Early fiberoptic bronchoscopy during non-invasive ventilation in patients with decompensated chronic obstructive pulmonary disease due to community-acquired-pneumonia

Abstract

IntroductionInefficient clearance of copious respiratory secretion is a cause of non-invasive positive pressure ventilation (NPPV) failure, especially in chronic respiratory patients with community-acquired-pneumonia (CAP) and impaired consciousness. We postulated that in such a clinical scenario, when intubation and conventional mechanical ventilation (CMV) are strongly recommended, the suction of secretions with fiberoptic bronchoscopy (FBO) may increase the chance of NPPV success. The objective of this pilot study was, firstly, to verify the safety and effectiveness of early FBO during NPPV and, secondly, to compare the hospital outcomes of this strategy versus a CMV-based strategy in patients with decompensated chronic obstructive pulmonary disease (COPD) due to CAP who are not appropriate candidates for NPPV because of inefficient mucous clearance and hypercapnic encephalopathy (HE).MethodsThis is a 12-month prospective matched case-control study performed in one respiratory semi-intensive care unit (RSICU) with expertise in NPPV and in one intensive care unit (ICU). Fifteen acutely decompensated COPD patients with copious secretion retention and HE due to CAP undergoing NPPV in RSICU, and 15 controls (matched for arterial blood gases, acute physiology and chronic health evaluation score III, Kelly-Matthay scale, pneumonia extension and severity) receiving CMV in the ICU were studied.ResultsTwo hours of NPPV significantly improved arterial blood gases, Kelly and cough efficiency scores without FBO-related complications. NPPV avoided intubation in 12/15 patients (80%). Improvement in arterial blood gases was similar in the two groups, except for a greater PaO2/fraction of inspired oxygen ratio with CMV. The rates of overall and septic complications, and of tracheostomy were lower in the NPPV group (20%, 20%, and 0%) versus the CMV group (80%, 60%, and 40%; P < 0.05). Hospital mortality, duration of hospitalisation and duration of ventilation were similar in the two groups.ConclusionsIn patients with decompensated COPD due to CAP who are candidates for CMV because of HE and inability to clear copious secretions, NPPV with early therapeutic FBO performed by an experienced team is a feasible, safe and effective alternative strategy.

Integrated Therapeutic Strategy During Noninvasive Ventilation in a Patient With End-Stage Respiratory Disease

“…Because of the do-not-intubate and do-not-cannulate decisions previously expressed by the patient and then shared by physicians and relatives, we decided to carry on with NIV integrated with clearing of the bronchial tree by means of fiberoptic bronchoscopy safely performed during ventilation treatment. 10 It is important to emphasize that we performed 2 fiberoptic bronchoscopy procedures with the aim of treating the left lower lobe atelectasis associated with the endobronchial encumbrance of the large amount of secretions accumulated during prolonged NIV assistance even if arterial blood gases revealed only a slight decrease in P aO 2 /F IO 2 with a stable pH. Accordingly, after fiberoptic bronchoscopy, we observed the resolution of lobar atelectasis with a quick improvement in the oxygenation status of the patient (P aO 2 /F IO 2 Ͼ 200) while the ventilatory pump was sustained by continuous NIV support.…”

“…On the third and fourth days after hospitalization, 2 fiberoptic bronchoscopy procedures with bronchoalveolar lavage during NIV were performed according to a standardized protocol 10 to remove the abundant bronchial secretions. A cap of thick mucus in the lower left lobar bronchus was aspirated, resulting in a rapid improvement of P aO 2 /F IO 2 and in radiographic signs of atelectasis (Table 1 and Fig.…”

“…8 To reduce the rate of treatment failure, different integrated strategies have been successfully implemented during NIV in expert RICU and ICU settings, such as careful pharmacologic sedation to improve a patient's cooperation, 9 early fiberoptic bronchoscopy, and/or high-frequency chest wall compressions (HFCWC) to promptly remove the excessive burden of secretion in COPD subjects with respiratory muscle fatigue and ineffective cough. 10,11 Extracorporeal CO 2 removal, which developed from the traditional extracorporeal membrane oxygenation, 12,13 has been recently proposed as an alternative or an integrated therapeutic option in patients with acute hypercapnic acidotic respiratory failure who are non-responders to an NIV trial. 14,15 Although extracorporeal membrane oxygenation is a total extracorporeal support that is able to oxygenate severely hypoxemic patients and remove up to 50% of the total body CO 2 production, extracorporeal CO 2 removal works as a partial extracorporeal support capable of removing lower amounts of CO 2 without substantial effects on oxygenation.…”

Unusual applications of noninvasive ventilation

“…Flexible bronchoscopy in spontaneously breathing young children was associated with significant decreases in tidal volume and respiratory flow that were reversed by CPAP [17]. In patients with acute exacerbation of COPD due to community-acquired pneumonia, who were candidates for ETI due to their hypercapnic encephalopathy and inability to clear copious secretions, NIV with early therapeutic bronchoscopy performed by an experienced team was considered a feasible, safe and effective strategy [18].…”

Noninvasive mechanical ventilation and bronchoscopy: advantages and limits of a synergistic strategy

“…ppNIMV significantly reduced serious infectious complications compared with CMV, as well as the need for tracheostomy. Even if this ppNIMV strategy may be a successful alternative to CMV in selected COPD patients within expert units, larger RCTs are necessary to confirm this result and, therefore, to test the efficacy of the FBO-ppNIMV protocol applied to an earlier time-course of COPD decompensations when ETI is not mandatory by comparing ppNIMV alone vs ppNIMV with early FBO (46). A recent experience published by the same group reported the successful management of ppNIMV failure, due to an excessive burden of both secretion and CO2 in an end-stage COPD patient with exacerbation of hypercapnic ARF, by means of a sequential and integrated use of ppNIMV together with FBO, high-frequency chest wall oscillation and veno-venous extra-corporeal CO2-removal (47).…”