Transcript The use of noninvasive ventilation (NIV) following extubation

Alastair Glossop
SpR Anaesthesia and Intensive Care Medicine
Sheffield Teaching Hospitals
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Introduction and background
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Use of NIV following extubation in different
clinical situations:
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Respiratory failure post extubation
Prevention of respiratory failure post extubation
Weaning of patients from MV
Post operative period
Summary and conclusions
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Intubation and mechanical ventilation (MV)
life saving interventions
Also have significant risk of morbidity and
mortality
VAP an increasing problem
Extubation at the earliest opportunity
reduces these problems
Premature extubation also detrimental to
patients
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NIV – “delivery of ventilatory support via the
patient’s upper airway using a mask and
similar device”¹
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Encompasses both
CPAP (continuous positive airway pressure)
and
NPPV (noninvasive positive pressure
ventilation)
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NIV used with success in exacerbations
COPD, pulmonary oedema,
immunocompromised patients
NPPV offers similar levels of pressure support
to stable patients as MV without need for
intubation and sedation
CPAP has beneficial effect on lung mechanics
and atelectasis
Provide ventilatory support without ETT and
sedation
Reverse or prevent processes that contribute to
respiratory failure
Reduce the need for reintubation in critical care
patients
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Up to 20% of patients successfully extubated
will require reintubation
Failed extubation and reintubation confers
increased patient morbidity and mortality
3 studies have looked at using NIV to treat
post extubation respiratory failure
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Case control study of 30 COPD patients
Developed type II RF within 72 hours of
extubation
NPPV for > 30 mins every 4 hours
Significant reduction in need for reintubation
in NIV group (20 vs 67%)
No effect on overall mortality
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RCT comparing NIV and SMT
81 patients developing RF within 48 hours of
extubation
Used NIV continuously for first 12 hours
No significant reduction in reintubation
rates, duration of MV, mortality, ITU or
hospital LOS between the two groups
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RCT of 221 patients comparing NIV and SMT
Initially powered to include 392
Patients developing RF within 48 hours of
extubation
No difference in reintubation rates between
the groups
Increased mortality in the NIV group
(increased mortality in those reintubated)
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Is it too late once patients have developed
RF?
Prolonged RF post extubation associated
with worse outcome
Despite negative findings of previous trials,
suggestion of some benefit in patients with
chronic respiratory disease
Two RCT’s looking at prophylacyic NIV in “at
risk” patient groups
Case control study in obese patients
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RCT, multicentre
97 pts ventilated > 48 hours “at risk” for
development of RF
NPPV > 8 hours / day for first 48 hours vs SMT
Significant reduction in reintubation rates
(8.3 vs 24.5%) and ICU mortality in NPPV
group
Concluded early
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RCT of NPPV vs SMT
Pts ventilated > 48 hours “at risk” of
developing post extubation RF
50% had COPD
Significant reduction in RF in NPPV group
No difference in ICU or hospital LOS, or 90
day and hospital survival
Post hoc analysis showed survival benefit in
hypercarbic patients
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Case control study of 62 patients
Obese (BMI > 35)
Nasal NPPV for 48 hours post extubation
Significant reduction in RF, ICU and hospital
LOS in NPPV group
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Prolonged MV associated with a number of
problems
NPPV can provide similar levels of pressure
support to pts as MV
Can it be used in pts meeting criteria to wean
but not ready for extubation?
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Case series of 15 patients post lung transplant
All ventilated for > 72 hours
Extubated despite not fulfilling criteria
6 sessions per day NPPV
Only 2 required reintubation
Both due to acute rejection syndrome, not RF
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RCT of 50 patients ventilated > 48 hours and
failing a SBT
Randomised to either continued MV and
weaning or extubation onto NPPV
Continuous NPPV for first 24 hours
Significant reduction in time spent on MV,
ICU LOS, pneumonia and 60 day mortality in
NPPV group
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RCT of 33 patients
Ventilated > 48 hours and failed SBT
NPPV 2 – 4 hour periods then withdrawn vs
MV and standard weaning
Significant reduction in time spent on MV in
NPPV group
No difference in ICU or hospital LOS
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RCT of 43 patients (powered to include 82)
Pts with COPD ventilated > 72 hours
Failed SBT on 3 consecutive days
Extubated onto continuous NPPV for first 24
hours vs continued MV and weaning
Significant reduction in time on MV, ITU and
hospital LOS, pneumonia, sepsis, 90 day and
hopsital mortality in NPPV group
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Several RCT’s, all very small numbers
Burns group published several meta analyses
Most recent pool of 509 pts
Concluded extubation onto NIV vs MV and
weaning significantly reduced mortality, ICU
and hospital LOS
Benefit most evident in patients with COPD
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Prolonged surgery and MV predisposes to
post operative RF
Multifactorial aetiology
Post op respiratory problems may be seen in
up to 30 – 50% of cases
8 – 10% may require reintubation
In certain patients groups (esp thoracic
surgery) reintubation caries huge risk of
mortality
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Aurient et al, 2001 (Am J Resp Crit Care)¹³
Pts with RF following lung resection surgery
NPPV significantly reduced reintubation, ICU
and 3 month mortality vs SMT
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Lefebvre et al, 2009 (ICM)¹⁴
Observational study supporting the above
findings of reducing reintubation rates
Greater benefit of NPPV in patients with type
II RF
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Squadrone et al, 2005 (JAMA)¹⁵
Compared CPAP to SMT for hypoxic RF
following major abdominal surgery
Patients without significant RS / CVS disease
Significant reduction in reintubation rates,
pneumonia and ICU LOS
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Benefits on oxygenation and avoidance of
extubation also demonstrated following
upper GI surgery by Jaber et al¹⁶
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Bohner et al, 2002 (Lang Arch Surg)¹⁷
RCT of elective CPAP following AAA repair vs
SMT
Significant improvement in oxygenation; no
effect on reintubation rates
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Kingden Milles et al, 2005 (Chest)¹⁸
RCT of prophylactic CPAP vs SMT following
TAAA repair
Significant reduction in reintubation, pneumonia
and hospital LOS in CPAP group
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Zarbock et al, 2009 (Chest)¹⁹
RCT of prophylactic CPAP vs SMT following
CABG; 468 patients
SMT included short periods of CPAP
Significant reduction in RF and reintubation
in CPAP group
No comment on mortality differences
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Not possible to recommend universal use of
NIV following extubation
Some specific benefits are evident
Useful prophylactically in patients with COPD
following extubation and to aid early
extubation and weaning from MV
Not recommended as a treatment for post
extubation respiratory failure
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CPAP effective following major surgery to
prevent and treat hypoxia
NPPV beneficial following lung resection
surgery
Methodological flaws in many trials included
Further work in several areas warranted
In particular focussing on patients with COPD
“Cost effective” analysis of benefits of NIV
following extubation
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