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NIV in acute respiratory failure

นพ.ภก.วิรัช ตั้งสุจริตวิจิตร , ภ.บ., พ.บ.หน่วยโรคระบบการหายใจและเวชบำบัดวิกฤต

โรงพยาบาลรามาธิบดี

• NIV in acute respiratory failure

• Hypercapnic respiratory failure : COPD

• Hypoxemic respiratory failure : ACPE

failure, we performed an additionalsensitivity analysis excluding patientswith a sleep apnea diagnosis (ICD-9-CM372.2 or 780.57). A two-sided a levelof 0.05 was selected for statisticalsignificance.

Results

Trends in Acute Respiratory FailureOf about 78 million (346 millionpopulation-weighted) discharges included

in the NIS during years 2000 to 2009, weidentified 2,380,632 (3%; 11,659,668 millionpopulation weighted) hospitalizations withan acute respiratory failure claim.Characteristics of patients with acuterespiratory failure claims in years 2000 and2009 are shown in Table 1. COPD waspresent in 900,750 (37%; 4.4 millionpopulation-weighted) cases with an acuterespiratory failure code (see Figure E1 inthe online supplement). From the years2000 to 2009, the incidence of acuterespiratory failure–coded hospitalizationsincreased from 165 to 257 per 100,000United States residents (56% increase) forpatients with COPD and increased from238 to 463 per 100,000 (95% increase) inpatients without COPD (Figure E2)

Trends in NIV and MVPopulation-based use of NIV duringa hospitalization with an acute respiratoryfailure claim increased in patients withCOPD from 8.6 to 39 per 100,000 UnitedStates residents (360% increase), and NIVuse in patients without COPD increasedfrom 6 to 39 patients per 100,000 UnitedStates residents during the years 2000 to2009 (560% increase); the use of MVincreased by 73% for patients withoutCOPD but remained relatively stable amongpatients with COPD (7% increase)(Figure 1).

Among patients with acute respiratoryfailure codes, practice patterns involvingthe choice of initial ventilator interfacechanged similarly for patients with COPD(Figure 2A) and patients without COPD(Figure 2B) from 2000 to 2009. Theproportion of patients with a COPDdiagnosis who received NIV increased from3.5% in 2000 to 12.3% in 2009 (250%increase), whereas 1.2% of patients withoutCOPD received NIV in 2000 comparedwith 6.0% in 2009 (400% increase). Theseresults represent a 14.3% APC (95% CI,12.1–16.8) in NIV among patients withCOPD and a 18.1% APC (95% CI, 15.9–20.7) among patients without COPD (P =0.02) (Figure E3). Results did not changesubstantially in a sensitivity analysis usingan alternative definition of COPD (COPD:260% increase in NIV; no COPD: 360%increase in NIV) or in a sensitivity analysiswhere patients with COPD or cardiogenicpulmonary edema (300% increase in NIV)were compared with patients withoutCOPD or cardiogenic pulmonary edema(340% increase in NIV). The proportion of

Figure 2. (A) United States trends in ventilator practice patterns during acute respiratory failurehospitalizations among patients with chronic obstructive pulmonary disease, 2000 to 2009. (B) UnitedStates trends in ventilator practice patterns during acute respiratory failure hospitalizations amongpatients without a diagnosis of chronic obstructive pulmonary disease, 2000 to 2009.

ORIGINAL ARTICLE

Walkey and Soylemez Wiener: Use of Noninvasive Ventilation 13

failure, we performed an additionalsensitivity analysis excluding patientswith a sleep apnea diagnosis (ICD-9-CM372.2 or 780.57). A two-sided a levelof 0.05 was selected for statisticalsignificance.

Results

Trends in Acute Respiratory FailureOf about 78 million (346 millionpopulation-weighted) discharges included

in the NIS during years 2000 to 2009, weidentified 2,380,632 (3%; 11,659,668 millionpopulation weighted) hospitalizations withan acute respiratory failure claim.Characteristics of patients with acuterespiratory failure claims in years 2000 and2009 are shown in Table 1. COPD waspresent in 900,750 (37%; 4.4 millionpopulation-weighted) cases with an acuterespiratory failure code (see Figure E1 inthe online supplement). From the years2000 to 2009, the incidence of acuterespiratory failure–coded hospitalizationsincreased from 165 to 257 per 100,000United States residents (56% increase) forpatients with COPD and increased from238 to 463 per 100,000 (95% increase) inpatients without COPD (Figure E2)

Trends in NIV and MVPopulation-based use of NIV duringa hospitalization with an acute respiratoryfailure claim increased in patients withCOPD from 8.6 to 39 per 100,000 UnitedStates residents (360% increase), and NIVuse in patients without COPD increasedfrom 6 to 39 patients per 100,000 UnitedStates residents during the years 2000 to2009 (560% increase); the use of MVincreased by 73% for patients withoutCOPD but remained relatively stable amongpatients with COPD (7% increase)(Figure 1).

Among patients with acute respiratoryfailure codes, practice patterns involvingthe choice of initial ventilator interfacechanged similarly for patients with COPD(Figure 2A) and patients without COPD(Figure 2B) from 2000 to 2009. Theproportion of patients with a COPDdiagnosis who received NIV increased from3.5% in 2000 to 12.3% in 2009 (250%increase), whereas 1.2% of patients withoutCOPD received NIV in 2000 comparedwith 6.0% in 2009 (400% increase). Theseresults represent a 14.3% APC (95% CI,12.1–16.8) in NIV among patients withCOPD and a 18.1% APC (95% CI, 15.9–20.7) among patients without COPD (P =0.02) (Figure E3). Results did not changesubstantially in a sensitivity analysis usingan alternative definition of COPD (COPD:260% increase in NIV; no COPD: 360%increase in NIV) or in a sensitivity analysiswhere patients with COPD or cardiogenicpulmonary edema (300% increase in NIV)were compared with patients withoutCOPD or cardiogenic pulmonary edema(340% increase in NIV). The proportion of

Figure 2. (A) United States trends in ventilator practice patterns during acute respiratory failurehospitalizations among patients with chronic obstructive pulmonary disease, 2000 to 2009. (B) UnitedStates trends in ventilator practice patterns during acute respiratory failure hospitalizations amongpatients without a diagnosis of chronic obstructive pulmonary disease, 2000 to 2009.

ORIGINAL ARTICLE

Walkey and Soylemez Wiener: Use of Noninvasive Ventilation 13

ORIGINAL ARTICLE

Use of Noninvasive Ventilation in Patients with Acute RespiratoryFailure, 2000–2009A Population-Based Study

Allan J. Walkey1 and Renda Soylemez Wiener2,3

1The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, and 2The Pulmonary Center, Divisionof Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts; and 3Center for Health Quality,Outcomes, & Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts

Abstract

Rationale: Although evidence supporting use of noninvasiveventilation (NIV) during acute exacerbations of chronic obstructivepulmonary disease (COPD) is strong, evidence varieswidely for othercauses of acute respiratory failure.

Objectives: To compare utilization trends and outcomes associatedwith NIV in patients with and without COPD.

Methods:We identified 11,659,668 cases of acute respiratory failurefrom theNationwide Inpatient Sample during years 2000 to 2009 andcompared NIV utilization trends and failure rates for cases with orwithout a diagnosis of COPD.

Measurements and Main Results: The proportion of patientswithCOPDwho receivedNIV increased from3.5% in 2000 to 12.3% in2009 (250% increase), and the proportion of patients without COPDwho received NIV increased from 1.2% in 2000 to 6.0% in 2009 (400%

increase). The rate of increase in the useofNIVwas significantly greaterfor patients without COPD (18.1% annual change) than for patientswith COPD (14.3% annual change; P = 0.02). Patients without COPDwere more likely to have failure of NIV requiring endotrachealintubation (adjusted odds ratio, 1.19; 95% confidence interval, 1.15–1.22; P, 0.0001). Patients in whom NIV failed had higher hospitalmortality than patients receiving mechanical ventilation withouta preceding trial of NIV (adjusted odds ratio, 1.14; 95% confidenceinterval, 1.11–1.17; P, 0.0001).

Conclusion: The use of NIV during acute respiratory failure hasincreased at a similar rate for all diagnoses, regardless ofsupporting evidence. However, NIV is more likely to fail inpatients without COPD, and NIV failure is associated withincreased mortality.

Keywords: respiratory insufficiency; noninvasive ventilation,positive-pressure; research, health services; outcome study

(Received in original form June 28, 2012; accepted in final form September 21, 2012 )

This work was supported by National Institutes of Health grant R21HL112672 (A.J.W.) and K07 CA138772 (R.S.W.) and by the Department of Veterans Affairs(R.S.W.).

Author Contributions: A.J.W.: concept, design, data analysis, interpretation, drafting of manuscript. R.S.W.: concept, design, data analysis, interpretation,drafting of manuscript.

Correspondence and requests for reprints should be addressed to Allan J. Walkey, M.D., M.Sc., Boston University School of Medicine, The Pulmonary Center,R-304, 715 Albany Street, Boston, MA 02118. E-mail: [email protected]

This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org

Ann Am Thorac Soc Vol 10, No 1, pp 10–17, Feb 2013Copyright ã 2013 by the American Thoracic SocietyDOI: 10.1513/AnnalsATS.201206-034OCInternet address: www.atsjournals.org

Physicians report wide use of noninvasiveventilation (NIV) for a variety of clinicalindications (1–4). NIV may be particularlyattractive to clinicians because it potentiallyoffers an “easier,” less invasive form ofrespiratory support for patients with acuterespiratory failure than traditionalmechanical ventilation (MV) implemented

through an endotracheal tube. However, theease of use of NIV may not translate intoimproved clinical outcomes. Indeed, thestrength of evidence supporting use of NIVfor acute respiratory failure variesaccording to the etiology of respiratoryfailure. Randomized trials consistentlysupport improvements in mortality and

reduction in endotracheal intubation rateswith the use of NIV during acuteexacerbations of chronic obstructivepulmonary disease (COPD) (5). Findingssupporting NIV for acute cardiogenicpulmonary edema are mixed (6), althoughthe weight of evidence favors a reductionin mortality and endotracheal intubation

10 AnnalsATS Volume 10 Number 1| February 2013

COPD Non-COPD

3.5%12.3%

1.2%6%

Ann Am Thorac Soc Vol 10, No 1, pp 10–17, Feb 2013

Acute respiratory failure

Oxygen device

NIV

MV

ER

ICU

WARD

Respiratory failure(definition)

• Inability of the respiratory system to provide adequate gas exchange to meet the requirements of the individual patient

In most cases, NIV is able to return our patients’ blood-gas values to moreappropriate, even if not completely normal, levels by correcting the respiratorypattern, that is, by increasing the tidal volume with the help of the ventilator and atthe same time reducing the respiratory rate. In patients with chronic obstructivepulmonary disease (COPD), this latter effect also has the result of giving theindividuals more time to exhale and, thereby, reduces the degree of dynamichyperinflation.

The pathophysiology of purely hypoxic respiratory failure is more complex anddepends of various factors, not all of which involve the lungs, such as cardiocir-culatory failure. However, the most common changes in the so-called respiratoryfailure of parenchymal origin are those in the ventilation/perfusion ratio, shunt,and diffusion.

The classical definition of acute respiratory failure is based on a PaO2/FiO2 \ 300, with increasing severity as the value of this ratio decreases. In theseforms of respiratory failure, NIV is often not as effective as invasive ventilationwhich is, therefore, preferred as the first-line treatment, at least in some cases, forquestions of safety. The reasons why intubation is often used are well-known:

• to protect the airways;• because of the need for continuous ventilation and, therefore, sedation and

sometimes even neuromuscular blockade;• severe hemodynamic instability;• use of high fractions of inspired oxygen, which is sometimes not possible with

non invasive ventilators.

Acute respiratory failure

Pump failure Lung failure

Alveolar hypoventilation

increased PaCO2 +++decreased PaO2 +

Impaired gas exchange

increased PaCO2 = or +decreased PaO2 +++

Fig. 1.1 Types of respiratory failure

2 1 Why I Ventilate a Patient Non Invasively

CNS Respiratory center

Corticospinal tract

Anterior horn cell

Motor neuron

Neuromuscular junction

muscle

Airways

Alveoli

Bellows component

Lung component Minute ventilation

PaO2 PaCO2

Feedback

Other influences: neural demands (anxiety) systemic demands (sepsis,acidosis) load placed on system (obesity) sleep/wake cycle

Schematic Representation of the Respiratory Pump

Acute Respiratory failure

Etiology

Ventilatory support

NIV for respiratory failure

• Adequacy of pulmonary gas exchange

• Normalizing/minimizing patient work of breathing (WOB)

“NIV is just support, not definite therapy”

Benefit : who?

0

23

45

68

90

COPD ACPE Post-extubation fail. Pneumonia ARDS

17

5353

79

89

Use of NIV in acute respiratory failure : Multicenter study in ICU

Fernández-Vivas M et al. Med Intensiva, 33 (2009), pp. 153-160

NIV : who?• To good to benefit : All post extubation patient, Not

sick enough patient

• To sick to benefit : Dangerous

• Most benefit (who?)

• Acute hypercapnic respiratory failure(COPD)

• Acute cardiogenic pulmonary edema

• ARF in immunocompromised(early)

Evidence A

NIV for respiratory failure

• Indications — A trial of NIV is worthwhile in most patients who

• Do not require emergent intubation and

• Disease known to respond to NPPV

• Lack of contraindications

Contraindication• Cardiac or respiratory arrest

• Inability to cooperate, protect the airway, or clear secretions

• Severely impaired consciousness

• Nonrespiratory organ failure

• Facial surgery, trauma, or deformity

• High aspiration risk

• Prolonged duration of mechanical ventilation anticipated

• Recent esophageal anastomosis

Potential indicators of success in noninvasive positive pressure ventilation

• Younger age

• Lower acuity of illness (APACHE score)

• Able to cooperate, better neurologic score

• Less air leaking, intact dentition

• Moderate hypercarbia (PaCO2 > 45 mmHG, < 92 mmHG)

• Moderate acidemia (pH < 7.35, > 7.10)

• Improvements in gas exchange and heart respiratory rates within first two hours

Noninvasive ventilation in AECOPD

⬆Airwayresistance

⬆lung elastance

hypoxemia

⬆WOB

COPD exacerbation

Muscle fatigue

Hypoventilation

Resp. failure

Auto-PEEP

⬆RR

Bronchospasm

Benefit of applying PEEP

• Reduces WOB by 2 mechanisms:

• Counterbalancing PEEPi and thereby reducing the threshold load to inspiration

• Increasing respiratory- system compliance and thereby reducing the elastic load to inspiration

Sydow M et al. Intensive Care Med 1995;21(11):887-895. Katz JA. et al. Anesthesiology 1985;63(6):598-607.

Waterfall concept

Tobin MJ. Chest. 1989; Sep :449-51

Combination of PEEP + PSV was the most effective

Appendini L et al. Am J Respir Crit Care Med. 1994 May;149(5):1069-76.

No change in lung volume in CPAP or PSV


Vanpee D et al. Chest 2002; 122(1):75-83.

Eur Respir J 2016; 47: 113–121

Benefit of NIV in COPD

Copyright 2014 American Medical Association. All rights reserved.

Results of Propensity-Adjusted, Propensity-Matched,and Instrumental Variable AnalysesIn models that adjusted for patient, hospital, and physiciancharacteristics, including the propensity for treatment withNIV and receipt of other treatments, the odds of in-hospitalmortality among patients treated with NIV was significantlylower than among those who received IMV (odds ratio [OR],0.54 [95% CI, 0.48-0.61]) (Figure 2). Treatment with NIV wasassociated with a lower risk of hospital-acquired pneumonia(OR, 0.53 [95% CI, 0.44-0.64]), a 19% shorter length of stay(ratio, 0.81 [95% CI, 0.79-0.82], an average absolute reductionof 1.6 days), and 32% lower costs (ratio 0.68 [95% CI, 0.67-0.69], an average absolute reduction of $5673). There was noassociation between mode of ventilation and the risk ofCOPD-specific or all-cause readmission within 1 month ofdischarge. Estimates based on stabilized inverse-probabilityand standardized mortality ratio weighting were similar(Figure 2).

Overall, 72% of patients treated with IMV were matchedwith a patient of similar propensity who was treated with NIV(eFigure 1 in the Supplement). The matched sample was bal-

anced for most factors (Table 3 and Table 4). Conditionallogistic regression models adjusting for unbalanced covari-ates on the matched sample yielded modestly attenuatedassociations (OR for mortality, 0.64 [95% CI, 0.55-0.74])(Figure 2).

Across the 286 hospitals that contributed at least 25 casesrequiring ventilatory assistance, the percentage of ventilatedpatients who were treated with NIV by the second hospitalday ranged from 34% at the 10th percentile to 87% at the 90th(eFigure 2 in the Supplement). Using the hospital as an instru-mental variable and adjusting for other potential confound-ers, the mortality benefit of NIV was modestly attenuated(OR, 0.66 [95% CI, 0.47-0.91]).

Analyses Stratified by Comorbidity Score, Pneumonia,and Restricted to Patients Younger Than 85 YearsThe relative advantage of NIV was attenuated in the face ofhigher comorbidity burden and among those with pneumo-nia present on admission (Figure 2). Finally, the association be-tween receipt of NIV and mortality was similar in an analysisrestricted to patients younger than 85 years.

Figure 2. Association Between Noninvasion Ventilation and Outcomes

1.0 2.00.2 0.6OR (95% CI)

MortalityOR (95% CI)

Propensity and covariate adjusted 0.54 (0.48-0.61)SIPTW 0.47 (0.42-0.52)SMRW 0.40 (0.37-0.44)Propensity matched and adjusteda 0.64 (0.55-0.74)

Hospital-acquired pneumoniaPropensity and covariate adjusted 0.53 (0.44-0.64)SIPTW 0.50 (0.43-0.58)SMRW 0.45 (0.39-0.51)Propensity matched and adjusteda 0.65 (0.53-0.81)

All-cause readmissionPropensity and covariate adjusted 1.04 (0.94-1.15)SIPTW 1.03 (0.95-1.13)SMRW 1.00 (0.93-1.07)Propensity matched and adjusteda 1.06 (0.94-1.20)

Length of stayPropensity and covariate adjusted 0.81 (0.79-0.82)SIPTW 0.81 (0.80-0.82)SMRW 0.79 (0.78-0.80)Propensity matched and adjusteda 0.82 (0.80-0.84)

CostPropensity and covariate adjusted 0.68 (0.67-0.69)SIPTW 0.68 (0.67-0.69)SMRW 0.65 (0.64-0.66)Propensity matched and adjusteda 0.70 (0.68-0.72)

Mortality within subgroupsComorbidity burden

Low 0.30 (0.22-0.40)Moderate 0.45 (0.37-0.56)High 0.71 (0.61-0.83)

Comorbid pneumoniaPresent 0.79 (0.65-0.97)Not present 0.46 (0.40-0.53)

Age <85 y 0.51 (0.45-0.58)

Association between noninvasiveventilation and mortality,hospital-acquired pneumonia,readmission, length of stay, and costs,overall and inpatient stratifiedcomorbidity burden, comorbidpneumonia, and among thoseyounger than 85 years. Subgroupanalyses are covariate adjusted.COPD indicates chronic obstructivepulmonary disease;DRG, diagnosis-related group;ICD-9-CM, International Classificationof Diseases, Ninth Revision, ClinicalModification; IMV, invasivemechanical ventilation;NIV, noninvasive ventilation;SIPTW, stabilized inverse-probability-of-treatment weighting;SMRW, standardized mortality ratioweighting.a Adjusted for unbalanced covariates.

Research Original Investigation Outcomes Associated With Invasive and Noninvasive Ventilation

1988 JAMA Internal Medicine December 2014 Volume 174, Number 12 jamainternalmedicine.com

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://archinte.jamanetwork.com/ by a Mahidol University User on 10/28/2015

MortalityHAPLOSCost

Lindenauer P.K et al JAMA Intern Med. 2014;174(12):1982-1993.

Intubation risk

NIV risk

Upper airway traumaPneumothoraxNosocomial pneumonia Morbidity Mortality

Delay intubationRisk from interface

Predictors of Success for NIV in the Acute Setting

• Cooperative

• Synchronous breathing

• Better neurologic score

• Better compliance*

• Able to Protect Airway

• Less secretions

• Less air leaking

• Dentate (corresponds with less air leaking)

• Not Too Acutely Ill

• No pneumonia

• Lower APACHE score

• Initial PaCO2 < 92 mm Hg

• Initial pH > 7.10

• Good Initial Response to NPPV (within first 1–2 h)

• Improvement in pH

• Reduction in respiratory rate

• Reduction in PaCO2

Respir Care 2016;61(3):277–284.


Benefit in Acute resp. failure : who?

AECOPD

ACPE

Acute cardiogenic pulmonary edema

⬆LVEDP

⬆PCWP

⬆pulm.interstitial fluid& alveolar space

⬆Airway resistance ⬇lung diffusioncapacity ⬇FRC ⬆Shunt

Hypoxemia

⬆Respiratory effort Respiratory failure

• % endotracheal intubation : 10–28%

• Using NIV : 3–12%, with both CPAP and NIPPV

Went CL. et al. Ann Intern Med, 152 (2010), pp. 590-600

Positive pressure ventilation

+ ITP

⬇VR

⬇RV preload

⬇gradient between LV and

extrathoracic arteries

⬇neg. swing of ITP

⬇LV afterload

Unload resp. muscle

⬆LV Contractility

NIV in cardiogenic pulmonary edema

Lancet 2000; 356: 2126–32

Masip J et al. Lancet 2000; 356: 2126–32

Saengeeta M et al. Crit Care Med 1997; 25:620-628

CPAP VS BIPAP in acute cardiogenic pulmonary edema

Nouira S et al. Intensive Care Med (2011) 37:249–256

NIPSV was associated to a shorter resolution time compared to CPAP (159 ± 54 vs. 210 ± 73 min; p<0.01)

Crit Care Med 2002; 30:2457–2461

CHEST 1999; 116:166 –171)

The mean IPAP in the success group was higher than that in the failure group: 12±2 cm H2O vs 1± 4 cm H2O (p<0.02)

CHEST 1999; 116:166 –171)

P<0.02

P<0.02

P<0.01

• 32 studies (2916 participants)

• Compared with standard medical care

• NPPV significantly reduced hospital mortality (RR 0.66, 95% CI 0.48-0.89) and endotracheal intubation (RR 0.52, 95% CI 0.36-0.75).

• No difference in hospital length of stay with NPPV

• No significant increases in the incidence of AMI with NPPV during its application (RR 1.24, 95% CI 0.79-1.95) or after (RR 0.70, 95% CI 0.11-4.26).

• Fewer adverse events with NPPV use (in particular progressive respiratory distress and neurological failure (coma))

Cochrane review 2013



AECOPD

ACPE

Immunocompromised?

Hilbert G et al. N Engl J Med 2001;344:481-7.)

Antonelli M et al. JAMA. 2000;283(2):235-241.


Timing of ET intubation

JAMA. 2015;314(16):1711-1719.



AECOPD

ACPE

Immunocompromised?

Window of opportunity!!!• Unsuccessful NIV was found to be independently

associated with death, especially in patients with de novo ARF

Use with Caution

Close monitoring

switch promptly to ETI Demoule A et al. Care Med 2006, 32:1756–1765.

Predictor of failureUse early

Disease

How?

ICU

Sub-ICU

Ward

When?

Where?

What?

ER

Mask

Machine

Setting Who?

Nurse Resident

Fellow

sStaffMonitor

Synchrony

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