Nasal Positive Pressure Ventilation in Patients with Acute Respiratory Failure: Difficult and Time-Consuming Procedure for Nurses

doi:10.1378/chest.100.3.775

Chest

Volume 100, Issue 3, September 1991, Pages 775-782

https://doi.org/10.1378/chest.100.3.775 Get rights and content

Intubation and mechanical ventilation are well-established techniques in the management of patients with acute respiratory failure; however, there are situations in which these procedures cannot be used safely for various reasons. A recently described noninvasive technique, nasal positive-pressure ventilation (NPPV), has been developed for home ventilation of certain patients with chronic ventilatory insufficiency. We hypothesized that NPPV could be used in selected patients in whom intubation and mechanical ventilation were clearly indicated, but not immediately possible, or even contraindicated. Six patients were treated with NPPV during an episode of acute respiratory failure and enrolled in a prospective study. We found that NPPV was successful in avoiding intubation, but only in the three patients suffering from a restrictive pulmonary disorder, whereas the procedure was unsuccessful in patients with obstructive disorders. Moreover, in every patient, acute NPPV was very time-consuming for the nursing staff: in patients with restrictive disorders, a nurse had to monitor a patient submitted to NPPV during 41 ± 9 percent of the duration of ventilation and during 91 ± 9 percent of the NPPV time in patients with obstructive disorders. We conclude that acute NPPV may be attempted in selected patients with acute respiratory failure, predominantly patients with restrictive respiratory disorders, but that this procedure is very time-consuming for nurses.

Section snippets

Patients

Six consecutive patients were prospectively studied. A patient was eligible for this study when he was considered by the clinical team in charge as needing urgent intubation and mechanical ventilation but, for any reason, intubation was refused or deemed to be detrimental or hazardous (see individual case reports for details and indications for intubation). The duration of this study was 12 months (ie, between Feb 3, 1989, and Jan 5, 1990). During the same period, we intubated and ventilated a

CASE 1

This 49-year-old male patient had suffered from severe coronary artery disease for 15 years (two myocardial infarctions, followed by two coronary artery bypass grafts) when he received a heart transplant in 1987 because of left ventricular failure and persistent angina. Two years later, in the context of a cytomegalovirus infection probably induced by his immunosuppressive therapy (cyclosporine A, azathioprine, and prednisone), the patient developed neurologic symptoms; 15 days before admission

TECHNIQUES

For NPPV, we used respirators specifically designed for chronic domiciliary nocturnal ventilation, a technique with which we are accustomed (ie, Bennett Companion 2000, Kontron ABT 4100, or Draeger EV 800). All of these ventilators were used in the same way: assist-control mode; without PEEP; and breathing frequency, tidal volume, inspiratory:expiratory time ratio, and “trigger” function chosen according to the patient's comfort and arterial blood gas levels, after trial-and-error assays. The

RESULTS

Considered as a group, all six patients suffered from severe respiratory impairment (mean FEV₁ <1 L) and acute-on-chronic respiratory acidosis (mean PaCO₂, 9.8 kPa [74 mm Hg]) with a marked gas exchange abnormality (mean P[A-a]O₂, 11 kPa [82 mm Hg]) (Table 2). In all patients, it was possible to lower the PaCO₂ to some extent by using NPPV and to reverse the trend of steadily increasing hypercapnia; PaCO₂ decreased by 33±13 percent (Fig 2), and there was a significant difference between the PaCO

DISCUSSION

Several elements of information can be derived from our study. First, nppv is feasible in acute respiratory failure, when only the possibility of lowering an increased PaCO₂ is considered; however, in some patients, particularly the obstructive group, intubation appears to be ultimately unavoidable. It is unlikely that this technique will be considered as a way to buy time before intubation in such patients; endotracheal intubation is widely available, safe, and very often technically easy,¹

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Cited by (180)

Noninvasive ventilation prescription and association with outcome in elders admitted for acute heart failure in Emergency Departments: A retrospective analysis
2019, Journal Europeen des Urgences et de Reanimation
Citation Excerpt :
This low prescription rate could have many explanations. First, ED could be an unfavourable environment in which to begin NIV, because of a lack of training or adherence to NIV, and because this procedure is time-consuming [13]. Secondly, NIV requires the complete compliance and cooperation of the patient to be beneficial[14,15] An altered mental status, commonly associated with age is a brake on its prescription because it may be associated with the failure of NIV[13].
Acute Heart Failure (AHF) is a main cause of acute respiratory failure for patients admitted to Emergency Departments (ED). Non-invasive ventilation (NIV) is recommended as a first-line therapy for acute respiratory failure in patients with AHF, but its role in the ED for very old patients is poorly defined. The primary goal of this study was to estimate NIV prescription for older patients with AHF. Secondary goals were to identify determinants of NIV prescription, and to measure the association between NIV and day-8 outcomes in elderly patients.
Retrospective observational study at the ED of the University Hospital of Poitiers, France, assessing patients over 75 years old with AHF who had indication for NIV.
A total of 213 patients were included and NIV was only performed as BiPAP and in 17.4%. Patients who received NIV were younger (median [interquartile range], 85 [81–90] versus 87 [84–92] years; P = 0.045) and had lower pH values (7.29 [7.21–7.37] versus 7.41 [7.34–7.45]; P < 0.001) than others. NIV prescription was independently associated with Age, SpO2, pH and pCO2. NIV was not associated with a better mortality rate (OR 0.50 [0.17–1.45]; P = 0.20).
In our ED, NIV for AHF is uncommonly performed in the elderly and seems not associated with better outcome in this population regardless of comorbidities and autonomy.
L’insuffisance cardiaque aiguë (ICA) est une des principales causes de détresse respiratoire aigüe (DRA) chez les patients consultant aux urgences. La ventilation non-invasive (VNI) est un traitement recommandé pour les patients présentant une DRA secondaire à une ICA. Cependant, son intérêt dans la prise en charge des patients très âgés a été peu évalué. L’objectif principal de cette étude a été d’estimer le taux de prescription de VNI pour les patients très âgés avec ICA. Les objectifs secondaires ont été d’identifier les déterminants de la prescription d’une VNI et d’estimer l’association entre la VNI et le pronostic à 8 jours des patients très âgés.
Etude observationnelle rétrospective conduite aux urgences du CHU de Poitiers, évaluant les patients de plus de 75 ans avec ICA avec indication d’une VNI.
Deux cent treize patients ont été inclus et une VNI a été prescrites par BiPAP et pour 17.4 %. Les patients ayant reçu une VNI était plus jeune (médiane [interquartile], 85 [91–90] versus 87 [84–92] ans ; p = 0,045) et avait des valeurs de pH plus faible. (7,29 [7,21–7,37] versus 7,41 [7,34–7,41] ; p < 0,001). La prescription d’une VNI était associée à l’âge, la SpO2, le pH et la pCO2. Elle n’a pas été associé avec une amélioration de la mortalité (OR 0,50 [0,17–1,45] ; p = 0,20).
Dans notre service d’urgence, la VNI pour ICA a été peu prescrite aux patients âgés et ne semble pas être associé à une amélioration du pronostic, indépendamment des comorbidités et de l’autonomie.
Cost-utility of non-invasive mechanical ventilation: Analysis and implications in acute respiratory failure. A brief narrative review
2018, Respiratory Investigation
Citation Excerpt :
The clinical benefits of NIV in patients with ARF are influenced by the knowledge and experience of managing staff. This applies to physicians, nurses, and respiratory therapists [21–24]. Several studies evaluated the use of pre-hospital NIV for ARF [25–27].
The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.
Non-invasive ventilation in acute respiratory failure
2009, The Lancet
Citation Excerpt :
Additionally, the use of protocols to guide use might improve selection of appropriate patients.101 Although Chevrolet and co-workers102 characterised non-invasive ventilation as excessively demanding on personnel time, subsequent studies26,103 have shown that, despite taking about 30–60 min longer, initiation with invasive mechanical ventilation is rated by staff as no more difficult to administer than is invasive mechanical ventilation. Optimum staffing and location for delivery depend on acuity of the patient and their severity of illness, monitoring capabilities of the unit, and experience of the staff.23
Non-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation. Compared with medical therapy, and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure. The main indications are exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, pulmonary infiltrates in immunocompromised patients, and weaning of previously intubated stable patients with chronic obstructive pulmonary disease. Furthermore, this technique can be used in postoperative patients or those with neurological diseases, to palliate symptoms in terminally ill patients, or to help with bronchoscopy; however further studies are needed in these situations before it can be regarded as first-line treatment. Non-invasive ventilation implemented as an alternative to intubation should be provided in an intensive care or high-dependency unit. When used to prevent intubation in otherwise stable patients it can be safely administered in an adequately staffed and monitored ward.
A multicenter, randomized trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease
2010, Critical Care Medicine
To assess the effect of a helium-oxygen mixture on intubation rate and clinical outcomes during noninvasive ventilation in acute exacerbation of chronic obstructive pulmonary disease.
Multicenter, prospective, randomized, controlled trial.
Seven intensive care units.
A total of 204 patients with known or suspected chronic obstructive pulmonary disease and acute dyspnea, PacO₂> 45 mm Hg and two among the following factors: pH <7.35, PacO₂ <50 mm Hg, respiratory rate >25/min.
Noninvasive ventilation randomly applied with or without helium (inspired oxygen fraction 0.35) via a face mask.
Duration and complications of NIV and mechanical ventilation, endotracheal intubation, discharge from intensive care unit and hospital, mortality at day 28, adverse and serious adverse events were recorded. Follow-up lasted until 28 days since enrollment. Intubation rate did not significantly differ between groups (24.5% vs. 30.4% with or without helium, p = .35). No difference was observed in terms of improvement of arterial blood gases, dyspnea, and respiratory rate between groups. Duration of noninvasive ventilation, length of stay, 28-day mortality, complications and adverse events were similar, although serious adverse events tended to be lower with helium (10.8% vs. 19.6%, p = .08).
Despite small trends favoring helium, this study did not show a statistical superiority of using helium during NIV to decrease the intubation rate in acute exacerbation of chronic obstructive pulmonary disease.
Impact of non-invasive ventilation and non-medical caregiver presence on nursing workload – an observational study
2023, Australian Journal of Advanced Nursing
APPLICATION OF HIGH-FLOW NASAL OXYGEN THERAPY IN THE TREATMENT OF PATIENTS WITH RESPIRATORY FAILURE CAUSED BY COVID-19 PNEUMONIA OUTSIDE THE INTENSIVE CARE UNIT
2023, Lege Artis Medicinae

View all citing articles on Scopus

: Manuscript received November 14; revision accepted April 8.

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Chest

Clinical Investigations in Critical CareNasal Positive Pressure Ventilation in Patients with Acute Respiratory Failure: Difficult and Time-Consuming Procedure for Nurses

Section snippets

Patients

CASE 1

TECHNIQUES

RESULTS

DISCUSSION

Crit Care Clinics

Chest

Chest

Chest

Complications of endotracheal intubation, tracheostomy, and artificial airways.

Respir Care

Work of breathing through different sized endotracheal tubes.

Crit Care Med

In vitro versus in vivo comparison of endotracheal tube airflow resistance.

Am Rev Respir Dis

Risk factors for pneumonia in patients receiving continuous mechanical ventilation.

Am Rev Respir Dis

Control of nocturnal hypoventilation by nasal intermittent positive pressure ventilation.

Thorax

Nocturnal positive pressure ventilation via nasal mask.

Am Rev Respir Dis

Home positive pressure ventilation via nasal face mask for patients with neuromuscular disorders.

Respir Care

Clinical Investigations in Critical Care
Nasal Positive Pressure Ventilation in Patients with Acute Respiratory Failure: Difficult and Time-Consuming Procedure for Nurses