1. Non-invasive Ventilation for Management of Pneumonia Problem Based Lecture January 28 th, 2016 S.Noll PGY-3

2.  Varied schools of thought  I don’t listen to podcasts, read blogs, nor FOAMed  NIV: Non-invasive positive pressure ventilation  RCT: Randomized controlled trial  ARF: Acute respiratory failure  ARDS: Acute respiratory distress syndrome  SAPS: Simplified Acute Physiologic Score  SOFA: Sequential Organ Failure Assessment Disclosure

3. Acute Respiratory Failure Chronic Respiratory Failure Hypoxemic Failure Hypercapneic Failure Hypercapneic & Hypoxemic De Novo ARF Background

4.  “Studies with pneumonia patients in respiratory distress have shown that, as long as secretions are controlled, NIV decreases intubation rates and respiratory rates…  …Very strong arguments for NIV versus intubation extend to immunocompromised patients with hypoxemic respiratory failure and pulmonary infiltrates” –ACEP 2010  “Patients with hypoxemia or respiratory distress should receive a cautious trial of NIV unless they require immediate intubation because of severe hypoxemia (PaO2/FiO2 ratio, <150) and bilateral alveolar infiltrates. “ -IDSA/ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults (Moderate recommendation; level I evidence)  “NIV should be used whenever possible in selected patients with respiratory failure” –IDSA/ATS Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare- associated Pneumonia (Level I evidence) Background

5.  Acute Respiratory Failure in Patients with Severe Community- acquired Pneumonia  Prospective RCT: NIV vs venturi mask for SpO2 >90%  Inclusion Criteria:  Severe dyspnea at rest, RR >35 /min, accessory muscle use  PaO2 40% FiO2, or PaO2:FIO2 50%  hypercapnia (PaCO2 50 mm Hg) with pH 7.33  XR showing multilobar involvement at admission or >50% increase in the size of the infiltrate within 48 h of admission  BP 4 h; or UOP< 80 ml in 4 h  Exclusion Criteria:  Emergent intubation for CPR, respiratory arrest, severe hemodynamic instability, encephalopathy/severe neurologic disease, life expectancy < 4 mo, long-term oxygen therapy or home mechanical ventilation, tracheostomy/facial deformities, or inability to expectorate Am J Respir Crit Care Med 1999

7.  Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure  RCT: NIV vs High-concentration O2 (Maintain SpO2 > 92%)  Inclusions: PaO2 persistently (>6-8 hours) <60 mm Hg or SpO2 <90% @ FiO2 50%  Exclusions: hypercapnia (PaCO2>45 mm Hg); need for emergency intubation; recent facial trauma/surgery/tracheostomy; GCS one severe organ dysfunction in addition to respiratory failure Am J Respir Crit Care Med 2003

9. Emerg Med J 2005  Non-invasive ventilation as a first-line treatment for acute respiratory failure: ‘‘real life’’ experience in the emergency department  Prospective/retrospective, observational study  Inclusion: Mod-severe dyspnea, pCO2>45 mm Hg & pH<7.35 or PaO2<60 mm Hg with FiO2 <60%

10. Emerg Med J 2005 “We believe the high death rate of CAP patients in our series to be related to their high comorbidity and high number of patients with do-not-intubate codes (44.4% in CAP patients and 42.8% in CAP patients with COPD) “

11.  Oxygen therapy for pneumonia in adults  Reviewed 3 RCTs  Am J Respir Crit Care Med: Acute Respiratory Failure in Patients with Severe Community-acquired Pneumonia. 1999, Confalonieri (N=56)  Reviewed  NEJM: Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and Acute Respiratory Failure. 2001. Hilbert (N=52)  “early initiation of NIV is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge”  Chest: Helmet continuous positive airway pressure vs oxygen therapy to improve oxygenation in community-acquired pneumonia: a randomized, controlled trial. 2010, Cosentini (N=47)  “CPAP delivered by helmet rapidly improves oxygenation in patients with CAP suffering from a moderate hypoxemic ARF” Cochrane Review 2012

12.  NIV can reduce the risk of:  death in the ICU  endotracheal intubation  shorten ICU stay  length of intubation  The review indicates that NIV is more beneficial than standard oxygen supplementation via a Venturi mask for pneumonia  The evidence is weak Cochrane Review 2012

13.  Non-invasive Ventilation in Community-Acquired Pneumonia and Severe Acute Respiratory Failure  Prospective Study  NIV Criteria: Mod-Severe dyspnea with RR>30/min, PaO2/FiO2 <250  Patients received NIV for 44 ± 33 h along 2.8 ± 1.9 days  NIV was successful in 116 patients (63%)  Success= No intubation, transferred out of ICU Intensive Care Med 2012

15.  NIV failure: 59 were intubated, 9 became DNI  worsening of respiratory insufficiency in (N=39)  uncontrolled shock (N=17)  intolerance to NIV (N=3)  Variables independently associated with NIV failure  worsening of radiological infiltrate 24 h after admission  maximum SOFA score during NIV *  HR,  PaO2/FiO2,  bicarbonate after 1 h of NIV Patients with CAP and previous cardiac or respiratory disease responded better to NIV than those with ‘‘de novo’’ ARF Unsure of association with delayed intubation and mortality Intensive Care Med 2012

16.  Non-Invasive Ventilation for Acute Hypoxemic Respiratory Failure: Intubation and Risk Factors  Observational Cohort Study, N=113  Inclusion: Dyspnea, RR>25/min, accessory muscle use, pulmonary infiltrates, PaCO2 <45 mm Hg  Exclusion: Pulmonary edema, absence of XR infiltrates  Pneumonia diagnosis: n=63  Rate of intubation in ARDS: 61%, Non-ARDS: 35%  ARDS Severity: Mild-31%, Moderate-62%, Severe-84% Mortality rate failing NIV did not differ with time to intubation Critical Care 2013

18.  Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia  Prospective study, 127 patients,  Inclusion: sCAP, RR>30/min, PaO2/FiO2 < 250  NIV Failure:  worsening of respiratory failure (18)  Cardiorespiratory arrest (3)  multi-organ system failure (4)  death: MOSF (7), respiratory failure (5) Clin Respir J 2016

20. NEJM 2015 High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure Inclusion: 1. RR > 25/min 2. PaO2/FiO2 <300 3. PaCO2 <45 4. No chronic resp failure Exclusion: PaCO2 >45, severe neutropenia, hemodynamic instability/vasopressors, GCS <12, DNI, urgent need to intubate RCT 310 patients NRB 10 L/Min (SpO2 >92%) HFNC FiO2 1.0 (SpO2 >92%) NIV PS (7-1o ml/kg Vt) 2-10 cm H2O

21. NEJM 2015 PaO2/FiO2: 150 mm Hg

22. 12/40 patients who received rescue NIV therapy avoided intubation NEJM 2015 Primary Outcome

23. NEJM 2015 Hazard ratio for death at 90 days compared to HFNC group -NRB: 2.01 (95% CI, 1.01 to 3.99) (P=0.046) -NIV: 2.50 (95% CI, 1.31 to 4.78) (P=0.006)

24.  Rate of NIV failure in patients with pneumonia in controlled clinical trials 21-26% however, observational studies: 33-66%  Patients with previous cardiac and respiratory disease have increased benefit from NIV  Worse outcomes with increased severity of disease  We need more analyses including delay of intubation with morbidity/mortality; ED use  HFNC is becoming more prominent in management of a variety of lung processes Conclusions

25. References http://www.acep.org/Clinical---Practice-Management/Focus-On--Noninvasive-Positive-Pressure-Ventilation-In-the- Emergency-Department/ https://www.thoracic.org/statements/resources/mtpi/guide1-29.pdf Confalonieri Am J Respir Crit Care Med Vol 160. pp 1585–1591, 1999 Ferrer. Am J Respir Crit Care Med Vol 168. pp 1438–1444, 2003 Antro. Emerg Med J 2005;22:772–777 Cosentini. ;Chest. 2010;138(1):114-120 Hilbert N Engl J Med 2001; 344:481-487 Cochrane Database Syst Rev. 2012 Mar 14;3 Carrillo. Intensive Care Med 2012. 38: 458-466 Thille. Critical Care 2013, 17:R269 Nicolini. Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia. Clin Respir J 2016; 10: 98–103 Frat. N Engl J Med 2015; 372:2185-2196