Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

@ERSpublications ARF management requires an escalation therapeutic strategy based on application of a wide range of ventilatory and non-ventilatory interventions; there are many unanswered questions that need to be addressed in the near future http://ow.ly/xbPi30iUP2y Acute respiratory failure (ARF) is a devastating condition for patients that results from either impaired function of the respiratory muscle pump or from dysfunction of the lung. ARF is a challenging field for clinicians working both within and outside the intensive care unit (ICU) and respiratory high dependency care unit environment because this heterogeneous syndrome is associated with a high hospital morbidity and mortality rate, ethical issues in managing end of life decisions and increased consumption of healthcare resources.In acute hypercapnic respiratory failure (i.e. pump failure) an imbalance exists between the load imposed on the respiratory muscles and the capacity of the muscle pump [1]. This category mainly includes patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), as well as patients with neuro-miopathies, chest wall deformities and obesity. The in-hospital mortality of patients hospitalised for COPD exacerbation is 2-8% (up to 15% for ICU patients), with a 1-year mortality of 22-43%. Readmissions after hospitalisation for an exacerbation are frequent events, ranging from 14% to 16% in the first month after discharge and 25-58% in the first year [2].Acute hypoxaemic failure covers miscellanea of causes of lung damage including acute cardiogenic pulmonary oedema, pneumonia and trauma. Acute respiratory distress syndrome (ARDS) is a frequent cause of severe hypoxaemia. This clinical syndrome is characterised by acute inflammatory lung injury, associated with increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue [3]. In its most severe form (arterial oxygen tension/inspiratory oxygen fraction <100 mmHg), hospital mortality is ∼42% [3]. The insight in the pathophysiology of acute hypoxaemic failure has improved over the past decade. This has important consequences for treatment and monitoring of patients with ARF.The management of ARF may require an "escalation therapeutic strategy" based on the application of a wide range of ventilatory and non-ventilatory interventions (figure 1) [1, 4]. The rationale for applying these artificial supports is essentially to buy time for the aetiological therapy to reverse the cause of the acute decompensation of the respiratory system while avoiding/minimising the potential lung injuring effects of therapeutic interventions, such as ventilator-induced lung injury. In noninvasive ventilation (NIV) a dedicated interface is used, while with invasive mechanical ventilation (IMV) assistance is provided through an endotracheal tube or tracheostomy. New therapeutic options include high-flow nasal cannula [5], noninvasive and invasive cough assist strategies, high-frequency chest wall oscillation, and

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“…4) The role of NIV in patients with hypoxaemic ARF is a subject of debate [10]. The peculiar advantages of NIV versus IMV (i.e.…”

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confidence: 99%

Highlights in acute respiratory failure

Scala

Heunks

2018

Eur Respir Rev

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“…A retrospective cohort study demonstrated that NPPV reduced the respiratory rate in patients with end-stage IPF [21]. The European Respiratory Society and American Society of Thoracic Diseases guidelines list NPPV as a means of palliative care for dyspneic patients [22]. However, NPPV with a total-face mask makes oral intake impossible, and conversation is quite difficult.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and Tolerability of High-Flow Nasal Cannula Oxygen Therapy for Hypoxemic Respiratory Failure in Patients with Interstitial Lung Disease with Do-Not-Intubate Orders: A Retrospective Single-Center Study

et al. 2018

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Background: High-flow nasal cannula (HFNC) oxygen therapy may provide effective respiratory management of hypoxemic respiratory failure in patients with interstitial lung disease (ILD) with a do-not-intubate (DNI) order. Objectives: The aim was to assess the efficacy and tolerability of HFNC for these patients. Methods: We retrospectively reviewed the records of patients requesting a DNI order for hypoxemic respiratory failure associated with ILD, comparing treatment with HFNC and noninvasive positive pressure ventilation (NPPV). Outcomes measured were 30-day survival, in-hospital mortality, temporary interruption and discontinuation of the treatment at the patient’s request, adverse events, oral intake, and communication ability at the end of life. Results: A total of 84 patients (HFNC, n = 54; NPPV, n = 30) were analyzed. Neither 30-day survival (HFNC 31.5% vs. NPPV 30.0%; p = 0.86) nor in-hospital mortality (HFNC 79.6% vs. NPPV 83.3%; p = 0.78) differed significantly. The temporary interruption and discontinuation rates were significantly lower in the HFNC group than in the NPPV group (3.7 vs. 23.3%; p = 0.009 and 0 vs. 10%; p = 0.043, respectively), and that group had significantly fewer adverse events. Among patients who died in the hospital, those treated with HFNC had significantly better oral intake and ability to converse until just before death. Conclusion: HFNC had a survival rate equivalent to that of NPPV and was better tolerated by patients with hypoxemic respiratory failure associated with ILD who had a DNI order. HFNC allowed patients to eat and converse until just before death, suggesting that HFNC in these patients is a reasonable palliative treatment.

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“…Thus uncertainty exists about the most effective strategy. Current European Respiratory Society/American Thoracic Society guidelines recommend that NIV be used as a weaning strategy from invasive ventilation, but this recommendation is limited to hypercapnic respiratory failure patients [11]. These guidelines are based on the 2014 Cochrane review on the use of non-invasive weaning, which included 16 randomised studies and concluded that NIV weaning was superior to invasive weaning with significantly reduced mortality, weaning failures, ventilator associated pneumonia (VAP), intensive care and hospital length of stay and total duration of mechanical ventilation [12].…”

Section: Introductionmentioning

confidence: 99%

Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis

et al. 2018

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PurposeA systematic review and meta-analysis was conducted to answer the question ‘In adults with respiratory failure requiring invasive ventilation for more than 24 h, does a weaning strategy with early extubation to non-invasive ventilation (NIV) compared to invasive ventilation weaning reduce all-cause hospital mortality?’MethodsWe included randomised and quasi-randomised controlled trials that evaluated the use of non-invasive ventilation, compared to invasive ventilation, as a weaning strategy in adults mechanically ventilated for at least 24 h. The EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) bibliographic databases were searched from inception to February 2018. Bayesian hierarchical models were used to perform the meta-analysis. The primary outcome was mortality at hospital discharge. Secondary outcomes included mortality (30, 60, 90 and 180 days), quality of life, duration of invasive ventilation, weaning failure, length of stay [intensive care unit (ICU) and hospital] and adverse events. ResultsTwenty-five relevant studies involving 1609 patients were included in the quantitative analysis. Studies had moderate to high risk of bias due to risk of performance and detection bias. Mortality at hospital discharge was lower in the NIV weaning group compared to the invasive weaning group [pooled odds ratio (OR) 0.58, 95% highest density interval (HDI) 0.29–0.89]. Subgroup analyses showed lower pooled mortality at hospital discharge rates in NIV weaning than those in the control group in chronic obstructive pulmonary disease (COPD) patients (pooled OR 0.43, 95% HDI 0.13–0.81) and the effect is less certain in the mixed ICU population (pooled OR 0.88, 95% HDI 0.25–1.48). NIV weaning reduced the duration of invasive ventilation in patients [standardised mean difference (SMD) − 1.34, 95% HDI − 1.92 to − 0.77] and ICU length of stay (SMD − 0.70, 95% HDI − 0.94 to − 0.46). Reported rates of ventilator associated pneumonia (VAP) were lower in the NIV group. NIV weaning did not reduce overall hospital length of stay or long-term mortality. There were insufficient data to compare other adverse events and health-related quality of life.ConclusionsThe use of NIV in weaning from mechanical ventilation decreases hospital mortality, the incidence of VAP and ICU length of stay. NIV as a weaning strategy appears to be most beneficial in patients with COPD.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5434-z) contains supplementary material, which is available to authorized users.

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Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

Cited by 1,191 publications

References 140 publications

Highlights in acute respiratory failure

Highlights in acute respiratory failure

Efficacy and Tolerability of High-Flow Nasal Cannula Oxygen Therapy for Hypoxemic Respiratory Failure in Patients with Interstitial Lung Disease with Do-Not-Intubate Orders: A Retrospective Single-Center Study

Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis

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