Indications for Noninvasive Ventilation Annual Symposium on Emergency and Critical Care Medicine 2012 – NEW IMAGE, NEW DEVELOPMENT 6th October 2012 Dr Arthur Chun-Wing Lau 劉俊穎醫生 Associate Consultant Department of Intensive Care Pamela Youde Nethersole Eastern Hospital, Hong Kong

Present status of Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for English-language studies published since 1990. BPAP was the most common NPPV modality. Compared with supportive care, NPPV reduced hospital mortality (odds ratio [OR] 0.56; 95% confidence interval [CI], 0.44 to 0.72), intubation rates (OR 0.31; 0.23 to 0.41), and hospital-acquired pneumonia. Compared with conventional weaning from invasive ventilation, NPPV was associated with a lower hospital mortality (OR 0.17; 0.05 to 0.65) and decreased rates of hospital-acquired pneumonia (OR 0.14; 0.04 to 0.48) in patients with COPD. When used to prevent recurrent respiratory failure postextubation, NPPV decreased mortality (OR 0.60; 0.34 to 1.04) and reintubation (OR 0.43; 0.24 to 0.77) only in those at high risk. Williams JW et al, 2012. Agency for Healthcare Research and Quality (US); 2012 Jul. Report No.: 12-EHC089-EF. AHRQ Comparative Effectiveness Reviews.

NIV is generally efficacious in the following clinical conditions Severe exacerbation of COPD Cardiogenic pulmonary edema (CPE) Immunosuppressed with acute respiratory failure Adjunct to early liberation from invasive ventilation Transition to spontaneous breathing after planned extubation Treatment of acute respiratory failure after operation Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting, Keenan SP, etal, CMAJ 2011;183:E195-E214

Inappropriate patients in general Impaired neurological state Respiratory arrest Shock or in general severe cardiovascular instability Excessive airway secretions Facial lesions that prevent the fitting of nasal or facial masks Upper GI Bleeding Undrained pneumothorax Vomiting ……

Factor associated with higher likelihood of failure from studies Predominantly immunocompetent patients Immunocompromised patients Higher severity score (SAPS II 35 or >34) Higher illness severity at baseline reflected by SAPS II Older age (> 40 years) Higher RR under NIV Presence of ARDS or CAP Later initiation of NIV after ICU admission Failure to improve after 1 h of treatment (PaO2/FiO2 <= 146, or <=175) Need for vasopressors RSBI > 105 (Berg KM et al 2012) Need for RRT Presence of ALI or ARDS

Severe exacerbation of COPD NPPV vs. standard therapy (Grade 1A) Recommend to use NPPV CPAP vs. standard therapy (No recommendation) Lack of RCTs NPPV + heliox vs. standard therapy (2C) NOT routinely used CPAP + heliox vs. standard therapy (NR) NPPV vs. conventional MV (NR) Insufficient evidence CPAP vs. conventional MV (NR)

COPD Largest RCT: 236 patients, multicentre, NIV vs standard therapy Plant P, et al. Lancet 2000; 355: 1931

Effects of maximum respiratory support during NIV in COPD Kallet RH et al. Respir Care 2009

Reports of non-invasive ventilation (NIV) use in clinical practice reveal higher mortality rates than in corresponding randomised clinical trials. National UK audit of clinical care of consecutive COPD admissions from March to May 2008. COPD exacerbation and ARF managed in general clinical practice from 232 hospital units. 9716 patients, mean age 73, 50% male. Conclusions: COPD admissions treated with NIV in usual clinical practice were severely ill, many with mixed metabolic acidosis. Some eligible patients failed to receive NIV, others received it inappropriately. NIV appears to be often used as a ceiling of treatment including patient groups in whom efficacy of NIV is uncertain. The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector. Roberts CM et al. Thorax 2011

Cardiogenic pulmonary edema (CPE) NPPV or CPAP vs. standard therapy (1A) CPAP is as effective as NPPV Recommend NPPV or CPAP for patient with CPE and respiratory failure in the absence of shock nor ACS requiring PCI

Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis Comparing NIPPV and CPAP on Hospital mortality Need for mechanical ventilation 23 trials (out of 43160 articles screened) fulfilling inclusion criteria Conclusions: CPAP and bilevel ventilation reduces the need for subsequent mechanical ventilation and reduces mortality also suggest a trend towards reduced mortality after bilevel NIPPV. Peter JV, et al. Lancet 2006

Need for invasive mechanical ventilation Peter JV, et al. Lancet 2006

Mortality Peter JV, et al. Lancet 2006

Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department. NIPSV was associated to a shorter resolution time compared to CPAP (159 ± 54 vs. 210 ± 73 min; p < 0.01), whereas the incidence of new myocardial infarction was not different between both groups. Noninvasive pressure support ventilation (NIPSV) vs continuous positive airway pressure (CPAP). METHODS: In a prospective, randomized, controlled study performed in four emergency departments, 200 patients were assigned to CPAP (n = 101) or NIPSV (n = 99). Primary outcome was combined events of hospital death and tracheal intubation. Nouira S, et al. Intensive Care Med 2011

Nouira S, et al. Intensive Care Med 2011

NIV in pulmonary edema cx AMI Yamamoto T, et al, 2012, Circulation J

Yamamoto T, et al, 2012, Circulation J

NIV effectively improved vital signs and oxygenation and lowered the intubation rate in patients with APO of all etiologies The outcome in patients with AMI treated with NIV depends primarily on the severity of the course of AMI and not the severity of acute respiratory failure Yamamoto T, et al, 2012, Circulation J

Immunosuppressed with respiratory failure NPPV vs. standard therapy (2B) Suggest to use NPPV in immunosuppressed patients with acute respiratory failure CPAP vs. standard therapy (NR) Lack of RCTs

Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: a 5-year multicenter observational survey. Retrospective analysis of observational data prospectively collected in 2002-2006 on 1,302 patients with hematologic malignancies admitted with acute respiratory failure to 158 Italian intensive care units. Few patients (21%) initially received noninvasive mechanical ventilation; 46% of these later required invasive mechanical ventilation. Better outcomes were associated with successful noninvasive mechanical ventilation (vs. invasive mechanical ventilation ab initio and vs. invasive mechanical ventilation after noninvasive mechanical ventilation failure), particularly in patients with acute lung injury/adult respiratory distress syndrome (mortality: 42% vs. 69% and 77%, respectively). Delayed vs. immediate invasive mechanical ventilation was associated with slightly but not significantly higher hospital mortality (65% vs. 58%, p=.12). After propensity-score adjustment, noninvasive mechanical ventilation was associated with significantly lower mortality than invasive mechanical ventilation. Gristina GR, et al. Crit Care Med. 2011

Non-invasive ventilation in immunosuppressed patients with pneumonia and extrapulmonary sepsis. N=120 immunodeficient patients treated with NIV in a medical ICU from 2005 to 2011 in Germany Razlaf P, et al. Resp Med 2012

Razlaf P, et al. Resp Med 2012

Almost 50% of the immunocompromised patients treated with NIV did not require intubation independent of the etiology of ARF. High APACHE II scores and severity of oxygenation failure were associated with NIV failure. NIV failure similar between pneumonia and SIRS.

Early liberation from invasive ventilation NPPV vs. conventional MV (with COPD) (2B) Suggest to use NPPV to facilitate early liberation from MV in centres with expertise in NPPV NPPV vs. conventional MV (without COPD) (NR) Insufficient evidence CPAP vs. conventional MV (NR) Lack of RCTs

Transition to spontaneous breathing after planned extubation NPPV vs. standard (high risk patients) (2B) Suggest to use NPPV, only in centres with expertise in NPPV NPPV vs. standard (low risk patients) (2C) Suggest NOT to use NPPV after planned extubation in patients with low risk of developing respiratory failure CPAP vs. standard (NR) Lack of RCTs

Recent metaanalyses NIV may be used in the ICU to shorten the weaning process in stable patients recovering from hypercapnic respiratory failure (HRF) who had previously failed a spontaneous breathing trial (SBT) May also reduce, compared to the standard weaning process, the mortality rate and the incidence of ventilator-associated pneumonia. Burns KE et al. BMJ 2009

Treatment for acute respiratory failure after extubation NPPV vs. conventional MV (without COPD) (2C) Suggest NOT to routinely use NPPV NPPV vs. conventional MV (with COPD) (NR) Insufficient evidence CPAP vs. conventional MV (NR) Lack of RCTs

Treatment of acute respiratory failure after operation NPPV (lung resection surgery) (2C) Use NPPV for patients with respiratory failure after lung resection surgery CPAP (abdominal surgery) (2C) Use CPAP for this group of patients developing respiratory failure NPPV (abdominal surgery) (NR) Lack of RCTs CPAP (lung resection surgery) (NR)

Prevention of acute respiratory failure NPPV or CPAP (low or high risk patients for low risk surgery) (NR) Insufficient evidence NPPV or CPAP (cardiac surgery) (NR) NPPV: lack of RCTs CPAP: insufficient evidence NPPV or CPAP (high risk surgery) (NR)

Exacerbations of asthma NPPV (NR) Insufficient evidence CPAP (NR) Lack of RCTs

A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Gupta D et al. Respir Care. 2010

Acute lung injury (ALI) / ARDS CPAP vs. standard therapy (1C) Recommend NOT to use CPAP in patients with ALI NPPV vs. standard therapy (NR) Lack of RCTs

Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial. In this controlled trial 21 adults with moderate to severe asthma attack were randomized to a control group (NEB, n=11) or experimental group (NIV+NEB, n=10). All patients inhaled bronchodilators for nine minutes and after particles were counted with a gamma camera to analyze regions of interest and PC at 0, 15, 30, 45 and 60 minutes. Coupling nebulization and NIV during asthma exacerbation did not improve radioaerosol pulmonary deposition, but we observed clinical improvement of pulmonary function in these patients. Galindo-Filho VC et al 2012. Respir Care

Severe community acquired pneumonia (no COPD) NPPV vs. standard therapy (NR) Insufficient evidence CPAP vs. standard therapy (NR) Lack of RCTs

“Unusual” indications for NIV Chest trauma, e.g. pulmonary contusion During bronchoscopy to avoid ETI, e.g. in immunocompromised patients Post cardiac and thoracic surgery During TEE to avoid the need for deep sedation Palliative intent in end-stage symptomatic patients Unplanned extubation (if patient is in weaning period) Negative pressure pulmonary edema Ambrosino N et al 2001. ERJ and others

Complications Mask-related: ulcer Positive pressure related: gastric distension, barotrauma Delayed intubation because of inappropriately prolonged NIV: assess response in one hour Better use of sedation: dexmedetomidine, remifentanil

Summary Severe exacerbation of COPD: NPPV Cardiogenic pulmonary edema (CPE): NPPV or CPAP Immunosuppressed with acute respiratory failure: NPPV Adjunct to early liberation from invasive mechanical ventilation: NPPV for patients with COPD Transition to spontaneous breathing after planned extubation: NPPV for high risk patients in special centre

Keenan SP et al 2011. CPG for the use of NPPV and NCPAP in the acute setting

Keenan SP et al 2011. CPG for the use of NPPV and NCPAP in the acute setting

End Thank you.