Noninvasive Nasal Mask Ventilation for Acute Respiratory Failure: Institution of a New Therapeutic Technology for Routine Use

doi:10.1378/chest.105.2.441

Chest

Volume 105, Issue 2, February 1994, Pages 441-444

https://doi.org/10.1378/chest.105.2.441 Get rights and content

Objective

We successfully implemented the delivery of noninvasive mechanical ventilation for patients with acute respiratory failure, a previously controversial use of this technique, using a simplified ventilator (BiPAP) with nasal mask. Pilot work showed this mode of support to be effective when administered by the members of a research team, and in the current study we were able to transfer this responsibility to usual care providers.

Setting

Almost 90 percent of the patients in this study were in either the 16-bed medical or 31-bed surgical intensive care units at our hospital.

Subjects

One hundred ten hemodynamically stable patients with acute respiratory failure being considered for intubation and mechanical ventilation participated in this study. Eighty percent were surgical patients, most of whom had hypercapnic failure.

Intervention

Patients were administered noninvasive ventilatory support using a ventilatory support system (BiPAP) applied with a nasal mask. This intervention was administered by a research team in the initial 31 patients (special care, phase 1). The administration was transferred to usual care personnel in the next 45 patients (transition, phase 2). Usual care personnel almost exclusively administered care in the final 34 patients (usual care, phase 3).

Results

Withdrawal of ventilatory support for greater than 48 h (successful outcome) was about the same during usual care (phase 3, 80 percent) as it was during special care (phase 1, 76 percent).

Section snippets

Methods

The protocol for this study was approved by the Institutional Review Board at Allegheny General Hospital, and the informed consent of participants was obtained.

Results

Successful outcome of therapy, defined as withdrawal of ventilatory support for greater than 48 h, occurred in 76 percent of the 31 patients who received special care (phase 1). In the next 45 consecutive patients, during transition to usual care (phase 2), this success rate was unchanged. Outcome was not evaluated for consecutive patients after phase 2 because the initiation of support was the responsibility of the usual care providers, and we were not confident that all trials were recorded.

Discussion

Noninvasive ventilatory support as a substitute for intubation and mechanical ventilation has obvious limitations. Nasal mask ventilation with a simplified ventilatory support system (BiPAP) sacrifices “control of the airway,” choice of pressure or volume delivery waveform, pressures above 22 cm H₂O, control of the level of inspiratory trigger, most alarms, graphic presentation of operating waveforms, etc. If the delivery of ventilatory support in a specific patient requires any of these

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Cited by (129)

Cost-utility of non-invasive mechanical ventilation: Analysis and implications in acute respiratory failure. A brief narrative review
2018, Respiratory Investigation
Citation Excerpt :
Pennock et al. described good efficacy of NIV in postoperative patients who had respiratory failure after extubation. NIV can prevent re-intubation, with a significant reduction in mortality, morbidity, length of hospital stay, and number of ICU readmissions [24]. Although it is not clear whether NIV may be useful in preventing ARF after low- and high-risk surgical procedures, it has been successfully used in patients who developed ARF after abdominal or lung resection surgery and have reduced the intubation rate [9,39].
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.
Use of non-invasive ventilation in acute respiratory failure. multicenter study in intensive care units
2009, Medicina Intensiva
Estudiar el uso de la ventilación no invasiva (VNI) en la insuficiencia respiratoria aguda, en las unidades de cuidados intensivos (UCI) de España.
Se realizó una encuesta a 254 UCI. Al final de ésta se invitó a participar en un estudio multicéntrico retrospectivo, y proporcionar información detallada sobre pacientes ventilados.
Contestaron 123 UCI; 119 utilizaban la VNI, de manera muy variable. En la enfermedad pulmonar obstructiva crónica (EPOC), la VNI fue de primera elección en el 89% de las unidades; en el edema agudo de pulmón (EAP), el 79%; en la insuficiencia respiratoria tras la extubación, el 53%; en la neumonía, el 53%, y en el síndrome de distrés respiratorio agudo (SDRA), el 17%. Su utilización en la EPOC fue ocasional o nula en el 11% de las unidades, y en el EAP, en el 21%. 18 hospitales enviaron información de 432 pacientes ventilados, de los que 232 (54%) recibieron VNI como primera elección. La neumonía o el SDRA fueron factores independientes en relación con el fracaso de la VNI (odds ratio ajustada [ORa] = 5,71; intervalo de confianza [IC] del 95%, 1,83-17,8; p = 0,003). La admisión en una unidad que ventilara de forma no invasiva a más de 50 pacientes/año (ORa = 0,22; IC del 95%, 0,07-0,63; p = 0,005) y una mayor razón PaO₂/FIO₂ tras una hora de ventilación (ORa = 0,98 por punto; IC del 95%, 0,97-0,99; p < 0,001) fueron factores protectores.
La VNI es ampliamente utilizada en las UCI de España, pero es posible que siga estando infrautilizada en la EPOC y el EAP. El diagnóstico de neumonía o SDRA fue un factor independiente en relación con el fracaso. Ventilar a más de 50 pacientes/año y una mayor PaO₂/FIO₂ tras una hora fueron factores protectores.
Study the use of non-invasive ventilation (NIV) in patients with acute respiratory fai-lure in intensive care units (ICUs) in Spain.
A questionnaire was sent to 254 ICUs, after which, they were invited to participate in a multicenter, retrospective study, providing detailed information on ventilated patients.
Answers were received from 123 hospitals. Of these, 119 used NIV, although its use varied greatly. NIV is the treatment of choice in 89% of the units for chronic obstructive pulmonary disease (COPD), in 79% for acute pulmonary edema (APE), in 53% for postextubation failure, in 53% for pneumonia 53%, and in 17% for acute respiratory distress syndrome (ARDS). It was used occasionally in COPD in 11% of the units, and in 21% of the units for APE. Eighteen hospitals provided additional information on 432 ventilated patients, 232 (54%) of whom received NIV as first line therapy. Presence of pneumonia or acute respiratory distress syndrome (ARDS) was an independent predictive factor of NIV failure (ORa = 5.71; CI 95%, 1.83-17.8; p = 0.003). Admission in a unit with experience in NIV in > 50 patients/year (ORa = 0.22; CI 95%, 0.07-0.63; p = 0.005) and a higher PaO₂/FiO₂ ratio after one hour of ventilation (ORa = 0.98 per point; CI 95%, 0.97-0.99; p < 0.001) were protector factors.
In Spain, NIV is widely used but it may continue to be underused in COPD and APE. The diagnosis of pneumonia or ARDS was an independent predictive risk factor. Admission in an ICU with NIV in more than 50 patients/year also have higher PaO₂/FiO₂ ratio after one hour of ventilation were predictive factors of success.
Can we still avoid non-invasive ventilation in acute exacerbations of COPD? Education of all centres is urgent!
2009, Revue des Maladies Respiratoires
JEUR: Introduction
2006, JEUR
Non-invasive ventilation (NIV) in surgical patients with post-operative acute respiratory failure
2006, Current Anaesthesia and Critical Care
Non-invasive ventilation (NIV) is a technique developed to assist patients with acute respiratory failure (ARF) of different origins, which avoids endotracheal intubation. NIV has already been demonstrated to be a useful alternative to invasive mechanical ventilation in patients with acute exacerbation of COPD, cardiogenic pulmonary oedema and other causes of hypoxemic ARF, avoiding several complications directly related to the presence of an endotracheal tube, such as the increased risk for nosocomial pneumonia.
Few studies have evaluated the possible role for NIV in patients developing post-operative acute respiratory failure: this chapter will review the possible indications and the clinical results obtained by applying NIV in patients developing ARF after thoracic and abdominal surgery. The role of different interfaces is also discussed.
Predictive factors related to success of non invasive ventilation and mortality in the treatment of acute cardiogenic pulmonary edema
2005, Medicina Clinica
Estudios recientes aconsejan el uso de la ventilación no invasiva (VNI) en pacientes con edema agudo de pulmón cardiogénico (EAP). El objetivo es determinar los factores relacionados con el éxito de la técnica y con la mortalidad hospitalaria en pacientes que ingresan en una Unidad de Cuidados Intensivos (UCI) con EAP y reciben tratamiento con VNI.
Estudio observacional y prospectivo realizado en UCI. Se incluyó a 199 pacientes consecutivos que ingresaron con EAP y recibieron VNI junto a tratamiento médico convencional. El éxito de la técnica se definió como la evitación de intubación endotraqueal en un paciente dado de alta vivo, sin disnea, que permanecía así durante las primeras 24 h. Se recogieron los parámetros clínicos, fisiológicos y gasométricos al ingreso y tras 1 h de tratamiento, así como frecuencia de intubación y mortalidad hospitalaria. Se realizó un modelo multivariante mediante regresión logística y se incluyeron las variables que en el univariante mostraron una relación significativa (p < 0,05).
La edad media de los pacientes fue de 73 años. El 43% eran varones. El Simplified Acute Physiology Score (SAPS II) al ingreso fue de 45. En 148 pacientes (74,4%) la técnica fue exitosa. se intubó a 25 pacientes (12,6%). En el análisis multivariante, el éxito de la técnica se asoció con (valores expresados como odds ratio ajustada y el intervalo de confianza [IC] del 95%): el SAPS II (0,95 [0,91-0,99]); la procedencia al Servicio de Urgencias (6,78 [1,85-24,79]); el valor de presión parcial de dióxido de carbono (pCO₂) al ingreso (1,05 [1,01-1,09]); el índice presión parcial de oxígeno en sangre arterial/fracción inspiratoria de oxígeno (pO₂/FiO₂) (1,03 [1,01-1,06]) y de la frecuencia respiratoria (FR) en la primera hora (0,91 [0,84-0,99]); el SOFA (Acute Failure Organics Score) (0,62 [0,49-0,78]); el infarto agudo de miocardio (IAM) (0,05 [0,01-0,22]) y el número de complicaciones (0,17 [0,47-0,65]). La mortalidad hospitalaria fue del 32,7%. La orden de no intubar (0,12 [0,04-0,32]) y el éxito de la técnica (100,03 [28,71-348,47]) se relacionaron con la mortalidad hospitalaria.
El éxito de la aplicación de la VNI en el tratamiento del EAP se asoció con un SAPS II más bajo, la procedencia del paciente desde urgencias, una pCO₂ elevada al ingreso, una mejoría de la pO₂/FiO₂ y de la FR en la primera hora, un SOFA menor, la ausencia de IAM y un menor número de complicaciones. La mortalidad hospitalaria se relacionó con el éxito de la técnica y con una orden de no intubar previa
Recent studies support the use of non invasive ventilation (NIV) in patients with acute cardiogenic pulmonary edema (ACPE). We aimed to evaluate the factors related to the success of the technique in patients admitted to an intensive care unit (ICU) with ACPE.
An observational prospective study was perfomed in ICU.199 consecutive patients were enrolled with ACPE at admission who received treatment with NIV and standardized pharmacological treatment. The success of the NIV was achieved when endotracheal intubation was avoided and patients were alive without dyspnea within and 24 hours after discharge from the ICU. Clinical, physiological and gasometric parameters were analyzed at admission and one hour after starting NIV.
Patient's age was 74 years. 43% were male. The SAPS II was 45. 74.4% of the patients were successfully treated with NIV. 12.6% required endotracheal intubation. In a multivariate analysis, the success of the technique (values expressed as odds ratio [95% confidence interval]) was related to: SAPS II (0.95 [0.91-0.99]); the place of admission (6.78 [1.85-24.79]); value of PCO₂ at admission (1.05 [1.01-1.09]); PO₂/FiO₂ index (1.03 [1.01-1.06]) and respiratory frecuency (0.91 [0.84-0.99]) within the first hour; SOFA (acute failure organics score) (0.62 [0.49-0.78]); concomitant acute myocardial infarction (AMI) (0.05 [0.01-0.22]) and number of complications (0.17 [0.47-0.65]). The hospital mortality rate was 32.7%. The non intubation order (0.12 [0.04-0.32]) and the success of the technique (100.03 [28.71-348.47]) were related to the hospital mortality.
The success of NIV in the treatment of ACPE is related to a lower SAPS II, admission at the emergency department, elevated PCO₂ at admission, improvement of the PO₂/FiO₂ index and the respiratory rate within the first hour. The non intubation order and the success of the technique were related to the hospital mortality.

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Chest

Clinical InvestigationsSleep, Breathing and Nasal VentilationNoninvasive Nasal Mask Ventilation for Acute Respiratory Failure: Institution of a New Therapeutic Technology for Routine Use

Objective

Setting

Subjects

Intervention

Results

Section snippets

Methods

Results

Discussion

Clin Chest Med

Chest

Chest

Chest

Chest

Chest

Clinical Investigations
Sleep, Breathing and Nasal Ventilation
Noninvasive Nasal Mask Ventilation for Acute Respiratory Failure: Institution of a New Therapeutic Technology for Routine Use