Noninvasive Ventilation Success Research Articles

Outcomes and predictors of success of noninvasive ventilation in acute exacerbation of chronic obstructive pulmonary disease

BackgroundNoninvasive ventilation is appropriately used as a first-line treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in many emergency departments. It has been evaluated in a large number of trials, often with clinically important benefits, but the use of noninvasive positive pressure ventilation remains highly variable across institutions and geographical regions. The aim of the study was first to emphasize the superiority of noninvasive ventilation (NIV) in acute hypercapneic respiratory failure in patients with an AECOPD in comparison with conventional therapy alone and second was to identify the predictors of NIV failure in such patients.Patientsand methods A total of 50 patients were randomly allocated into two equal groups: 25 patients subjected to medical and oxygen therapy (group I) and 25 to medical and NIV (group II). All patients were followed until death or discharge.ResultsGroup II had a success rate (for weaning and discharge) of 76%, whereas in group I, it was 20% (odds ratio=0.0789, 95% confidence interval=0.021–0.302 and P<0.001). Hospital stay was significantly longer in group I. Complications were significantly higher in group I. Mortality was significantly higher in group I. Improvement of arterial blood gases, respiratory rate, dyspnea scores and hypercarbic encephalopathy was significantly better in non-invasive positive pressure ventilation (NIPPV) group.ConclusionThe addition of NIPPV to standard therapy confers more benefits in patients with AECOPD, with significant reduction of in-hospital mortality, rate of endotracheal intubation, incidence of complications and length of hospital stay compared with standard therapy alone. On the contrary, failure can be predicted by the presence of more comorbidities, signs of severe exacerbation, high BMI, high baseline blood sugar, rapid respiratory rate at admission, abnormal baseline renal functions, high baseline C-reactive protein, high baseline acute physiology and chronic health evaluation II and BAP 65: B=BUN; A=Altered mental status; P=Pulse rate; 65-age years (BAP 65) scores, severe acidosis before NIV treatment and persistent severe acidosis after 1 h of treatment.

Risk factors for noninvasive ventilation failure in patients with post-extubation acute respiratory failure after cardiac surgery.

The effect of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF) after cardiac surgery is controversial. This study identified the feasibility of NIV and assessed the risk factors of NIV failure in patients with ARF after cardiac surgery. We retrospectively reviewed data from 112 patients with ARF requiring NIV and categorized them into the NIV failure and success groups. Patient data were extracted for further analysis, the primary outcomes were the need for endotracheal intubation and NIV-related in-hospital mortality. The risk factors for NIV failure in patients with post-extubation ARF was analyzed. The median time from extubation to NIV was 11 hours. No difference in the EuroSCORE existed between the two groups. NIV failed in 38.4% of the patients. The NIV failure group had a higher in-hospital mortality and stay at the longer intensive care unit (ICU). Most cases of NIV failure occurred within 1-48 hours of the treatment. The main causes of early NIV failure were a weak cough reflex and/or excessive secretions and hemodynamic instability. A Sequential Organ Failure Assessment (SOFA) score ≥10.5, vasoactive-inotropic score ≥6, and pneumonia were predictors of NIV failure, whereas a body mass index (BMI) ≥25.0 kg/m2 predicted NIV success. NIV was effective in the study population. Multiple organ dysfunction, pneumonia, and significant inotropic drug support before NIV were associated with NIV failure, whereas a BMI ≥25 kg/m2 was a predictor of NIV success.

Abstract P-581: NON-INVASIVE VENTILATION WITH NASAL-PHARYNGEAL TUBE IN LIMITED RESOURCE: CASE SERIES

Aims & Objectives: Use of non-invasive ventilation (NIV) has increased in past years. Successful NIV requires compatible interface, however, NIV masks have not been widely available in our country so we tried alternative interface, albeit less effective because of potential leakage. Methods Case series Results Case 1. A 3-months-old baby, 3.6kg, was admitted with respiratory failure, pneumonia, and large PDA. She was intubated for 8 days then switched to NIV–pressure control (PC) mode (Servo-i) with ET tube 3.0 inserted 8 cm from nostril, respiratory rate (RR) 30x/minute, FiO2 40%, PIP 15/PEEP 6. Minute volume (MV) 0.6–0.9 L, PaO2 108.8, and PaCO2 32.7 were achieved without increased work of breathing. Case 2. A 4-months-old boy, 7.6kg, was admitted with pneumonia and respiratory failure. He had diaphoresis, chest indrawing, SaO2 90%, PaO2 33.2, and PaCO2 59.7, with 6 lpm oxygen (PaO2/FiO2 ratio 83). NIV–PC mode was started with ET tube 3.5 inserted 9 cm from nostril, RR 20x/minute, FiO2 65%, PIP 15/PEEP 5. His work of breathing was reduced significantly after NIV, RR was decreased from 60 to 30x/minute, and SaO2 was improved. Case 3. A 3.5-years-old boy, 15kg, admitted with dilated cardiomyopathy, cardiogenic shock, and increased work of breathing on 1 lpm nasal oxygen. NIV–PC was administered using ET tube 4.0, 12 cm depth, RR 30x/minute, FiO2 40%, PIP 15/PEEP 5. Chest wall retraction was diminished after NIV. Conclusions Despite of our limited resource, NIV showed promising results in respiratory failure and prevention of reintubation. Shortened ET tube might be used as alternative interface in pediatric NIV.

How should we monitor patients with acute respiratory failure treated with noninvasive ventilation?

Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.

Characteristics of influenza pneumonia patients admitted to the ICU due to hypoxemic respiratory failure.

Hypoxemic respiratory failure due to influenza pneumonia during epidemic seasons sometimes may require mechanical ventilation support and intensive care unit (ICU) stay. We aimed to evaluate the characteristics and risk factors of influenza pneumonia patients admitted to our ICU due to hypoxemic respiratory failure. Patients admitted to our ICU between December 2015 and March 2016 who had hypoxemic respiratory failure due to clinically and radiologically suspected influenza pneumonia were enrolled. Twenty two patients (11 male) met the enrollment criteria. Median age and APACHE II score was 45 (36-63) years and 19 (13-25) respectively. Maximum set PEEP levels during mechanical ventilation was significantly lower in patients who survived [10 (8-10) vs 13 (10-16), p= 0.025)]. Deceased patients spent more time under a PaO2/FiO2 ratio below 100 [72 (24-90) vs. 0 (0-48) hours, p= 0.024]. Survival rate was 88% (7/8) in patients who had noninvasive ventilation (NIV) success while it was only 7% (1/14) in patients who had undergone invasive mechanical ventilation (p< 0.001). Overall mortality was 64%. Viral pneumonia may result in severe hypoxemic respiratory failure and ARDS especially during epidemic seasons. NIV success, time spent under a PaO2/FiO2 ratio below 100 and low serum albumin levels at admission may be predictors of severity of the disease and mortality.

Effectiveness of non-invasive ventilation in acute respiratory failure of obese patients: a brief narrative review

Non-invasive ventilation (NIV) has been used successfully for the management of acute respiratory failure (ARF) more often in the last two decades compared to prior decades; nevertheless, NIV can have failure rates ranging from 5% to 50%. However, there are particular groups of patients that are more likely to benefit from NIV. One of these groups is patients with hypoventilation syndrome (OHS). The aim of this review is to seek evaluation of the effectiveness of NIV in acute setting. Only a few studies have investigated NIV success or failure in OHS patients. More than 30% of them were diagnosed when hospitalized for ARF. NIV rarely failed in reversing ARF. OHS patients who exhibited early NIV failure had a high severity score and a low HCO3 level at admission; more than half of hypercapnic patients with decompensated OHS exhibited a delayed but successful response to NIV. Patients with decompensation of OHS have a better prognosis and response to NIV than other hypercapnic patients. They require more aggressive NIV settings, a longer time to reduce PaCO2 levels, and more frequently a delayed but successful response to NIV.

Efficacy of noninvasive ventilation on treatment of ARDS caused by severe pneumonia after kidney transplantation

To observe the clinical efficacy of noninvasive ventilation (NIV) on the treatment of acute respiratory distress syndrome (ARDS) caused by severe pneumonia after kidney transplantation. The clinical data of 17 patients who were diagnosed as ARDS caused by severe pneumonia after kidney transplantation and treated with NIV in Sichuan Provincial People's Hospital from January 1st, 2014 to June 1st, 2016 were collected and retrospectively analyzed. According to the result of NIV treatment, the patients were divided into NIV success group (n = 9) and NIV failure group (n = 8). The differences in gender, age, underlying diseases, acute physiology and chronic health evaluation II (APACHE II) score, laboratory parameters on the day when ARDS was diagnosed, daily immunosuppressive dosage, NIV support condition and duration, arterial blood gas analysis and adverse reactions between the two groups were compared. Receiver operating characteristic curve (ROC) was plotted, and the predictive value of each parameters for NIV results was evaluated. The two groups were similar in gender, age, and underlying diseases. The APACHE II score, serum levels of procalcitonin (PCT) and brain natriuretic peptide (BNP), serum creatinine (SCr), daily tacrolimus dose, and NIV support condition in NIV failure group were significantly higher than those in NIV success group [APACHE II score: 16.7±5.7 vs. 10.3±2.1, PCT (μg/L): 32.8 (1.2, 187.7) vs. 0.3 (0.1, 2.9), BNP (ng/L): 832.4 (263.7, 1 180.2) vs. 157.0 (33.9, 218.5), SCr (μmol/L): 284.8 (90.5, 474.2) vs. 186.6 (76.7, 206.3), daily tacrolimus dose (mg): 3.6 (3.1, 4.0) vs. 2.6 (2.0, 3.5), inspiratory positive airway pressure (IPAP, cmH2O, 1 cmH2O = 0.098 kPa): 14.8±4.1 vs. 9.0±1.1, expiratory positive airway pressure (EPAP, cmH2O): 7.6±1.8 vs. 4.7±0.8, fraction of inspired oxygen (FiO2): 0.75±0.25 vs. 0.43±0.06, all P < 0.05], and the oxygenation index (PaO2/FiO2) after treatment was significantly lower than that of NIV success group [mmHg (1 mmHg = 0.133 kPa): 107.4±65.2 vs. 268.7±98.8, P < 0.05]. There was no significant difference in albumin (Alb), white blood cell count (WBC), daily mycophenolate mofetil dose, use of glucocorticold, NIV duration, pH value, arterial partial pressure of carbon dioxide (PaCO2), or the incidence of sputum drainage disorder or pneumothorax between the two groups. ROC curve analysis showed that the predictive value of APACHEII score, serum PCT and BNP levels, tacrolimus daily dosage and PaO2/FiO2 changes after NIV treatment for the efficacy of NIV was high, the area under the ROC curve (AUC) was 0.813, 0.778, 0.903, 0.778, 0.764, respectively; when the cut-off value of APACHE II score was 16.0, PCT was 4.1 μg/L, BNP was 180.5 ng/L, tacrolimus daily dosage was 2.5 mg, PaO2/FiO2 increased 49.5 mmHg, the sensitivity was 87.5%, 75.2%, 87.5%, 87.5% and 75.0%, respectively, and the specificity was 77.8%, 66.7%, 88.9%, 74.4%, 88.9%, respectively. However, SCr was not sensitive to the NIV effect prediction. NIV in the treatment of ARDS caused by severe pneumonia after kidney transplantation has a certain value. The fewer tacrolimus daily dosage, the lower APACHE II score and levels of PCT and BNP, the more effective promotion of PaO2/FiO2 after NIV treatment, and the better curative effect is suggested.

Choosing the Proper Interface for Positive Airway Pressure Therapy in Subjects With Acute Respiratory Failure.

Noninvasive ventilation is an effective treatment for a significant proportion of patients with acute respiratory failure. The success of noninvasive ventilation, however, depends on several factors, a major one being the selection of the proper interface. The choice and application of the interface in patients with acute respiratory failure is a considerable challenge for any treatment team. This review discusses the different types of interfaces that can be used in patients with acute respiratory failure, the differences between nasal, oro-nasal, and total face masks and the helmet, as well as the effect of interface type on treatment success and upper airway patency, mask fitting, problems related to the interface, and the relationship between ventilator type and interface choice.

Predictors of noninvasive ventilation failure in critically ill obese patients: a brief narrative review.

&nbsp;Non-invasive ventilation ( NIV ) has been used successfully for the management of acute respiratory failure (ARF) more often in the last two decades than previously. Unfortunately, NIV can have failure rates ranging from 5% to 50% and patient selection is the key to success. There are particular groups of patients that are more likely to benefit from NIV. For patients with hypoventilation syndrome (OHS) this treatment can be beneficial. This review seeks to evaluate the effectiveness of NIV in acute ARF and determine predictors of NIV failure in morbidly obese patients. Only a few studies have investigated NIV success or failure in these patients. NIV was most often effective when patients were carefully selected. Obese patients who exhibited early NIV failure had a high severity score at admission. In contrast, more than half of hypercapnic patients with decompensated OHS exhibited a delayed but successful response to NIV. Patients with decompensation of OHS had better prognosis and response to NIV than other hypercapnic patients. They required more aggressive NIV settings, a longer time to reduce paCO₂ levels , and more frequently a delayed but successful response to NIV which should encourage the use of NIV rather than early intubation. Since clear predictors of NIV failure have not been identified, a strict and prolonged monitoring is mandatory.

Use of Non-invasive Ventilation in Neuromuscular Disease

The purpose of this review is to add to the growing body of literature on non-invasive ventilation (NIV) for patients with neuromuscular disease (NMD). We synthesize information on screening for respiratory failure, describe protocols for initiating and troubleshooting NIV in NMD patients, discuss the use of advanced modes of ventilation such as volume-assured pressure support (VAPS), and provide recommendations for long-term follow-up and management. Screening of respiratory insufficiency increases by testing supine FVC, MIP, nocturnal oximetry, and a higher threshold for FVC. PSG may not be needed in all patients starting NIV. VAPS mode can increase patient comfort and compliance. Sialorrhea management is essential to successful NIV, and myriad options exist. Utilization of NIV will increase as the NMD population increases. Clinicians must be comfortable with screening and diagnosing chronic respiratory failure, initiating NIV, and the long-term follow-up of these patients.

Risk Factors for Noninvasive Ventilation Failure in Critically Ill Subjects With Confirmed Influenza Infection

Despite wide use of noninvasive ventilation (NIV) in several clinical settings, the beneficial effects of NIV in patients with hypoxemic acute respiratory failure (ARF) due to influenza infection remain controversial. The aim of this study was to identify the profile of patients with risk factors for NIV failure using chi-square automatic interaction detection (CHAID) analysis and to determine whether NIV failure is associated with ICU mortality. This work was a secondary analysis from prospective and observational multi-center analysis in critically ill subjects admitted to the ICU with ARF due to influenza infection requiring mechanical ventilation. Three groups of subjects were compared: (1) subjects who received NIV immediately after ICU admission for ARF and then failed (NIV failure group); (2) subjects who received NIV immediately after ICU admission for ARF and then succeeded (NIV success group); and (3) subjects who received invasive mechanical ventilation immediately after ICU admission for ARF (invasive mechanical ventilation group). Profiles of subjects with risk factors for NIV failure were obtained using CHAID analysis. Of 1,898 subjects, 806 underwent NIV, and 56.8% of them failed. Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, infiltrates in chest radiograph, and ICU mortality (38.4% vs 6.3%) were higher (P < .001) in the NIV failure than in the NIV success group. SOFA score was the variable most associated with NIV failure, and 2 cutoffs were determined. Subjects with SOFA ≥ 5 had a higher risk of NIV failure (odds ratio = 3.3, 95% CI 2.4-4.5). ICU mortality was higher in subjects with NIV failure (38.4%) compared with invasive mechanical ventilation subjects (31.3%, P = .018), and NIV failure was associated with increased ICU mortality (odds ratio = 11.4, 95% CI 6.5-20.1). An automatic and non-subjective algorithm based on CHAID decision-tree analysis can help to define the profile of patients with different risks of NIV failure, which might be a promising tool to assist in clinical decision making to avoid the possible complications associated with NIV failure.

The impact of frailty on noninvasive mechanical ventilation in elderly medical intensive care unit patients.

Many factors affecting noninvasive ventilation (NIV) in critically ill patients have been reported in the literature, but there is no study about the effect of frailty. With this study, the frailty prevalence was evaluated with two different frailty scores among the NIV population of a medical intensive care unit (ICU). Besides, the impact of frailty on NIV success and mortality and its association with NIV application problems were evaluated. A prospective observational cohort study was performed on patients who were over 50 years of age and assigned to NIV due to hypercapnic respiratory failure. For the assessment of frailty, Clinical Frailty Scale (CFS) and The Edmonton Frailty Scale (EFS) were used and the ones with CFS ≥5 and EFS ≥8 were considered as fragile. The study population was classified and compared according to NIV success, ICU outcome (discharge or exitus) and NIV application problems. A total of 103 patients with the mean age of 73 ± 11 years were included. The incidence of frailty was 41% with CFS ≥5 and 36% with EFS ≥8. The NIV failure occurred in 30 (29%) patients. Among them frailty and SOFA score was higher; Glasgow Coma Scale (GCS) was lower. In multivariate analysis GCS (OR: 1.2, p: 0.042) and frailty with EFS (OR: 2.8, p: 0.027) were identified as independent risk factors of NIV failure. Sixty-five (63%) patients had NIV application problems and frailty was higher among them with both CFS and EFS (p < 0.05). Mortality occurred in 18 (17%) patients; NIV failure and frailty according to CFS were independent risk factors of mortality. The frailty is associated with higher NIV application problems, failure and mortality risk in elderly ICU patients. The CFS and EFS frailty scores can be used to predict NIV success and outcomes in ICUs.

Randomized crossover trial of a pressure sensing visual feedback system to improve mask fitting in noninvasive ventilation.

A good mask fit, avoiding air leaks and pressure effects on the skin are key elements for a successful noninvasive ventilation (NIV). However, delivering practical training for NIV is challenging, and it takes time to build experience and competency. This study investigated whether a pressure sensing system with real-time visual feedback improved mask fitting. During an NIV training session, 30 healthcare professionals (14 trained in mask fitting and 16 untrained) performed two mask fittings on the same healthy volunteer in a randomized order: one using standard mask-fitting procedures and one with additional visual feedback on mask pressure on the nasal bridge. Participants were required to achieve a mask fit with low mask pressure and minimal air leak (<10 L/min). Pressure exerted on the nasal bridge, perceived comfort of mask fit and staff- confidence were measured. Compared with standard mask fitting, a lower pressure was exerted on the nasal bridge using the feedback system (71.1 ± 17.6 mm Hg vs 63.2 ± 14.6 mm Hg, P < 0.001). Both untrained and trained healthcare professionals were able to reduce the pressure on the nasal bridge (74.5 ± 21.2 mm Hg vs 66.1 ± 17.4 mm Hg, P = 0.023 and 67 ± 12.1 mm Hg vs 60 ± 10.6 mm Hg, P = 0.002, respectively) using the feedback system and self-rated confidence increased in the untrained group. Real-time visual feedback using pressure sensing technology supported healthcare professionals during mask-fitting training, resulted in a lower pressure on the skin and better mask fit for the volunteer, with increased staff confidence.

Obesity and perioperative noninvasive ventilation in bariatric surgery.

The incidence and prevalence of obesity continues to increase globally. Physicians will therefore provide care for an increasing number of obese patients in their clinical practice. Optimal management of these patients is required to minimize the risk of perioperative complications that increase morbidity and mortality. Obesity affects the respiratory function. It is generally associated with reduced lung volume with increased atelectasis, decreased lung and chest wall compliance, increased airway resistance, and moderate to severe hypoxemia. These physiologic alterations are generally more pronounced in obesity complicated by obstructive sleep apnea syndrome or obesity hypoventilation syndrome. Anesthesia and surgery can profoundly impair respiratory function, increasing the risk of postoperative respiratory complications and acute respiratory failure. Certain comorbidities associated with obesity (e.g., metabolic syndrome, obstructive sleep apnea, pulmonary disease) further increase the risk of perioperative complications. Non-invasive ventilation (NIV) is emerging as an important strategy to minimize perioperative complications. It may ameliorate obesity-related comorbidities, counteract upper airway obstruction, reduce hypoventilation and atelectasis, improve gas exchange and respiratory function, relieve dyspnea, and decrease breathing effort in obese patients in the perioperative period. Thus, NIV may lower the risk of acute respiratory failure after bariatric surgery. Selecting the appropriate interface and type of NIV is fundamental for increasing the likelihood of NIV success in such high-risk patients. NIV is a safe therapy, which should be considered in the perioperative period to help optimize the management of obese patients undergoing bariatric surgery and improve their postoperative course.

Salvage treatment for non-invasive ventilation intolerance in cardiac surgical patients with dexmedetomidine: a pilot feasibility trial

Objective To investigate the efficacy of dexmedetomidine on sedation in post-cardiac surgery patients with NIV intolerance. The changes of respiratory function and hemodynamics of the patients as well as non-invasive ventilation (NIV) failure rate were also under evaluation. Methods Thirty-five post-cardiac surgery patients with NIV intolerance and hypoxemia were enrolled in this prospective study. All patients were sedated with dexmedetomidine. NIV was standardized according to the uniform protocol. The main outcome was NIV success (avoiding endotracheal intubation) or NIV failure (requiring endotracheal intubation or die). The cardiorespiratory parameters (BP, HR and RR) and artery blood gas analysis were prospectively recorded before and after sedation. The respiratory function and hemodynamics changes in both groups (NIV success group and NIV failure group ) were then evaluated. Factors independently associated with NIV failure were identified using a logistic regression model. Results Twenty out of 35 patients (57.14%) survived while 15 (42.86%) patients failed NIV. After 1 h and 4 h of NIV with dexmedetomidine sedation, respiratory rate in both groups were decreased compared with baseline, especially in NIV success group. The PaO2/FiO2 was also improved after 1h and 4h of NIV treatment compared with baseline. The improvement was more significantly in NIV success group. The heart rate was decreased compared with baseline with no differences between two groups. There were no significant changes on PaCO2 and mean arterial pressure (MAP) during the treatment. The respiratory and hemodynamics variables identified as predictors of NIV failure were included in a multivariate logistic regression. RR>23 time/min(OR=3.2, 95%CI: 2.043~4.301, P 20 time/min(OR=2.1, 95%CI: 1.659~3.231, P=0.025)4 h after NIV, PaO2/FiO2 <178 mmHg(OR=2.4, 95%CI: 1.892~3.287, P<0.01)1 h after NIV and PaO2/FiO2 <185 mmHg(OR=1.7, 95%CI: 1.243~2.365, P=0.041)4 h after NIV independently predicted NIV failure. Conclusions Dexmedetomidine might be considered as an effective and safe sedative for post-cardiac surgery patients with NIV intolerance. Early identification of predictors of NIV failure may facilitate early intervention. Key words: Non-invasive ventilation; Sedation; Dexmedetomidine; Cardiac surgery

Non-invasive ventilation for acute hypercapnic respiratory failure in older patients.

This trial was conducted to carry out an age and etiology-based analysis of the clinical efficacy of non-invasive ventilation (NIV) in acute hypercapnic respiratory failure (AHRF). This single center, prospective, cohort study included patients aged≥65years with chronic obstructive pulmonary disease (COPD), acute cardiogenic pulmonary edema (ACPE), community-acquired pneumonia (CAP), bronchiectasis, and kyphoscoliosis, who were treated with NIV for AHRF in the intensive care unit within a4-year period. From 496 patients aged 65years or older treated with NIV for AHRF, 162 patients were included. Of the patients 71 were aged 65-74years, 70 were 75-84years, and 21 were aged ≥85years. Of the patients 90 had COPD, 31 had ACPE, 19 had CAP, 15 had bronchiectasis exacerbation and 7had kyphoscoliosis as the AHRF etiology. The treatment with NIV was successful in 119 patients. No significant difference was found between the age groups regarding NIV success rates (p= 0.803). An etiology-based analysis revealed that NIV was significantly more successful in the COPD and ACPE groups (p= 0.029, p= 0.035). Amultivariate analysis revealed that Glasgow coma scale (GCS) (hazard ratio HR 0.215, 95% confidence interval CI: 0.104 to 0.442; p< 0.001), COPD assessment test (CAT) (HR 1.563, 95%CI: 1.229 to 1.987; p< 0.001), and acute physiology and chronic health evaluation(APACHE) ΙΙ (HR 1.009, 95%CI: 1.001 to 1.018; p= 0.031) as significant independent predictors of NIV failure in patients with COPD and AHRF. The efficacy of NIV was independent of age in patients aged ≥65years with AHRF and NIV was most successful when the etiology of AHRF was COPD or ACPE. Dyspnea level, GCS, and APACHE-ΙΙ scores were independent predictors of NIV failure in COPD.

Noninvasive Ventilation in Patients With Hematologic Malignancy.

Noninvasive ventilation (NIV) is commonly used as first-line therapy for immunocompromised patients with acute respiratory failure. However, it may not be appropriate for all patients, as failure of NIV and delayed endotracheal intubation (ETI) may increase mortality. We report our center's experience and outcomes for patients with active hematologic malignancy (HM) treated with NIV. We conducted a retrospective study of consecutive patients with HM who were admitted to the intensive care unit (ICU) of Mount Sinai Hospital for acute respiratory failure between January 1, 2010, and May 31, 2015, and were initially treated with NIV. We compared the characteristics of patients who were successfully treated with NIV and avoided intubation and those who failed NIV. Seventy-nine patients (mean age 56 ± 14 years, mean Acute Physiology and Chronic Health Evaluation II score 27 ± 5) with HM were treated with NIV for acute respiratory failure. The etiology of respiratory failure was multifactorial in 31 (39%) patients, with features of pneumonia in 61 (77%) patients, severe sepsis or septic shock in 33 (42%) patients, and pulmonary edema in 24 (30%) patients. The majority of patients were admitted with acute leukemia (n = 60, 76%), 8 (10%) with lymphoma, and 11 (14%) with chronic leukemia, multiple myeloma, or myelodysplastic syndrome. Of the 79 patients treated with NIV, 44 (56%) failed NIV and required ETI, 7 (9%) had a do-not-intubate (DNI) order and died, and 28 (35%) avoided ETI. Compared with patients who avoided ETI, those who failed NIV or had a DNI order and died were more likely to have acute leukemia (84% vs 61%; P = .02) and at baseline had higher Paco2 (39 vs 30; P = .038), higher fraction of inspired oxygen (Fio2) requirements (0.6 vs 0.4; P = .002), and more vasopressor use (31% vs 11%; P = .059). The ICU mortality was 42%; 3-month mortality was 57% overall and was significantly lower in the NIV success patients compared with the NIV failure group (21% vs 74%; P < .001). Two-thirds of patients with HM and respiratory failure failed NIV and required ETI, and had high subsequent mortality. Patients who failed NIV had higher Paco2, higher Fio2, and a trend toward more vasopressor use.

Success or failure of non-invasive positive pressure ventilation in children with acute respiratory failure. Could it be predicted?

&lt;b&gt;Introduction: &lt;/b&gt; Noninvasive ventilation (NIV) has been developed to reduce complications associated with invasive ventilation (IV). Failure of NIV and delay in endotracheal intubation can increase patients’ morbidity and mortality. Thus early determination of patients who are unlikely to benefit from NIV is crucial for their management. We aimed in this study to identify the early predictors of success of NIV in children with acute respiratory failure (ARF).&lt;br /&gt; &lt;b&gt;Material and methods: &lt;/b&gt; Fifty patients with ARF who fulfilled the study selection criteria were ventilated non-invasively and were assessed initially for their severity of critical illness by the Pediatric Logistic Organ Dysfunction (PELOD) score. Clinical, gasometric, respiratory mechanics and oxygenation indices were assessed at 0, 30 and 60 min and 4 and 24 h from the start of NIV. The success group was identified by reduction in respiratory effort, reduction in oxygen demand, improvement in gasometric parameters, and avoidance of intubation.&lt;br /&gt; &lt;b&gt;Results&lt;/b&gt;: Sixty-two percent of patients had successful NIV. Neither type of ARF nor patients’ demographics affected the outcome of NIV. The success rate was 80% among patients with mild to moderate acute respiratory distress syndrome (ARDS), 20% with severe ARDS, and 71.8% in patients with bronchopneumonia. Multivariate analysis revealed that baseline PELOD score of less than 14.5 ±2.7, SpO2/FiO2 ratio more than 208 ±57, oxygenation index (OI) 7 ±3.4 and mean airway pressure (MAP) 8.6 ±1.3 are independent predictors for success of NIV.&lt;br /&gt; &lt;b&gt;Conclusions&lt;/b&gt;: The NIV is a promising respiratory support modality in pediatric ARF. Baseline degree of critical illness and saturation oxygenation indices together with MAP change after the 1st h from the NIV trial represented the best predictors of success of the trial in the current study.

Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study.

Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse. To determine whether, during NIV, the categorization of ARDS severity based on the PaO2/FiO2 Berlin criteria is useful. The LUNG SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) study described the management of patients with ARDS. This substudy examines the current practice of NIV use in ARDS, the utility of the PaO2/FiO2 ratio in classifying patients receiving NIV, and the impact of NIV on outcome. Of 2,813 patients with ARDS, 436 (15.5%) were managed with NIV on Days 1 and 2 following fulfillment of diagnostic criteria. Classification of ARDS severity based on PaO2/FiO2 ratio was associated with an increase in intensity of ventilatory support, NIV failure, and intensive care unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate, and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1% and 45.4%, respectively. NIV use was independently associated with increased ICU (hazard ratio, 1.446 [95% confidence interval, 1.159-1.805]), but not hospital, mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FiO2 lower than 150 mm Hg. NIV was used in 15% of patients with ARDS, irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FiO2 lower than 150 mm Hg. Clinical trial registered with www.clinicaltrials.gov (NCT 02010073).

Noninvasive ventilation in cancer children with acute respiratory failure

Objective: To establish the effectiveness of noninvasive ventilation in cancer children with acute respiratory failure. Methods: The data of 33 cancer patients were obtained prospectively from six different pediatric intensive care units in Turkey between the years of 2012 and 2013. Results: The diagnosis was leukemias in 25 (75.8%), lymphomas in 3 (9.1%) and other solid tumors in 5 (15.1%) patients. Pneumonia in 12 (36.3%) and sepsis in 15 (45.4%) patients were seen as the common reasons of respiratory failure. The mean PaO2/FiO2 ratios were (164.22 ± 37.24) and (126.80 ± 42.73) in noninvasive ventilation success and failure group, respectively. Noninvasive ventilation was successful in 18 (54.5%) patients. The failure group consisted of 15 patients required intubation. A total of 14 (42.4%) patients died. The clinical outcome in terms of success and failure was meaningful statistically (P = 0.0 00 1). Conclusions: Our results could encourage the use of noninvasive ventilation in children with cancer who develop acute respiratory failure. It should be considered as a useful therapeutic approach to avoid endotracheal intubation