Treatment of Acute Exacerbations of Chronic Respiratory Failure * (original) (raw)
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Noninvasive vs Conventional Mechanical Ventilation in Acute Respiratory Failure
CHEST Journal, 2005
Study objective: Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. Design: A randomized, multicenter, controlled trial. Setting: Seven multipurpose ICUs. Patients: Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. Intervention: The noninvasive group received ventilation through a face mask in pressuresupport mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. Measurements and results: Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p ؍ 0.09) and complications occurred in 52% and 70% (p ؍ 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. Conclusions: NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.
IP innovative publication pvt. ltd, 2019
Background: The aim of this study was to determine whether, non-invasive ventilation (NIV) may be an effective as well as a safe alternative to invasive mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD) with acute severe respiratory failure who meet criteria for mechanical ventilation. Methodology: The sample size was a total of 40 subjects; 20 subjects for each of the two groups. Group 1 was given NIV trial and the group 2 was given Endotracheal Tube Mechanical Ventilation or (ETMV). Results: Mean age of NIV group was 59.5 ± 6.25 years, and ETMV group was 62.7 ± 7.3 years. The mean Respiratory rate of NIV group was 35.2 ± 3.4 breaths per minute and ETMV group was 37.2 ± 2.4 breaths per minute. The mean pH level of NIV group was 7.2 ± 0.02, and ETMV group was 7.17 ± 0.04. There was a marked improvement in pH after intubation, but there was not much of a significant change with NIV management. The mean PCO2 level of NIV was 69.4 ± 7.4 mmHg, and ETMV was 78.1 ± 13.12mmHg. The mean PaO2 level of NIV was 64.3 ± 13.9mmHg, and ETMV was 75.65 ± 19.12mmHg. In the total of 20 subjects in this group, 8 had recovered from NPPV, and 12 were intubated, in which there were 4 mortalities and 8 had recovered after being intubated. The NIV in this group had failed, was reached. However, the overall complications and outcome had been better resulted than expected, when compared to the ETMV group. The complications in the NIV group were dryness of mouth (10%), Pneumonia (10%), and Multi-organ failure (5%). In ETMV group, in the total of 20 subjects in this group, out of which there were 6 mortalities and 14 recovered. Conclusion: The results of this study show that the NIV trial failed. However, this type of ventilation has an advancement when it is presented in an ICU setup, as complications can be avoided and managed. Even though it is a slightly inconvenient preference, it is preferred over ETMV. This preference comes as an inclination due to its cost effectiveness and fewer complications when compared to ETMV.
ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs
Indian Journal of Critical Care Medicine
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 airborne 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)
Study of Non Invasive Ventilation in Acute Respiratory Failure
Introduction: Noninvasive positive-pressure ventilation is a safe and effective means of improving gas exchange in patients with many types of acute respiratory failure. This study focuses on use of NPPV in the intensive care unit and in the care of patients with acute respiratory failure due to various diagnoses. Materials and methods: We included 50 consecutive patients admitted to medical intensive care unit satisfying our inclusion/exclusion criteria from April 1, 2014 till March 31, 2015. Various clinical and physical parameters were monitored during the period of the stay. All the complications experienced by the patients were also noted. Data was analyzed by applying appropriate statistical tests. Statistical analysis was applied P < 0.05 was considered as significant. Results: Average age of the patients was 42 years and the most common diagnosis was Acute Respiratory Distress Syndrome (ARDS) followed by pneumonia. Our analysis we did find a statistically significant association between the type of diagnosis and non-invasive ventilation failing (chi-square = 22.22; p-value = 0.004). This was however not true for patients' clinical outcome in terms of mortality (chi-square = 13.51; p-value = 0.09). In our patients air leak was the most common complication and hemodynamic instability was the least common. We also observed that death occurred in patients who failed to recover on NIV. Conclusions: Our study showed that non-invasive failure has no statistically significant relation to age of the patient. The diagnosis of patient is a good predictor for NIV success or failure. We recommend the use of full face mask with proper exhalation device for preventing air leak.
Panacea Journal of Medical Sciences, 2023
Abstract Background: Failure of respiratory system in one or both of its gas-exchanging functions- oxygenation of pulmonary arterial blood and carbon-dioxide elimination from mixed venous blood. Non-Invasive Ventilation is an alternative to invasive ventilation in many conditions it is a valuable component in patient management. Its use in acute respiratory failure is widely accepted and well known. Aim: To Study the indications, outcomes, and complications of NIV. Materials and Methods: This is a prospective observational study conducted on 100 patients admitted with either Type-I or Type -II respiratory failure. Results: Various common indications for use of NIV in acute Respiratory Failure are COPD, ILD, Bronchiectasis, Pneumonia, Pulmonary Thromboembolism, Kyphoscoliosis, and Pulmonary Tuberculosis in that order. The overall success rate of NIV is 84%. Conclusion: NIV helps in improving gas exchange in acute respiratory failure irrespective of its type, reduces intubation and length of hospital stay hence, its use as the first modality of treatment in patients without overt contraindications is recommended. Overall, NIV is safe and effective in patients with acute respiratory failure as there are no major complications associated with its use. Keywords: Respiratory failure, Complications, NonInvasive Ventilation
Noninvasive mechanical ventilation in acute respiratory failure
European Respiratory Journal, 1996
Background -Non-invasive mechanical ventilation is increasingly used in the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to identify simple parameters to predict the success of this technique. Methods -Fifty nine episodes of acute respiratory failure in 47 patients with COPD treated with non-invasive mechanical ventilation were analysed, considering each one as successful (78%) or unsuccessful (22%) according to survival and to the need for endotracheal intubation. Results -Pneumonia was the cause of acute respiratory failure in 38% of the unsuccessful episodes but only in 9% of the successful ones. Success with non-invasive mechanical ventilation was associated with less severely abnormal baseline clinical and functional parameters, and with less severe levels of acidosis assessed during an initial trial of non-invasive mechanical ventilation. Conclusions -The severity of the episode of acute respiratory failure as assessed by clinical and functional compromise, and the level of acidosis and hypercapnia during an initial trial of non-invasive mechanical ventilation, have an influence on the likelihood for success with non-invasive mechanical ventilation and may prove to be useful in deciding whether to continue with this treatment. (Thorax 1995;50:755-757) Keywords: non-invasive mechanical ventilation, acute respiratory failure, chronic obstructive pulmonary disease.
Conventional Vs Non Invasive Ventilation In Acute Respiratory Failure
Australian Journal of …, 2009
Treatment of patients with acute respiratory failure (ARF) often involves mechanical ventilation via endotracheal intubation. Non-invasive positive pressure ventilation (NIV) using Bi-level positive airway pressure (BiPAP) can be a safe and effective means of improving gas exchange. The aim of the present study is to: 1) Assess non-invasive positive pressure ventilation (BiPAP) as an alternative way for ventilation in ARF, and to 2) Determine factors that can predict the successful use of BiPAP. Thirty patients with acute respiratory failure (both type I and II) were enrolled in the study and divided into two groups. Group I included 10 patients who were subjected to invasive mechanical ventilation. Group II included 20 patients were subjected to NIV using BiPAP. Both groups were compared regarding the following parameters: arterial blood gases (ABG) on admission, 30 minutes after beginning of mechanical ventilation, 1 ½ hour then once daily. Complications namely ventilator 2 associated pneumonia (VAP), skin necrosis and CO narcosis; static compliance and resistance were measured at day one and day two. Compared to group I, group II patients were associated with similar improvement in ABGs data at 30 minutes and at discontinuation of ventilation (Table 1). Group II patients showed significantly lower incidence in VAP (20% vs 80%), shorter duration of mechanical ventilation (3±3 vs 6±5 days, P = 0.006), with shorter length of hospital stay (5.8±3.6
Incidence and causes of non-invasive mechanical ventilation failure after initial success
Thorax, 2000
Background-The rate of failure of noninvasive mechanical ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD) with acute respiratory insuYciency ranges from 5% to 40%. Most of the studies report an incidence of "late failure" (after >48 hours of NIMV) of about 10-20%. The recognition of this subset of patients is critical because prolonged application of NIMV may unduly delay the time of intubation. Methods-In this multicentre study the primary aims were to assess the rate of "late NIMV failure" and possible associated predictive factors; secondary aims of the study were evaluation of the best ventilatory strategy in this subset of patients and their outcomes in and out of hospital. The study was performed in two respiratory intensive care units (ICUs) on patients with COPD admitted with an episode of hypercapnic respiratory failure (mean (SD) pH 7.23 (0.07), PaCO 2 85.3 (15.8) mm Hg). Results-One hundred and thirty seven patients initially responded to NIMV in terms of objective (arterial blood gas tensions) and subjective improvement. After 8.4 (2.8) days of NIMV 31 patients (23%; 95% confidence interval (CI) 18 to 33) experienced a new episode of acute respiratory failure while still ventilated. The occurrence of "late NIMV failure" was significantly associated with functional limitations (ADL scale) before admission to the respiratory ICU, the presence of medical complications (particularly hyperglycaemia), and a lower pH on admission. Depending on their willingness or not to be intubated, the patients received invasive ventilation (n=19) or "more aggressive" (more hours/day) NIMV (n=12). Eleven (92%) of those in this latter subgroup died while in the respiratory ICU compared with 10 (53%) of the patients receiving invasive ventilation. The overall 90 day mortality was 21% and, after discharge from hospital, was similar in the "late NIMV failure" group and in patients who did not experience a second episode of acute respiratory failure.
Pathophysiological Basis of Acute Respiratory Failure on Non-Invasive Mechanical Ventilation
The Open Respiratory Medicine Journal, 2015
Noninvasive mechanical ventilation (NIMV) was created for patients who needed noninvasive ventilator support, this procedure decreases the complications associated with the use of endotracheal intubation (ETT). The application of NIMV has acquired major relevance in the last few years in the management of acute respiratory failure (ARF), in patients with hypoxemic and hypercapnic failure. The main advantage of NIMV as compared to invasive mechanical ventilation (IMV) is that it can be used earlier outside intensive care units (ICUs). The evidence strongly supports its use in patients with COPD exacerbation, support in weaning process in chronic obstructive pulmonary disease (COPD) patients, patients with acute cardiogenic pulmonary edema (ACPE), and Immunosuppressed patients. On the other hand, there is poor evidence that supports the use of NIMV in other pathologies such as pneumonia, acute respiratory distress syndrome (ARDS), and during procedures as bronchoscopy, where its use i...