Noninvasive Mechanical Ventilation Success Research Articles

Benefits of dexmedetomidine during noninvasive mechanical ventilation in major abdominal surgery patients with postoperative respiratory failure.

The efficacy of non-invasive mechanical ventilation (NIMV) on the postoperative ARF is conflicting and the failure rate of NIMV in this patient population is high. In our study, we hypothesized that the use of dexmedetomidine during NIMV in major abdominal surgical patients can reduce NIMV failure without significant side affect. Medical records of patients who underwent major abdominal surgery, admitted to our general surgery intensive care unit (ICU), developed postoperative ARF, received NIMV (with oro-nasal mask) and dexmedetomidine infusion were enrolled in this study. The infusion rate was adjusted to maintain a target sedation level of a Richmond Agitation-Sedation Scale (RASS) (-2)-(-3). The sedation was stopped when NIMV was discontinued. A total of 60 patients, 42 (70.0%) male, and 18 (30.0%) female, with a mean age of 68 ± 11 years were included in the study. The mean APACHE II score was 20 ± 6. Dexmedetomidine was infused for a median of 25 h (loading dose of 0.2 mcg/kg for 10 min, maintained at 0.2-0.7 mcg/kg/h, titrated every 30 min). RASS score of all study group significantly improved at the 2 h of dexmedetomidine initiation (+3 vs. -2, p = 0.01). A targeted sedation level was achieved in 92.5% of patients. Six (10.0%) patients developed bradycardia and 5 (8.3%) patients had hypotension. The mean NIMV application time was 23.4 ± 6.1 h. Seven (11.6%) patients experienced NIMV failure, all due to worsening pulmonary conditions, and required intubation and invasive ventilation. Fifty-three (88.3%) patients were successfully weaned from NIMV with dexmedetomidine sedation and discharged from ICU. The duration of NIMV application and ICU stay was shorter in NIMV succeded group (21.4 ± 3.2 vs. 29.9 ± 6.4; p = 0.012). Our study suggests that dexmedetomidine demonstrates effective sedation in patients with postoperative ARF during NIMV application after abdominal surgery. Dexmedetomidine can be considered safe and capable of improving NIMV success.

Noninvasive mechanical ventilation

Noninvasive mechanical ventilation (NIMV) is positive pressure ventilation applied through a mask without an artificial airway and is frequently used in acute and chronic respiratory failure. It is the first choice in the weaning process for patients with acute cardiogenic pulmonary edema, acute exacerbations of chronic obstructive pulmonary disease (COPD), and COPD patients with invasive mechanical ventilation. The choice of device, mode, and mask is important to the application and success of NIMV. In appropriate diagnosis and indication, NIMV should be the first choice in patients who are cooperative, able to protect their airways, clinically stable, and to whom the mask can be applied. In this review, the NIMV application, especially in acute respiratory failure, is summarized.

Non-invasive Ventilation Failure - Predict and Protect.

Pratyusha K, Jindal A. Non-invasive Ventilation Failure - Predict and Protect. Indian J Crit Care Med 2023;27(2):149.

The Success of Noninvasive Mechanical Ventilation in Relation with Concomitant Disorders in Copd Patients with Acute Hypercapnic Respiratory Failure

The Success of Noninvasive Mechanical Ventilation in Relation with Concomitant Disorders in Copd Patients with Acute Hypercapnic Respiratory Failure

Comparison of full-face and oronasal mask effectiveness in hypercapnic respiratory failure patients with non-invasive mechanical ventilation.

Non-invasive mechanical ventilation (NIMV) is a successful treatment modality in hypercapnic respiratory failure. Patient compliance and mask selection are the most important factors in the success of NIMV. In our prospective randomized study, we aimed to investigate the efficacy of full-face and oronasal masks in the treatment of patients with hypercapnic respiratory failure who underwent NIMV and to investigate the mask compliance of the patients. In this prospective randomized study, 60 patients with hypercapnic respiratory failure were divided into two groups; the full face mask group (n= 30) and the oronasal mask group (n= 30). Arterial blood gas values and respiratory rates were measured before the treatment and at the 1st, 6th, 24th, and 72nd hours of the treatment. The compliance of the patients with the treatment was evaluated with the patient compliance scale (PCS) at the 1st, 6th, and 24th hours of the treatment. Eight patients from the full-face mask group were excluded because of mask-face mismatch and claustrophobia, and two patients from the oronasal mask group due to persistent hypercapnia. In the full face mask group, improvement in pH was observed at the 1st and 24th hours of treatment (p= 0.042, p= 0.033), and PCO2 decreased at the 72nd hour of treatment (p= 0.024). There was no difference in patient compliance and respiratory rate between groups. The complaints of burning sensation and pressure in the eyes were higher in the full face mask group (p= 0.025), and pressure ulcers were more common in the oronasal mask group (p= 0.025). The reduction in PCO2 and improvement in pH were greater with a full face mask. Pressure sores were less common with a full face mask. In our study, no difference was found in terms of patient compliance between groups. It should be noted that choosing a full face mask in patients with high compliance will increase the success in the treatment of hypercapnic respiratory failure.

Noninvasive or Invasive Mechanical Ventilation in Oncohematologic Patients with Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Background: Acute respiratory failure (ARF) in oncohematologic subjects is one of the most common causes of high mortality rates. Noninvasive mechanical ventilation (NIMV) has arisen as an accessory treatment in this clinical scenario. Objective: This study aimed to compare mortality rates and severity of illness associated with NIMV or invasive mechanical ventilation (IMV) in oncohematologic patients with ARF. Methods: A search was conducted in the PubMed, SCOPUS, Cochrane Library, LILACS, Web of Science, and gray literature databases, published between November 2007 and May 2021. Results: Eight studies with a total of 570 patients were included. Patients with good responses to NIMV showed lower values of the Simplified Acute Physiology Score III (SAPS 3) (range: 42±7 to 53±17) when compared to those intubated following NIMV failure (range: 50±11 to 63.3±17.4) and those who underwent IMV as the primary ventilator support (range: 64.9±17.5 to 66±17). Similarly, patients whose NIMV treatment failed and those that initially used IMV had higher baseline values of Sequential Organ Failure Assessment Score (SOFA) when compared to the group with a good response to NIMV. ICU mortality ranged from 40% to 68% in NIMV success, 54% to 79% in NIMV failure, and from 54% to 80% in the group treated with IMV. NIMV therapy had a significant protective effect on mortality (RR=0.71, 95% CI: 0.53-0.94, p=0.02). Conclusions: NIMV use in oncohematologic patients admitted to the intensive care units (ICU) with ARF was associated with lower mortality. Patients successfully treated in the NIMV group showed lower values of SOFA and SAPS 3 (Prospero Systematic Review -protocol number: 132770).

The success of non-invasive mechanical ventilation in lung cancer patients with respiratory failure.

Despite the improvement in survival among patients with lung cancer as a result of the development of novel treatment options, acute respiratory failure (ARF), which may occur because of the disease itself, comorbidities or complications in treatment may be life threatening. The most commonly utilised treatment option in cancer patients with ARF is invasive mechanical ventilation (IMV). The prognosis of lung cancer patients admitted to the intensive care unit is poor. The use of non-invasive mechanical ventilation (NIMV) in the setting of ARF not only supports the respiratory muscles and facilitates alveolar ventilation and airway patency, but also reduces the risk of serious complications of IMV, such as ventilator-associated pneumonia. NIMV treatment in the event of respiratory failure has been associated with a high rate of mortality in recently diagnosed or progressive lung cancer with organ failure. However, studies in this regard are limited, and the role of NIMV has yet to be investigated in patients in hospital wards. Accordingly, the present study investigates retrospectively the success of NIMV among patients with lung cancer (including all stages and histopathological types) in a hospital ward setting and the influential factors. The data of 42 patients with lung cancer and respiratory failure who were admitted to the palliative care service and received NIMV between 2014 and 2018 were reviewed retrospectively. Demographic features, comorbidities, respiratory failure types, rate of withdrawal from NIMV, frequencies of tracheostomy and intubation, bacteriologic examination of the airway samples, rate of discharge from hospital and any history of NIMV/USOT use at home were recorded. NIMV success was defined as the discharge of the patient from the hospital, with or without a respiratory support device. The primary end-point of the study was NIMV success, while the secondary end-point was NIMV success with respect to the underlying diagnosis and respiratory failure type. A total of 42 patients (38 males and 4 females) were included in the study, with a mean age of 67.4±9.5years. The rate of discharge from hospital was 71% across the entire study population, among which, 13 (31%) were discharged with USOT and 16 (38.1%) with NIMV. Among the 12 patients under palliative supportive treatment, 8 were discharged from the hospital. The success rates of NIMV in the respiratory failure aetiological subgroups were: 66% (12 patients) in the pneumonia subgroup and 71.4% (15 patients) in the COPD subgroup. The difference between these subgroups was not significant (P=.841). The success rate of NIMV in the hypercapnic and hypoxaemic respiratory failure subgroups was 72.7% (24 patients) and 66.6% (6 patients), respectively. There were no significant differences between the type of respiratory failure subgroups (P=.667). The success rate of NIMV was similar in patients with a positive airway sample microbiology (71.4%, n=14) and those with no growth identified in the culture (70.3%, n=28) (P=.834). In lung cancer patients with no contraindication, NIMV can be used to reduce or postpone the need for ICU admission, independent of disease stage, cellular type and underlying cause.

The Neutrophil/Lymphocyte Ratio Could Predict Noninvasive Mechanical Ventilation Failure in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Observational Study.

PurposeTo determine the effectiveness of neutrophil/lymphocyte ratio (NLR), compared to traditional inflammatory markers, for predicting noninvasive mechanical ventilation (NIMV) failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients.Patients and MethodsWe conducted this retrospective observational study including 212 AECOPD patients who required NIMV during hospitalization from January 2015 to December 2020 in the department of respiratory and critical care medicine of Beijing Chao-Yang Hospital (west campus). We reviewed the medical record to determine if NIMV succeeded or failed for each patient, and compared NLR with traditional markers (leukocyte, C-reactive protein [CRP] and procalcitonin [PCT]) between NIMV failure and NIMV success group. Receiver-operating characteristic (ROC) curve and multivariate logistic regression analysis were used to assess the accuracy of these markers for predicting NIMV failure.ResultsA total of 38 (17.9%) patients experienced NIMV failure. NLR was a more sensitive biomarker to predict NIMV failure (AUC, 0.858; 95% CI 0.785–0.931) than leukocyte counts (AUC, 0.723; 95% CI 0.623–0.823), CRP (AUC, 0.670; 95% CI 0.567–0.773) and PCT (AUC, 0.719; 95% CI 0.615–0.823). There was statistically positive correlation between NLR and leukocytes count (r=0.35, p<0.001), between NLR and CRP (r=0.258, p<0.001), between NLR and PCT (r=0.306, p<0.001). The cutoff value of NLR to predict NIMV failure was 8.9 with sensitivity 0.688, specificity 0.886 and diagnostic accuracy 0.868. NLR>8.9 (odds ratio, 10.783; 95% CI, 2.069–56.194; P=0.05) was an independent predictor of NIMV failure in the multivariate logistic regression model.ConclusionNLR may be an effective marker for predicting NIMV failure in AECOPD patients, and the patients with NLR>8.9 should be handled with caution since they are at higher risk of NIMV failure and require intubation. Further study with a larger sample size and with more data is necessary to confirm our study.

Non-invasive mechanical ventilation with average volume-assured pressure support. Results according to the aetiology of acute respiratory failure.

Until now, the ventilatory strategy with BiPAP S/T plus average volume-assured pressure support (AVAPS) has not been evaluated for its use in the different types of acute respiratory failure (ARF). Consequently we report the results of the use of this ventilatory strategy in these clinical scenarios. This is asingle-centre prospective study. The subjects were categorised according to the type of ARF: (1) hypercapnic ARF: chronic obstructive pulmonary disease and bronchial asthma; and (2) hypoxaemic ARF: pneumonia, acute respiratory distress syndrome, congestive heart failure, and interstitial lung disease. Multiple logistic regression was used to determine predictors of non-invasive mechanical ventilation (NIV) failure (intubation). Further, in asubgroup of patients with de novo hypoxaemic ARF, analysis of variances with repeated measures was used to determine factors associated with NIV outcome. Sixty-eight subjects were included in this study. The NIV success rate was 69.1% and the mortality rate was 20.6%. Amultivariate analysis showed that the number of affected lung quadrants on chest X-ray (OR: 4.23, 95% CI: 4.17-4.31; P < 0.001) and ARF precipitating disease (OR: 4.46, 95% CI: 4.43-4.51; P < 0.001) were determinants of NIV failure. In the hypoxaemic ARF subgroup (n = 58), significant differences in several parameters were found between patients with positive and negative outcomes. The use of BiPAP S/T - AVAPS in subjects with hypercapnic ARF is associated with abetter outcome than in those with de novo hypoxaemic ARF.

Risk factors of unfavorable outcomes in chronic obstructive pulmonary disease patients treated with noninvasive ventilation for acute hypercapnic respiratory failure.

Noninvasive mechanical ventilation (NIV) failure rate is reported to be 5%-60% of intensive care unit (ICU) patients. Despite all precautions and well-known reasons, the risk factors of NIV failure are unclear for chronic obstructive pulmonary disease (COPD) with acute respiratory failure (ARF). The aim of this study was to examine risk factors for NIV failure in COPD patients with ARF, other than well defined. The retrospective cohort study was done in ICU of a chest disease hospital. All consecutive COPD patients with hypercapnic ARF were enrolled in study. Demographics, comorbidities, arterial blood gases, reasons of ARF and length of ICU stay were recorded. NIV success was defined as discharge from ICU and NIV failure was defined as need for intubation or died during NIV. Patients were grouped into; NIV failure and success. The groups were compared and NIV failure risk factors were analyzed. About 265 NIV success and 142 NIV failure patients were enrolled into the study. Logistic regression test showed the risk factors for NIV failure; higher APACHE-II (≥ 29) (OR:11.71, CI95%4.39-31.18, P<0.001), culture positivity (OR:7.59, CI95%3.21-17.92, P<0.001), sepsis (OR:6.53 CI95%3.59-11.85, P<0.001) and pneumonia (OR:3.71 CI95%0.60-2.02, P<0.043) significantly. COPD patients using home-based NIV had less risk for NIV failure (OR: 0.49 CI95%0.28-0.87, P<0.014). APACHE II≥29 score, culture positivity, sepsis and pneumonia are the risk factors for NIV failure in COPD patients with ARF. COPD patients previously on home-based NIV showed half times less risk for NIV failure.

Clinical study on optimal switching mode in sequential noninvasive-invasive mechanical ventilation for acute exacerbation of chronic obstructive pulmonary disease

To explore the switch time of noninvasive-invasive mechanical ventilation sequential treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and effectively reduce the rate of tracheal intubation. A retrospective study was performed on patients with AECOPD, who underwent mechanical ventilation in emergency resuscitation room and admitted to department of respiration of Kaifeng Central Hospital Emergency Center from July 2014 to March 2019. The patients who used noninvasive mechanical ventilation (NIV) were included in NIV group (118 cases), and those who used invasive positive pressure ventilation (IPPV) were included in IPPV group (52 cases). The usage of breathing machine time, hospital days and hospital mortality were compared between the two groups. Clinical indicators such as age, gender, body temperature, respiratory rate, body mass index (BMI), mean arterial pressure (MAP), oxygenation index (PaO2/FiO2), respiratory index (RI), pH value, D-dimer, hemoglobin (HB), albumin, blood lactate (Lac), brain natriuretic peptide (BNP), C-reactive protein (CRP), procalcitonin (PCT), serum creatinine (SCr), white blood cell count (WBC), Glasgow coma scale (GCS), sputum excretion drainage were collected. The factors influencing the failure of NIV were analyzed by Logistic stepwise regression analysis. The receiver operating characteristic (ROC) curve was used to test the value of the NIV failure risk prediction model. There was no significant difference in total mechanical ventilation time and hospital mortality between NIV group and IPPV group (hours: 65.6±11.11 vs. 66.9±12.1, 6.8% vs. 9.6%, both P > 0.05), but the hospital time in group NIV was significantly shorter than that in IPPV group (days: 12.3±2.1 vs. 14.2±2.5, P < 0.05). In NIV group, 101 cases completed NIV continuously, 17 cases of NIV failure turned to IPPV, and the failure rate of NIV was 14.4%. There were statistically significant differences in gender, PaO2/FiO2, RI, pH value, D-dimer, PCT, WBC, Lac, sputum excretion drainage and GCS score between NIV failure patients and NIV success patients. Logistic regression analysis showed that RI, pH value, WBC and sputum excretion drainage were independent risk factors for NIV failure [RI: odds ratio (OR) = 3.879, 95% confidence interval (95%CI) was 1.258-11.963, P = 0.018; pH value: OR = 3.316, 95%CI was 1.270-8.660, P = 0.014; WBC: OR = 3.684, 95%CI was 1.172-11.581, P = 0.026; sputum excretion drainage: OR = 0.125, 95%CI was 0.042-0.366, P = 0.000]. The NIV failure risk prediction model based on the above independent risk factors had a good goodness of fit (χ 2 = 9.02, P = 0.34). ROC curve analysis showed that the NIV failure risk prediction model had a high predictive value for the patients with AECOPD [the area under ROC curve (AUC) was 0.818±0.051, 95%CI was 0.718-0.918, P = 0.000]. If patients with AECOPD have relative contraindications of NIV but still insist on using NIV, further risk stratification of NIV failure is needed. For those with RI, pH value, WBC abnormalities and sputum excretion drainage, the risk of choosing NIV is significantly increased. We need to pay more attention to the change of the condition and switch to IPPV in time to avoid exacerbation of the condition.

Can NT-pro BNP Levels Predict Prognosis of Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Intensive Care Unit?

Background:The prognostic value of amino terminal pro-brain natriuretic peptide levels in patients with acute exacerbation of chronic obstructive pulmonary disease has not been fully established.Aims:To investigate the predictive value of amino terminal pro-brain natriuretic peptide levels in terms of mortality, need for noninvasive mechanical ventilation, invasive mechanical ventilation, and weaning success.Study Design:Cohort study.Methods:Patients who were admitted to intensive care unit between December 2015 and December 2016 due to acute exacerbation of chronic obstructive pulmonary disease were included in the study. Demographic data, noninvasive mechanical ventilation application, need for invasive mechanical ventilation, amino terminal pro-brain natriuretic peptide level, duration of mechanical ventilation, intensive care unit and hospital stay, weaning success, and mortality rates were recorded.Results:A total of 110 patients (75 males) were included in the study. The mean age of the participants was 69 (61-76) years, and the mean Acute Physiology and Chronic Health Evaluation II score was 19 (15-23). The mean amino terminal pro-brain natriuretic peptide level was found to be lower in cases with noninvasive mechanical ventilation success than those with noninvasive mechanical ventilation failure (p=0.053). In addition, the mean amino terminal pro-brain natriuretic peptide level was significantly higher (4740 pg/mL vs. 3004 pg/mL, p=0.001) in patients who needed invasive mechanical ventilation support than in patients who did not. The mortality rate was significantly higher in patients who had an increasing trend of amino terminal pro-brain natriuretic peptide levels during hospitalization than in patients who had decreasing levels (59% vs. 23%, p=0.015). Based on the receiver operating characteristic analysis, the increasing trend of amino terminal pro-brain natriuretic peptide levels during intensive care unit stay predicted mortality with area under curve of 0.84 (p<0.0001, 95% CI: 0.75-0.93) and predicted invasive mechanical ventilation need with area under curve of 0.68.Conclusion:In cases of acute exacerbation of chronic obstructive pulmonary disease requiring mechanical ventilation, amino terminal pro-brain natriuretic peptide measurement and monitoring of its trend may be a valuable asset in predicting mortality, noninvasive mechanical ventilation, weaning success, and need for invasive mechanical ventilation.

Does the Body Mass Index Affect the Success of Noninvasive Mechanical Ventilation in Patients with Acute Hypercapnic Respiratory Failure?

Objective: Obesity has many negative effects on lung functions. It is not yet clear whether body mass index (BMI) affects the success of noninvasive mechanical ventilation (NIMV). The aim of this study was to investigate the differences in NIMV strategies, on the basis of BMI, in patients with acute hypercapnic respiratory failure and the effect of BMI on the success of NIMV. Methods: A total of 86 patients who had acute hypercapnic respiratory failure were enrolled consecutively. They were grouped according to BMI as follows: BMI 18.5 - 24.9kg/m 2 (normal); group 1, BMI 25 - 30kg/m2 (overweight); group 2, BMI>30kg/m2 (obese); group 3. Age, gender, duration of ICU stay, pressures of NIMV and Arterial Blood Gas (ABG) before, during and after the NIMV were recorded. Results: In total, 52 patients (60%) were male. The mean age of the patients was 70 ± 12 years. The success rates of NIMV in groups 1, 2 and 3 were 50%, 28% and 21%, respectively. The success rates were not significantly different between groups (p=0.79). In group 3, the respiratory rate was higher and pH was lower during the first hour compared to the other groups (p<0.05, p<0.05). PaCO 2 levels were higher in group 3 on the first day and at the end of NIMV treatment (p=0.04, p<0.05). Conclusion: NIMV strategies should be different in acute hypercapnic respiratory failure patients with a high BMI, and in these patients, clinical improvement requires a long duration.

Diaphragmatic motility assessment in COPD exacerbation, early detection of Non-Invasive Mechanical Ventilation failure: a pilot study

Background Patients with respiratory failure due to Chronic Obstructive Pulmonary Disease (COPD) have decreased diaphragmatic mobility [1]. Non Invasive Mechanical Ventilation (NIMV) is a cornerstone in COPD exacerbation therapy. The availability of early predictors of NIMV failure may be helpful to guide decision-making. Only pH, respiratory rate and PaO2/FiO2 have been considered predictors of response to NIMV [2]. Ultrasonographic (US) assessment of diaphragmatic kinetic is a fast, reliable and reproducible method [3], but its predictive value on NIMV success is not known.

Akut Solunum Yetmezliğinde Non-İnvaziv Mekanik Ventilasyon Kullanım Sürelerinin Başarıya Etkisi

Non-invasive mechanical ventilation (NIMV) is an important factor for decreasing mortality and morbidity in patients with chronic obstructive pulmonary disease (COPD) with respiratory failure. The relation is not clear between NIMV success and optimal NIMV usage duration. In this study, we aimed to investigate the effect of NIMV duration (total, night-daytime, at one time) on the treatment success. 35 patients (25 M, 10 F) with COPD with respiratory failure were included in this study and their mean age was 66.7±8.6. Patients’ initial mean APACHE II score was 18.8±4.7, PaCO2 70.0±19.6, pH 7.31±0.9, respiratory rate 28.5±6.0. Patients who required mechanichal ventilation with tracheal intubation and death were defined as treatment failure (n=7). NIMV durations were 13.1±3.0 hour/day, 5.5±2.1 hour/daytime and 7.6±2.7 hour/night. The mean duration of stay in the ICU was 11.7±6.9 day and the avarage total NIMV duration was 79.6±56.3 hours. The mean NIMV duration at one time was 2.7±0.9 hours and NIMV was used 4.7±1.7 times in a day. In logistic regression analysis, the total, nightday time and at one time duration of NIMV usage was not associated with the treatment failure but the duration of all day NIMV usage was significantly lower in the success group than failure group. The high APACHE II scorewas alsoa predicting factor for the treatment failure. We concluded that NIMV duration except duration of NIMV usage all day, is not a factor for the treatment success in patients with COPD with respiratory failure, however APACHE II score affects the treatment success.

Nonventilatory factors affecting noninvasive mechanical ventilation success in hypercapnic critical care patients

The aim was to determine the nonventilatory factors that affect the noninvasive mechanical ventilation (NIMV) success in patients with hypercapnic respiratory failure.

Effect of the presence of pneumonia on noninvasive ventilation success in chronic obstructive pulmonary disease cases with acute hypercapnic respiratory failure

To investigate the effect of the presence of pneumonia on the success of noninvasive mechanical ventilation (NIMV) in chronic obstructive pulmonary disease (COPD) cases with acute respiratory failure. Materials and methods: Sixty patients admitted to the intensive care unit (ICU) due to COPD exacerbation were included. The patients were divided into 2 groups as those with pneumonia (Group 1) and without pneumonia (Group 2). According to initial pH values, cases were also divided into 3 subgroups based on pH values. C-reactive protein (CRP), APACHE II scores, requirement of endotracheal intubation, mortality, and duration of ICU and hospital stay were also recorded. Results: NIMV success was found to be 85.5% in Group 1 and 51.1% in Group 2. Endotracheal intubation rates were higher in Group 2 (P = 0.008). NIMV failure was 70.1% in Group 2 and 10% in Group 1 in patients with severe acidosis. The APACHE II scores and CRP levels were significantly higher and independent risk factors in patients with NIMV failure (P < 0.002, P < 0.001). A significant difference was not found between groups in terms of duration of hospital and ICU stays and mortality. Conclusion: The presence of pneumonia in COPD cases is a factor that reduces NIMV success, but this does not affect mortality and the duration of ICU and hospital stay.

Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients

Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure.

Ventilatory support in critically ill hematology patients with respiratory failure

IntroductionHematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation. Noninvasive mechanical ventilation (NIMV) may decrease the risk of intubation, but NIMV failure poses its own risks.MethodsTo establish the impact of ventilatory management and NIMV failure on outcome, data from a prospective, multicenter, observational study were analyzed. All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up. Data on demographics, diagnosis, severity, organ failure, and supportive therapies were recorded. A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure.ResultsOf 450 patients, 300 required ventilatory support. A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival, whereas APACHE II score, allogeneic transplantation, and NIMV failure increased the risk of death. The risk factors associated with NIMV success were age, congestive heart failure, and bacteremia. Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated.ConclusionsNIMV improves the outcome of hematology patients with respiratory insufficiency, but NIMV failure may have the opposite effect. A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success.

Efficacy of Corticosteroid Therapy in Patients With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Ventilatory Support

Randomized trials assessing the effect of systemic corticosteroids on chronic obstructive pulmonary disease (COPD) exacerbations excluded patients who were mechanically ventilated or admitted to the intensive care unit (ICU). Critically ill patients constitute a population of persons who are prone to develop complications that are potentially associated with the use of corticosteroids (eg, infections, hyperglycemia, ICU-acquired paresis) that could prolong the duration of mechanical ventilation and even increase mortality. A double-blind placebo-controlled trial was conducted to evaluate the efficacy and safety of systemic corticosteroid treatment in patients with an exacerbation of COPD who were receiving ventilatory support (invasive or noninvasive mechanical ventilation). A total of 354 adult patients who were admitted to the ICUs of 8 hospitals in 4 countries from July 2005 through July 2009 were screened, and 83 were randomized to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo. The main outcome measures were duration of mechanical ventilation, length of ICU stay, and need for intubation in patients treated with noninvasive mechanical ventilation. There were no significant differences between the groups in demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables, and corticosteroid rescue treatment. Corticosteroid treatment was associated with a significant reduction in the median duration of mechanical ventilation (3 days vs 4 days; P = .04), a trend toward a shorter median length of ICU stay (6 days vs 7 days; P = .09), and significant reduction in the rate of NIV failure (0% vs 37%; P = .04). Systemic corticosteroid therapy in patients with COPD exacerbations requiring mechanical ventilation is associated with a significant increase in the success of noninvasive mechanical ventilation and a reduction in the duration of mechanical ventilation. clinicaltrials.gov Identifier: NCT01281748.