Noninvasive Bilevel Positive Pressure Ventilation Research Articles

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study.

Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain. To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure. Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability. Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation. The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality. Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates. In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen. NCT04971213 ( https://clinicaltrials.gov ).

Positive pressure ventilation in the weaning of preterm newborns.

Weaning from invasive mechanical ventilation (IMV) of preterm newborns (PTNB) is one of the critical stages of life support in the Neonatal Intensive Care Unit (NICU). Noninvasive positive pressure ventilation (NPPV) has been used to facilitate weaning from IMV and includes continuous positive airway pressure (CPAP) without or with inspiratory pressure support (bilevel NPPV). Nevertheless, there is little information about their adherence and success rate during weaning process. In this retrospective cohort study, weaning data from patients admitted to a NICU from the northeast region of Brazil were analyzed. Sample was composed of PTNB submitted to IMV and divided in two groups according to the weaning strategy adopted: bilevel NPPV or NCPAP. Weaning failure was defined as returning to IMV within less than 48 h after extubation. Fifty-seven PTNB were included. Majority were females, had caesarean delivery, very low weight upon birth (760-1480 g) and neonatal hypoxemia scores (Apgar) <7 in the first minute. Respiratory distress syndrome occurred in 56.7% of PTNB whilst respiratory infections occurred in 35.1% of patients. Bilevel NPPV was the most chosen modality of weaning. No difference in success rate was found between bilevel NPPV and NCPAP (P=0.17). In this study, the application of noninvasive ventilation in preterm newborns for weaning from IMV was similar success rate between bilevel NPPV and NCPAP.

Quantitative Assessment of Viral Dispersion Associated with Respiratory Support Devices in a Simulated Critical Care Environment.

Rationale: Patients with severe coronavirus disease (COVID-19) require supplemental oxygen and ventilatory support. It is unclear whether some respiratory support devices may increase the dispersion of infectious bioaerosols and thereby place healthcare workers at increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Objectives: To quantitatively compare viral dispersion from invasive and noninvasive respiratory support modalities.Methods: This study used a simulated ICU room with a breathing-patient simulator exhaling nebulized bacteriophages from the lower respiratory tract with various respiratory support modalities: invasive ventilation (through an endotracheal tube with an inflated cuff connected to a mechanical ventilator), helmet ventilation with a positive end-expiratory pressure (PEEP) valve, noninvasive bilevel positive-pressure ventilation, nonrebreather face masks, high-flow nasal oxygen (HFNO), and nasal prongs.Measurements and Main Results: Invasive ventilation and helmet ventilation with a PEEP valve were associated with the lowest bacteriophage concentrations in the air, and HFNO and nasal prongs were associated with the highest concentrations. At the intubating position, bacteriophage concentrations associated with HFNO (2.66 × 104 plaque-forming units [PFU]/L of air sampled), nasal prongs (1.60 × 104 PFU/L of air sampled), nonrebreather face masks (7.87 × 102 PFU/L of air sampled), and bilevel positive airway pressure (1.91 × 102 PFU/L of air sampled) were significantly higher than those associated with invasive ventilation (P < 0.05 for each). The difference between bacteriophage concentrations associated with helmet ventilation with a PEEP valve (4.29 × 10–1 PFU/L of air sampled) and bacteriophage concentrations associated with invasive ventilation was not statistically significant.Conclusions: These findings highlight the potential differential risk of dispersing virus among respiratory support devices and the importance of appropriate infection prevention and control practices and personal protective equipment for healthcare workers when caring for patients with transmissible respiratory viral infections such as SARS-CoV-2.

Pregnancy in congenital central hypoventilation syndrome

Congenital central hypoventilation syndrome is a rare genetic disorder of autonomic regulation of breathing resulting from mutations in the paired-like homeobox gene. Individuals with congenital central hypoventilation syndrome demonstrate an absent or diminished physiological response to hypercapnia and hypoxia that is most severe during sleep and depend on mechanical ventilation to maintain normal gas exchange. Increased disease awareness and availability of paired-like homeobox gene testing has improved congenital central hypoventilation syndrome morbidity and mortality, and patients are now living into adulthood. During pregnancy, delivery, and the postpartum period, women with congenital central hypoventilation syndrome are vulnerable to developing respiratory insufficiency. Currently, there is no standardized approach to monitoring ventilatory status and anticipating the need for changes to existing ventilatory support for women with congenital central hypoventilation syndrome during pregnancy, labor, and delivery. This study aimed to characterize current practices for monitoring ventilatory status and managing ventilatory needs in women with congenital central hypoventilation syndrome during pregnancy; identify specific circumstances through which ventilation may be compromised during pregnancy, delivery, and postpartum; evaluate utilization of prenatal congenital central hypoventilation syndrome testing; and report any adverse pregnancy outcomes. We conducted an anonymous cross-sectional survey of women with congenital central hypoventilation syndrome with current or prior pregnancy. The 26-item electronic questionnaire included questions on congenital central hypoventilation syndrome genotype; number and outcome of pregnancies; use of mechanical ventilation; and issues with or adjustments made to ventilation during pregnancy, delivery, and the postpartum period. We received 10 responses. Three patients were not diagnosed with congenital central hypoventilation syndrome until after pregnancy and delivery. The 7 patients with a preexisting congenital central hypoventilation syndrome diagnosis reported information on 10 total pregnancies. At baseline, patients relied on various types of ventilatory support including positive pressure ventilation via tracheostomy, bilevel noninvasive positive pressure ventilation, and diaphragm pacing by phrenic nerve stimulation. Polysomnography for objective assessment of nocturnal ventilation was not consistently utilized. Changes to baseline ventilatory support were required during 3 out of 10 pregnancies. In addition, 2 patients using diaphragm pacing reported discomfort with pacing during the third trimester or after cesarean delivery, prompting discontinuation of diaphragm pacing. In 1 instance, discontinuation of diaphragm pacing and lack of recognition of need for an alternative support method led to respiratory arrest and need for emergent resuscitation. All patients who were offered prenatal congenital central hypoventilation syndrome testing chose to undergo testing. Of note, 9 out of 10 pregnancies were carried successfully to term and 5 infants were diagnosed with congenital central hypoventilation syndrome. Women with congenital central hypoventilation syndrome may experience issues maintaining adequate ventilation during pregnancy, necessitating an adjustment of ventilator settings or use of an alternative type of ventilation. Objective assessment of nocturnal ventilation by means of polysomnography is an important part of congenital central hypoventilation syndrome pregnancy care to optimize maintenance of adequate gas exchange. Patients who rely on diaphragm pacing may experience discomfort with pacing during the later stages of pregnancy and after cesarean delivery. Anticipatory guidance and contingency planning for changing ventilatory needs should be discussed early in pregnancy. Prenatal congenital central hypoventilation syndrome testing should be offered to pregnant patients with congenital central hypoventilation syndrome to inform delivery decisions and prepare for the provision of advanced neonatal care.

Positive pressure ventilation in the weaning of preterm newborns.

Weaning from invasive mechanical ventilation (IMV) of preterm newborns (PTNB) is one of the critical stages of life support in the neonatal intensive care unit (NICU). Noninvasive positive pressure ventilation (NPPV) has been used to facilitate weaning from IMV and includes continuous positive airway pressure (CPAP) without or with inspiratory pressure support (Bilevel NPPV). Nevertheless, there is little information about their adherence and success rate during weaning process. In this retrospective cohort study, weaning data from patients admitted to a NICU from the northeast region of Brazil were analyzed. Sample was composed of PTNB submitted to IMV and divided in two groups according to the weaning strategy adopted: Bilevel NPPVor NCPAP. Weaning failure was defined as returning to IMV within less than 48h after extubation. Fifty-seven PTNB were included. Majority were female, had caesarean delivery, very low weight upon birth (760-1,480g) and neonatal hypoxemia scores (Apgar) <7 in the first minute. Respiratory distress syndrome occurred in 56.7% of PTNB whilst respiratory infections occurred in 35.1% of patients. Bilevel NPPV was the most chosen modality of weaning. No difference in success rate was found between Bilevel NPPV and NCPAP (p=0.17). In this study, the application of noninvasive ventilation in preterm newborns for weaning from IMV was similar success rate between Bilevel NPPV and NCPAP.

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema.

Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE. To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates. We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions. We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone. Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations. We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I2 = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I2 = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I2 = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I2 = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality. Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.

无创双水平正压通气联合枸橼酸咖啡因治疗早产儿频繁呼吸暂停的效果观察

无创双水平正压通气联合枸橼酸咖啡因治疗早产儿频繁呼吸暂停的效果观察

Enteral Nutrition Practices in Critically Ill Children Requiring Noninvasive Positive Pressure Ventilation.

Evaluate the practice of providing enteral nutrition in critically ill children requiring noninvasive positive pressure ventilation. Retrospective cohort study. PICU within a quaternary care children's hospital. PICU patients older than 30 days requiring noninvasive positive pressure ventilation for greater than or equal to 24 hours from August 2014 to June 2015. Invasive mechanical ventilation prior to noninvasive positive pressure ventilation and inability to receive enteral nutrition at baseline were additional exclusionary criteria. None. The primary outcome was enteral nutrition initiation within 24 hours of admission. Secondary outcomes included time to goal enteral nutrition rate, adequacy of nutrition, adverse events (pneumonia not present at admission, intubation after enteral nutrition initiation, feeding tube misplacement), and lengths of noninvasive positive pressure ventilation and PICU stay. Among those included (n = 562), the median age was 2 years (interquartile range, 39 d to 6.8 yr), 54% had at least one chronic condition, and 43% had malnutrition at baseline. The most common primary diagnosis was bronchiolitis/viral pneumonia. The median length of time on noninvasive positive pressure ventilation was 2 days (interquartile range, 2.0-4.0). Most (83%) required continuous positive airway pressure or bi-level support during their PICU course. Sixty-four percent started enteral nutrition within 24 hours, with 72% achieving goal enteral nutrition rate within 72 hours. Forty-nine percent and 44% received an adequate cumulative calorie and protein intake, respectively, during their PICU admission. Oral feeding was the most common delivery method. On multivariable analysis, use of bi-level noninvasive positive pressure ventilation (odds ratio, 0.40; 95% CI, 0.25-0.63) and continuous dexmedetomidine (odds ratio, 0.59; 95% CI, 0.35-0.97) were independently associated with decreased likelihood of early enteral nutrition. Twelve percent of patients had at least one adverse event. A majority of patients requiring noninvasive positive pressure ventilation received enteral nutrition within 24 hours. However, less than half achieved caloric and protein goals during their PICU admission. Further investigation is warranted to determine the safety and effectiveness of early enteral nutrition in this population.

Respiratory Failure From Enlarging Diaphragmatic Hernia: A Rare Complication of Noninvasive Positive Pressure Ventilation

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Non-invasive positive pressure ventilation (NIPV) is useful for management of hypercapnic respiratory failure. Use of NIPV can have devastating complications.We report a rare case of diaphragmatic herniation that worsened due to gastric insufflation. CASE PRESENTATION: An 87-year-old man with history of COPD and left-sided diaphragmatic hernia presented with cough, worsening shortness of breath and wheezing. Vitals were significant for heart rate of 98 bpm, BP 140/90 mmHg, respiratory rate 28/min, and oxygen saturation 78% on room air. Physical examination demonstrated diffuse wheezing in the both lungs and tympanic percussion in the left hemi-thorax. The initial chest X-ray showed left hemi-diaphragm elevation (Figure 1). Patient was placed on bilevel NIPV (10/5 cm H2O and FIO2:60%) for hypercapnia due to COPD exacerbation. Patient’s respiratory distress worsened while on bilevel NIPV. Repeat CXR showed bowel loops compressing the whole left lung (Figure 2). NIPV was discontinued and patient was made NPO. CT thorax showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon, and proximal descending colon within the hernia. After discontinuing NIPV, patient’s respiratory status improved with O2 saturation of 95% on 2 L/min NC. Patient underwent surgical repair for bowel strangulation. Post-operative imaging confirmed re-expansion of the left lung with minimal basilar atelectasis and normal vasculature. Patient’s symptoms significantly improved after surgery. DISCUSSION: NIPV reduces the need for intubation, mortality, complications, and length of stay in COPD exacerbation. Some of the NIPV complications are mask intolerance, nasal bridge ulceration, inadequate gas exchange, sinus pain, aspiration and mucus plugging. Pneumothorax and pneumocephalus have been reported as the most serious complications of NIPV. Gastric insufflation is usually a minor adverse effect; however, our patient had significant worsening of diaphragmatic herniation and dyspnea due to to gastric insufflation with NIPV. CONCLUSIONS: There is no ideal target pressure when choosing NIPV settings. There should be a balance between inspiratory pressure supporting gas exchange and patient’s tolerance and comfort. When choosing NIPV physicians should watch for pre-existing diaphragmatic hernia and be aware that applying NIPV could potentially worsen herniation and gas exchange. Reference #1: Gay PC1.Complications of noninvasive ventilation in acute care.Respir Care. 2009 Feb;54(2):246-57. DISCLOSURE: The following authors have nothing to disclose: Mahsan Farokhi, Viren Kaul, Assad Oskuei, Michael Megally, Daniel Nicastri, Martin Warshawsky No Product/Research Disclosure Information

A Case of Iatrogenic Vascular Air Embolism Treated with Bipap and Nitroglycerin

Vascular air embolisms are very rare but fatal complication of diving and many procedures, mostly central line catheterizations. Treatment is mostly supportive with 100% oxygen and in severe cases, hyperbaric therapy. Recent therapy has shown that nitric oxide can decrease the rate of bubble formation in animal studies after compression. We describe a case of iatrogenic air embolism treated with Bi-level non-invasive positive pressure ventilation (BiPAP) and IV nitroglycerin. This case illustrated the importance of recognizing this rare but potentially fatal syndrome, and the need for further research on the utility of nitroglycerin in the treatment of this syndrome.

Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery.

Each year, more than four million abdominal surgeries are performed in the US and over 250,000 in England. Acute respiratory failure, a common complication that can affect 30% to 50% of people after upper abdominal surgery, can lead to significant morbidity and mortality. Noninvasive ventilation has been associated with lower rates of tracheal intubation in adults with acute respiratory failure, thus reducing the incidence of complications and mortality. This review compared the effectiveness and safety of noninvasive positive pressure ventilation (NPPV) versus standard oxygen therapy in the treatment of acute respiratory failure after upper abdominal surgery. To assess the effectiveness and safety of noninvasive positive pressure ventilation (NPPV), that is, continuous positive airway pressure (CPAP) or bilevel NPPV, in reducing mortality and the rate of tracheal intubation in adults with acute respiratory failure after upper abdominal surgery, compared to standard therapy (oxygen therapy), and to assess changes in arterial blood gas levels, hospital and intensive care unit (ICU) length of stay, gastric insufflation, and anastomotic leakage. The date of the last search was 12 May 2015. We searched the following databases: the Cochrane Handbook for Systematic Reviews of Interventions (CENTRAL) (2015, Issue 5), MEDLINE (Ovid SP, 1966 to May 2015), EMBASE (Ovid SP, 1974 to May 2015); the physiotherapy evidence database (PEDro) (1999 to May 2015); the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCOhost, 1982 to May 2015), and LILACS (BIREME, 1986 to May 2015). We reviewed reference lists of included studies and contacted experts. We also searched grey literature sources. We checked databases of ongoing trials such as www.controlled-trials.com/ and www.trialscentral.org/. We did not apply language restrictions. We selected randomized or quasi-randomized controlled trials involving adults with acute respiratory failure after upper abdominal surgery who were treated with CPAP or bilevel NPPV with, or without, drug therapy as standard medical care, compared to adults treated with oxygen therapy with, or without, standard medical care. Two authors independently selected and abstracted data from eligible studies using a standardized form. We evaluated study quality by assessing allocation concealment; random sequence generation; incomplete outcome data; blinding of participants, personnel, and outcome assessors; selective reporting; and adherence to the intention-to-treat (ITT) principle. We included two trials involving 269 participants. The participants were mostly men (67%); the mean age was 65 years. The trials were conducted in China and Italy (one was a multicentre trial). Both trials included adults with acute respiratory failure after upper abdominal surgery. We judged both trials at high risk of bias. Compared to oxygen therapy, CPAP or bilevel NPPV may reduce the rate of tracheal intubation (risk ratio (RR) 0.25; 95% confidence interval (CI) 0.08 to 0.83; low quality evidence) with a number needed to treat for an additional beneficial outcome of 11. There was very low quality evidence that the intervention may also reduce ICU length of stay (mean difference (MD) -1.84 days; 95% CI -3.53 to -0.15). We found no differences for mortality (low quality evidence) and hospital length of stay. There was insufficient evidence to be certain that CPAP or NPPV had an effect on anastomotic leakage, pneumonia-related complications, and sepsis or infections. Findings from one trial of 60 participants suggested that bilevel NPPV, compared to oxygen therapy, may improve blood gas levels and blood pH one hour after the intervention (partial pressure of arterial oxygen (PaO2): MD 22.5 mm Hg; 95% CI 17.19 to 27.81; pH: MD 0.06; 95% CI 0.01 to 0.11; partial pressure of arterial carbon dioxide (PCO2) levels (MD -9.8 mm Hg; 95% CI -14.07 to -5.53). The trials included in this systematic review did not present data on the following outcomes that we intended to assess: gastric insufflation, fistulae, pneumothorax, bleeding, skin breakdown, eye irritation, sinus congestion, oronasal drying, and patient-ventilator asynchrony. The findings of this review indicate that CPAP or bilevel NPPV is an effective and safe intervention for the treatment of adults with acute respiratory failure after upper abdominal surgery. However, based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, the quality of the evidence was low or very low. More good quality studies are needed to confirm these findings.

Noninvasive Mechanical Ventilation in Helicopter Emergency Medical Services Saves Time and Oxygen and Improves Patient and Mission Safety: A Pilot Study

Noninvasive mechanical ventilation (NIMV) is used increasingly in patients with severe respiratory distress and has clear benefits over standard medical therapy (SMT) in terms of patient safety. NIMV is particularly useful in cardiogenic acute pulmonary edema and in exacerbations of chronic obstructive pulmonary disease, both of which are frequent reasons for an emergency medical services dispatch. Early use of NIMV avoids complications in these patients in many cases. To date, the use of noninvasive positive-pressure ventilation in the air medical environment has been minimally researched. We evaluated NIMV versus SMT in the helicopter emergency medical services environment in patients with cardiogenic acute pulmonary edema and exacerbated chronic obstructive pulmonary disease. The parameters assessed were stabilization time, tolerance, safety, clinical response, and oxygen consumption. Bilevel noninvasive positive-pressure ventilation was the ventilatory mode used for all patients. The technique of NIMV in medical air transport is useful, easy to operate, and safe. It offers increased patient safety, reducing the need for invasive mechanical ventilation and its complications; better intervention times (35.8 minutes [NIMV] vs. 57.65 minutes [SMT], P < .05); improvement in aircraft operability; and a reduction in oxygen consumption (6.2 L/min vs. 9.8 L/min, P < .05), contributing to mission operability and safety.

Clinical efficacy of noninvasive positive pressure ventilation on elderly chronic obstructive pulmonary patients with respiratory failure

Objective To investigate the clinical efficacy of noninvasive positive pressure ventilation for elderly patients with chronic obstructive pulmonary disease and respiratory failure. Methods A total of 64 elderly patients with chronic obstructive pulmonary disease and respiratory failure were collected. The patients were treated with conventional therapy, while using BiPAP ventilator line through the nose and mouth mask bilevel noninvasive positive pressure ventilation therapy, and to give effective care. After treatment for 3d,the p H,PaO2,PaCO2,SaO2 index changes, respiration, heart rate changes and APACHEⅡ,GCS and accessory muscle score were observed.Adverse reactions were recorded. Results Before treatment the PH value of patient was(7.30±0.06), which significantly increased to(7.36±0.03)after treatment, PaO2 values was significantly increased to(43.58±5.54) from(84.52±8.27),SaO2 value was significantly increased to(94.93±5.61)from(74.86±7.25),PaCO 2 value from(71.69±8.48)decreased to(42.55±6.23). There was statistically significant before and after treatment(t=5.98,6.35,4.86,7.23,all P<0.05),respiratory rate,heart rate were significantly improved,showing a significant difference(t=4.87,5.32,all P<0.05),APACHEⅡ,GCS and accessory muscle scores were significantly improved, which APACHEⅡ, accessory muscle score was significantly lower, GCS score was significantly increased, were statistically significant(t=4.09,4.01,4.33,all P<0.05). Conclusion It shows that noninvasive positive pressure ventilation combined with conventional drug therapy can improve elderly patients with chronic obstructive pulmonary disease and respiratory failure in patients with clinical symptoms, increase ventilation and improve hypercapnia, clinical efficacy is better,with no serious adverse reactions. Key words: Respiratory failure; Noninvasive positive pressure ventilation; Pulmonary disease; Chronic obstructive

Observation of the effect of bi-level noninvasive positive pressure ventilation in the treatment of acute respiratory chronic obstructive pulmonary disease patients with respiratory failure

目的 观察双水平无创正压通气(BiPAP)对COPD急性加重期合并呼吸衰竭患者的疗效.方法 采用11病例匹配选择COPD急性加重期合并呼吸衰竭患者60例,对照组30例给予常规治疗,观察组30例在对照组基础上给予BiPAP治疗,比较两组治疗前、治疗后2、24、48 h的RR、HR及SaO2、pH值,PaO2、PaCO2以及急性生理和慢性健康状况(APACHE Ⅱ)评分和辅助呼吸机评分的变化情况,并比较两组患者的生存率.结果 观察组在治疗后2、24、48 h的SaO2、pH值、PaO2均高于对照组(t=4.46、3.82、3.49、2.97、4.08、7.75、5.09、3.72、4.13,均P＜0.01),治疗后24、48 h的RR低于对照组(t=2.63、3.81,均P＜0.01).观察组治疗48 h后APACHE Ⅱ评分为(16.7±1.2)分,低于对照组的(18.9±1.1)分(t=6.73,P＜0.01);辅助呼吸机评分为(3.0±0.5)分,低于对照组的(3.5±0.6)分(t=3.51,P＜0.01).观察组病死率为6.66%,对照组的病死率为36.66%,观察组生存率高于对照组(χ2=6.054,P＜0.05).结论 BiPAP治疗COPD合并呼吸衰竭患者临床效果好,在临床应用中应在掌握患者病情的前提下优先考虑应用。

Pulmonary hypertension in hypoventilation syndromes

The object that presented itself to the eyes of the astonished clerk, was a boy – a wonderfully fat boy – habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep. – Dickens [1] In this issue of the European Respiratory Journal , Held et al. [2] report on 18 patients with severe pulmonary hypertension due to alveolar hypoventilation, who were markedly improved after 3 months of noninvasive bi-level positive-pressure ventilation (NIPPV). Mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) were 50 mmHg and 6–7 Wood units, respectively, at baseline, and decreased to 30 mmHg and 3–4 Wood units with NIPPV; this was accompanied by improved catherisation and echocardiographic indices of right ventricular (RV) function. The N-terminal pro-brain natriuretic peptide (NT-proBNP) levels also decreased, and the 6-min walk distance (6MWD) improved by 80 m. These results are in striking contrast with the “borderline” (mPAP 20–25 mmHg) or mild (mPAP 25–30 mmHg) pulmonary hypertension generally seen, but with rare exceptions, in patients with respiratory conditions. Borderline or mild pulmonary hypertension due to respiratory conditions is of uncertain clinical relevance, exhibits slow progression controlled by supplemental oxygen and is refractory to drugs targeting the pulmonary circulation [3, 4]. 12 of the 18 patients reported by Held et al. [2] fulfilled the criteria of obesity hypoventilation syndrome (OHS), defined by a combination of awake hypercapnia (arterial carbon dioxide tension ( P aCO2) >45 mmHg), a body mass index >30 kg·m−2 and exclusion of other causes that could account for hypoventilation, such as lung or neuromuscular disease [5, 6]. Three of the OHS patients had concomitant chronic obstructive pulmonary disease (COPD) and five patients had COPD without obesity. …

Effect of non-invasive bi-level positive airway pressure ventilation combined with naloxone in the treatment of AECOPD complicated with pulmonary encephalopathy: a meta-analysis

Objective To review the effect of non-invasive bi-level positive airway pressure ventilation combined with naloxone in the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with pulmonary encephalopathy (PE). Methods Related published studies involving BiPAP combined with naloxone in the treatment of AECOPD complicated with PE were recruited and identified from Pubmed, ISI Web of knowledge, CBM Disc, CNKI, Wanfang Data, and randomized controlled trails(RCTs) primarily collected were screened according to inclusive criteria and exclusive criteria.Valid data were extracted after quality evaluation for meta-analysis utilizing RevMan 5.2. Results A total of 10 Chinese RCTs were enrolled, including 697 patients (353 patients in experimental group while 343 patients in control group). The results of meta-analysis indicated that BiPAP combined with naloxone improved PaO2(WMD=4.10, 95%CI(2.83, 5.38), P<0.00001), PH value(WMD=0.04, 95%CI(0.02, 0.05), P<0.00001) and clinical efficiency rate(OR=3.58, 95% CI((2.22, 5.76), P<0.00001), and reduced PaCO2(WMD=-5.78, 95%CI(-6.87, 4.69), P<0.00001), re-endotracheal intubation rate (OR=0.19, 95%CI(0.11, 0.35), P<0.00001), but failed to decrease mortality(OR=0.38, 95%CI(0.11, 1.34), P=0.13) of patients with AECOPD complicated with PE. Conclusions BiPAP combined with naloxone play a protective role in enhancing arterial blood gas indexes, improving clinical efficiency rate and limiting re-endotracheal intubation rate.However, the mortality of patients cannot be reduced. Key words: BiPAP; Naloxone; AECOPD; Pulmonary encephalopathy; Meta-analysis

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema

This is an update of a systematic review previously published in 2008 about non-invasive positive pressure ventilation (NPPV). NPPV has been widely used to alleviate signs and symptoms of respiratory distress due to cardiogenic pulmonary oedema. NPPV prevents alveolar collapse and helps redistribute intra-alveolar fluid, improving pulmonary compliance and reducing the pressure of breathing. To determine the effectiveness and safety of NPPV in the treatment of adult patients with cardiogenic pulmonary oedema in its acute stage. We searched the following databases on 20 April 2011: CENTRAL and DARE, (The Cochrane Library, Issue 2 of 4, 2011); MEDLINE (Ovid, 1950 to April 2011); EMBASE (Ovid, 1980 to April 2011); CINAHL (1982 to April 2011); and LILACS (1982 to April 2011). We also reviewed reference lists of included studies and contacted experts and equipment manufacturers. We did not apply language restrictions. We selected blinded or unblinded randomised or quasi-randomised clinical trials, reporting on adult patients with acute or acute-on-chronic cardiogenic pulmonary oedema and where NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care was compared with standard medical care alone. Two authors independently selected articles and abstracted data using a standardised data collection form. We evaluated study quality with emphasis on allocation concealment, sequence generation allocation, losses to follow-up, outcome assessors, selective outcome reporting and adherence to the intention-to-treat principle. We included 32 studies (2916 participants), of generally low or uncertain risk of bias. Compared with standard medical care, NPPV significantly reduced hospital mortality (RR 0.66, 95% CI 0.48 to 0.89) and endotracheal intubation (RR 0.52, 95% CI 0.36 to 0.75). We found no difference in hospital length of stay with NPPV; however, intensive care unit stay was reduced by 1 day (WMD -0.89 days, 95% CI -1.33 to -0.45). Compared with standard medical care, we did not observe significant increases in the incidence of acute myocardial infarction with NPPV during its application (RR 1.24, 95% CI 0.79 to 1.95) or after (RR 0.70, 95% CI 0.11 to 4.26). We identified fewer adverse events with NPPV use (in particular progressive respiratory distress and neurological failure (coma)) when compared with standard medical care. NPPV in addition to standard medical care is an effective and safe intervention for the treatment of adult patients with acute cardiogenic pulmonary oedema. The evidence to date on the potential benefit of NPPV in reducing mortality is entirely derived from small-trials and further large-scale trials are needed.

Non-invasive mechanical ventilation in the treatment of acute cardiogenic pulmonary edema Application

Objective To investigate the non-invasive mechanical ventilation (NMV) treatment of acute cardiogenic pulmonary edema (ACPE) for clinical application.Methods 80 patients with different causes of acute pulmonary edema were randomly divided into NMV treatment group and control group 39 cases,41 cases of conventional therapy control group,high-flow oxygen by nasal catheter,NMV in the conventional treatment group,drug treatment basis for pressure support ventilation (PSV) plus PEEP (PEEP) ventilation node,were monitored before treatment and after treatment of clinical manifestations,blood gas analysis,oxygen saturation,respiratory rate,heart rate,blood pressure changes.Results After treatment,39 patients were in remission within 30 min,in addition to three cases of heavy patients can be assisted ventilation weaning 2 h,the other are at weaning within 1 h.Supine position after weaning can breathe,looking back to normal,sweating away,no purple lips,bubble-like sputum disappeared,bilateral pulmonary rales,decreased or even disappeared.Clinical difference between the two groups of indicators were statistically significant (P ＜ 0.05).Conclusion In routine cardiac,diuretic,while expanding treatment and other infrastructure management,plus non-invasive bi-level positive pressure ventilation treatment of acute pulmonary edema,hypoxia can be corrected quickly,to improve the condition,improve the success rate,reduce and tracheal intubation cut rates and reduce mortality. Key words: Acute pulmonary edema; Non-invasive mechanical ventilation; Effect

Effects of non-invasive positive pressure ventilation (NIPPV) in stable chronic obstructive pulmonary disease (COPD)

Summary This review provides an overview of the randomised controlled trials covering the topic of chronic non-invasive positive pressure ventilation (NIPPV) in severe stable COPD patients. Studies investigating patients receiving bilevel NIPPV via nasal, oronasal or total face mask interfaces for at least 1 week or more, were described. Eight RCTs were included, from which six trials used NIPPV for up to 3 months (short-term) and two trials also obtained long-term effects (3 months to ⩾2 years). Outcome parameters were: arterial blood gases, pulmonary function, respiratory mechanics, respiratory muscle strength, dyspnoea, exercise tolerance, health-related quality of life, neuropsychologic function, sleep quality, hospital admissions and survival. We found that NIPPV in addition to standard care can have beneficial effects on certain outcome measures, however results are conflicting. Therefore, evidence is insufficient to recommend NIPPV routinely in stable but severe COPD patients. Nevertheless, it seems that hypercapnic patients, who receive enough time to adjust to the ventilator and so obtain improved ventilation, could benefit from NIPPV.

Novel therapies for children with severe asthma

Novel therapies, such as a heliox gaseous mixture and noninvasive bilevel positive pressure ventilation, are being utilized in the treatment of the patient with severe asthma who is unresponsive to conventional medical management. Aggressive treatment may prevent intubation and its untoward complications. Both heliox and bilevel positive pressure ventilation have demonstrated clinical improvement in studies of patients refractory to standard care, both in adults and children. The studies in children are limited but show promise, especially when these therapies are used early in the treatment course and in certain subsets of patients.