1. 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

2. 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

3. 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

4. Practical aspects

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

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

7. Hybrid ventilators
Viasys Vela
Bird VSO2

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

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

11. 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

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

13. Facial
Nasal
Nasal pillow
Total face

14. Helmet
Nasal prong device

15. 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

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

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

18. 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

19. 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 Aug;31(8):

20. Exhalation device

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

23. Literature review

24. 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 total patients)
NIV used in 4.9
Esteban, A. et al. JAMA 2002;287:

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

26. 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

27. 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

28. COPD

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

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

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

32. 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

33. Cardiogenic pulmonary edema (CPE)

34. 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

35. 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

36. 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

37. 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:

38. Masip J, et al. JAMA. 2005;294:

39. Masip J, et al. JAMA. 2005;294:

40. Masip J, et al. JAMA. 2005;294:

41. 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:

42. Another 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; 367: 1155–63

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

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

45. Hypoxemic ARF
A mixed bag of diagnoses

46. 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

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

48. 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

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

52. 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

53. Pneumonia

54. 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

55. Pneumonia: more trials

56. 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

57. 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: