1. 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

2. 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; to 0.77) only in those at high risk.
Williams JW et al, Agency for Healthcare Research and Quality (US); 2012 Jul. Report No.: 12-EHC089-EF. AHRQ Comparative Effectiveness Reviews.

3. 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

4. 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 ……

5. 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

7. 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)

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

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

10. 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 COPD exacerbation and ARF managed in general clinical practice from 232 hospital units 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

11. 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

12. 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 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

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

14. Mortality
Peter JV, et al. Lancet 2006

15. 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

16. Nouira S, et al. Intensive Care Med 2011

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

18. Yamamoto T, et al, 2012, Circulation J

19. 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

20. 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

21. 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 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

22. 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

23. Razlaf P, et al. Resp Med 2012

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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)

30. 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)

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

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

33. 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

34. 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 Respir Care

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

36. “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 ERJ and others

37. 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

38. 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

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

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

41. End
Thank you.