. A total of 17,302 patients were included. VAP developed in 2.6% of the patients (444/17,302), 2.3% (285/12,518) of patients among those who did not have NIVO, 1.6% (30/1879) of patients who had CPAP, 2.5% (17/690) of patients who had HFNC, 8.1% (16/197) of patients who had BiPAP, and 4.8% (96/2018) of patients who had a combination of NIVO types. Compared to those who did not have NIVO, VAP was more likely to develop among those who had BiPAP (adj OR 3.11, 95% CI 1.80-5.37, p < 0.001) or a combination of NIVO types (adj OR 1.91, 95% CI 1.49-2.44, p < 0.001) after adjusting for patient demographics and comorbidities. The use of BiPAP or a combination of NIVO types significantly increases the odds of developing VAP once receiving IMV.

Noninvasive positive pressure in acute exacerbations of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Noninvasive positive pressure ventilation (NIV) is standard of care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We review the most current evidence and highlight areas of uncertainty and ongoing research. We highlight key concepts for the clinician caring for patients with AECOPD which require NIV.

RECENT FINDINGS

Implementation of NIV in AECOPD is not uniform in spite of the evidence and guidelines. Initiation of NIV should be done early and following protocols. Low-intensity NIV remains the standard of care, although research and guidelines are evaluating higher intensity NIV. Scores to predict NIV failure continue to be refined to allow early identification and interventions. Several areas of uncertainty remain, among them are interventions to improve tolerance, length of support and titration and nutritional support during NIV.

SUMMARY

The use of NIV in AECOPD is the standard of care as it has demonstrated benefits in several patient-centered outcomes. Current developments and research is related to the implementation and adjustment of NIV.

Clinical Application of Ultrasound-Guided Internal Branch of Superior Laryngeal Nerve Block in Patients with Severe COPD Undergoing Awake Fibreoptic Nasotracheal Intubation: A Randomized Controlled Clinical Trial

Purpose

The aim was to investigate the time for intubation, adverse events and the comfort score of ultrasound-guided internal branch of superior laryngeal nerve block in patients with severe chronic obstructive pulmonary disorder (COPD) undergoing awake fibreoptic nasotracheal intubation.

Methods

Sixty patients with COPD who needed awake fibreoptic nasotracheal intubation were randomly and evenly divided into the ultrasound-guided internal branch of the superior laryngeal nerve block group (group S) and the control group (group C). All patients received procedural sedation with dexmedetomidine and adequate topical anaesthesia of the upper respiratory tract. Then, bilateral block was performed (with 2 mL of 2% lidocaine or the same volume of saline) followed by fibreoptic nasotracheal intubation. The primary outcomes were time for intubation, adverse reactions and comfort score. The secondary outcomes were haemodynamic changes and serum norepinephrine (NE) and adrenaline (AD) concentrations immediately before intubation (T0); immediately after intubation to the laryngopharynx (T1); and immediately (T2), 5 min (T3) and 10 min (T4) after intubation between the groups.

Results

Compared with group C, the time for intubation, the incidence of adverse reactions and the comfort score in group S were significantly lower (P<0.01). Compared with T0, the mean arterial pressure (MAP), heart rate (HR), NE and AD were significantly higher at T1 - T4 in group C (P<0.05), but were not obviously higher at T1 - T4 in group S (P>0.05). MAP, HR, NE and AD at T1-T4 were significantly lower in group S than in group C (P<0.05).

Conclusion

Ultrasound-guided internal branch of the superior laryngeal nerve block can effectively shorten the time for intubation, reduce the incidence of adverse reactions, improve comfort score, maintain considerable haemodynamic stability and inhibit stress response in patients with severe COPD undergoing awake fibreoptic nasotracheal intubation.

Improving mobility in the intensive care unit with a protocolized, early mobilization program: observations of a single center before-and-after the implementation of a multidisciplinary program

Background

Early intensive care unit (ICU) protocolized rehabilitative programs have been described previously, yet with differing starting time points and mostly on mechanically ventilated patients. We extended the concept to all admitted ICU patients and investigate the efficacy of early mobilization in improving mobility of the critically ill, address issues surrounding the timing and intensity of an early rehabilitative program.

Methods

Prospective cohorts of patients admitted consecutively before-and-after (control, n=92; intervention, n=90) the introduction of an early mobilization program in a single center, general hospital ICU. Improvement in mobility as assessed by ICU mobility score, on ICU admission and upon ICU discharge, was measured as a primary outcome.

Results

Those receiving early mobilization in the intensive care unit had higher ICU mobility score (2.63; 95% confidence interval, 0.65–4.61; P<0.001) upon discharge from the intensive care, with earlier out of bed mobilization on day 5 compared to the control group of day 21 (P<0.001). No differences were found in terms of mortality, intensive care hospitalization and subsequent hospitalization duration after discharge from ICU.

Conclusions

Here, we report that improvement in mobility score earlier in the course of intensive care hospitalization with the introduction of a protocolized early rehabilitative program.

Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation

Background

Non-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients’ illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity.

Methods

We retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals.

Results

In 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9–64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2–84.2%) in rural and 55.1% (IQI=10.8–86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups.

Conclusion

NIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.

The Combination of Hemogram Indexes to Predict Exacerbation in Stable Chronic Obstructive Pulmonary Disease

Background: Chronic obstructive pulmonary disease (COPD) is characterized by pulmonary and systemic inflammatory processes, and exacerbation of COPD represents a critical moment in the progression of COPD. Several biomarkers of inflammation have been proposed to have a predictive function in acute exacerbation. However, their use is still limited in routine clinical practice. The purpose of our study is to explore the prognostic efficacy of novel inflammatory hemogram indexes in the exacerbation among stable COPD patients. Method: A total of 275 stable COPD patients from the Shanghai COPD Investigation Comorbidity Program were analyzed in our study. Blood examinations, especially ratio indexes like platelet-lymphocyte ratio (PLR), platelet × neutrophil/lymphocyte ratio [systemic immune-inflammation index (SII)], and monocyte × neutrophil/lymphocyte ratio [systemic inflammation response index (SIRI)], lung function test, CT scans, and questionnaires were performed at baseline and routine follow-ups. Clinical characteristics and information of exacerbations were collected every 6 months. The relationship between hemogram indexes and diverse degrees of exacerbation was assessed by logistic regression. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to evaluate the ability of hemogram indexes to predict exacerbation of COPD. Furthermore, the discrimination and accuracy of combined indexes were measured by ROC and calibration curve. Result: There was a significant positive correlation between PLR levels and total exacerbation of COPD patients in a stable stage in a year. Also, the predictive ability of PLR exceeded any other ratio indexes, with an AUC of 0.66. SII and SIRI ranked second only to PLR, with an AUC of 0.64. When combining PLR with other indexes (sex, COPD year, and St. George's Respiratory Questionnaire scores), they were considered as the most suitable panel of index to predict total exacerbation. Based on the result of the ROC curve and calibration curve, the combination shows optimal discrimination and accuracy to predict exacerbation events in COPD patients. Conclusion: The hemogram indexes PLR, SII, and SIRI were associated with COPD exacerbation. Moreover, the prediction capacity of exacerbation was significantly elevated after combining inflammatory hemogram index PLR with other indexes, which will make it a promisingly simple and effective marker to predict exacerbation in patients with stable COPD.