Controversial Issues in NIV

Controversial Issues in Non-Invasive Ventilation

Gamal Rabie Agmy, MD,FCCP

Professor of Chest Diseases

,Assiut University

The normal ventilatory balance

Respiratory load Respiratory muscles

capacity

Ventilatory drive

Respiratory Failure

Respiratory load

Respiratory muscles

capacity

Abnormal Ventilatory drive

Mechanical ventilation unloads the

respiratory muscles

Respiratory load Respiratory muscles

Mechanical

ventilation

NPPV: definition

Any form of ventilatory support applied without

the use of an endotracheal tube considered to

include:

*CPAP with or without pressure support

*Volume- and pressure- cycled systems

*Proportional assist ventilation (PAV).

AJRCCM 2001; 163:283-91

Ventilators for NIV: Not all are useful in each indication

Standard interfaces

Facial masks

advantages:

– sufficient ventilation also during mouth breathing

– sufficient ventilation in patients with limited co-operation

disadvantages:

– coughing is difficult

– skin lesions (bridge of the nose)

Nasal masks

advantages:

– better comfort

– good seal

– coughing is possible

– communication is possible

disadvantages:

– effective in nose breathing only

– good co-operation is necessary

Standard interfaces

Nasal prong/nasal pillow systems

* for patients with

claustrophobia

*for patients with allergies

against straps

*for low to moderate

pressures only

(< 20 cmH2O)

Standard interfaces

total-face masks

• Safe interface for acute

respiratory

insufficiency with high pressures

• well tolerated by the patients

Standard interfaces

helmet

• well tolerated by the patient

• no direct contact to the skin of

the face

• large dead space

• may influence the triggering of

the patient; use with CPAP

• very noisy

Standard interfaces

mouthpieces

• simple and cheap

• short-interval alternative

interface for long-term

ventilated patients

Custom-made masks

• for long-term

ventilation

• if standard masks are

not tolerated

Standard interfaces

Physiologic evaluation of three different

interfaces

cohort: 26 stable patients with hypercapnic COPD or interstitial lung disease.

intervention: three 30 minute tests in two ventilatory modes with

Conclusions: NIPPV was effective with all interfaces.

patients‘ tolerance: nasal mask > facial mask or nasal prongs

pCO2 reduction: facial mask or nasal prongs > nasal mask Navalesi P et al. Crit Care Med 2000;28:2139-2140

Frequency of adverse effects and

complications of NIPPV

Mehta et al. Am J Respir Crit Care Med 2001;163:540-577

% occurrence

Interfaces available for adults

Acute

respiratory

failure

Chronic

respiratory

failure

Facial mask 63% 6%

Nasal mask 31% 73%

Nasal prongs 6% 11%

Mouth piece 0% 5%

THE RATIONALE

LV failure

Pulmonary

edema

Pulmonary

compliance

Airway

resistance

Negative

Intrathoracic

Pressure Swing

Work of

breathing

CO

PaO2 Respiratory

muscle

fatigue

DaO2

+

PaCO2

LV failure

Pulmonary

edema

Pulmonary

compliance

Airway

resistance

Negative

Intrathoracic

Pressure Swing

LV

transmural

pressure

O2

Cost of

breathing

LV afterload

+

Rasen et al: Chest 1985; 87: 158-162

Negative intrathoracic pressure swings during CPE

Pes (cmH20)

0

-20

IntraThoracicPressure

and

LV function

AO

LV

ITP effort = ITP = Ptm

LV afterload

100

-20

Ptm = 100-(-20) = 120

CPAP IN CPE

Rasen et al: Chest 1985; 87: 158-162

Pes

(cmH20)

0

-20

Spontaneous breathing CPAP 15 cmH20

IntraThoracicPressure

and

LV function

AO

LV

ITP effort = ITP = Ptm

LV afterload

100

-5

Ptm = 100-(-5) = 105

Rationale of positive pressure ventilation in CPE

Positive Pressure

ITP FRC

Pre-load Venous return

LVafterload PTM

PaO2 WOB

Cardiac performance pulmonary congestion

CPAP Standard treatment

total intubated died total intubated died mortality intubation

rate

Rasasen, 1985

20 6 3 20 12 6 -15% -30%

Bersten,

1991

19 0 2 20 7 4 -9.5% -35%

Lin, 1995 50 8 4 50 18 6 -4% -20%

89 14 9 90 37 16 -6.6% -26%

CPAP vs. standard treatment in acute pulmonary oedema

Pang D et al.: Chest 1998; 114: 1185-92

• Multi-centre, randomized, prospective study with

130 patients with respiratory insufficiency.

• Setting: emergency room.

• Intervention: standard treatment with drugs and

high flow oxygen versus

standard treatment and NIV (nPSV).

Noninvasive Ventilation in Cardiogenic Pulmonary Edema A Multicenter Randomized Trial

Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437



Results:

• Similar intubation rate in both arms.

• Patients receiving NIV had a significantly better improvement

of PaO2/FiO2 within the first 30 minutes and within the first 3

hours of treatment.

• Hypercapnic patients: Significantly shorter time to

normalisation of PaCO2; lower intubation rate with NIV (2/33

vs. 9/33).

• Hypocapnic patients: Significantly higher intubation-

frequency.





Pi 14,5 ± 21,1 mbar; Pe 6,1 ± 3,2 mbar mean ventilation time: 11,4 ± 3,6 hrs

Multicentre clinical trial: Noninvasive ventilation in

acute cardiogenic pulmonary edema.

Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51.

primary endpoint:

death within 7 days

primary endpoint:

death or intubation within 7 days

Multicentre clinical trial:

Noninvasive ventilation in

acute cardiogenic pulmonary edema.

Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51.

Intervention

*Standard nitrate, diuretic and opioid therapy

*Consent + Randomised for 2 hours to:

-Standard oxygen therapy (by facial mask)

-CPAP (5 cmH2O to a max 15 cmH2O)

-NIPPV (8/4 cmH2O to a max 20/10 cmH2O)

*Fi02 0.6

Primary Outcome: Mortality Standard

Therapy

Non-

Invasive

Ventilation

OR

95% CI

P Value

7-Day

9.8%

9.5%

0.97

0.63 -

1.48

0.869

30-

Day

16.7%

15.4%

0.93

0.65 -

1.32

0.685

7-day mortality, non-recruited 9.9%

No interaction with disease severity

NIV in Stable COPD:

Pro

Zeit (Tage)

1 2 3 5 9

B G A

(m m H g)

30

40

50

60

70

80

90

100

Zeit (Tage)

1 2 3 5 9

B G A

(m m H g)

30

40

50

60

70

80

90

100

PaC O 2

PaO 2

Windisch W. et al. Respir Med 2002; 96:572-579

Days

mmHg

NPPV (assPCV)

- mean IPAP 30 ±4 mbar

- mean bf 23 ±2 /min

Tim e after cessation of nocturnal NPPV

baseline 0 0,5 1 3 7 11 15

Pa

CO

2 d

urin

g s

po

nta

ne

ou

s b

re

ath

ing

46

48

50

52

54

56

58

[hours]

[m m Hg]

P < 0.001

P = 0.26

PaCO2

Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260

NPPV (assPCV)



NPPV Controls

Tim e after cessation of nocturnal N PPV

baseline 0 0,5 1 3 7 11 15

VT

du

rin

g s

po

nta

ne

ou

s b

re

ath

ing

0,50

0,55

0,60

0,65

0,70

[L]

[hours]

P = 0.28

P < 0.05

Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260

Tidal volume

NPPV Controls

NPPV (assPCV)



Windisch W. et al. Chest 2005; 128:657-662

NPPV (assPCV)



2-year survival: 86%

N = 34

Budweiser S. et al. Respir Care 2006; 51:126-132

BMI <20 kg/m2 = 21%

N = 141

NPPV (assPCV)



Severe Respiratory

Insufficiency Questionnaire

SRI

ATS homepage:

http://www.atsqol.org/sections/instruments/pt/pages/sri.html

Windisch W. et al. J Clin Epidemiol 2003; 56:752-759 Windisch W. et al. J Clin Epidemiol 2008; 61:848-853

T0 (baseline) T1 T12 Months

• Multicenter Study (N = 135)

• Outcomes: - Quality of life (SF-36; SRI)

- Side effects

- Hospitalisations

- Compliance

- Physiological parameters

Windisch W. Eur Respir J 2008; 32:1328-1336

45

55

65

T0 T1 T12

COPD

Restriktiv

Neuromuskulär

Changes in SRI-SS

independent from the underlying disease

MANOVA; F=0,62; P=0,65.

P < 0.001 COPD

P < 0.001 neuromuscular

P < 0.001 restrictive thoracic

45

55

65

T0 T1 T12

COPD RTD NMD

SR

I-S

um

mary S

cale

(S

RI-S

S)

IPAP/EPAP (mbar)

20/3

19/4

25/1

Windisch W. Eur Respir J 2008; 32:1328-1336

suppl. O2 (2.3 L/min) suppl. O2 (2.3 L/min) + NPPV (29/4 mbar, 20/min)

Dreher M. et al. Eur Respir J 2007; 29: 930-936

suppl. O2 suppl. O2 + NPPV

PaCO22 (mmHg)

50 53 50 51 P < 0.001 N.S.

Six-minute walking test

BDS

Walking distance (m)

6 4 P < 0.001

209 252 P < 0.05

Dreher M. et al. Eur Respir J 2007; 29: 930-936

m ean before after m ean

Pa

O2 (

mm

Hg

)

50

60

70

80

90

100

110P < 0.001

m ean before after m ean

Pa

O2

(m

mH

g)

45

50

55

60

65

70

75

80

85 P < 0.001

PaO

2 (

mm

Hg)

Rehab

Rehab + NPPV

Duiverman ML. et al. Thorax 2008; 63:1052-1057

ERS Congress 2008 in Berlin

A randomised trial of home non-invasive ventilation vs. sham

ventilation in survivors of acute hypercapnic respiratory failure

in COPD.

Chu CM et al. Eur Respir J 2008; 32(Suppl.52):38s.

•42 COPD patients were randomised to receive either NPPV or sham

ventilation following acute NIV

• At days 120 patients were free of acute hypercapnic respiratory failure:

• 81% NPPV group

• 33% sham ventilation

Nocturnal non-invasive positive pressure ventilation (NIPPV) in

stable hypercapnic COPD patients – a randomized controlled

trial. Funk GC et al. Eur Respir J 2008; 32(Suppl.52):37s.

• 26 COPD patients received NIPPV over 6 months following mechanical ventilation on

the ICU

• After 6 months patients were randomised to stop NIPPV or to continue NPPV

• Discontinuation of NIPPV caused clinical worsening (resumption of NPPV or ICU

admission)

NIV in Stable COPD:

con

Home NIV not recommended

(Casanova et al Chest 2000;118:1582-90)

Clini E. et al. Eur Respir J 2002; 20:529-538

Hospitalisation following NPPV-establishment

LTOT: +27%

NPPV + LTOT: -45%

ICU-Admission following NPPV-establishment

LTOT: -20%

NPPV + LTOT: -75% n.s

n.s

mesi

SURVIVAL NPPV

LTOT

THE ITALIAN MULTICENTRE STUDY ON

NONINVASIVE POSITIVE PRESSURE VENTILATION

IN COPD PATIENTS

Clini et al ERJ 2001

COPD

HOSPITAL ADMISSIONS

0

0,5

1

1,5

2

2,5

3

3,5

4

Follow-back

Follow-up

Total hospital admissions (nr/pt/year)

0

0,5

1

1,5

2

ICU admissions (nr/pt/year)

NPPV LTOT NPPV LTOT Clini et al ERJ 2001

Nocturnal NIPPV for at least three months in hypercapnic patients

with stable COPD had no consistent clinically or statistically

significant effect on lung function, gas exchange, respiratory muscle

strength, sleep efficiency or exercise tolerance.

Current evidence about the therapeutic benefit of

mechanical ventilation is weak, but consistent,

suggesting alleviation of the symptoms of chronic

hypoventilation in the short term, and in two small

studies survival was prolonged. Mechanical ventilation

should be offered as a therapeutic option to patients

with chronic hypoventilation due to neuromuscular

diseases.

Annane, D; Chevrolet, JC; Chevret, S; Raphael, JC

Nocturnal mechanical ventilation for chronic

hypoventilation in patients with neuromuscular and chest

wall disorders.

Cochrane Database of Systematic Reviews. Issue 1, 2001

http://gateway2.ovid.com/ovidweb.cgi?S=IDNJHKAHGGJFGO00D&Search+Link=%22Annane%2c+D%22.au.

http://gateway2.ovid.com/ovidweb.cgi?S=IDNJHKAHGGJFGO00D&Search+Link=%22Chevrolet%2c+JC%22.au.

http://gateway2.ovid.com/ovidweb.cgi?S=IDNJHKAHGGJFGO00D&Search+Link=%22Chevret%2c+S%22.au.

http://gateway2.ovid.com/ovidweb.cgi?S=IDNJHKAHGGJFGO00D&Search+Link=%22Raphael%2c+JC%22.au.

v

v

IPS 16 cmH2O

PEEP 3 cmH2O

IPS 15 cmH2O

PEEP 3 cmH2O

K. Marquis et al. AJRCCM 2002; 166:809-813

S. Bernard et al. AJRCCM 1998; 158:629-634

NORMAL COPD

Surface 118.5 cm2 Surface 79.6 cm2

Exercise in COPD patients: PSV reduces inspiratory effort

Maltais et al. Am J Respir Crit Care Med, 1995; 151:1027

PSV 10 cmH2O ( )

PSV 5 cmH2O ( )

van 't Hul et al ERJ 2006

Lack of additional effect of adjunct of assisted ventilation to

pulmonary rehabilitation in mild COPD patients

L. Bianchi, K. Foglio, R. Porta, P. Baiardi, M. Vitacca, N. Ambrosino

“Assisted ventilation

during training

sessions…., was not well

tolerated by all patients

and gave no additional

physiological benefit in

comparison with exercise

training alone.“

Respiratory Med, 2002; 96:359-367

PAV

SB

40

50

60

70

80

90

100

110

120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Training session (days)

Tra

inin

g i

nte

nsi

ty

(% P

eak

Work

rate

)

No clinically or statistically significant effect on survival,

hospital admission, lung function, respiratory muscle strength

As an adjunct to exercise training in selected patients with

severe COPD, NIV may produce modest additional

improvements in exercise performance

Future research should primarily focus on adequate patient

selection and recognition of the mechanisms through which NIV

may work

Severe acute hypoxemic respiratory failure

• Heterogeneous clinical condition • Results of studies on NIV unrelated to CPE are

inconsistent

Main goal of NIV: Avoid ETI

Severe AHRF Often need ETI-IMV

Improved morbidity and mortality?

IMV morbidity and mortality

Avoidance of endotracheal intubation

Severe Community-Acquired Pneumonia

Major criteria • Mechanical ventilation

• Septic shock

Minor criteria • Respiratory rate >30 min-1 • PaO2/FiO2 <250 • Bilateral or multilobar • SBP <90 mmHg * • BUN >25 • Platelets <100,000 • Leukocytes <4,000 • Confusion • Hypothermia

Clin Infect Dis. 2007;44 Suppl 2:S27-S72

1 Major or 3 Minor Criteria

Pneumonia is associated with poor outcome in patients

receiving NIV

NIV in acute COPD: correlates for success

Retrospective analysis 59 episodes of ARF in 47

COPD patients • NIV success: 46 • NIV failure: 13

Predictors for NIV failure: • Higher PaCO2 at admission • Worse functional condition • Reduced treatment

compliance

• Pneumonia Ambrosino N. Thorax 1995;50:755-7

NIV failure

O ther Pneum onia

%

0

20

40

60

n=8

p=0.019n=5

NIV failure in acute hypoxemic respiratory failure

Antonelli M. Intensive Care Med 2001; 27: 1718-28

• Eight ICUs • n=354:

• Success: 246 • Failure: 108

Non-invasive ventilation and pneumonia

Conclusion: Patients with pneumonia causing ARF and

needing NIV are among those with worst outcome

but, …..

is NIV effective in patients with pneumonia?

???

NIV in severe community-acquired pneumonia

Prospective, randomised, controlled

Severe CAP (ATS criteria).

Standard treatment vs ST + NPPV. n: 28 + 28 = 56

Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91

O verall population

N IV C ontro l

%

0

20

40

60p=0.03

n=6

n=14

C O PD +

H ypercapnia

N IV C ontro l

%

0

20

40

60

N on-C O PD +

N on-hypercapnia

N IV C ontro l

0

20

40

60

n=0

n=6

n=6

n=8

p=0.005p=0.73

In tubation rate

NIV in severe community-acquired pneumonia

O verall population

N IV C ontro l

%

0

20

40

60

p=N S

n=7

n=10

C O PD +

H ypercapnia

N IV C ontro l

%

0

20

40

60

N on-C O PD +

N on-hypercapnia

N IV C ontro l

0

20

40

60

p=0.05p=0.71

n=1

n=5

n=6

n=5

2-m onth m ortality

Shorter length of stay only in COPD patients with hypercapnia

Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91

CPAP in severe hypoxemic ARF

Delclaux C. JAMA 2000;284:2352

R espiratory rate

B aseline 60' after

20

30

40

C PA P + O2

O2 a lone

PaO 2/F iO 2

B aseline 60' after

100

150

200

250

p<0.001

p<0.001

Intubation

123 patients: 54% pneumonia, 34% cardiac disease • 34/62 CPAP + O2 • 33/61 O2 alone

O verall population

N IV C ontro l

%

0

20

40

60

80

100

p=0.010

n=13

n=28

Pneum onia

N IV C ontro l

%

0

20

40

60

80

100

Cardiogenic

pulm onary edem a

N IV C ontro l

%

0

20

40

60

80

100

A LI/A R D S

N IV C ontro l

0

20

40

60

80

100

Thoracic traum a

N IV C ontro l

0

20

40

60

80

100

n=5

n=11

n=1n=2

n=6

n=1

n=5

n=8p=0.017

p=0.467

p>0.999

p=0.333

NIV in severe AHRF: Intubation rate

Ferrer M et al. Am J Respir Crit Care Med 2003;168:1438

Prospective, randomised, controlled, 3 centres

N=105. Pneumonia: 34 (32%)

O verall population

N IV C ontro l

%

0

20

40

60

80

100

p=0.028

n=9

n=21

Pneum onia

N IV C ontro l

%

0

20

40

60

80

100

Cardiogenic

pulm onary edem a

N IV C ontro l

%

0

20

40

60

80

100

A LI/A R D S

N IV C ontro l

0

20

40

60

80

100

Thoracic traum a

N IV C ontro l

0

20

40

60

80

100

n=3

n=8

n=1n=2

n=5

n=0

n=3

n=7p=0.030

p=0.569

p>0.999 p=0.515

NIV in severe AHRF: ICU mortality

Ferrer M et al. Am J Respir Crit Care Med 2003; 168:1438

NIV as an alternative to ETI in severe AHRF

Antonelli M et al. N Engl J Med 1998;339:429-35

Patients with ETI predefined criteria

NIV vs intubation+IMV

In tubated patients

%0 20 40 60 80 100

ETI-IM V

N IVp<0.001n=11

n=32

Pneum onia

(% )

0

10

20

30

Sinusitis

N IV

ETI-IM V

n=1

n=8

n=0

n=2

p<0.01

Patients w ith com plications

N IV ETI-IM V

%

0

20

40

60

80 p<0.05

n=12

n=21

NIV in immunosuppressed patients with pulmonary infiltrates and AHRF

NIV in immunosuppressed patients with pulmonary infiltrates and ARF

• Early administration of NIV: 26 NIV vs 26 control – Haematological + neutropenia (BMT, chemotherapy)

– Immunosuppressor therapy (transplant, steroids)

– AIDS

In tubation

N IV C ontro l

(% )

0

20

40

60

80

100

H ospital m ortality

N IV C ontro l

0

20

40

60

80

100p=0.03 p=0.02

Hilbert G. N Engl J Med 2001;344:481

NIV vs control:

• Faster improvement of hypoxemia

• Less severe complications

NIV in ARF after solid organ transplant

• Solid organ transplant: lung, liver, renal

• Incidence of ARF in postop. period: 21%

• Patients: 20 NIV vs 20 control

In tubation

N IV C ontro l

(% )

0

20

40

60

80

100

IC U m ortality

N IV C ontro l

0

20

40

60

80

100p=0.002

p=0.05

Antonelli M. JAMA 2000;283:235

NIV vs control:

• Faster improvement of hypoxemia

• Less severe complications

• Hospital mortality unchanged

NIV in AHRF: A systematic review

• RCTs on standard treatment with and without NIV

• Not due to cardiogenic pulmonary oedema

Endotracheal intubation ICU mortality

Absolute risk reduction: 23% (10-35%) Absolute risk reduction: 17% (8-26%) Trial results significantly heterogeneous

Keenan S. Crit Care Med 2004;32:2516

Why is NIV more effective than CPAP in severe hypoxemic ARF?

Physiologic effect of CPAP and NIV in ALI-ARDS 10 patients with indication for NIV Short-term effects of:

• CPAP 10 cmH2O • 2 combinations of NIV: PSV 10–PEEP 10; PSV 15-PEEP 5

L’Her E. Am J Respir Crit Care Med 2005;172:1112-8

Respiratory rate

In itial

CPAP-10

PSV 10-10

PSV 15-5Final

26

28

30

32

34 PaO 2/F iO 2

In itial

CPAP-10

PSV 10-10

PSV 15-5Final

120

150

180

210

240

270

* **

CPAP and NIV in ALI-ARDS: Work of breathing, neuromuscular drive and dyspnea

L’Her E et al. Am J Respir Crit Care Med 2005;172:1112-8

PSV + PEEP is needed to reduce inspiratory muscle effort

CPAP improves oxygenation but fails to unload the respiratory muscles

PSV levels of 10 and 15 cmH2O provide similar unloading but differ in their effects on dyspnea

PTPdi

In itial

CPAP-10

PSV 10-10

PSV 15-5Final

100

200

300

400

P 0.1

In itial

CPAP-10

PSV 10-10

PSV 15-5Final

1

2

3

4

*

**

*

Different efficacy of NIV in severe pneumonia (no hypercapnia, no COPD)

Confalonieri'99NIV G roup

Control G roupConfalonieri'99

AP

AC

HE

-II

0

5

10

15

20

25

Ferrer'03S

AP

S-I

I

0

10

20

30

40

Ferrer'03

Pa

O2/F

iO2

0

50

100

150

200

p=0.05

Arterial hypoxem ia Baseline severity

Ferrer'03

%

0

20

40

60

80

C onfalonieri'99 Ferrer'03

0

20

40

60

C onfalonieri'99

p<0.05

ET Intubation H ospital m ortality

p<0.05

Don’t forget contraindications for NIV

Need for immediate intubation: • Cardiac or respiratory arrest • Respiratory pauses + alertness + gasping • Psychomotor agitation sedation • Massive aspiration • Inability to manage secretions

Other limitations for NIV: • Severe non-respiratory organ failure • Face surgery, trauma or deformity • Upper airway obstruction • Inability to cooperate/protect the airways

Am J Respir Crit Care Med 2001;163:283-91

Ventilators for NIV: Not all are useful in each indication

Summary

Lower likelihood to need ETI when NIV is added to standard medical treatment in severe AHRF

Effects of NIV on mortality are less evident

Different efficacy of NIV among different populations:

Pneumonia with severe hypoxemia and causing COPD exacerbation

The routine use of NIV in all patients with severe AHRF is not supported

CPAP: No evidences on benefits in AHRF (post-op excluded)

Facilities for close monitoring and rapid intubation are advised

ERS Postgraduate Course NIV

Hannover 2009

NIV in Acute Respiratory Failure

CONTRA

• Acute Respiratory Failure could have

different pathophysiology

• Clinical Studies does not reflect real life and

exclude the more severly ill patients

• NIV in hypoxemic patients cause potential

harm, the risk-benefit-ratio is not positive


Hannover 2009


Hannover 2009

• Conclusion: Randomized trials suggest that patients with acute

hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations.

As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.

Crit Care Med 2004; 32:2516 –2523


Hannover 2009

NIV in Acute Respiratory Failure

• Meta-Analysis of RCT of patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema

• interventions compared noninvasive ventilation and standard therapy with standard therapy alone

• outcomes included

– need for endotracheal intubation,

– length of intensive care unit or hospital stay

– intensive care unit or hospital survival.

Author Year No.of pts

Wysocki 1995 41

Confalioneri 1999 33 (out of 56)

Martin 2000 32 (out of 61)

Antonelli 2000 31 (out of 40)

Hilbert 2001 52

Ferrer 2003 75 (out of 105)

Auriant 2001 48

Keenan SP. Crit Care Med 2004; 32:2516 –2523


Hannover 2009

Risk of Endotracheal Intubation Length of ICU Stay

Keenan SP. Crit Care Med 2004; 32:2516 –2523


Hannover 2009


Hannover 2009

NIV in immunosuppressed patients

• Randomized trial in 52 immunosuppressed patients with pulmonary infiltrates, fever and hypoxemic respiratory failure

• Group A: Standard treatment (Antimicrobial agents, diuretics, bronchodilators, immunosuppressive agents, heparine s.c.)

• Group B: Standard + NIPPV

NIPPV Setting: Vt 7 ml/kg, PEEP til 10 cm H2O duration of NIPPV: at least 45 min. every 3 hours

Hilbert G et al. N Engl J Med 2001; 344: 481-7


Hannover 2009


Outcome NIV Standard p RR

Intubation 12/26 20/26 0.03 0.60

initial improve in

pO2 / FiO2

12 4 0.02

sustained improve in

pO2 / FiO2

13 5 0.02

death on ICU 10/26 18/26 0.03 0.56

death in hospital 13/26 21/26 0.02 0.62

Death in the hospital



Hannover 2009


• Exclusion Criteria

– hemodynamic instability (RRsyst < 80 mmHg)

– ECG: Ischemia or ventricular arrhythmia

– cardiac failure

– COPD

– pCO2 > 55 mmHg, pH < 7.35

– multiorgan failure

– deterioration in neurological status (GCS < 8)



Hannover 2009

Patient Demographics:

• Pneumonia (34)

• Cardiogenic Pulmonary Oedema (30)

• Thoracic trauma (17)

• ARDS (15)

• others (9)

Severe Hypoxemic Respiratory Failure

Basic Disease

Ferrer M, et al. Am J Respir Crit Care Med 2003;168:1438-1444


Hannover 2009

0

20

40

60

80

100

120

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ati

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CPE Pulm c ont Inh PN Ate le c t NP ARDSp CAP ARDSe xp Pu lm F ib r/PE

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90

80

70

60

50

40

30

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NIV Failure

Antonelli M. Intensive Care Med 2001;27:1718-28


Hannover 2009

NIV in transplantation patients

• 40 pts. undergoing solid organ transplantation with acute respiratory failure

• Design: prospective, randomised

• Group A: Standard Therapy

Group B: Standard Therapy + NIPPV

• Primary Endpoint:

Need for Endotracheal Intubation

• Secondary Endpoint: ICU mortality, Length of ICU stay and ventilatory assistance

Antonelli M. JAMA 2000; 283: 235-41


Hannover 2009

• Evaluation of all 449 patients receiving NPPV for a 1-yr period for acute or acute on chronic respiratory failure – cardiogenic pulmonary edema (n = 97)

– AECOPD (n = 87)

– non-chronic obstructive pulmonary disease acute hypercapnic respiratory failure (n = 35)

– postextubation respiratory failure (n = 95)

– acute hypoxemic respiratory failure (n = 144)

• Intubation rate was 18%, 24%, 38%, 40%, and 60%,

• respectively,

• Hospital mortality for patients with acute hypoxemicrespiratory failure who failed NPPV was 64%.

• Variables associated with NPPV failure – SAPS II (OR 1.07)

– Glasgow Coma Scale (OR, 0.76)

– PaO2/FIO2 ratio (OR, 0.98)

– serum albumin (OR, 0.30)

Schettino G. Crit Care Med 2008; 36:441 –447

NIV – Real Life


Hannover 2009

Schettino G. Crit Care Med 2008; 36:441 –447


Hannover 2009

Conditions associated with NIV failure

in acute hypoxemic ARF


Hannover 2009

NIV in ARDS

• Prospective, multiple-center cohort study

• Three European intensive care units having expertise

• with NPPV

• 147 patients on NPPV

• NPPV improved gas exchange and avoided intubation in 79 patients (54%)

• Avoidance of intubation was associated with – less VAP (2% vs. 20%)

– lower ICU mortality rate (6% vs. 53%)

• Intubation was more likely – in patients who were older

– had a higher SAPS II

– needed a higher level of PEEP and PSV

• SAPS II >34 and a PaO2/FIO2 <175 after 1 hr of NPPV were independently associated with NPPV failure and need for ETI

Antonelli M. Crit Care Med 2007; 35:18 –27


Hannover 2009

Postextubation ARF

• Randomised, controlled study

• 37 centres, 8 countries

• MV < 48h

• Respiratory Failure in between 48 h after extubation

• NIV – Vt 5ml/kg BW

– Goal: SaO2 > 90%

• Vs. Standardtherapie – O2-Insufflation

– Physiotherapy

Esteban A. NEJM 2004; 350: 2452-60


Hannover 2009

Postextubation ARF

Esteban A. NEJM 2004; 350: 2452-60

Mortality 25 % (NIV) vs. 14 %

(O2)

RR for death for NIV 1,78 (95% CI 1,03 – 3,20)


Hannover 2009

• Prospective cross over study

• 10 pts. with acute lung injury

– paO2/FiO2 < 300 mmHg (mean 132, PCO2 41 mmHg)

– SaO2> 92% under NIV

– RRsyst > 90 mmHg

• Objective:

To assess the short term efffects of non invasive ventilation and CPAP

Non invasive Ventilation in ALI

L´Her E. AJRCCM 2005; online August 4


Hannover 2009

Non invasive Ventilation in ALI

• Prospective cross over study

• 10 pts. with acute lung injury

– paO2/FiO2 < 300 mmHg (mean 132, PCO2 41 mmHg)

– SaO2> 92% under NIV

– RRsyst > 90 mmHg

• Objective:

To assess the short term efffects of non invasive ventilation and CPAP

L´Her E. AJRCCM 2005; online August 4


Hannover 2009

ARMA trial, 2000

NEJM 342:1301,

ARMA trial - major outcome parameters


Hannover 2009

ALVEOLI trial, 2004

NEJM 351:327,

ALVEOLI trial - outcome


Hannover 2009

NIV in ARDS

Antonelli M. Crit Care Med 2007; 35:18 –27


Hannover 2009

ILA in ARDS

• Retrospective analysis of

extracorporal interventional

lung assist (ILA)

• 90 pts. with ARDS in a

tertiary university center

• Before, 2 and 24 hrs after

implementation

– Improvement in Oxygen

– Normalisation of pCO2

– 73 of 90 pts. survived

– Complication Rate 24.4%

Bein T. CCM 2006: 34: 1372-77


Hannover 2009

ILA in Postoperative ARDS

• 7 Patients with postoperative ARDS in Barcelona, Spain

– 5 pneumonectomy

– 2 lobectomy

• 29% of CO perfuse ILA

• No Change in Hemodynamics

• Improvement in Respiratory Function

• Decrease in Il-6

• 6 of 7 pts. survived in comparision to 2 of 9 in a historical cohort

Iglesias M. Ann Thorac Surg 2008: 85: 237-44

Health & Medicine

Controversial Issues in NIV