Laurent Brochard NIV in the ICU: Lessons learnt in the last 20 years

The Engström ventilator (1951) Ventilatory problems in thoracic anesthesia; VO Björk, CG Engström et al J Thoracic Surg. 1956; 31:117

Sadoul, Bull.physio-pathol.Resp. 1965

Traitement par ventilation instrumentale de 100 cas d'insuffisance respiratoire aigue severe (pACO2> 70) chez des pulmonaires chroniques Sadoul, Bull.physio-pathol.Resp NIV and 2y mortality

Mask ventilation difficult Need for respiratory stimulant Tracheal ventilation considered much easier Pr A.B. Tonnel

Chest 1990 Chest 1994

Brochard L ARRD 1987

Brochard L et al. ARRD 1989; 139:

NIV and exacerbations of COPD Effects on arterial blood gases Brochard et al NEJM 1990, 323, 1523

Brochard et al NIV and exacerbations of COPD

Intubation Hosp Stay Mortality NIV - PS 20 ( n=43 ) 26 % 23 ± 17 j 9 % O 2 ( n=42 ) 74 % 35 ± 33 j 29 % NIV and exacerbations of COPD Brochard et al NEJM 1995; 333,

Respiratory Rate Endotracheal Intubation Mortality Rate

CPAP vs BIPAP in CPE: Overall

No sedation No central line No urinary catheter No endotracheal tube

NIV & Nosocomial infections p< p=0.02 p<0.001 Girou et al. JAMA 2000

Ferrer et al. AJRCCM 2003; 168: 1438 n = 51 n = 54

CCM 2007

NIV in hypoxemic or hypercapnic patients: Is there a different impact?

Demoule A et al ICM 2006 Mortality

Reintubation 48% Postextubation ARF Reintubation 72%

Reintubation 8% Reintubation 11% Prevention of postextubation ARF

2004 Incidence study 353 ICU 26 countries Esteban et al, AJRCCM Incidence study 361 ICU 20 countries Esteban et al, JAMA Incidence study 553 ICU 39 countries Esteban et al Use of Mechanical ventilation

1 st, 2 d, 3 rd International Studies of Mechanical Ventilation Countries 37 ICUs 1,267 Patients 18,321

n = 5183 n = 4986 n = 8313 Age, mean (SD) Age, mean (SD) 59 (17) 59 /17 61/17 Gender, female (%) Gender, female (%) 39 % 40 % 38 % SAPS II, mean (SD) SAPS II, mean (SD) 44 (17) 42 (18) 45 (18) BMI. mean (SD) BMI. mean (SD) 27 (6) Baseline Demographics

NIV as first attempt

Use of NIV

SRLF Results of the 3 rd NIV incidence study (France and Belgium) A Demoule, S Jaber, A Kouatchet, J Lambert, F Meziani, S Perbet, L Camous, R Janssen-Langenstein, M Alves, B Zuber, F Collet, J Messika, X Favre, O Guisset, B Misset, A Lafabrie, L Brochard, E Azoulay For the oVNI group

Methods Prospective longitudinal study 54 ICUs 2 months (Nov April 2011) 2653 patients included 2445 invasive ventilatory assistance or NIV Survey

Results 1 Incidence NIV 23 vs.31% - pre 23% - post-extub 8% * *

* $ Results 2 Indications CPE: 53 vs.37% - « de novo » : 16 vs. 22% * *

Results 3 success overall success rate : 68 vs. 56% $

Summary The global NIV rate is stable –Increase for post-extubation Variations across indications –Increase for CPE –Stable in exacerbations of CRF –Decrease in « de novo » ARF Success rate is increasing Compared to 2002

Crit Care Med 2007;35:932–939

Azoulay E et al ICM 2012

Patients Azoulay E et al ICM 2012

Relatives Azoulay E et al ICM 2012

Non invasive ventilation for acute respiratory failure Reduces the complications associated with mechanical ventilation Improves the outcome of COPD exacerbations and cardiogenic pulmonary edema A careful use in hypoxemic respiratory failure may be interesting NIV represents an interesting therapy when intensity of therapy is limited

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NIV rate (%) NIV rate (%)4.4(0.001) % SAPS II SAPS II 39.5 (16) 39.0 (15) 38.5 (15) Failure (intubation) (%) Failure (intubation) (%)31(0.39) 37 % 30.5% Mortality in NIV failure Mortality in NIV failure47%(0.94)48%49% Mortality in NIV success Mortality in NIV success21%(0.36)15% 9 % Non-Invasive Ventilation NIV POSTEXTUBATION NIV POSTEXTUBATION 11.1 % FOR PREVENTION 5.9 % FOR TREATMENT FOR TREATMENT 5.2 %

n = 5183 n = 4986 n = 8576 Main Reason for M.V: Main Reason for M.V:  COPD 10 % 5 % 6 %  Asthma 1 %  Coma 17 % 19 %  Neuromuscular disease 2 % 1 %  ARF 68.5 % ARDS 4.5 % 5 % 3 % Postoperative 21 % CHF 10 % 6 % 8 % Pneumonia 14 % 11 % 10 % Sepsis 9 % Trauma 8 % 6% 4.5 %  COPD 10 %5 %6 % ARDS4.5 %5 %3 %

Oxygen (15) CPAP (15) P/F 169 (71-240) 167 (76-270) RR 30 (18-44) 2 (20-60) BAL(ml) 66   19 p<0.03 ETI 4 0 p<0.03 NIV 1 0

CCM 2009

Rouzé A et al Mémoire M2 Univ Paris Est

Secular Trends in Mortality and Use of NIV in COPD and Severe CPE P< P=0.012 Girou et al. JAMA 2003