Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Which patients with acute exacerbation [r]
(1)(2) Recognize Exacerbations
Review Causal Etiologies
Pharmacologic Therapies
Ventilator Support
◦ Non-Invasive Mechanical Ventilation
(3) Increased Frequency of Cough
Change in Sputum Production
◦ Color
◦ Quantity
◦ Consistency
Worsened Shortness of Breath
Change in Baseline Symptoms
Out-Patient Management
(4) Differential Diagnosis
◦ Pulmonary Edema
◦ Pulmonary Embolism
◦ Pneumonia
Not All Dyspnea Not All Dyspnea and/or Wheezing is
(5)• Steroids
• Parenteral
• Methylprednisolone
• Enteral
• Equivalent Bioavailability
• Prednisone 40 mg
• Antimicrobial Agents
• Methylxanthines
• Not Recommended acutely
• Oxygen
• AVOID Hyperoxia
• Beta Adrenergic Agonists
• Anticholingeric Agents
• Inhaled Corticosteroids
• Little Data
• ? Outpatient Role
(6) Non-Invasive
• Face Mask
• Nasal Mask
• Nasal Prongs (Pillows)
Invasive
• Endotracheal Tube
• [Tracheostomy]
• Sub-acute to longer-term weaning
Out-Patient
(7) Non-Invasive Positive Pressure Ventilation (NPPV)
• Uncompensated Hypercarbic Respiratory Failure
• pH < 7.3
• PaCO2 > 45mmHg
Mortality
•11% vs 21%
Intubation Rate
•16% vs 33%
Treatment Failure
•20% vs 42%
(8) Invasive Positive Pressure Ventilation (IPPV)
• WHEN ?
• Severity of Presenting Respiratory Distress • Underlying Etiology of Exacerbation
• Failure of BPAP
• Progressive Hypercarbic Encephalopathy • Worsening Respiratory Acidosis
• Unrelief of Dyspnea
• Hemodynamic Instability
(9) Invasive Positive Pressure Ventilation (IPPV)
• Management
1. Patient Participation
• Triggering Modes • Assist Control (AC)
• Intermittent Mandatory Ventilation/Pressure Support (IMV/PS) • [ Pressure Support Ventilation ] (PSV) – Do NOT use acutely
• Wean FIO2 for PaO2 = 60mmH (SpO2 = 88-92%)
• Minimize Sedation – Richland Aggitation Scale Score (RASS): zero - neg one • Physical Therapy
2. Respiratory Mechanics & Ventilator Asynchrony 3. Aggressive Extubation
Usually set as
SIMV
(10) Invasive Positive Pressure Ventilation (IPPV) – Participation
• Assist Control (AC) – First Choice
• Clinician Controlled Minimal Minute Ventilation
• Clinician Set Tidal Volume (5-7ml/Kg IBW)
• Clinician Set Respiratory Rate (4 BPM less than Patient Respiratory Rate) • Patient Rate Above the Set Rate Receives Clinician-Set Tidal Volume
• Intermittent Mandatory Ventilation with Pressure Support • Clinician Controlled Minimal Minute Ventilation
• Clinician Set Tidal Volume Respiratory Rate
• Patient Rate Above Set Rate Receives Tidal Volume Based on Flow
• Pressure Support Ventilation – NOT Recommended Acutely • Patient Controlled Minute Ventilation
• Patient Determined Rate and Tidal Volume
• Clinician: Set Pressure Support to Keep RR < 30 BPM • Associated with Poorer Sleep Architecture than AC
Acute
Sub – Acute
(11) Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
• Causes
A. Auto-PEEP (Intrinsic-PEEP) B. Trigger Sensitivity
• Flow (1L/Second) • Pressure (-2cmH2O)
C. Inspiratory Flow Rate (How Quickly the Breath Is Delivered)
(12) Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
• Troubleshoot
• COPD Obstructive Disease Air Cannot Get Out A. Auto-PEEP (Intrinsic PEEP)
• Additional End-Expiratory Pressure • Perform End-Expiratory Hold
• Auto-PEEP = End-Exp Hold Pressure – Set PEEP • Applied PEEP Overcomes the added work created by Auto-PEEP
• Additional PEEP added to Set PEEP • Auto-PEEP (0.80) + Set PEEP
End-Exp Hold 12 cmH2O Set PEEP 5 cmH2O Auto-PEEP 7 cmH2O
0.80 Applied PEEP 6 cmH2O
Suggested Starting Value
Example
(13) Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
• Troubleshoot
B. Trigger Sensitivity
• Flow (2L/min)
• Volume per unit time (L/min) patient generates to “tell” the Ventilator a breath is desired
• Pressure (-2cmH2O)
• Negative pressure patient generates to “tell” the Ventilator a breath is desired
Suggested Starting Value
(14) Invasive Positive Pressure Ventilation (IPPV) - Asynchrony
• Troubleshoot
C. Inspiratory Flow Rate
• Default of 60L/min is often inadequate
• Increase Flow Rate = Increasing Inspiratory Time
(15) Invasive Positive Pressure Ventilation (IPPV) - Extubation
• Aggressive Extubation
• Spontaneous Breathing Trial (SBT)
• Performed When
• Cause of Respiratory Failure Reversed
• Minimal Ventilator Support (FIO2 = 0.4, PEEP = 5cmH2O) • Ventilation via:
• T-Piece,
• Minimal PS/PEEP (5 cmH2O/5 cmH2O)
• Automatic Tube Compensation (ATC)
• 30min Rapid Shallow Breathing Index < 104
• With Appropriate Mental Status and Few Secretions • If SBT Failure Extubate to BPAP
Reduction: Mortality
Ventilator Associated Pneumonia Duration of Mechanical Ventilation Frequency of Tracheostomy Placement
COPD ONLY!
(16) Rappaport SH, Shpiner R, Yoshihara G, et al Randomized, prospective trial of pressure-limitedversus volume-controlled ventilation
in severe respiratory failure Crit Care Med 1994; 22:22.10
Prella M, Feihl F, Domenighetti G Effects of short-term pressure-controlled ventilation on gasexchange, airway pressures, and gas
distribution in patients with acute lung injury/ARDS: comparisonwith volume-controlled ventilation Chest 2002; 122:1382.11
Chiumello D, Pelosi P, Calvi E, et al Different modes of assisted ventilation in patients with acuterespiratory failure Eur Respir J
2002; 20:925
Jeffrey AA, Warren PM, Flenley DC Acute hypercapnic respiratory failure in patients with chronicobstructive lung disease: risk factors
and use of guidelines for management Thorax 1992; 47:34
Seneff MG, Wagner DP, Wagner RP, et al Hospital and 1-year survival of patients admitted tointensive care units with acute
exacerbation of chronic obstructive pulmonary disease JAMA 1995;274:1852
Slutsky AS Mechanical ventilation American College of Chest Physicians' Consensus Conference Chest 1993; 104:1833 Laghi, F, Tobin, MJ Indications for mechanical ventilation In: Principles and Practice of Mechanical Ventilation Tobin, MJ (Ed),
McGraw Hill, New York, 2006.p.129
Tobin MJ, Perez W, Guenther SM, et al The pattern of breathing during successful and unsuccessful trials of weaning from
mechanical ventilation Am Rev Respir Dis 1986; 134:1111
Tobin MJ, Guenther SM, Perez W, et al in acute respiratory failureribcage-abdominal motion during Adults Remove successful and
unsuccessful trials of weaning from mechanical ventilation Am Rev Respir Dis 1987;135:1320
Tobin MJ, Perez W, Guenther SM, et al Does rib cage-abdominal paradox signify respiratory muscle fatigue? J Appl Physiol (1985)
1987; 63:851
Marini JJ, Smith TC, Lamb VJ External work output and force generation during synchronizedintermittent mechanical ventilation
Effect of machine assistance on breathing effort Am Rev RespirDis 1988; 138:1169
Ward ME, Corbeil C, Gibbons W, et al Optimization of respiratory muscle relaxation duringmechanical ventilation Anesthesiology
1988; 69:29
Imsand C, Feihl F, Perret C, Fitting JW Regulation of inspiratory neuromuscular output during synchronized intermittent mechanical
ventilation Anesthesiology 1994; 80:13
MacIntyre NR Respiratory function during pressure support ventilation Chest 1986; 89:677.12 Brochard, L, Lellouche, F Pressure
support ventilation In: Principles and Practice of Mechanical Ventilation, Tobin, MJ (Ed), McGraw Hill, New York, 2006.p.221
Jubran A, Van de Graaff WB, Tobin MJ Variability of patient-ventilator interaction with pressure support ventilation in patients with
chronic obstructive pulmonary disease Am J Respir Crit Care Med 1995; 152:129
Parthasarathy S, Jubran A, Tobin MJ Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation Am
J Respir Crit Care Med 1998; 158:1471
Leung P, Jubran A, Tobin MJ Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea Am J Respir Crit
(17) Tobin MJ, Jubran A, Laghi F Patient-ventilator interaction Am J Respir Crit Care Med 2001;163:1059
Maheshwari V, Paioli D, Rothaar R, Hill NS Utilization of noninvasive ventilation in acute carehospitals: a regional survey Chest 2006; 129:1226 Demoule A, Girou E, Richard JC, et al Increased use of noninvasive ventilation in French intensivecare units Intensive Care Med 2006; 32:1747 Celikel T, Sungur M, Ceyhan B, Karakurt S Comparison of noninvasive positive pressure ventilationwith standard medical therapy in hypercapnic
acute respiratory failure Chest 1998; 114:1636
Sweet DD, Naismith A, Keenan SP, et al Missed opportunities for noninvasive positive pressureventilation: a utilization review J Crit Care 2008; 23:111
Organized jointly by the American Thoracic Society, the European Respiratory Society, the EuropeanSociety of Intensive Care Medicine, and the SociÈtÈ de RÈanimation de Langue FranÁaise, andapproved by ATS Board of Directors, December 2000 International Consensus Conferences inIntensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure Am JRespir Crit Care Med 2001; 163:283
DÌaz GG, Alcaraz AC, Talavera JC, et al Noninvasive positive-pressure ventilation to treathypercapnic coma secondary to respiratory failure Chest 2005; 127:952
Scala R, Naldi M, Archinucci I, et al Noninvasive positive pressure ventilation in patients with acuteexacerbations of COPD and varying levels of consciousness Chest 2005; 128:1657
Squadrone E, Frigerio P, Fogliati C, et al Noninvasive vs invasive ventilation in COPD patients withsevere acute respiratory failure deemed to require ventilatory assistance Intensive Care Med 2004;30:1303
Paus-Jenssen ES, Reid JK, Cockcroft DW, et al The use of noninvasive ventilation in acuterespiratory failure at a tertiary care center Chest 2004; 126:165
Nava S, Navalesi P, Conti G Time of non-invasive ventilation Intensive Care Med 2006; 32:361
Collaborative Research Group of Noninvasive Mechanical Ventilation for Chronic ObstructivePulmonary Disease Early use of non-invasive positive pressure ventilation for acute exacerbations of chronic obstructive pulmonary disease: a multicentre randomized controlled trial Chin Med J (Engl)2005; 118:2034
Liesching T, Kwok H, Hill NS Acute applications of noninvasive positive pressure ventilation Chest2003; 124:699.13 Kacmarek, RM Characteristics of pressure-targeted ventilators used for noninvasive positive pressureventilation Respir Care 1997; 42:380
Ferguson GT, Gilmartin M CO2 rebreathing during BiPAP ventilatory assistance Am J Respir CritCare Med 1995; 151:1126
Navalesi P, Fanfulla F, Frigerio P, et al Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure Crit CareMed 2000; 28:1785
Lemyze M, Mallat J, Nigeon O, et al Rescue therapy by switching to total face mask after failure offace mask-delivered noninvasive ventilation in do-not-intubate patients in acute respiratory failure CritCare Med 2013; 41:481
(18) Soo Hoo GW, Santiago S, Williams AJ Nasal mechanical ventilation for hypercapnic respiratoryfailure in chronic obstructive
pulmonary disease: determinants of success and failure Crit Care Med1994; 22:1253
Hess, D Noninvasive positive pressure ventilation: Predictors of success and failure for adult acutecare applications Respir Care
1997; 42:424.20 Turner, RE NIPPV: Face versus Interface Respir Care 1997; 42:389
Holland AE, Denehy L, Buchan CA, Wilson JW Efficacy of a heated passover humidifier duringnoninvasive ventilation: a bench study
Respir Care 2007; 52:38
Antonelli M, Conti G, Pelosi P, et al New treatment of acute hypoxemic respiratory failure:noninvasive pressure support ventilation
delivered by helmet a pilot controlled trial Crit Care Med2002; 30:602
Gregoretti C, Confalonieri M, Navalesi P, et al Evaluation of patient skin breakdown and comfort witha new face mask for
non-invasive ventilation: a multi-center study Intensive Care Med 2002; 28:278
Antonelli M, Pennisi MA, Pelosi P, et al Noninvasive positive pressure ventilation using a helmet inpatients with acute exacerbation
of chronic obstructive pulmonary disease: a feasibility study.Anesthesiology 2004; 100:16
Navalesi P, Costa R, Ceriana P, et al Non-invasive ventilation in chronic obstructive pulmonary disease patients: helmet versus facial
mask Intensive Care Med 2007; 33:74
Patroniti N, Foti G, Manfio A, et al Head helmet versus face mask for non-invasive continuous positive airway pressure: a
physiological study Intensive Care Med 2003; 29:1680
Cavaliere F, Conti G, Costa R, et al Noise exposure during noninvasive ventilation with a helmet, a nasal mask, and a facial mask
Intensive Care Med 2004; 30:1755
Racca F, Appendini L, Gregoretti C, et al Helmet ventilation and carbon dioxide rebreathing: effects of adding a leak at the helmet
ports Intensive Care Med 2008; 34:1461
Bott J, Carroll MP, Conway JH, et al Randomised controlled trial of nasal ventilation in acuteventilatory failure due to chronic
obstructive airways disease Lancet 1993; 341:1555
Brochard, L, Mancebo, J, Wysocki, M, et al Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease
(19) Ferrer M, Esquinas A, Leon M, et al Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial Am J
Respir Crit Care Med 2003; 168:1438
Wysocki M, Tric L, Wolff MA, et al Noninvasive pressure support ventilation in patients with acute respiratory failure A randomized
comparison with conventional therapy Chest 1995; 107:761
Kramer N, Meyer TJ, Meharg J, et al Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory
failure Am J Respir Crit Care Med 1995; 151:1799
Martin TJ, Hovis JD, Costantino JP, et al A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure
Am J Respir Crit Care Med 2000; 161:807
Gay PC, Hess DR, Hill NS Noninvasive proportional assist ventilation for acute respiratoryinsufficiency Comparison with pressure
support ventilation Am J Respir Crit Care Med 2001;164:1606
Wysocki M, Richard JC, Meshaka P Noninvasive proportional assist ventilation compared with noninvasive pressure support
ventilation in hypercapnic acute respiratory failure Crit Care Med 2002;30:323
Fern·ndez-Vivas M, Caturla-Such J, Gonz·lez de la Rosa J, et al Noninvasive pressure support versus proportional assist ventilation
in acute respiratory failure Intensive Care Med 2003; 29:1126
Girault C, Richard JC, Chevron V, et al Comparative physiologic effects of noninvasive assist-control and pressure support
ventilation in acute hypercapnic respiratory failure Chest 1997; 111:1639
Vitacca M, Rubini F, Foglio K, et al Non-invasive modalities of positive pressure ventilation improve the outcome of acute
exacerbations in COLD patients Intensive Care Med 1993; 19:450
AntÛn A, G¸ell R, GÛmez J, et al Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with
chronic airflow limitation Chest 2000; 117:828
Appendini L, Patessio A, Zanaboni S, et al Physiologic effects of positive end-expiratory pressure and mask pressure support during
exacerbations of chronic obstructive pulmonary disease Am J Respir Crit Care Med 1994; 149:1069
Peter JV, Moran JL, Phillips-Hughes J, et al Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with
acute cardiogenic pulmonary oedema: a meta-analysis Lancet 2006; 367:1155
Nouira S, Boukef R, Bouida W, et al Non-invasive pressure support ventilation and CPAP incardiogenic pulmonary edema: a
multicenter randomized study in the emergency department.Intensive Care Med 2011; 37:249
Kacmarek RM NIPPV: patient-ventilator synchrony, the difference between success and failure? Intensive Care Med 1999; 25:645 Vignaux L, Vargas F, Roeseler J, et al Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a
(20) Vitacca M New things are not always Better: proportional assist ventilation vs pressure support ventilation Intensive Care Med 2003; 29:1038 Calderini E, Confalonieri M, Puccio PG, et al Patient-ventilator asynchrony during noninvasive ventilation: the role of expiratory trigger Intensive Care
Med 1999; 25:662
Poponick JM, Renston JP, Bennett RP, Emerman CL Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department Chest 1999; 116:166
Karnik AM Noninvasive positive pressure ventilation: testing the bridge Chest 2000; 117:625.50 Antonelli M, Conti G, Moro ML, et al Predictors of failure of noninvasive positive pressure ventilationin patients with acute hypoxemic respiratory failure: a multi-center study Intensive Care Med 2001;27:1718
Esteban A, Anzueto A, Frutos F, et al Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study JAMA 2002; 287:345 Page 12 of 1452
Wunderink, RG, Hill, NS Continuous and periodic applications of noninvasive ventilation in respiratory failure Respir Care 1997; 42:394 Demoule A, Girou E, Richard JC, et al Benefits and risks of success or failure of noninvasiveventilation Intensive Care Med 2006; 32:1756
GuÈrin C, Girard R, Chemorin C, et al Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia A prospective epidemiological survey from a single ICU.Intensive Care Med 1997; 23:1024
Hess DR Noninvasive positive-pressure ventilation and ventilator-associated pneumonia Respir Care 2005; 50:924
Antonelli M, Conti G, Rocco M, et al A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure N Engl J Med 1998;339:429
Girou E, Schortgen F, Delclaux C, et al Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients JAMA 2000; 284:2361
Peter JV, Moran JL, Phillips-Hughes J, Warn D Noninvasive ventilation in acute respiratory failure a meta-analysis update Crit Care Med 2002; 30:555
Mehta S, Hill NS Noninvasive ventilation Am J Respir Crit Care Med 2001; 163:540.60 Ram FS, Picot J, Lightowler J, Wedzicha JA Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease CochraneDatabase Syst Rev 2004; :CD004104
Keenan SP, Sinuff T, Cook DJ, Hill NS Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature Ann Intern Med 2003; 138:861
Williams JW, Cox CE, Hargett CW, et al Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure Duke Evidence-based Practice Center; Agency for Healthcare Research and Quality (US), Rockville, MD 2012.63 Keenan SP, Powers CE, McCormack DG Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial Respir Care 2005; 50:610
(21) Diaz O, Iglesia R, Ferrer M, et al Effects of noninvasive ventilation on pulmonary gas exchange and hemodynamics during acute
hypercapnic exacerbations of chronic obstructive pulmonary disease Am J Respir Crit Care Med 1997; 156:1840
Masip J, Roque M, S·nchez B, et al Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and
meta-analysis JAMA 2005; 294:3124
Winck JC, Azevedo LF, Costa-Pereira A, et al Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic
pulmonary edema a systematic review and meta-analysis Crit Care 2006; 10:R69
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 Emerg Med 2006; 48:260
Gray A, Goodacre S, Newby DE, et al Noninvasive ventilation in acute cardiogenic pulmonary edema N Engl J Med 2008; 359:142 Weng CL, Zhao YT, Liu QH, et al Meta-analysis: Noninvasive ventilation in acute cardiogenicpulmonary edema Ann Intern Med
2010; 152:590
Masip J, BetbesÈ AJ, P·ez J, et al Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic
pulmonary oedema: a randomised trial Lancet 2000; 356:2126
Vital FM, Ladeira MT, Atallah AN Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary
oedema Cochrane Database Syst Rev 2013; 5:CD005351
Banner MJ, Kirby RR, Blanch PB, Layon AJ Decreasing imposed work of the breathing apparatus to zero using pressure-support
ventilation Crit Care Med 1993; 21:1333
Brochard L, Rua F, Lorino H, et al Inspiratory pressure support compensates for the additional workof breathing caused by the
endotracheal tube Anesthesiology 1991; 75:739.ez
P, Cabello B, et al Patient-ventilator asynchrony during assisted mechanicalventilation Intensive Care Med 2006; 32:1515 Toublanc B, Rose D, GlÈrant JC, et al Assist-control ventilation vs low levels of pressure support ventilation on sleep quality in
intubated ICU patients Intensive Care Med 2007; 33:1148
Vitacca M, Bianchi L, Zanotti E, et al Assessment of physiologic variables and subjective comfort under different levels of pressure