Non-invasive Ventilation for Management of Pneumonia - PowerPoint Presentation

Slide1

Non-invasive Ventilation for Management of Pneumonia

Problem Based Lecture

January 28

th

,

2016

S.Noll

PGY-3Slide2

Varied schools of thought

I don’t listen to podcasts, read blogs, nor

FOAMedNIV: Non-invasive positive pressure ventilationRCT: Randomized controlled trialARF: Acute respiratory failureARDS: Acute respiratory distress syndromeSAPS: Simplified Acute Physiologic ScoreSOFA: Sequential Organ Failure Assessment

DisclosureSlide3

BackgroundSlide4

“Studies with pneumonia patients in respiratory distress have shown that, as long as secretions are controlled,

NIV

decreases intubation rates and respiratory rates……Very strong arguments for NIV versus intubation extend to immunocompromised patients with hypoxemic respiratory failure and pulmonary infiltrates” –ACEP 2010“Patients with hypoxemia or respiratory distress should receive a cautious trial of NIV unless they require immediate intubation because of severe hypoxemia (PaO2/FiO2 ratio, <150) and bilateral alveolar infiltrates. “ -IDSA/ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults (Moderate recommendation; level I evidence) “NIV should be used whenever possible in selected patients with respiratory failure” –IDSA/ATS Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia (Level I evidence)

BackgroundSlide5

Acute Respiratory Failure in Patients with Severe Community-acquired Pneumonia

Prospective RCT: NIV

vs venturi mask for SpO2 >90%Inclusion Criteria: Severe dyspnea at rest, RR >35 /min, accessory muscle use PaO2􏰀<68 mm Hg @ >40% FiO2, or PaO2:FIO2 < 250 mmHg @ FIO2>50%hypercapnia (PaCO2 􏰁 50 mm Hg) with pH 􏰀 7.33XR showing multilobar involvement at admission or >50% increase in the size of the infiltrate within 48 h of admissionBP<90/60 mm Hg, necessity for vasopressors 􏰁>4 h; or UOP<􏰀 80 ml in 4 h Exclusion Criteria:Emergent intubation for CPR, respiratory arrest, severe hemodynamic instability,

encephalopathy

/

severe neurologic

disease,

life expectancy < 4

mo

, long-term oxygen therapy or home mechanical ventilation, tracheostomy/facial deformities, or inability to expectorate

Am J

Respir

Crit

Care

Med

1999Slide6

Am J Respir

Crit Care Med 1999Slide7

Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure

RCT: NIV

vs High-concentration O2 (Maintain SpO2 > 92%)Inclusions: PaO2 persistently (>6-8 hours) <60 mm Hg or SpO2 <90% @ FiO2 50% Exclusions: hypercapnia (PaCO2>45 mm Hg); need for emergency intubation; recent facial trauma/surgery/tracheostomy; GCS< 11; severe HD instability despite fluid repletion and use of vasoactive agents; lack of cooperation; severe ventricular arrhythmia or myocardial ischemia; active upper GIl bleed; an inability to clear respiratory secretions; and >one severe organ dysfunction in addition to respiratory failureAm J Respir Crit Care Med 2003Slide8

Am

J

Respir Crit Care Med 2003Slide9

Emerg Med J 2005

Non-invasive ventilation as a first-line treatment for acute respiratory failure: ‘‘real life’’ experience in the emergency department

Prospective/retrospective, observational study Inclusion: Mod-severe dyspnea, pCO2>45 mm Hg & pH<7.35 or PaO2<60 mm Hg with FiO2 <60%Slide10

Emerg Med J 2005

“We

believe the high death rate of CAP patients in our series to be related to their high comorbidity and high number of patients with do-not-intubate codes (44.4% in CAP patients and 42.8% in CAP patients with COPD) “Slide11

Oxygen therapy for pneumonia in adults

Reviewed 3 RCTs

Am J Respir Crit Care Med: Acute Respiratory Failure in Patients with Severe Community-acquired Pneumonia. 1999, Confalonieri (N=56)ReviewedNEJM: Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and Acute Respiratory Failure. 2001. Hilbert (N=52)“early initiation of NIV is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge”Chest: Helmet continuous positive airway pressure vs oxygen therapy to improve oxygenation in community-acquired pneumonia: a randomized, controlled trial. 2010, Cosentini (N=47)“CPAP delivered by helmet rapidly improves oxygenation in patients with CAP suffering from a moderate hypoxemic ARF”Cochrane Review 2012Slide12

NIV can reduce the risk

of:

death in the ICUendotracheal intubationshorten ICU staylength of intubationThe review indicates that NIV is more beneficial than standard oxygen supplementation via a Venturi mask for pneumoniaThe evidence is weakCochrane Review 2012Slide13

Non-invasive Ventilation in Community-Acquired Pneumonia and Severe Acute Respiratory FailureProspective Study

NIV Criteria:

Mod-Severe dyspnea with RR>30/min, PaO2/FiO2 <250Patients received NIV for 44 ± 33 h along 2.8 ± 1.9 daysNIV was successful in 116 patients (63%) Success= No intubation, transferred out of ICUIntensive Care Med 2012Slide14

Intensive Care Med 2012Slide15

NIV failure: 59 were

intubated,

9 became DNIworsening of respiratory insufficiency in (N=39)uncontrolled shock (N=17)intolerance to NIV (N=3) Variables independently associated with NIV failure worsening of radiological infiltrate 24 h after admission maximum SOFA score during NIV* HR, PaO2/FiO2, bicarbonate after 1 h of NIV Patients with CAP and previous cardiac or respiratory disease responded better to NIV than those with ‘‘de novo’’

ARF

Unsure of association with delayed intubation and mortality

Intensive Care Med 2012Slide16

Non-Invasive Ventilation for Acute Hypoxemic Respiratory Failure: Intubation and Risk FactorsObservational Cohort Study, N=113

Inclusion: Dyspnea, RR>25/min, accessory muscle use, pulmonary infiltrates, PaCO2 <45 mm Hg

Exclusion: Pulmonary edema, absence of XR infiltratesPneumonia diagnosis: n=63Rate of intubation in ARDS: 61%, Non-ARDS: 35%ARDS Severity: Mild-31%, Moderate-62%, Severe-84%Mortality rate failing NIV did not differ with time to intubationCritical Care 2013Slide17

Critical Care 2013Slide18

Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired

pneumonia

Prospective study, 127 patients, Inclusion: sCAP, RR>30/min, PaO2/FiO2 < 250NIV Failure: worsening of respiratory failure (18)Cardiorespiratory arrest (3) multi-organ system failure (4)death: MOSF (7), respiratory failure (5)Clin Respir J 2016Slide19

Clin Respir J 2016Slide20

NEJM 2015

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

Inclusion: 1. RR > 25/min 2. PaO2/FiO2 <300 3. PaCO2 <45 4. No chronic

resp

failure

Exclusion: PaCO2 >45, severe neutropenia, hemodynamic instability/vasopressors, GCS <12, DNI, urgent need to intubate

RCT

310 patients

NRB 10 L/Min

(SpO2 >92%)

HFNC FiO2 1.0 (SpO2 >92%)

NIV PS (7-1o ml/kg

Vt

) 2-10 cm H2O Slide21

NEJM 2015

PaO2/FiO2: 150 mm HgSlide22

12/40 patients who received rescue NIV therapy avoided intubation

NEJM 2015

Primary OutcomeSlide23

NEJM 2015

Hazard ratio

for death at 90 days compared to HFNC group -NRB: 2.01 (95% CI, 1.01 to 3.99) (P=0.046) -NIV: 2.50 (95% CI, 1.31 to 4.78) (P=0.006) Slide24

Rate of NIV failure in patients with pneumonia in controlled clinical trials 21-26% however, observational studies: 33-66%

Patients with previous cardiac and respiratory disease have increased benefit from NIV

Worse outcomes with increased severity of diseaseWe need more analyses including delay of intubation with morbidity/mortality; ED useHFNC is becoming more prominent in management of a variety of lung processesConclusionsSlide25

References

http://www.acep.org/Clinical---Practice-Management/Focus-On--Noninvasive-Positive-Pressure-Ventilation-In-the-Emergency-Department/

https://www.thoracic.org/statements/resources/mtpi/guide1-29.pdfConfalonieri Am J Respir Crit Care Med Vol 160. pp 1585–1591, 1999Ferrer.

Am

J

Respir

Crit

Care Med Vol

168.

pp

1438–1444, 2003

Antro

.

Emerg

Med J 2005;22:772–777

Cosentini

. ;

Chest.

2010;138(1):114-120

Hilbert

N

Engl

J Med 2001; 344:481-

487

Cochrane Database

Syst

Rev. 2012 Mar

14;3

Carrillo. Intensive Care Med 2012. 38: 458-466

Thille

.

Critical Care 2013, 17:R269

Nicolini

. Early

non-invasive ventilation treatment for respiratory failure

due to severe community-acquired pneumonia.

Clin

Respir

J 2016; 10: 98–103

Frat

.

N

Engl

J Med 2015; 372:2185-2196