NON INVASIVE VENTILATION

IN ACUTE RESPIRATORY
FAILURE
Tasbirul Islam MD,FCCP,MRCP(UK)
Adjunct Assistant Clinical Professor
Indiana University School of Medicine
Division of Pulmonary & Critical care medicine
Indiana University Hospital Arnett
Lafayette, IN
 ??????????????????
 NIV should be used only in ICU or step down unit---True
or False.
 Patient with hypercarbic respiratory failure have poorer
response to NIV---True or False
 Patient with hypercarbic respiratory failure have poorer
response to NIV---True or False
 Higher the PCO2, use the lower pressure support (PS)---
True or False
 CPAP can provide adequate ventilator support---True or
False
 Which of the following condition is least responsive to
NIV
---COPD ---APE
---Pneumonia ---Post-extubation failure
 NPPV is not just a bridge, it is a
viable treatment for respiratory failure

 Patient selection
 Indications & Contraindications
 Predictors of success.
 Specific Clinical Scenarios
 Acute exacerbation of COPD
 Asthma
 Cardiogenic pulmonary edema
 Weaning off mechanical ventilation
 Pneumonia
 Evidenced based conclusions
 Noninvasive Ventilation
Patient Selection Criteria:
pH < 7.35 with PaCO2 > 45 mmHg:
Respiratory Rate  25 bpm
Respiratory Distress with
Moderate to severe dyspnea
Use of accessory muscles
Abdominal paradox

Kramer, Am J Respir Crit Care Med 1995; 151:1799- 1806

 Why the interest in NIV

The desire to avoid complications of invasive

ventilation
Complications related to the process of
intubation and mechanical ventilation
 Aspiration
 Trauma
 Arrythmias and hypotension
 barotrauma
Complications caused by loss of airway
defense mechanisms
 Direct conduit to lower airway  chronic bacterial colonization
Complication that occur after
removal of ETT
 Hoarseness, sore throat, cough
 Sputum production
 Upper airway obstruction
 hemoptysis

From the patient’s point of view

 Uncomfortable : sedation and paralysis
 Decreased ability to eat and communicate

Cost and LOS

 NIV & Nosocomial infections

p<0.001
100
p<0.0001

80

60
% VNI
40 p=0.02
VM
20

0
Inf Noso Pn Noso AB

Girou et al. JAMA 2000

No central line
No sedation
No endotracheal tube

No urinary catheter
 Advantages of NIV

Leaves upper airway intact

Preserve airway defense mechanisms
Allows patient to eat, drink, verbalize and
expectorate
Enhance comfort, convenience and
portability
Less cost
 French ICU NIV Utilization

70
60
% 50
of 40 1997
Pts 30 2002
20
10
0
1st Use Hypercap Hypox CPE

Carlucci et al, AJRCCM, 2001; Demoule et al, AJRCCM, ‘03

 NIV Application: The
“Learning Effect”

479 COPD & CHF pts

1994 2001
% Vent Starts NIV 20%  90%
Health Care Acq Pna 20%  8%
ICU mortality 21%  7%

Henri Mondor Hosp, Girou et al, JAMA 2003: 290:2985

 Reasons for low utilization

Respiratory staff
inadequately trained
4

Physicians lack knowledge 23

Equipement not appropriate 9

Poor previous experience 4

Other 9

0 5 10 15 20 25
 Mechanism of benefit
 Improved alveolar ventilation
 Reduced work of breathing
 Rest of the respiratory musculature
 Increased intrathoracic pressure, decreases
preload and afterload

 Why does it decrease mortality?

Decreased hospital-acquired infections
Decreased trauma from intubation
Less complications of sedation
 NIV: utilization classification

 Mandatory ventilation
 Alternative to intubation
 severe ARF, meet criteria for IMV
 Failed medical treatment
 Trials: NIV vs IMV after failed MT
 Primary outcome: mortality
 Supportive ventilation
 Prevent intubation
 mild-to-moderate ARF/does not meet
criteria for IMV
 Trials: NIV+MT vs MT
 Primary outcome: intubation
 NIV: utilization classification

 Prophylactic ventilation
 To prevent ARF in patients
 no substantial impairment
of gas exchange
 Trials: NIV+MT vs MT
 Primary outcome: Blood
gas values, FEV1, etc
 Other purpose ventilation
 bronchodilation
 Pre-oxygenation
 Facilitate sleep
BiPAP Graphics
 How do I start NPPV?
Monitored location, >30 degree angle
Select appropriate mask (Nasal or
Oronasal)

Select
ventilator
 First hour……..
Titrate settings and FiO2
Aim to reduce work of breathing /RR
Assist patient comfort and tolerate mask
Minimal sedation may be used Morphine 2
mg or Haldol 2 mg
Monitor mental status
Intubate if worsening
KEEP PATIENT NPO!
Check ABGs in 1-2 hours
Who should not be considered
for NPPV?
Contraindications
Cardiac or respiratory arrest Too
Nonrespiratory organ failure Sick
Hemodynamic instability
Severe encephalopathy
Severe UGI bleed Can’t
Facial or neurosurgery, trauma protect
Upper airway obstruction airway
Inability to cooperate or protect airway
High risk for aspiration
 Indicators for success
 Younger age
 Lower acuity of illness
 Able to cooperate
 Less air leaking
 Moderate hypercarbia (46-91 mm Hg)
 Moderate acidemia (pH 7.11-7.34)
 Improvements of gas exchange,ventilation
(pH/PCO2) and vitals within 30 min to 2 hours
 Complications of NPPV
Air leak- 30%-50%
Ulceration- 5%-10%
Aspiration pneumonia- < 5%
Pneumothorax- < 5%
Hypotension- < 5%

Hills NS. Complications of noninvasive positive pressure ventilation. Respir Care 1997; 42:432
 NIV Failure: Decide Early
 Worsening Encephalopathy or Agitation
 Inability to Clear Secretion
 Inability to Accept Any Interface
 Hemodynamic Instability
 Worsening Oxygenation
 Progressive Hypercapnia, pH <7.20
 Persistent tachypnea /tachycardia
 Survival to hospital discharge per
diagnostic category

Levy M, Maged A, et al. Crit Care Med 2004

NIV in COPD
 RCT’s: NIPPV in ARF
Primarily COPD

 Bott Lancett 1993; 341:1555

 Kramer AJRCCM 1995; 151:1799
 Wysocki Chest 1995; 107:761
 Brochard NEJM 1995; 338:817
 Barbe Eur Respir J 1996; 9; 1240
 Celikel Chest 1998; 114:1636
 Plant Lancet 2000; 355:1931
 Martin AJRCCM 2000; 161:807
 Bardi Eur Respir J 2000; 15:98
 Respiratory Failure due to Acute
Exacerbation of COPD
 First line intervention as an adjunct to usual medical care.
NPPV should be considered early in the course of
respiratory failure.

 Decrease in mortality of 48%

 RR=.52, 95%CI .35-.76

 Decrease of intubation by 59%

 RR=.41, 95%CI .33-.53

 Decrease hospital length of stay 3.24 days

 95%CI -4.42 to -2.06.
Ram FSF, Picot J, Lightowler J, Wedzicha JA. Cochrane Database of Systematic Reviews 2004, Issue 3. Art.
No.: CD004104. DOI: 10.1002/14651858.CD004104.pub3
 NIV in Acute Respiratory Failure:

80

60 Control
12 (8)
% COPD Patients 67%
Needing 40
Intubation NPPV
11 (1)
20 9%
* *

0 * p < 0.05

0 1 2 3 6 12 24 48 72
Time in Hours
Kramer et al, Am J Respir Crit Care Med 1995; 151: 1799-806
 NIV for acute exacerbations of chronic
obstructive pulmonary disease
(AECOPD)
 Multicenter trial
 85/275 pts enrolled
 FEV1~ 30 % predicted… similar in both groups
 43 pts NIV vs 42 pts standard care (std)
 Intubation: 74 % (std) vs 26 % (NIV)
 Mortality: 29 % (std) vs 9 % (NIV)
 Complications: 48 % (std) vs 16% (NIV)
 Hospital LOS (d): 35 ± 33 (std) vs 23 ± 17 (NIV)

Brochard et al NEJM 1995;333:817-822

 The Time at Which Endotracheal Intubation Was
Performed in the Two Treatment Groups.

A total of 17
patients required
after the first hour
in the standard
treatment group as
compared with
only 3 patients in
the non-invasive
group.

Brochard L et al. N Engl J Med 1995; 333:817-822.

 The Length of the Hospital Stay among the Surviving Patients in
the Two Treatment Groups.

Seven of the patient (18%)

in the non-invasive group
Stayed in the hospital for
More than 4 weeks as
Compared with 14 (47%)
in the standard treatment
group.

Brochard L et al. N Engl J Med 1995; 333:817-822.

Respiratory Rate Endotracheal
Mortality Rate
Intubation
 pH~7.30

pH~7.40

Keenan SP, et al. Ann Intern Med 2003.

 pH~7.30

pH~7.40

Keenan SP, et al. Ann Intern Med 2003.

RECOMMENDED ALGORITHM
Noninvasive ventilation in acute exacerbations of COPD
M.W. Elliott, Eur Respir Rev 2005
 COPD:NIV studies summary

 Success rate 50-80% in avoiding ETI

 Reduces mortality : 1 life saved for every 8
patients treated
 Reduces LOS over 3 days
 Baseline pH is important predictor of success
 Improvement in pH, pCO2 and RR usually in 1-2
hours
NIV in Asthma
Evidence is weaker for the use of NIV in asthma patients with acute respiratory
failure.

An uncontrolled study observed improved gas exchange and avoidance

of intubation in 15 of 17 patients with status asthmaticus, and all patients
survived.
Meduri GU, Cook TR, Turner RE, et al: Chest 1996; 110:767-774

Randomized pilot study in 33 patients with acute asthma but not ARF
showed improved flow rates and decreased hospitalizations with NIV vs.
sham NIV.
Soroksky A, Stav D, Shpirer I:Chest 2003; 123:1018-1025

Ram and colleagues concluded that large randomized controlled trials

(RCTs) are needed before recommending NIV use in status asthmaticus.
Ram FS, Wellington S, Rowe B, et al:. Cochrane Database Syst Rev 2005; 1:CD004360
 Noninvasive Positive Pressure Ventilation in Status
Asthmaticus,
Meduri, G: Chest 1996

 17 patients with severe asthma exacerbation, not improved

with medical management, and not immediately intubated in
ED.
 Average pH 7.25, PCO2 67
 2 required intubation due to rising PCO2
 There were no controls
A Pilot Prospective, Randomized, Placebo-Controlled
Trial of Bilevel Positive Airway Pressure in Acute
Asthmatic Attack, Arie Soroksky, MD, Chest 2003
PROPHYLACTIC Ventilation

 Patients in ED
 Nasal BPAP at EPAP 5, IPAP
8-15
 pH both groups 7.4, PCO2= 34
 FEV1
– 37%  57% pred in NIV
group
– 34%  44% pred in control
 Also significant improvement in
ED ↓ HR, ↓ RR
NIV in Acute Cardiogenic
edema
 RCT’S: NIPPV Acute Pulmonary
Edema

 Mehta CCM 1997; 25:620

 Takeda Japan Circ J 1998; 62:553
 Masip Lancet 2000; 356:2126
 Sharon JACC 2000; 36:832
 Levitt JEM 2001; 21:363
 Winc J Crit Care 2006; 10(2):R69
 Winck JC, et al. (2006)
Both CPAP and BiPAP modes have been used to
treat cardiogenic pulmonary edema.
 Systematic review and meta-analysis
Efficacy and safety of noninvasive ventilation in
the treatment of ACPE
6 electronic databases up to May 2005
17 RCTS included (790 citations)
 Outcome measures
Need for intubation
Mortality
Incidence of acute myocardial infarction

Winck JC, Azevedo L, et al. Efficacy and safety of non-invasive ventilation in the treatment of acute
cardiogenic pulmonary edema – a systematic review and meta-analysis. Crit Care 2006; 10(2):R69
 10 studies of CPAP compared to standard therapy (SMT)
Significant 22% absolute risk reduction (ARR) in need for ETI significant
13 % ARR in mortality.

6 studies of BiPAP compared to SMT

18% ARR in NETI
7% ARR in mortality

7 studies of BiPAP compared to CPAP

Nonsignificant 3% ARR in NETI
Nonsignificant 2 % ARR in mortality

NONE of these methods increased acute myocardial infarction risk.

Winck JC, Azevedo L, et al. a systematic review and meta-analysis. Crit Care 2006; 10(2):R69
Trials comparing CPAP vs. SMT in ACPE

Winck JC, Azevedo LF, et al. Crit Care 2006.

 BiPAP vs. SMT in ACPE

Winck JC, Azevedo LF, et al. Crit Care 2006.

 CPAP vs. BiPAP in ACPE

Winck JC, Azevedo LF, et al. Crit Care 2006

 Metha CCM 1997; 25:620

 NIPPV vs CPAP in acute cardiogenic

pulmonary edema
 13 patients NIPPV vs 14 patients CPAP
 BiPAP group has more patient with CP
 Study stopped early because of myocardial
infarction rate
 71% NIPPV
 31% CPAP
 Mortality Benefit of
CPAP/NIPPV
in Patients with ACPO

Mortality reduced
from 22% to 11%

RR 0.53
(95% CI 0.35-0.81)

(Individual Group
Sizes of n = 9 to 46)

Masip et al. JAMA 2005;294:3124-3130

 Summary
NIV useful in treatment of cardiogenic
pulmonary edema
Rapid normalization of ‘physiology’
Likely decreases intubation rate
Possibly higher benefit in hypercapnic
subset
Larger trials to assess mortality benefit
NIV in Pneumonia
 NPPV in Pneumonia
 Early on, pneumonia was associated with a poor
outcome in patients treated with NPPV.
Difficulties in managing secretions
Inability to manage secretions is now an
accepted contraindication to the use of NPPV.
 NPPV may be beneficial in patients with
pneumonia if they are able to manage their
secretions.
Ambrosino N, et al. Non-invasive mechanical ventilation in acute respiratory failure due to chronic
obstructive pulmonary disease: correlate of success. Thorax 1995; 60:755-757.
Two thirds of patients with severe community-acquired pneumonia required
intubation after being started on NIV in one cohort study, even though those
who succeeded with NIV had very good outcomes

Jolliet P, Abajo B, Pasquina P, et al:. Intensive Care Med 2001; 27:812-821

An RCT on patients with severe community-acquired pneumonia showed

that NIV reduced intubation rates, ICU length of stay, and 2-month mortality
rate, but only in the subgroup with underlying COPD.

Confalonieri M, et al. Am J Respir Crit Care Med 1999; 160:1585-1591.

Another RCT on patients with hypoxemic respiratory failure[30]
showed that NIV reduced the need for intubation among patients
with pneumonia (26% vs. 73% in the conventional therapy group)

Ferrer M, Esquinas A, Leon M, et al: Am J Respir Crit Care Med 2003; 168:1438-1444

A more recent RCT testing NIV as an alternative to invasive ventilation in

patients with various types of ARF found that the subgroup with pneumonia
did very poorly, with all eight patients randomized to NIV requiring
intubation.

Honrubia T, Garcia Lopez FJ, Franco N, et al: Chest 2005; 128:3916-3924

 Confalonieri M, et al (1999)
 Prospective, randomized trial
 56 patients with hypoxemic ARF due to severe CAP
 Randomized to receive NPPV or conventional
management.
 Overall, NPPV group had decreased rate of
endotracheal intubation and ICU length of stay.
 Only patients with COPD, all of whom were
hypercapneic, benefited from NPPV.
 The non-COPD patients did not have a decrease
in the rate of intubation or length of ICU stay
Confalonieri M, et al. Acute respiratory failure in patients with severe community-acquired pneumonia:
a prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999;
160:1585-1591.
 Conclusion
The scant and conflicting data do not
support the routine use of NIV in patients
with severe pneumonia, with the exception
of patients with underlying COPD.
However, a cautious trial of NIV may be
considered in patients with pneumonia
deemed to be excellent candidates, but
they need careful monitoring, because the
risk of failure is high.
NIV in Post extubation failure
 Post extubation respiratory
failure

Up to 20% of patients successfully

extubated will require reintubation
Failed extubation and reintubation confers
increased patient morbidity and mortality
3 studies have looked at using NIV to treat
post extubation respiratory failure
Reintubation 48%

Reintubation 72%
 NIV in post extubation ARF
 97 patients post extubation RCT with high risk pts: CHF,
previous failure, comorbid condition, weak cough,
increase pCO2
 NIV >8h /day for 48 hrs vs. standard care
 NIV group had 12% lower mortality, 16% lower
reintubation rate and LOS
 Reintubation was associated with 60% increase
mortality in ICU

CONCLUSION
USEFUL MODALITY IN SELECT HIGH RISK PATIENTS

» Nava. CCM 2005:33:2465

Reintubation 11%

Reintubation 8%
RCT found no reduction in reintubations among patients who developed
respiratory distress within 48 hrs of extubation, although few patients with
COPD were included in this study and the level of pressure support used
may have been subtherapeutic.
Keenan SP, Powers C, McCormack DG, et al: JAMA 2002; 287:3238-3244

RCT attempted to prevent extubation failure by starting NIV (or continuing

standard therapy) as soon as patients developed signs of extubation failure.
Surprisingly, not only did NIV fail to reduce reintubations, but its use also
was associated with increased ICU mortality. Only 10% of patients in this
trial had COPD.
Esteban A, Frutos-Vivar F, Ferguson ND, et al: N Engl J Med 2004; 350:2452-2460
 Two RCTs on patients deemed to be at high risk for extubation
failure found that NIV applied immediately after extubation
reduced the need for reintubation and ICU mortality, but in one
of the studies the hypercapnic subgroup (mainly COPD
patients) had most of the benefit
Nava S, Gregoretti C, Fanfulla F, et al: Crit Care Med 2005; 33:2465-2470 Ferrer M, Valencia
M, Nicolas JM, et al: A randomized trial. Am J Respir Crit Care Med 2006; 173:164-170

•Case control study of 62 patients

•Obese (BMI > 35)
•Nasal NPPV for 48 hours post extubation
•Significant reduction in RF, ICU and hospital LOS in NPPV group
El-Solh AA, et al Noninvasive ventilation for prevention of post-extubation respiratory failure in obese
patients. European Respiratory Journal 2006; 28: 588-95
 Conclusion
Useful prophylactically in patients with
COPD following immediate extubation and
to aid early extubation and weaning from
MV
Not recommended as a treatment for post
extubation respiratory failure.
 Initiate in the E.D:
 58 patients with ARF (COPD/CHF) started on
BiPAP and medical therapy
 74% success rate.
 Average pH 7.26 baseline
 Success predicted by 30 min pH, HR, RR
 Reduced utilization in success group:
 Ventilator 10.4 days vs. 1.8 days
 ICU 12.3 days vs. 4.2 days

–Poponick J. Chest: 1999:116:166

 Is NIV safe on wards..?
 Prospective, multicenter, NIV on wards with 8
hrs. training, 1:11pts. nurse ratio
 118 COPD patients standard therapy alone and
118 with NIV for 3 days:
pH 7.25 –7.35 with R.R >23/min
 ETI in 27% vs. 15% if NIV used : 44% less
 Mortality 20% vs. 10% in NIV

Plant P: Lancet 2000: 355: 1931-35

 Conclusions from Level 1
Evidence
Consider use in COPD, pulmonary edema
and post extubation.
NPPV
Decreases mortality
Decreases need for intubation
Decrease hospital stay

If rapid improvement not seen, intubate

 Evidence for efficacy and strength of
recommendation: Noninvasive ventilation in
acute respiratory failure
Nicholas S. Hill, MD; John Brennan, MD; Erik Garpestad, MD; Stefano Nava, MD 2007

• Strength of
Recommendation
• Recommended:
first choice for
ventilatory support
in selected patients
• Guideline: can
be used in
appropriate
patients but careful
monitoring advised
• Option: suitable
Level of evidence for a very carefully
selected and
A: multiple randomized controlled trials and meta-analyses monitored minority
B: more than one randomized, controlled trial, case control of patients.
series, or cohort studies
C: case series or conflicting data
 ??????????????????
 NIV should be used only in ICU or step down unit---True or False.
 Patient with hypercarbic respiratory failure have poorer response to
NIV---True or False
 Patient with hypoxic respiratory failure have poorer response to NIV-
--True or False
 Higher the PCO2, use the lower pressure support (PS)---True or
False
 CPAP can provide adequate ventilator support---True or False
 Which of the following condition is least responsive to NIV
---COPD
---Pneumonia
---APE
---Post-extubation failure