NIV should be delivered in do-not-intubate patients in acute respiratory failure, but how?

Lemyze, Malcolm; Mallat, Jihad; Gasan, Gaëlle; Grunderbeeck, Nicolas Van; Tronchon, Laurent; Thévenin, Didier

doi:10.1007/s00134-013-2859-2

Cited by 3 publications

(5 citation statements)

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“…In the context of limited availability of ICU beds, some clinicians may consider that admission of debilitated patients with an underlying end-stage chronic illness, like those with COPD, may merely deprive other critically ill candidates who could benefit more from ICU resources. So the question is no longer “should we use NIV in ‘do-not-intubate’ patients?”, the answer is obviously “Yes”, NIV should at least be offered to these patients, especially when the underlying cause of the AHRF is reversible, but rather “how can we apply NIV to ‘do-not-intubate’ patients without drifting toward unreasonable care?”[ 14 ].…”

Section: Summary and Prospectmentioning

confidence: 99%

Early ward-based acute noninvasive ventilation: a paper that changed practice

Mukherjee

Nenna

Turner

2018

Breathe

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Noninvasive ventilation (NIV) is now an established evidence-based treatment for acute hypercapnic respiratory failure (AHRF), predominantly for defined patients admitted with exacerbations of chronic obstructive pulmonary disease (COPD), but also a range of other conditions including obesity-related respiratory failure and chest wall deformities requiring an acute hospital admission. Over the past two decades, there has been a significant shift towards greater use of NIV in place of invasive mechanical ventilation (IMV) in this group of patients. Here we set out to discuss a landmark paper in this respect: the report of the YONIV trial (Yorkshire Noninvasive Ventilation Trial), published in June 2000, which addressed the key practical questions around the early use of ward-based NIV at the time [1]. A recent narrative review on the epidemiology of NIV for acute respiratory failure in COPD patients concluded that this dramatic increase in NIV use is probably due to the increased experience of the medical teams, treating sicker patients with comorbidities and utilising NIV outside the intensive care unit (ICU), further confirming the pivotal role of the original trial enabling the early use of acute NIV on medical wards [2].

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Section: Summary and Prospectmentioning

confidence: 99%

Early ward-based acute noninvasive ventilation: a paper that changed practice

Mukherjee

Nenna

Turner

2018

Breathe

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“…In our interviews, the physicians asked for guidelines for the decision-making process. Both national and international guidelines do exist for treatment and decisions regarding EOL issues, 5,7,8 although these guidelines seem to be have been poorly incorporated in Norwegian hospitals. Strong paternalism is also evident in the failure to share information with competent patients and the similar failure to include them in decision-making about their own future and wellbeing.…”

Section: Tension Between Non-maleficence and Beneficencementioning

confidence: 99%

“…Such decisions are both medically and ethically challenging for the physicians and other health professionals involved, including nurses. 5 Both Norwegian health policy guidelines and healthcare legislation have mandated the involvement of patients, their next of kin and a multi-disciplinary team in the decision-making process. [6][7][8] This corresponds with trends across the western world [9][10][11] and is likewise highlighted in the recommendations of the Global Initiative for Obstructive Pulmonary Disease (GOLD).…”

Section: Introductionmentioning

confidence: 99%

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Considerations and values in decision making regarding mechanical ventilation for older patients with severe to very severe COPD

et al. 2016

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Background: The different considerations involved in decisions regarding whether or not to initiate mechanical ventilation for patients with severe chronic obstructive pulmonary disease (COPD) are challenging for health professionals. Aim: To investigate the considerations and values that influences decision-making regarding mechanical ventilation in older patients (≥65-years-old) with severe to very severe COPD. Furthermore, it aims to elucidate how physicians involve their patient in decision-making process. Participants and setting: Seven intensive care physicians and seven physicians working in the pulmonary wards at two university hospitals and two district hospitals in Norway. Methods: A focus group study using a hermeneutic-phenomenological approach. The data was analysed according to the interpretative contexts: self-understanding, critical commonsense understanding and theoretical understanding. Results: Decisions regarding mechanical ventilation were mainly based on the physicians' own experiences, their perceptions of the patients' situation, and biomedical data. The patients were not involved in the decision-making and such decisions were only occasionally made in a multi-professional context. Conclusion: To decide whether older patients with severe COPD should be treated with mechanical ventilation is both medically and ethically challenging for physicians. Decision making in this context seems to be mainly driven by a paternalistic attitude, since the physicians interviewed in our study, in general, make such decisions without involving either the patient, their next of kin or the nurses. There is a need for broader cooperation between health professional and for the involvement of patients in the decision-making process regarding mechanical ventilation in cases of advanced COPD.

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“…This last observation may reflect the difference in success probability of NIV according to the type of respiratory failure, as demonstrated previously [23–27], since NIV was the main organ support used in these patients. Thus, the use of NIV, rather than an “NIV for DNI patient with respiratory failure” approach, should imply thoughts about etiologic diagnoses, goals of care, and patients’ response [28, 29]. This point is important, since NIV-limited use in LSC limited patients with a poor predicted outcome might be considered as “unreasonable” if it doesn’t support patient’s relief, or necessitates more constraints [16].…”

Section: Discussionmentioning

confidence: 99%

Patients with limitation or withdrawal of life supporting care admitted in a medico-surgical intermediate care unit: Prevalence, description and outcome over a six-month period

et al. 2019

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PurposeThere have been few studies on the limitation of Life Supporting Care (LSC) and Withdrawal of LSC in Intermediate Care Units (IMCUs). We report the prevalence of LSC limited patients in a medico-surgical IMCU over a six-month period, examining the description, outcomes, and patterns of LSC Limitations and Withdrawal of LSC.MethodsSingle center, retrospective observational study in an IMCU of a 500-bed general hospital.ResultsOur study of 404 patients, reported 79 (19.5%, 95%CI: [16.0–23.7]%) being admitted with LSC limitations in the IMCU. This group of LSC limited patients presented with higher chronic and acute severity scores. The most common admission diagnosis of LSC limited patients was acute respiratory failure (51%). Non-invasive ventilation (NIV) was frequently used within this population (39%). Hospital mortality for LSC limited patients was high (53%) and associated with age (OR = 1.07, 95%CI: [1.01–1.13)]), SOFA score (OR 1.29, 95%CI: [1.01–1.64]), and hypoxemic respiratory failure (OR 7.2, 95%CI: [1.27–40.9]). Withdrawal of LSC occurred in 19.5% of cases, often accompanied with terminal sedation with or without NIV removal (43.8%).ConclusionsPatients with limitation of LSC are frequently admitted into IMCU. Hospital mortality rate was high and associated with age, acute organ failures, and hypoxemic respiratory failure. Life support withdrawal includes palliative sedation with or without NIV discontinuation.

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NIV should be delivered in do-not-intubate patients in acute respiratory failure, but how?

Cited by 3 publications

References 4 publications

Early ward-based acute noninvasive ventilation: a paper that changed practice

Early ward-based acute noninvasive ventilation: a paper that changed practice

Considerations and values in decision making regarding mechanical ventilation for older patients with severe to very severe COPD

Patients with limitation or withdrawal of life supporting care admitted in a medico-surgical intermediate care unit: Prevalence, description and outcome over a six-month period

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