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Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure

Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Paul Crawford, Maj, USAF, MC, FAAFP Eglin AFB Family Medicine Residency Eglin AFB, FL 29 Jan 2007. NPPV is not just a bridge, it is a viable treatment for respiratory failure. Introduction/mechanism Patient selection

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Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure

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  1. Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Paul Crawford, Maj, USAF, MC, FAAFP Eglin AFB Family Medicine Residency Eglin AFB, FL 29 Jan 2007

  2. NPPV is not just a bridge, it is a viable treatment for respiratory failure • Introduction/mechanism • Patient selection • Specific Clinical Scenarios • Acute exacerbation of COPD • Cardiogenic pulmonary edema • Asthma • Weaning off mechanical ventilation • Immunocompromised patients • Evidenced based conclusions

  3. Reduce the need for intubation in Emergency Room and ICU setting Improve survival of our patients with respiratory failure Why do I need to know about NPPV?

  4. Introduction • Noninvasive positive pressure ventilation (NPPV) is the delivery of mechanically assisted or generated breaths without placement of artificial airway • Both CPAP and BiPAP are considered NPPV • Reduces mortality, length of hospital stay, and the need for mechanical ventilation

  5. Mechanism of benefit • Improved alveolar ventilation • Reduced work of breathing • Rest of the respiratory musculature • Increased intrathoracic pressure, decreases preload and afterload • Why does it decrease mortality? • Decreased hospital-acquired infections • Decreased trauma from intubation • Less complications of sedation

  6. Who should not be considered for NPPV? • Contraindications • Cardiac or respiratory arrest • Nonrespiratory organ failure • Hemodynamic instability • Severe encephalopathy • Severe UGI bleed • Facial or neurosurgery, trauma • Upper airway obstruction • Inability to cooperate or protect airway • High risk for aspiration Too Sick Can’t protect airway

  7. Indicators for success • Younger age • Lower acuity of illness • Able to cooperate • Less air leaking • Moderate hypercarbia (46-91 mm Hg) • Moderate acidemia (pH 7.11-7.34) • Improvements of gas exchange and vitals within 2 hours

  8. How do I start NPPV? • Monitored location, >30 degree angle • Select appropriate mask (Nasal or Oronasal) • Select ventilator • Apply headgear (1-2 fingers under strap)

  9. How do I start NPPV? • Start with low pressure PSV or PAV (8-12/3-5) • Example 10/4 • Gradually increase inspiratory pressure to alleviate dypnea, decrease respiratory rate • Oxygen sat >90 • Check for air leaks, Consider mild sedation • Monitor blood gas at 1 hr

  10. When do I use NPPV? • Specific scenarios supported by the evidence

  11. Acute exacerbation of COPD • 74 yo M with known COPD presents with 5 days of worsening dyspnea. RR=32, pulse oximetry 81%. Alert, tripodding. Poor air movement. • Treatment initiated with oxygen, nebs, steroids. ABG drawn. • pH=7.16, pO2=58, CO2=54, Bicarb=34 Treatment does not really help—what should you do?

  12. Respiratory Failure due to Acute Exacerbation of COPD • First line intervention as an adjunct to usual medical care. NPPV should be considered early in the course of respiratory failure. • Decrease in mortality of 48% • RR=.52, 95%CI .35-.76 • Decrease of intubation by 59% • RR=.41, 95%CI .33-.53 • Decrease hospital length of stay 3.24 days • 95%CI -4.42 to -2.06 Ram FSF, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004104. DOI: 10.1002/14651858.CD004104.pub3.

  13. Cardiogenic pulmonary edema • 63 yo F with known ischemic cardiomyopathy (EF=30%) presents with severe respiratory distress, cough, pulse ox=83%, RR=36, afebrile, gasping, crackles on exam, +JVD, 3+ edema, BNP=888 • pH=7.32, pO2=46, CO2=54, Bicarb=21 • Patient intubated. In ICU for 9 days, developed sepsis, died on day 12

  14. Cardiogenic pulmonary edema • There are clear benefits in meta-analysis of randomized trials for CPAP • risk of mortality 0.59 • 95%CI 0.38-0.90 • risk of intubation 0.44 • 95%CI 0.29-0.66 • Effective up to CPAP of 12.5 Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367: 1155–1163. Collins SP, Mielniczuk LM, Whittingham HA, et al. The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: A systematic review. Ann Emer Med. 2006; 48:260-269.

  15. Asthma • No recommendation due to poor quality of evidence Ram FSF, Wellington SR, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004360. DOI: 10.1002/14651858.CD004360.pub3.

  16. Weaning strategy for intubated adults • Possibly indicated in weaning patients with COPD • Decrease in mortality of 59% • RR=0.41 95%CI 0.22-0.76 • Decrease ventilator assoc. pneumonia 72% • RR=0.28 95%CI 0.09-0.85 • Decrease hospital length of stay 7.33 days • 95%CI -14.05 to -0.61 Burns KEA, Adhikari NKJ, Meade MO. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database of Systematic Reviews 2003, Issue 4. Art.No.: CD004127. DOI: 10.1002/14651858.CD004127.

  17. Immunosuppressed patients • Apparent benefit of NPPV in immunosuppressed patients based on one randomized trial Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. NEJM 2001 Feb; 344(7):481-487.

  18. Special situations • DNR • Viable option to give patient and family time and comfort • Emergency Room • Pick the right patient—hypercapnic COPD or CHF

  19. Conclusions from Level 1 Evidence • Consider use in COPD, pulmonary edema, immunosuppressed states • NPPV • Decreases mortality • Decreases need for intubation • Decrease hospital stay • If rapid improvement not seen, intubate

  20. NPPV is a very viable treatment for respiratory failure due to • Acute exacerbation of COPD • Acute cardiogenic pulmonary edema • Immunocompromised patients with pneumonitis

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