BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

Davidson, Alan; Banham, S. W.; Elliott, Mark; Kennedy, Daniel; Gelder, Colin; Glossop, Alastair J.; Church, Alistair Colin; Creagh-Brown, Ben; Dodd, James; Felton, Tim; Foëx, Bernard A; Mansfield, Leigh; McDonnell, Lynn; Parker, Robert; Patterson, Caroline; Sovani, Milind; Thomas, Lynn M.

doi:10.1136/thoraxjnl-2015-208209

Cited by 321 publications

(343 citation statements)

References 273 publications

(226 reference statements)

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“…There are other situations requiring enhanced monitoring and special care, e.g. pneumothorax, haemodynamic instability 20 . Coma has been described as a contraindication to NIV, but in a large case series, Diaz et al 23 showed no difference in outcome between patients with and without hypercapnic coma.…”

Section: Contraindicationsmentioning

confidence: 99%

“…44 . Similar criteria to initiate NIV as for AECOPD can be used 20 . Patients with these conditions with chronic hypercapnia (indicated by an elevated bicarbonate and base excess) are likely to require longer term ventilatory support and it is appropriate to consider NIV, even in the absence of acidosis.…”

Section: Duration Of Nivmentioning

confidence: 99%

“…Plant et al 17 showed that 20% of patients acidotic on arrival in hospital corrected their pH into the normal range with the above measures. Patients who remain acidotic (pH < 7.35) with tachypnoea (respiratory rate > 23 breaths per minute) and hypercapnic (PaCO 2 > 45 mmHG) after one hour should be started on NIV 20 . In the pH range 7.30 to 7.35, 80% of patients will get better without NIV, though only 10 patients need to be treated with NIV to avoid one intubation 15 ; if the patient is reluctant to use NIV, it is reasonable to repeat arterial blood gases after one hour, and, if the pH and respiratory rate are improving, to continue standard treatment.…”

Section: When To Start Nivmentioning

confidence: 99%

“…Hypercapnia usually indicates that the patient is in a precarious situation and it is reasonable to start NIV if patients are admitted with an acute respiratory illness and hypercapnia but without acidosis. Indeed, in patients with NMD, NIV can be started if they have a markedly reduced vital capacity and are tachypnoeic, even if normocapnic 20 . A high respiratory rate cannot be sustained and the patient will fatigue and the CO 2 will rise.…”

Section: Duration Of Nivmentioning

confidence: 99%

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Non Invasive Ventilation in Acute Hypercapnic Respiratory Failure

Elliott¹

2021

BRN

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This article reviews the use of non invasive ventilation (NIV) in the management of acute hypercapnic respiratory failure (AHRF). Most of the evidence and experience comes from treating acute exacerbations of chronic obstructive pulmonary disease (AECOPD) but this has been extrapolated to other conditions. Patient selection, contraindications, how to monitor and recognise when NIV is failing and what the options are then, are discussed. There are differences in criteria for initiation of NIV and the way that it is applied in patients with neuromuscular disease, chest wall disorders and obesity. The importance of staff experience and training as well as the need for regular audit are stressed.

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Section: Contraindicationsmentioning

confidence: 99%

Section: Duration Of Nivmentioning

confidence: 99%

Section: When To Start Nivmentioning

confidence: 99%

Section: Duration Of Nivmentioning

confidence: 99%

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Non Invasive Ventilation in Acute Hypercapnic Respiratory Failure

Elliott¹

2021

BRN

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“…This technique has been shown to be the first-line treatment by numerous position papers and guidelines [15,16], nevertheless its real-life use is still not well elucidated, and obviously a consistent variability is present according to the geographical location and the different environment (i.e., ICU vs respiratory ward) [17,18].…”

mentioning

confidence: 99%

Invited Review Series Introduction

Nava

2017

COPD: Journal of Chronic Obstructive Pulmonary Disease

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Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure

Perkins

Mistry

Gates

et al. 2018

JAMA

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In adults in whom weaning from invasive mechanical ventilation is difficult, noninvasive ventilation may facilitate early liberation, but there is uncertainty about its effectiveness in a general intensive care patient population. OBJECTIVE To investigate among patients with difficulty weaning the effects of protocolized weaning with early extubation to noninvasive ventilation on time to liberation from ventilation compared with protocolized invasive weaning. DESIGN, SETTING, AND PARTICIPANTS Randomized, allocation-concealed, open-label, multicenter clinical trial enrolling patients between March 2013 and October 2016 from 41 intensive care units in the UK National Health Service. Follow-up continued until April 2017. Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed were enrolled. INTERVENTIONS Patients were randomized to receive either protocolized weaning via early extubation to noninvasive ventilation (n = 182) or protocolized standard weaning (continued invasive ventilation until successful spontaneous breathing trial, followed by extubation) (n = 182). MAIN OUTCOMES AND MEASURES Primary outcome was time from randomization to successful liberation from all forms of mechanical ventilation among survivors, measured in days, with the minimal clinically important difference defined as 1 day. Secondary outcomes were duration of invasive and total ventilation (days), reintubation or tracheostomy rates, and survival. RESULTS Among 364 randomized patients (mean age, 63.1 [SD, 14.8] years; 50.5% male), 319 were evaluable for the primary effectiveness outcome (41 died before liberation, 2 withdrew, and 2 were discharged with ongoing ventilation). The median time to liberation was 4.3 days in the noninvasive group vs 4.5 days in the invasive group (adjusted hazard ratio, 1.1; 95% CI, 0.89-1.40). Competing risk analysis accounting for deaths had a similar result (adjusted hazard ratio, 1.1; 95% CI, 0.86-1.34). The noninvasive group received less invasive ventilation (median, 1 day vs 4 days; incidence rate ratio, 0.6; 95% CI, 0.47-0.87) and fewer total ventilator days (median, 3 days vs 4 days; incidence rate ratio, 0.8; 95% CI, 0.62-1.0). There was no significant difference in reintubation, tracheostomy rates, or survival. Adverse events occurred in 45 patients (24.7%) in the noninvasive group compared with 47 (25.8%) in the invasive group. CONCLUSIONS AND RELEVANCE Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed, early extubation to noninvasive ventilation did not shorten time to liberation from any ventilation.

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BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

Cited by 321 publications

References 273 publications

Non Invasive Ventilation in Acute Hypercapnic Respiratory Failure

Non Invasive Ventilation in Acute Hypercapnic Respiratory Failure

Invited Review Series Introduction

Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure

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