Noninvasive Mechanical

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Noninvasive Mechanical Ventilation in the ICU
Antalya, Turkey April 2011 Nicholas Hill
MD Tufts Medical Center Boston, MA USA
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Disclosures

• Research Grants
• Respironics, Inc
• Breathe Technologies, Inc

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Outline

• ICU Applications of NIV
• Epidemiology
• Main indications
• Patient Selection
• Practical Application

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Why Noninvasive Ventilation?

• Avoids trauma of intubation
• Reduces respiratory infections
• More comfortable, less sedation
• Less costly
• Respiratory System Protective Strategy
• Must be used selectively

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French ICU/ US NIV Utilization
of Pts
Carlucci et al, AJRCCM, 2001 Demoule et al, ICM,
06 Ozsancak et al, Chest 08
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Use of NIV for COPDMassachusetts and Rhode Island
of Vent starts for COPD exacerbations treated
with NIV
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Main Indications for Acute Noninvasive
Ventilation (NIV)
Strong (Level A) Acute hypercapnic RF (COPD)
Cardiogenic pulmonary edema ARF in
immunocompromised
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Physiologic Rationale for NIV in COPD Effect of
Pressure Support plus PEEP
NIV (BiPAP) Combines expiratory (PEEP) with
higher inspiratory pressure (PSV)
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Benefits of NIV in Acute COPDcompared to
Conventional Rx

• More rapidly improves dyspnea
• More rapid ? RR, HR,
• breathing effort
• More rapid ? PaCO2, ? O2
• Lowers intubation rate (50?20)
• Lowers mortality, morbidity rate
• Less time in hospital

Based on 7 RCTs
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NIV for COPD Risk of Treatment Failure (Death,
ETT, Intolerance)
Lightowler JV, et.al BMJ 326185, 2003
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NIV for COPD associated with

• Difficult weaning (to facilitate extubation)
• Pneumonia
• Extubation failure
• Do-not-intubate status
• Post-operative Respiratory Failure

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NIV for Acute Pulmonary Edema Physiologic
Rationale

• CPAP
• Increased FRC
• Re-expands flooded alveoli
• Improved oxygenation
• Increased compliance
• Afterload reduction - ? cardiac function
• Pressure Support
• Further reduction in work

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Meta-analysis CPAP vs NIV for ACPE
Evidence is now robustand use as a first line
intervention is becoming mandatory.
Winck et al, Crit Care 2006 10R69
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Multicenter RCT of CPE (3CPO)
26 cntrs, RRgt20, pHlt7.35, excl if need for
intervention
NIV(8/4) or CPAP(5) STD n
702 367 Death 7 days () 9.5
9.8 Intubation () 2.9
2.8 MI () 27 24.9 Dyspnea
(analog) -4.6 -3.9 pH (1 hr)
0.11 0.08 RR (1 hr)
-7.2 -7.3
P lt 0.05
Gray et al, NEJM 2008
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Out-of-Hospital CPAP Vs Usual Care in Acute
Respiratory Failure A RCT
Thompson et al, Ann Emerg Med. 200852232-241
CPAP Control
(10
cm H2O) n 35
34 SaO2 82
75 RR/min 38
38 CHF/COPD/Asthma 99 100
Intubation 7(20)
17(50) Hosp Mortal () 4(14)
12(35)
Plt0.05
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Indications for Acute NIV
Weaker (Level B) Asthma Extubation
failure(COPD) Hypoxemic Respiratory
Failure Postoperative Respiratory
Failure Do-not-intubate pts (COPD and CHF)
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RCT of NPPV for Asthma Exacerbations

• NPPV Sham
• n 17 16
• FEV1 () 37.3 33.8
• 50 FEV1 (1h) 80 20
• ? FEV1 (1h) 53.5 28.5
• Hospitalized 3 (17.6) 10 (63.5)
• Soroksky et al, Chest 2003 1231018.

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Use of NIV as Bronchodilator
? FEV1
8/6 cm H2O 6/4 cm H2O O2 by FM
44 asthmatics, FEV1 33 P 80-90, RR 20 3 Groups,
High, Low and O2 ctls for 1hr Hydrocort BUT
NO BDs!
Soma T et al, Intern Med 08
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NIV for Asthma

• Used for pts with status asthmaticus severe
  and refractory to treatment
• May combine with continuous neb and heliox
  (anecdotal evidence)
• Monitor very closely
• ? Role early for bronchodilator effect and to
  reduce dyspnea more rapidly?

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Selection Criteria in Trials to
Prevent Extubation Failure

• NIV for Extubation Failure
• 2004 trial - no reduction in reintub-
• ations and ? mortality in NIV group
• -Esteban et al, NEJM 04
• Recent RCT showed ? resp failure and
• ? 90 d mortality in hypercapnics on NIV
• -Ferrer et al, Lancet 09
• Dont delay needed intubation!

• Nava
• PaCO2gt45,
• MVgt72h
• gt1 failed weaning attempt
• excess secretions
• upper airway disorder

• Esteban
• PaCO2 gt 45
• MVgt48h
• Resp muscle fatigue RR gt 25
• pH lt 7.35
• O2sat lt 90, PaO2 lt 80

Ferrer Age gt 65, CHF, APACHE score gt 12
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Acute Hypoxemic Respiratory Failure

• Italian multicenter study of 354 NIV cases, 30
  failures 50 ARDS or CAP, 10
  cardiogenic pulmonary edema
• Condition Odds Ratio
• ARDS or Comm Acq Pna 3.75
• PaO2FIO2 ? 146 p 1st hr 2.51
• SAPS II ? 35 1.81
• Age gt 40 1.72

PaO2/FIO2 lt 200 Resp Distress, RR gt
30-35 Non-COPD dx Pneumonia (incl
immunosuppr) ARDS Trauma Cardiogenic Pulm
Edema
Antonelli et al, Int Care Med 2001 271718
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Hypoxemic Respiratory FailureNIV as First
Line Therapy in ARDS

• 147 pts eligible of 479 (332 intubated), had
  dyspnea, RR gt 30 and 2 new organ failures
• 54 avoided intubation (15 of Total)
• VAP rate 2 vs 20, mortality 6 vs 53
• Success more likely if SAPS II 34 and PaO2/FIO2
  gt 175 p 1st hr of NIV therapy

Antonelli et al, CCM, 2006
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NIV for Do-not-intubate pts

• 75 and 50 of Pulmonary Edema and COPD pts,
  respectively, survive hospital
• Roughly 25 of pneumonia and cancer pts survive
  hospital
• If can awaken and cough, survival better
• Two main goals must be clear
• Treat respiratory failure (CHF COPD)
• Palliate for dyspnea or transient life
  prolongation

Levy et al, Crit Care Med 2004 322002
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RCTs of Noninvasive Techniques for Postoperative
Patients

• For Prophylaxis
• Thoracoabdominal vascular (CPAP)
• Kindgren-Milles et al, Chest 06
• Bariatric surgery (NIV)
• Joris Chest 97
• Major abd surgery (CPAP)
• Squadrone JAMA 05
• For Resp Failure
• Lung resection (NIV)
• Auriant et al, AJRCCM 01

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Non-invasive ventilation reduces intubation in
chest-trauma related hypoxemia A RCT
Hernandez et al, Chest 2010 13774-80
NPPV Control n 25
25 PaO2/FIO2 108
110 APACHE II 17.5
14.1 Intubation 3(12) 10(40)
Exhaustion 2(8) 6(24) VAP 2(8)
3(12) Hosp LOS (days) 14
21 Hosp Mortal () 1(4) 1(4)
Plt0.05
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Non-invasive ventilation reduces intubation in
chest-trauma related hypoxemia An RCT
Hernandez et al, Chest 2010 13774-80
(P lt 0.05)
Plt0.05
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Use Selectively and with Caution
Neuromuscular Disease Obesity
Hypoventilation Upper Airway Obstruction Not to
be used ARDS with MODS
Pulmonary Fibrosis
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NIV Practical Application

• Patient Selection
• Favorable Diagnosis (reversibility COPD, CHF)
• Need for ventilatory assistance
• Absence of contraindications

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Step 1 Is there need for Ventilatory Assistance?
When clinical features reveal Dyspnea is at
least moderate Respiratory rate gt 24 (COPD), gt30
(hypoxemic) Accessory muscle use Abdominal
paradox Gas exchange abnormalities PaCO2 gt 45 mm
Hg, pH lt 7.35 PaO2/FIO2 lt 300
Likelihood of needing intubation 50 Window of
Opportunity
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Step 2 Are there contraindications to NIV?
The Patient is Apneic (arresting) Medically
unstable (shock, acute MI or upper GI
bleed) Agitated and uncooperative (but ? CO2 coma
OK!) Unable to clear secretions Severely
hypoxemic (PaO2/FIO2 lt 75) Or has Multiorgan
failure
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Forehead Adjuster
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ORONASAL VS NASAL MASK
FOR ARF
(Kwok et al, Crit Care Med 2003 31468)
Oronasal
Nasal


P value
n
35
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Success
23 (66)
17 (49) 0.15
Intolerance
4 (11)
12 (34) 0.02
Intubation
8 (23)
8 (23) 1.00
Mortality
2 (6)
4 (11) 0.40
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(No Transcript)
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Newer Developments in Mask Technology
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Helmet
Mainly for CPAP High flow to minimize
rebreathing Noisy and expensive Not approved by
FDA for NIV
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Bilevel Vents for Acute Applications (80 US)
NIV modes on Critical Care Vents Leak
compensation Adjustable Rise Time Inspiratory
Time Limit Silence nuisance alarms Need
adjustments if leaks Ferreira, Chest 09
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Ventilator NIV or Crit Care, But Use the
Right Settings!

• Mode Bilevel or NIV mode (PSPEEP)
• Settings start low (IPAP 8-10, EPAP 4-5 cm H20),
  then readjust promptly to achieve adequate ? (PS
  gt 8-10 cm)
• IPAP titration Relief of respiratory distress vs
  intolerance of higher pressures (max 20 cm H2O)
• EPAP titration counterbalance auto-PEEP, improve
  oxygenation (max 8-10 cm H2O)
• FIO2/O2 flow adjusted to maintain O2satgt90-92

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Monitoring NPPV

• Assure comfort
• Minimize Dyspnea
• Maximize Comfort
• Optimize Synchrony
• Vital signs
• respiratory rate should drop
• Neck muscle activity should fall
• Oximetry (gt90), Tidal Vol (gt6-7ml/kg)
• Occasional blood gases (start 1-2 hrs)
• In ICU or step-down until stable

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Summary NIV for ICU

• Main Indications COPD, CHF, Immunocompromised
• Data accumulating for others Asthma, Hypoxemic
  (Trauma), Extub Failure
• Technological advances New masks, ventilators
• Proper application techniques, monitoring and
  skilled staff still important