Reengineering Respiratory Support Following Extubation

Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation

“…A value greater than 105 breaths per minute per liter is associated with an increased risk of reintubation. 1719 (18) Gradual reduction of pressure support 29 (25) 28 (26) Other 5 (4) 6 (6) * Plus-minus values are means ±SD. in patients with acute respiratory failure, 17 this technique has been used in a number of clinical situations.…”

“…Until very recently, the published literature addressing this question consisted entirely of physiological case series and nonrandomized studies. 12,13,[24][25][26] One randomized, controlled trial examining the use of noninvasive positive-pressure ventilation in patients with respiratory failure after extubation was conducted while we were planning this study and was recently published. 14 In that trial, Keenan and colleagues enrolled 81 patients in a single-center study and, as in the current study, found that the use of noninvasive ventilation did not significantly alter the need for reintubation.…”

Decision to extubate

“…Several studies, including two randomized controlled investigations in primarily COPD patients, indicate that NIV can be used to facilitate weaning from mechanical ventilation [114,115,116]. A number of uncontrolled series suggested that NIV could prevent the need for reintubation in approximately two-thirds of patients experiencing extubation failure [117,118,119,120,121,122]. In the largest observational report, Meduri et al observed that NIV was effective in 26 of 39 patients (17 with COPD) with hypercapnic respiratory failure after extubation [119].…”

“…Chiang and Lee 1995 [118] Prospective, observational Bi-level 11/19 (58%) Meduri et al 1996 [119] Retrospective, observational NIPSV 26/39 (65%) Munshi et al 1999 [120] Prospective, observational Mask or nasal, 52/72 (72%) CPAP or bi-level Kindgen-Milles et al 2000 [122] Prospective, observational CPAP 18/20 (90%) Hilbert et al 1996 [123] Case (historic) control, NIPSV 24/30 (80%) COPD with hypercapnic failure post-extubation vs standard care 10/30 (33%) Jiang et al 1999 [128] RCT, all extubated patients Nasal bi-level 34/47(72%) vs Oxygen 39/46 (85%) Keenan et al 2000 [129] RCT, respiratory failure post-extubation Bi-level 10/36 (28%) vs standard care 12/39 (31%) Rosinha et al 2000 [130] RCT, all planned extubations Nasal bi-level 19/20 (95%) vs Oxygen 11/18 (61%) Carlucci et al 2001 [86] RCT, extubated patients at high risk NIPSV 22/24 (92%) for extubation failure vs Standard care 21/28 (75%) trols [123]. A combination of non-invasive ventilation (NIV) and Heliox may be effective primary therapy for acute exacerbations of COPD [124,125].…”

Ventilação mecânica não invasiva com pressão positiva

“…Dentre as principais causas de reintubação estão a obstrução de vias aéreas superiores (edema de glote), fadiga muscular respi-ratória, edema cardiogênico, infecções, inabilidade de eliminar secreções, hipoxemia grave, alteração no estado mental e balanço hídrico positivo. Algumas séries de casos e estudos não randomizados (82)(83)(84)(85)(86) foram publicados, desde a década de 90, utilizando a VNI para evitar a reintubação na falência respiratória pós-extubação, com resultados promissores. No entanto, dois estudos (87,88) randomizados não confirmaram o benefício da VNI como método de resgate da insuficiência respiratória após extubação.…”