Acute Applications of Non-invasive ventilation (NIV) and its special application in SARS Dr Arthur Chun-Wing LAU 刘俊颖 Associate Consultant, Department of Intensive Care & Honorary Associate Consultant, Division of Respiratory and Critical Care Medicine, Department of Medicine 香港东区尤德夫人那打素医院 Pamela Youde Nethersole Eastern Hospital Hong Kong SAR, China 29 Apr 2006

Objectives To know about the practical aspects of NIV Literature review of the application and efficacy of NIV in various acute clinical conditions, including SARS Predictors of NIV failure in general

General benefits of NIV Avoid complications of endotracheal tube intubation Reduce ventilator-associated pneumonia (VAP) Improve clinical outcomes (morbidity, mortality, ICU and hosp LOS, costs) Patient comfort

Practical aspects

Initiation of NPPV Ventilator type Facial appliance as interface Explain to patient Adjust ventilatory pressures depending on clinical requirement

ICU ventilators Siemens Servo i Viasys Avea Draeger Evita 4 Puritan Bennett 840

Hybrid ventilators Viasys Vela Bird VSO2

Home ventilators Versamed iVent Breas PV 102 Respironics BiPAP Vision Breas LTV 1000 Sirio NIV-S

Ventilators ICU ventilators Hybrid ventilators Home ventilators Insp/exp lines independent single Flow, L/min 150 120 - 140 < 120 Software complex easy Price $$$$$ $$$ $$

Factors to consider “Hybrid” and “ICU” ventilators (independent inspiratory and expiratory line) are to be preferred for NIV in more severe patients Ventilator setting and ventilator’s performance depend on the interface (mask or helmet) BIPAP is to be preferred when helmet is used

Facial appliance Some facial appliance designed for specific NIV ventilators For acute hypercapnia, low dead space volume and minimal leak essential

Facial Nasal Nasal pillow Total face

Helmet Nasal prong device

Studies comparing interfaces Navalesi et al. CCM 2000; 28: 1785 Kwok et al. CCM 2003; 31: 468 Anton et al. RC 2003; 48: 919 Antonelli Anes 2004; 100: 16

Masks (1: a little; 4: a lot) Nasal Face Helmet Pillows Total FM Amount of Ventilation 2 3 1 Claustrophobia Ease to speak 4 Ease to cough Air leak Dead space Comfort

Exhalation device In mask In circuit Whisper-Swivel Whisper-Swivel II Plateau valve Whisper-Swivel II, Respironics Whisper-Swivel Plateau valve

No difference in daytime arterial blood gas levels, pulmonary functions, nocturnal vital signs or oximetry, or PtcCO2 N = 7 only Hill N, et al 2002; 122: 84

Position of exhalation port and CO2 rebreathing Compare: A facial mask (inner volume of 165 mL) with exhalation port within the mask (Facial-MEP) Same facial mask with exhalation port in the ventilator circuit (Facial-WS) Total face mask with exhalation port within the mask (inner volume 875 mL, Total Face) DESIGN: Lung model evaluation. Results: Facial-MEP with its exhalation port within the mask and the smallest mask volume demonstrated less rebreathed CO2 Additional studies are necessary to confirm if mask design can clinically affect patient's inspiratory effort during noninvasive positive pressure ventilation. Schettino GP, et al. Crit Care Med. 2003 Aug;31(8):2178-82

Exhalation device

Humidification High flows and high FIO2 result in dried retained secretions Use heated pass over humidifier

Literature review

Use of NIV in acute respiratory failure Prospective international study of all consecutive ICU patients requiring >12 hours MV (non-invasive and invasive) 5183 patients (from 15757 total patients) NIV used in 4.9 Esteban, A. et al. JAMA 2002;287:345-355.

Ventilator Modes Used Each Day During the Course of Mechanical Ventilation Esteban, A. et al. JAMA 2002;287:345-355. Copyright restrictions may apply.

NIV in ARF (2) Multi-centre, prospective, observational study screened all patients admitted to 16 ICU’s over a 2 month period in mid-2003 in Australia and New Zealand Non-intubated patients with hypoxemic ARF (except COPD and cardiogenic pulmonary edema) 200/1156 had hypoxemic ARF NIV was used in 77 (38.5%) initially Bersten A, et al. ICM 2004; 30: S5

Clinical conditions COPD Acute cardiogenic pulmonary edema (CPE) Hypoxemic respiratory failure (ARF) Pneumonia Immunosuppressed with ARF ALI/ARDS Post-operative ARF Asthma Chest trauma Post-extubation ARF Weaning from mechanical ventilation SARS

COPD

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

Endotracheal intubation Keenan et al. Annals of Int Med 2003; 138: 861

Hospital mortality Keenan et al. Annals of Int Med 2003; 138: 861

COPD: Use NIV Fourteen studies Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease - metaanalysis COPD: Use NIV Fourteen studies decreased mortality decreased need for intubation reduction in treatment failure rapid improvement within the first hour in pH PaCO2 dec respiratory rate dec complications associated with treatment reduced length of hospital stay was also reduced Ram FSF et al. Cochrane Database of Systematic Reviews. 1, 2006

Cardiogenic pulmonary edema (CPE)

Cardiogenic pulmonary edema Initial RCT: 39 patient RCT of CPAP 10 cmH2O vs standard therapy CPAP patients had Improved respiratory rate, oxygenation and PaCO2 Dec intubation rate 0% vs 35% (p -= 0.01) Bersten A, et al. NEJM 1991; 325: 1825

CPE: NIV complicated by AMI? 27 patient RCT of BiPAP (15/5) vs CPAP (10/10) AMI rate higher in BiPAP gp, study thus terminated No difference in rates of intubation, hypotension or mortality Mehta S, et al. Crit Care Med 1997; 25: 620

CPE: meta-analysis BiPAP vs CPAP No effect on Mortality Need for intubation Duration of hospital stay Trend toward increased new AMI with BiPAP RR 1.5 (95%CI 0.9 – 2.5), p = 0.12 Peter J, Moran J, et al. ANZICS ASM 2005, p 113

CPE: metaanalysis MEDLINE and EMBASE (from inception to October 2005) and Cochrane databases (library issue 4, 2005) were searched to identify relevant randomized controlled trials and systematic reviews published from January 1, 1988, to October 31, 2005. Conclusions NIV reduces the need for intubation and mortality in patients with acute cardiogenic pulmonary edema Although the level of evidence is higher for CPAP, there are no significant differences in clinical outcomes when comparing CPAP vs NIPSV. Masip J, et al. JAMA. 2005;294:3124-3130

Masip J, et al. JAMA. 2005;294:3124-3130

Masip J, et al. JAMA. 2005;294:3124-3130

Masip J, et al. JAMA. 2005;294:3124-3130

How about CPE with hypercapnia? Hypothesis: CPE + inc PCO2 = ?muscle fatigue, so BIPAP more helpful than CPAP Randomized prospective study in an emergency department in patients with acute pulmonary edema and arterial hypercapnia (PaCO(2) >45 mmHg) NIPSV (n=18) vs CPAP through a face mask (n=18). Conclusion: NIPSV as effective as CPAP, did not improve resolution time. Bellone A, et al. ICM 2005; 31: 807 - 811

Another 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; 367: 1155–63

Need for invasive mechanical ventilation Peter JV, et al. Lancet 2006; 367: 1155–63

Mortality CPE: Use CPAP Peter JV, et al. Lancet 2006; 367: 1155–63

Hypoxemic ARF A mixed bag of diagnoses

Hypoxemic ARF: RCT 64 patient RCT of NIV vs ETT NIV group: 30% were intubated Dec ICU stay (9 vs 16 days, p = 0.04) Similar hospital mortality Dec serious complications Dec pneumonia or sinusitis Antonelli M, et al. NEJM 1998; 339: 429

Antonelli M, et al. NEJM 1998; 339: 429

Hypoxemic ARF: RCT 105 patient RCT of oxygen vs NIV (IPAP 10 – 12 & EPAP 5 – 6) NIV group had decreased Intubation requirement (25% vs 52%, p = 0.01) Septic shock (12% vs 31%, p = 0.03) ICU mortality (18% vs 39%, p = 0.03) Ferrer M, et al. AJRCCM 2003; 168: 1438

Ferrer M, et al. AJRCCM 2003; 168: 1438

Hypoxemic ARF: meta-analysis MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003) The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation ICU length of stay ICU mortality effect on mortality is less clear Heterogeneity found among studies suggests that effectiveness varies among different populations: Conclusion: the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure. Hypoxemic ARF: Use NIV, but consider individual condition Keenan S, et al. CCM 2004; 32(12): 2516

Pneumonia

Pneumonia: RCT 56 patient RCT of NIV vs standard therapy Severe CPAP Same antibiotics and O2 targets Set criteria for intubation NIV patients had Dec intubation rate Dec ICU LOS Hospital stay and mortality similar Nursing workload similar BUT: benefit lost if COPD patients (40% of patients) were excluded Confalonieri M, et al. AJRCCM 1999; 160: 1585

Pneumonia: more trials

Immunosuppressed ARF 40 patient RCT of NIV(20) vs standard therapy(20) Solid organ transplant patients Respiratory distress Intermittent NIV NIV group Inc P/F ratio at 1 hr Dec intubation rate Dec rate of severe sepsis Dec ICU mortality Hospital mortality: same Antonelli M, et al. JAMA 2000; 283: 235

Timing of Endotracheal Intubation in the 2 Groups Changes in the Ratio of PaO2 to Fraction of Inspired Oxygen (FIO2) and PaCO2 Over Time Timing of Endotracheal Intubation in the 2 Groups Antonelli, M. et al. JAMA 2000;283:235-241.