The Latest Developments in Noninvasive Mechanical

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The Latest Developments in Noninvasive
Mechanical Ventilation
Nicholas Hill MD Tufts Medical Center Boston, MA
USA
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Disclosures

• Research Grants
• Respironics, Inc
• Breathe Technologies, Inc

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Outline

• ICU Applications of NIV
• Main indications
• COPD, Pulm Edema
• ALI/ARDS
• Extubation Failure, Trauma
• Epidemiology of use
• Practical Application
• Masks, Ventilators

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Why Noninvasive Ventilation?

• Avoids trauma of intubation
• Reduces respiratory infections
• More comfortable, less sedation
• Less costly
• Respiratory System Protective Strategy
• Must be used selectively

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Main Indications for Acute Noninvasive
Ventilation (NIV)
Strong (Level A) Acute hypercapnic RF (COPD)
Cardiogenic pulmonary edema ARF in
immunocompromised
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NIV for COPD associated with

• Difficult weaning (to facilitate extubation)
• Pneumonia
• Extubation failure
• Do-not-intubate status
• Post-operative Respiratory Failure

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NIV for Acute Pulmonary Edema Physiologic
Rationale

• CPAP
• Increased FRC
• Re-expands flooded alveoli
• Improved oxygenation
• Increased compliance
• Afterload reduction - ? cardiac function
• Pressure Support
• Further reduction in work

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Meta-analysis CPAP vs NIV for ACPE
Evidence is now robustand use as a first line
intervention is becoming mandatory.
Winck et al, Crit Care 2006 10R69
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Out-of-Hospital CPAP Vs Usual Care in Acute
Respiratory Failure A RCT
Thompson et al, Ann Emerg Med. 200852232-241
CPAP Control
(10
cm H2O) n 35
34 SaO2 82
75 RR/min 38
38 CHF/COPD/Asthma 99 100
Intubation 7(20)
17(50) Hosp Mortal () 4(14)
12(35)
Plt0.05
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Indications for Acute NIV
Weaker (Level B) Asthma Extubation
failure(COPD) Hypoxemic Respiratory
Failure Postoperative Respiratory
Failure Do-not-intubate pts (COPD and CHF)
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RCT of NPPV for Asthma Exacerbations

• NPPV Sham
• n 17 16
• FEV1 () 37.3 33.8
• 50 FEV1 (1h) 80 20
• ? FEV1 (1h) 53.5 28.5
• Hospitalized 3 (17.6) 10 (63.5)
• Soroksky et al, Chest 2003 1231018.

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Use of NIV as Bronchodilator
? FEV1
8/6 cm H2O 6/4 cm H2O O2 by FM
44 asthmatics, FEV1 33 P 80-90, RR 20 3 Groups,
High, Low and O2 ctls for 1hr Hydrocort BUT
NO BDs!
Soma T et al, Intern Med 08
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NIV for Asthma

• Used for pts with status asthmaticus severe
  and refractory to treatment
• May combine with continuous neb and heliox
  (anecdotal evidence)
• Monitor very closely
• ? Role early for bronchodilator effect and to
  reduce dyspnea more rapidly?

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NIV for Hypoxemic Resp Failure?
72 yo M with 3-4 days ? dyspnea, fever, chills,
dry cough. No chest pain, takes beta blocker
for HBP. In the ICU, moderately dyspneic, RR 30.
Not using access muscles. BP 146/80, P 92, O2
Sat 98 on 40 Facemask. No JVD, lungs - bilat
crackles, heart no m, g no edema. ABG on 40
FM is 7.36/42 PaCO2/100 PaO2. Renal, liver fxn
nl. CXR - bilat interstitial infiltrates, new
since 3 mos earlier, EKG shows ST with NSSTTs.
Diagnosis Community-acquired pneumonia
Does he have ALI/ARDS?
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(No Transcript)
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What to do?

• O2 Alone
• CPAP
• NIV
• Intubate

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Poor Outcomes of ALI/ARDS/ Pneumonia treated
with NIV

• Pneumonia associated with poor outcome with NIV
  Ambrosino N, Thorax 95
• Severe CAP (RCT) Better outcomes only in COPD
  pts with ALI/ARDS Confalonieri M et al, AJRCCM
  99
• Severe CAP initial oxygenation better, 66 need
  for intubation Jolliet P et al, ICM 2001
• ARDS 38/54 (70) intubation. P/F 147 success
  112 failure all septic shock failed Rana S et
  al, Crit Care 06

The Last Frontier
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Acute Hypoxemic Respiratory Failure

• Italian multicenter study of 354 NIV cases, 30
  failures 50 ARDS or CAP, 10
  cardiogenic pulmonary edema
• Condition Odds Ratio
• ARDS or Comm Acq Pna 3.75
• PaO2FIO2 ? 146 p 1st hr 2.51
• SAPS II ? 35 1.81
• Age gt 40 1.72

PaO2/FIO2 lt 200 Resp Distress, RR gt
30-35 Non-COPD dx Pneumonia (incl
immunosuppr) ARDS Trauma Cardiogenic Pulm
Edema
Antonelli et al, Int Care Med 2001 271718
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Why is NIV in ALI/ARDS so challenging?

• Severe oxygenation defect more PEEP, more leak,
  desaturation if mask falls off
• High minute volumes, tachypnea harder to meet
  demands, synchronize
• Stiff lungs Higher insp pressure, more leak,
  less comfort
• Sick patients sepsis, secretions, MODS,
  deteriorating

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NIV as First Line Therapy in ARDS

• 147 pts eligible of 479 (332 intubated), had
  dyspnea, RR gt 30 and 2 new organ failures
• 54 avoided intubation
• VAP rate 2 vs 20, mortality 6 vs 53
• Success more likely if SAPS II 34 and PaO2/FIO2
  gt 175 p 1st hr of NIV therapy

Antonelli et al, CCM, 2006
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RCTDoes Early Use of NPPV for ALI prevent
ARDS/ARF?
Incl 200 lt PaO2/FIO2 lt 300, FIO2 50, Resp
Distress Excl Age gt 70, PaCO2 gt 50, GCS lt11.
SOFA gt 2
10 ctrs stopped early Zhan Q et al, CCM 2012
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Early Use of NPPV for ALI

• NPPV (17/6.5) O2
• n 21
  19
• Males 76 42
• Intub (need/actual) 1/1 7/4
• Organ Failures 3 14
• Death 1 5
• Stay (ICU/Hosp d) 5.9/17.5 7.8/23

P lt 0.05 Zhan Q et al, CCM
2012
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Early Use of NPPV for ALI

Zhan Q et al, CCM 2012
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What would you do now?Do you see a role for
prophylactic NIV in ALI?

• O2 Alone?
• NIV?

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Who might get NIV for ALI/ARDS?

• Careful selection!
• Excellent candidate for NIV no multiorgan
  system disease, cooperative, no excessive
  secretions SAPS 34
• Can oxygenate adequately on NIV (FIO2 to 60)
  FIO2/PaO2 improves quickly (1st hr) (gt150-175)
• Skilled center with experienced physicians,
  respiratory therapists and nurses

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Selection Criteria in Trials to
Prevent Extubation Failure

• NIV for Extubation Failure
• 2004 trial - no reduction in reintub-
• ations and ? mortality in NIV group
• -Esteban et al, NEJM 04
• Recent RCT showed ? resp failure and
• ? 90 d mortality in hypercapnics on NIV
• -Ferrer et al, Lancet 09
• Dont delay needed intubation!

• Nava
• PaCO2gt45,
• MVgt72h
• gt1 failed weaning attempt
• excess secretions
• upper airway disorder

• Esteban
• PaCO2 gt 45
• MVgt48h
• Resp muscle fatigue RR gt 25
• pH lt 7.35
• O2sat lt 90, PaO2 lt 80

Ferrer Age gt 65, CHF, APACHE score gt 12
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Non-invasive ventilation after extubation in
hypercapnic chronic lung disease A RCT
Ferrer et al, Lancet Aug 2009
NPPV Control n 54
52 PaCO2 (mm Hg) 48
48 Resp Failure 8(15)
25(48) NIV rescue 15/20(75) Intubatio
n () 6(11) 10(19) Hosp LOS (days)
29 24 Hosp Mortal () 6(11)
11(22) 90 d Mortal () 6(11)
16(31)
Plt0.05
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Non-invasive ventilation reduces intubation in
chest-trauma related hypoxemia A RCT
Hernandez et al, Chest 2010 13774-80
NPPV Control n 25
25 PaO2/FIO2 108
110 APACHE II 17.5
14.1 Intubation 3(12) 10(40)
Exhaustion 2(8) 6(24) VAP 2(8)
3(12) Hosp LOS (days) 14
21 Hosp Mortal () 1(4) 1(4)
Plt0.05
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Non-invasive ventilation reduces intubation in
chest-trauma related hypoxemia An RCT
Hernandez et al, Chest 2010 13774-80
(P lt 0.05)
Plt0.05
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NIV Epidemiology How are we doing? Increasing
Use of NIV in French and US ICUs
of Pts
Carlucci et al, AJRCCM, 2001 Demoule et al, ICM,
06 Ozsancak et al, Chest 08
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Use of NIV for COPDMassachusetts and Rhode Island
of Vent starts for COPD exacerbations treated
with NIV
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Increasing Use of NIV for COPD in US

• Healthcare Cost and Utilization Projects
  Nationwide Inpatient Sample 1998-2008
• 7,511,267 Admissions for exacerbations
• NIV increased 1 to 4.5 of admissions (468
  increase)
• Invasive Vent dropped 42 from 6 to 3.5 of
  admissions

Chandra D et al, AJRCCM 2012
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Increasing Use of NIV for COPD in US (gt 7X106
admissions)
Chandra D et al, AJRCCM 2012
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Diminishing Mortality Overall
Chandra D et al, AJRCCM 2012
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Forehead Adjuster
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RCT TotalTM vs Full Face Mask
60 pts with ARF on NIV

• No difference in
• time for application
• 8 switched from TFM
• to FFM, none FFM
• to TFM

Ozsancak A et al, Chest 2011
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Bilevel Vents for Acute Applications (80 US)
NIV modes on Critical Care Vents Leak
compensation Adjustable Rise Time Inspiratory
Time Limit Silence nuisance alarms Need
adjustments if leaks Ferreira, Chest 09
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NIV Modes on Critical Care Ventilators Effect
of Leak
Time to 90 of Target Inspiratory Pressure
Ferreira JC at al, Chest 2009
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Summary NIV for Acute Care

• Main Indications COPD, CHF, Immunocompromised
• Data accumulating for others Asthma, Hypoxemic
  (Trauma), Extub Failure
• Technological advances New masks, ventilators
• Proper application techniques, monitoring and
  skilled staff still important