Non-Invasive Ventilation in Patients with an Altered Level of Consciousness. A Clinical Review and Practical Insights (original) (raw)
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Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure
American Journal of Respiratory and Critical Care Medicine, 2003
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure A Randomized Clinical Trial
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
Intensive Care Medicine, 2011
Purpose: The use of noninvasive ventilation (NIV) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure (hypoxemic ARF) has never been explored. This pilot study aims to assess the feasibility of early extubation followed by immediate NIV, compared conventional weaning, in patients with resolving hypoxemic ARF. Methods: Twenty consecutive hypoxemic patients were randomly assigned to receive either conventional weaning or NIV. The changes in arterial blood gases and respiratory rate were compared between the two groups at 1, 12, 24 and 48 h. Differences in the rate of extubation failure, ICU and hospital mortality, number of invasive-ventilation-free-days at day 28, septic complications, number of tracheotomies, days and rates of continuous intravenous sedation, and ICU length of stay were also determined. Results: No patient interrupted the study protocol. Arterial blood gases were similar during invasive mechanical ventilation, 1 h after NIV application following extubation, and after 12, 24 and 48 h. Respiratory rate was higher after 1 h in the NIV group, but no different after 12, 24 and 48 h. The number of invasive-ventilation-free-days at day 28 was 20 ± 8 (min = 0, max = 25) days in the treatment group and 10 ± 9 (min = 0, max = 25) days in the control group (p = 0.014). The rate of extubation failure, ICU and hospital mortality, tracheotomies, septic complications, days and rates of continuous sedation, and ICU length of stay were not significantly different between the two groups. Conclusions: In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF.
BMC Anesthesiology
Background: Noninvasive ventilation is used worldwide in many settings. Its effectiveness has been proven for common clinical conditions in critical care such as cardiogenic pulmonary edema and chronic obstructive pulmonary disease exacerbations. Since the first pioneering studies of noninvasive ventilation in critical care in the late 1980s, thousands of studies and articles have been published on this topic. Interestingly, some aspects remain controversial (e.g. its use in de-novo hypoxemic respiratory failure, role of sedation, self-induced lung injury). Moreover, the role of NIV has recently been questioned and reconsidered in light of the recent reports of new techniques such as high-flow oxygen nasal therapy. Methods: We conducted a survey among leading experts on NIV aiming to 1) identify a selection of 10 important articles on NIV in the critical care setting 2) summarize the reasons for the selection of each study 3) offer insights on the future for both clinical application and research on NIV. Results: The experts selected articles over a span of 26 years, more clustered in the last 15 years. The most voted article studied the role of NIV in acute exacerbation chronic pulmonary disease. Concerning the future of clinical applications for and research on NIV, most of the experts forecast the development of innovative new interfaces more adaptable to patients characteristics, the need for good well-designed large randomized controlled trials of NIV in acute "de novo" hypoxemic respiratory failure (including its comparison with high-flow oxygen nasal therapy) and the development of software-based NIV settings to enhance patient-ventilator synchrony. Conclusions: The selection made by the experts suggests that some applications of NIV in critical care are supported by solid data (e.g. COPD exacerbation) while others are still waiting for confirmation. Moreover, the identified insights for the future would lead to improved clinical effectiveness, new comparisons and evaluation of its role in still "lack of full evidence" clinical settings.
Respiratory Care
BACKGROUND: The use of noninvasive ventilation (NIV) in the emergency setting to reverse hypercapnic coma in frail patients with end-stage chronic respiratory failure and do-not-intubate orders remains a questionable issue given the poor outcome of this vulnerable population. We aimed to answer this issue by assessing not only subjects' outcome with NIV but also subjects' point of view regarding NIV for this indication. METHODS: A prospective observational case-control study was conducted in 3 French tertiary care hospitals during a 2-y period. Forty-three individuals who were comatose (with pH < 7.25 and P aCO 2 > 100 mm Hg at admission) were compared with 43 subjects who were not comatose and who were treated with NIV for acute hypercapnic respiratory failure. NIV was applied by using the same protocol in both groups. They all had a do-notintubate order and were considered vulnerable individuals with end-stage chronic respiratory failure according to well-validated scores. RESULTS: NIV yielded similar outcomes in the 2 groups regarding in-hospital mortality (n ؍ 12 [28%] vs n ؍ 12 [28%] in the noncomatose controls, P > .99) and 6-month survival (n ؍ 28 [65%] vs n ؍ 22 [51%] in the noncomatose controls, P ؍ .31). Despite poor quality of life scores (21.5 ؎ 10 vs 31 ؎ 6 in the awakened controls, P ؍ .056) as assessed by using the VQ11 questionnaire 6 months to 1 y after hospital discharge, a large majority of the survivors (n ؍ 23 [85%]) would be willing to receive NIV again if a new episode of acute hypercapnic respiratory failure occurs. CONCLUSIONS: In the frailest subjects with supposed end-stage chronic respiratory failure that justifies treatment limitation decisions, it is worth trying NIV when acute hypercapnic respiratory failure occurs, even in the case of extreme respiratory acidosis with hypercapnic coma at admission.
New advances in the use of noninvasive ventilation for acute hypoxaemic respiratory failure
European Respiratory Journal, 2003
Noninvasive ventilation (NIV) includes various techniques for augmenting alveolar ventilation without an endotracheal airway. The theoretical advantages of this approach include avoiding the complications associated with endotracheal intubation, improving patient comfort, preserving airway defence mechanisms, speech and swallowing. The successful application of NIV in hypoxaemic acute respiratory failure (ARF) of varied etiologies has been extensively described but success rate is strictly dependent on ARF etiology and until today the application of NIV strategies in the setting of hypoxaemic ARF is controversial. Larger, controlled studies are required to clarify the role of NIV in the setting of hypoxaemic ARF. The correct choice of the patient ventilator interface is a crucial issue in noninvasive ventilation. The study of new interfaces could improve tolerability reducing the noninvasive ventilation failure rate.