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TURKISH THORACIC SOCIETY 9TH ANNUAL CONGRESS ANTALYA, TURKEY 21, APRIL, 2006. WEANING Role of Non-Invasive Mechanical Ventilation. Peter C Gay MD Associate Professor Mayo Clinic College of Medicine Rochester, MN. Sean Caples, Peter Gay. Concise Review CCM 33: 2005.

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turkish thoracic society 9th annual congress antalya turkey 21 april 2006

TURKISH THORACIC SOCIETY9TH ANNUAL CONGRESSANTALYA, TURKEY21, APRIL, 2006

WEANINGRole of Non-Invasive Mechanical Ventilation

Peter C Gay MD

Associate Professor

Mayo Clinic College of Medicine

Rochester, MN

nppv to reduce reintubation mv time
NPPV to ReduceReintubation & MV time
  • Issues/Rationale
  • After extubation
    • Routine
    • Respiratory distress after extubation
    • Prevention in selected high risk patients
  • Adjunct to weaning:

Early extubation for prolonged weaning failure

what can we extrapolate from nppv in acute respiratory failure
What Can we Extrapolate from NPPV in Acute Respiratory Failure?
  • Need for assisted ventilation
  • Pathophysiology may be similar but not identical
  • Unique issues related to weaning, post-operative period, and extubation
rationale for nppv for weaning
Pathophysiology

Increased WOB/RSB

Respiratory muscle weakness

Abnormal gas exchange

Atelectasis

Increased PEEPi

Adverse CV effects

NPPV Effect

Decrease WOB/RSB

Unload respiratory muscles

Improve gas exchange, raise MV

Decrease atelectasis

Counterbalance PEEPi

?Reduce CV events

Rationale for NPPV for Weaning
slide6
Routine Use of NPPV to Prevent Extubation Failure/ReintubationJiang et al, Respirology 4:161-165, 1999
  • Prospective, RCT: 93 pts, Mean age 73
    • (56 planned, 37 unplanned)
  • 47 BiPAP (face mask) vs 46 Oxygen pts
  • No Sig Difference for BiPAP vs O2 pts
    • Failed extubation:

13/47 (28%) BiPAP

          • 7/46 (15%) Oxygen
  • -BiPAP pts had more unplanned extubations
slide7
NPPV for Post-extubation Respiratory Distress: Randomized Controlled TrialKeenan SP, JAMA 287:3238-3244, 2002
  • Objective-
    • Prevent reintubation in high-risk pts with established mixed cause respiratory distress during first 48 hrs after extubation.
  • Patients-
    • 2763 screened/880 eligible/358 consent
    • Total 81 cardiac or respiratory disease pts requiring MV for > 48 hours
  • Interventions-
    • Std medical therapy alone vs. NPPV
slide8
NPPV for Post-extubation Respiratory Distress: Randomized Controlled TrialKeenan SP, JAMA 287:3238-3244, 2002
  • Results-No difference NPPV vs Std Care:
    • Rate of reintubation (72% vs 69%)
    • Hospital mortality (31% for both)
    • Duration of MV (8.4 vs 17.5 days; p=0.11)
    • Length of ICU (11.9 vs 10.8 days)
    • Hospital stay (32.2 vs 29.8 days)
  • Conclusions-NPPV no benefit in heterogeneous patients with respiratory distress <48 hours after planned extubation
nppv for post extubation respiratory distress keenan et al jama 2002
NPPV for Post-extubation Respiratory DistressKeenan et al, JAMA 2002
  • Excluded COPD pts after 1st yr
  • I/E= 10/5 cmH20
  • Start up to 48 hrs
  • Selection bias
nppv with early signs of extubation failure esteban et al nejm 2004 350 2452
37 ICUs, 8 countries, N = 993 MV>48h

228 dev resp distress within 48h of extubation

Separate randomization for COPD

Randomization (within 48h of extubation) if:

Hypercapnia (PaCO2>45 or >20% from pre-extubation)

Clinical signs of resp muscle fatigue or increased WOB

Resp rate >25 (for 2 hours)

Resp acidosis: pH < 7.30 with PaCO2 > 50

Hypoxemia: SpO2 < 90% or PaO2 < 80 on FiO2 > 0.50

NPPV with Early Signs of Extubation FailureEsteban et al, NEJM 2004; 350:2452
nppv with early signs of extubation failure
No diff in age, SAPS II, duration of vent (10 v 11d), initial cause for RF or pre-extubation variablesNPPV with Early Signs of Extubation Failure

% of pts

*

*

Esteban et al, NEJM 2004; 350:2452

esteban trial commentary is nppv making some pts worse
Esteban Trial CommentaryIs NPPV Making Some Pts Worse?
  • Very few COPD patients (13%)
  • Patients quite mild; RR 29, pH 7.39, PaCO2 46, PaO2 79 at time of randomization
  • Multicenter design; strength and weakness
  • 28 pts crossed over to NPPV in the control group, only 7 required intubation
    • If these are counted as “need for intubation”, failures in controls rise to 68% compared to 48% in NPPV
nppv to prevent extubation failure recommendations
NPPV to Prevent Extubation Failure: Recommendations

Routine (self-extubated)- No

Overt, severe post-extubation failure; unstable cardiac or other medical problems- No

In Selected High Risk Patients - Possibly

If you use it: Don’t delay reintubation beyond 2 – 3 hours if the patient is not responding

nppv during persistent wf rct of early extubation ferrer ajrccm 168 2003
NPPV DURING PERSISTENT WF- RCT of Early ExtubationFerrer, AJRCCM, 168 2003
  • Results- NPPV vs Conventional pts had:
    • Shorter intubation (9.5 vs 20.1 days, p=0.003)
    • Less ICU stay (14.1 vs 25 , p=0.002)
    • Less Hospital stay (27.8 vs 40.8 days, p=0.026)
    • Lower needs of tracheotomy to withdraw ventilation (5% vs 59%, p<0.001)

Trial was terminated after a planned interim analysis

nppv during persistent wf rct of early extubation ferrer ajrccm 168 20031
NPPV DURING PERSISTENT WF- RCT of Early ExtubationFerrer, AJRCCM, 168 2003
  • Comments
    • Well designed study
    • Most pts (75%) with COPD or CHF
  • 3) Unblinded- selection bias
  • 4) Huge number of pts trached
  • Results- NPPV vs Conventional pts had:
    • Less septic shock (10 vs 45%, p=0.045)
    • Less nosocomial pneumonia (24 vs 59%, p=0.042)
    • Decreased ICU mortality (10 vs 45%, p=0.045) and increased 90-days survival (p=0.044).
    • Conventional weaning an indep risk factor
  • Conclusions-Earlier extubation with NPPV has tremendous advantages in ?highly selected pts.
can nppv be used to expedite weaning
1) For selected COPD/CHF pts? Yes

2) As a routine? No

Caveats

1) Excellent candidate for NPPV

2) Unassisted breathing for >5 min

3) Able to breathe on same PSV settings

4) Not be difficult for re-intubation

Can NPPV be used to expedite Weaning?
nppv to prevent respiratory failure after extubation in high risk patients nava s ccm 33 2005
NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33: 2005

Multiple-center, randomized controlled study.

>8 hrs/d in first 48 hrs

nppv to prevent respiratory failure after extubation in high risk patients nava s ccm 33 20051
NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005
nppv to prevent respiratory failure after extubation in high risk patients nava s ccm 33 20052
NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005
nppv to prevent respiratory failure after extubation in high risk patients nava s ccm 33 20053
NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005

EDITORIAL- Girault, C MD

NPPV for Post-extubation respiratory failure:

Perhaps not to treat but at least to prevent!

  • Comments-
    • Preventive application of NPPV immediately after extubation is associated with clear benefit
    • Use of NPPV independently associated with a reduced risk of postextubation failure
    • Act of reintubation per se a strong predictor of mortality.
    • Recognize difference from recent negative studies to treat postextubation respiratory failure,
    • Very selected patients at high risk before developing postextubation respiratory distress.
nppv for post extubation respiratory distress post operative patients auriant ajrccm 164 2001
NPPV for Post-extubation Respiratory Distress: Post-operative PatientsAuriant,AJRCCM 164: 2001
  • Design-
    • Randomized 24 pts with ARF after Lung Resection
    • Dyspnea, RR>24/min, access musc use, P/F<200
  • Results- NPPV pts vs. usual care had:
    • Less intubation= 50% vs. 21% (p= 0.035)
    • Hosp LOS= 23 vs. 27 days
    • Lower mortality= 38% vs. 13 % (p= 0.045)
  • Conclusions- NPPV is safe and effective in reducing intubation and improving survival
slide22

NPPV with Post-op Organ TransplantationAntonelli M, JAMA; 283: 235-241, 2000

  • Randomized 40 solid organ transplant pts
    • NPPV pts had better gas exchange and:
      • Lower intubation rate (20% vs. 70%; p=0.002)
      • Less fatal complications (20% vs. 50%; p= 0.05)
      • Lower ICU mortality (20% vs. 50%; p= 0.05), but hospital mortality same
  • Consider NPPV use in these types of patient
nppv to avoid re intubation in extubated pts
NPPV to Avoid Re-intubation in Extubated Pts
  • After extubation?
    • Routine, prophylactic- No
    • Prevention high risk patients- Yes, but selectively
    • Post-operatively- Yes,

but selectively

conclusions
Conclusions
  • Issues/Rationale
  • After extubation
    • Routine
    • Respiratory distress after extubation
    • Prevention in selected high risk patients
  • Adjunct to weaning:

Early extubation for prolonged weaning failure