Article

The Growing Role of Noninvasive Ventilation in Patients Requiring Prolonged Mechanical Ventilation

Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
Respiratory care (Impact Factor: 1.84). 06/2012; 57(6):900-18; discussion 918-20. DOI: 10.4187/respcare.01692
Source: PubMed

ABSTRACT For many patients with chronic respiratory failure requiring ventilator support, noninvasive ventilation (NIV) is preferable to invasive support by tracheostomy. Currently available evidence does not support the use of nocturnal NIV in unselected patients with stable COPD. Several European studies have reported benefit for high intensity NIV, in which setting of inspiratory pressure and respiratory rate are selected to achieve normocapnia. There have also been studies reporting benefit for the use of NIV as an adjunct to exercise training. NIV may be useful as an adjunct to airway clearance techniques in patients with cystic fibrosis. Accumulating evidence supports the use of NIV in patients with obesity hypoventilation syndrome. There is considerable observational evidence supporting the use of NIV in patients with chronic respiratory failure related to neuromuscular disease, and one randomized controlled trial reported that the use of NIV was life-prolonging in patients with amyotrophic lateral sclerosis. A variety of interfaces can be used to provide NIV in patients with stable chronic respiratory failure. The mouthpiece is an interface that is unique in this patient population, and has been used with success in patients with neuromuscular disease. Bi-level pressure ventilators are commonly used for NIV, although there are now a new generation of intermediate ventilators that are portable, have a long battery life, and can be used for NIV and invasive applications. Pressure support ventilation, pressure controlled ventilation, and volume controlled ventilation have been used successfully for chronic applications of NIV. New modes have recently become available, but their benefits await evidence to support their widespread use. The success of NIV in a given patient population depends on selection of an appropriate patient, selection of an appropriate interface, selection of an appropriate ventilator and ventilator settings, the skills of the clinician, the motivation of the patient, and the support of the family.

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    ABSTRACT: Background and Objectives: Delay in identifying patients in whom NIV will be unsuccessful may postpone endotracheal intubation, increasing morbidity and mortality. Aim of this study was to determine factors associated with NIV failure in patients with COPD exacerbations. Methods: We retrospectively evaluated COPD patients with acute respiratory failure due to an acute exacerbation, undergoing NIV for at least 12 hours. Univariable analysis was performed on: age, gender, APACHE II, GCS, gas exchange at admission, during NIV and at discharge/death, length of stay. A ROC curve for the variable pH START (arterial pH value at admission) was performed and sensitivity,specificity, likelihood ratios and confidence intervals, were calculated. Results: Among 201 enrolled individuals, NIV failed in 50 subjects, leading to invasive ventilation and/or death. NIV succeeded in patients with: lower APACHE II (20.02±4.81 in succeeding group vs 24.84±6.35 in failing group, p<0.001) and PaCO2 at admission (93.10±15.08 vs 98.45±16.09, respectively, p=0.029) and after 2-4 hours of NIV (77.62±13.62 vs 82.12±15.24, respectively, p=0.044), and higher pH at admission (7.26±0.06 vs 7.23±0.08, respectively, p=0.033), and GCS (12.94±2.44 vs 11.24±3.32, respectively, p=0.001). No variable was found to be able to predict NIV failure in patients with pH START >7.20 and ≤7.25, despite the high percentage of successes observed in this subset of individuals (81%). Conclusion: Further multicentric studies are needed to better define NIV indications, with special reference to pH thresholds.
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    ABSTRACT: Abstract Background and Objectives: Delay in identifying patients in whom NIV will be unsuccessful may postpone endotracheal intubation, increasing morbidity and mortality. Aim of this study was to determine factors associated with NIV failure in patients with COPD exacerbations. Methods: We retrospectively evaluated COPD patients with acute respiratory failure due to an acute exacerbation, undergoing NIV for at least 12 hours. Univariable analysis was performed on: age, gender, APACHE II, GCS, gas exchange at admission, during NIV and at discharge/death, length of stay. A ROC curve for the variable pH START (arterial pH value at admission) was performed and sensitivity,specificity, likelihood ratios and confidence intervals, were calculated. Results: Among 201 enrolled individuals, NIV failed in 50 subjects, leading to invasive ventilation and/or death. NIV succeeded in patients with: lower APACHE II (20.02±4.81 in succeeding group vs 24.84±6.35 in failing group, p<0.001) and PaCO2 at admission (93.10±15.08 vs 98.45±16.09, respectively, p=0.029) and after 2-4 hours of NIV (77.62±13.62 vs 82.12±15.24, respectively, p=0.044), and higher pH at admission (7.26±0.06 vs 7.23±0.08, respectively, p=0.033), and GCS (12.94±2.44 vs 11.24±3.32, respectively, p=0.001). No variable was found to be able to predict NIV failure in patients with pH START >7.20 and ≤7.25, despite the high percentage of successes observed in this subset of individuals (81%). Conclusion: Further multicentric studies are needed to better define NIV indications, with special reference to pH thresholds. Keywords: Non invasive mechanical ventilation; COPD; Respiratory failure; Predictors