Importance of Protocols in the Decision to Use Noninvasive Ventilation

Importance of Protocols in the Decision to Use Noninvasive Ventilation Janice L. Zimmerman, M.D. Weill Cornell Medical College The Methodist Hospital Houston, Texas Objectives Review application of protocols in critically ill patients Understand impediments to use of protocols Discuss components of a protocol for noninvasive ventilation Protocols in Critical Care -Mayo Clin Proc 2004;79:992 -Crit Care Med 2007;35:41 1

Protocols in Critical Care -Crit Care Med 2008;36:1444 -Crit Care Med 2007;35:1660 -Lancet 2008;371:126 Value of Protocols Apply best practice Standardize management Education Decrease complications Improve outcomes Decrease costs Protocol Compliance Lung protective strategy for ALI Little change in academic centers Often discontinued Barriers Control of ventilator Recognition of ALI Concern over adverse effects 2

Protocol Compliance Loss of physician control Lack of agreement with protocol Lack of knowledge/awareness Failure to diagnose Lack of resources Fear of adverse events Inertia/lack of motivation Why develop an NIV protocol? Frequently (or infrequently) used Easy to identify patients Management variability Good for patient care Avoid intubation Complications of MV Improve outcomes Components of NIV Protocol Patient selection Clinical manifestations Respiratory condition Initiation Adaptation Monitoring Weaning 3

Which one of the following patients with a COPD exacerbation is the best candidate for noninvasive ventilation? A. Obtunded patient with ABG ph 7.25, PCO 2 80, PO 2 60 on room air B. Patient with hematemesis (red blood) on arrival to hospital C. Patient with ABG ph 7.37, PCO 2 52, PO 2 60 on room air; RR 18/min D. Alert patient with RR 28/min, use of accessory muscles after 2 nebs E. Obese patient with RR 24/min, HR 120/min, BP 82/40 mm Hg Patient Selection Step 1: Need for ventilatory assistance Clinical signs and symptoms* Moderate - severe dyspnea Use of accessory muscles Paradoxical breathing Respiratory rate 25/min *At least 2 should be present Patient Selection Step 1: Need for ventilatory assistance Gas exchange parameters ph <7.35 with PaCO 2 >45 mm Hg PO 2 /FiO 2 <300 4

Patient Selection Step 2: Presence of contraindications Absolute exclusion criteria Need for intubation Respiratory arrest Hemodynamic instability Cardiac ischemia or arrhythmia Inability to cooperate Patient Selection Step 2: Presence of contraindications Absolute exclusion criteria Craniofacial trauma/burns Recent facial surgery Active upper GI bleed High aspiration risk Inability to protect airway Patient Selection Step 2: Presence of contraindications Relative exclusion criteria Extreme anxiety Massive obesity Excessive secretions Condition not expected to improve in 48-72 hrs 5

Which one of the following patients is most likely to avoid intubation when NIV is used? A. Patient with asthma exacerbation B. Patient with lobar pneumonia C. Patient with acute pulmonary edema D. Patient with pulmonary edema who failed extubation E. Patient with COPD exacerbation Patient Selection Step 3: Appropriate respiratory condition COPD exacerbation Acute asthma Acute pulmonary edema/chf Pneumonia Immunocompromised patients ARDS Weaning from MV Extubation failure Postoperative respiratory failure Neuromuscular disease -Lancet 2008;371:126 COPD Patients in the ICU Prospective, randomized study (n=85) Per cent (%) --Brochard, et al. NEJM 1995;333:817 6

NIV on General Ward Prospective, randomized, controlled study in 236 COPD patients Per cent (%) --Plant et al. Lancet 2000;355:1931 Systematic Review of NIV 15 COPD studies 2 studies of mild COPD --Keenan et al. Ann Intern Med 2003;138:861 NIV in Hypercapnic Coma Prospective, open uncontrolled study Compared patients with/without coma Per cent (%) --Diaz, et al. Chest 2005;127:952 7

Asthma 5/39 required intubation (Meduri et al, Chest 1996;110:767, Fernandez et al, Inten Care Med 2001;27:486) No significant advantage (Holley et al, Acad Emerg Med 2001;8:1128) More effective for delivery of nebulized medications (Pollack et al, Ann Emerg Med 1995;26:552) NIV for Asthma in the ED Severe asthma (FEV 1 <60%) Treatment with NIV for 3 hrs Hospitalization (17.6% v. 62.5%) n=30 n=15 n=15 Soroksky et al. Chest 2003; 123:1018 NIV in Asthma Moderate-severe asthma that does not respond to initial therapy Use nasal or face mask Use 2 levels of pressure Inspiratory 10 (8-18) cm H 2 O Expiratory 4-5 (3-8) cm H 2 O 8

Which one of the following is most correct regarding use of NIV in acute pulmonary edema? A. Bilevel NIV is associated with a lower intubation rate than CPAP B. Bilevel NIV reduces left ventricular preload (PAOP) more than CPAP C. CPAP is associated with a lower incidence of MI than bilevel NIV D. Improvement in oxygenation is similar with CPAP and bilevel NIV Acute Pulmonary Edema Nonrandomized study (n=27) 2 levels of support (NIV) compared to CPAP Frequency of MI with NIV CPAP NIV Hemodynamic Effects of NIV in Heart Failure Variable Baseline NIV Systolic pressure (mm Hg) 136 124 Heart rate (bpm) 85 75 Respiratory rate (rpm) 23 15 SVR (dyne s cm 3 ) 1671 1236 Cardiac output (L/min) 5.1 6.4 Ejection fraction (%) 28.7 34.4 --Acosta et al. Chest 2000;118:1004 9

Acute Pulmonary Edema Randomized study of O 2, CPAP and NIV (n=80) Intubation: 42% with O 2, 7% with CPAP, 7% with NIV Oxygen Respiratory rate/min Oxygen CPAP NIV PaO 2/FiO2 ratio --Park et al, Crit Care Med 2004;32:2407 Acute Pulmonary Edema Randomized study of O 2, CPAP & NIV No difference in intubation n=1069 Oxygen --Gray et al, NEJM 2008;359:142 NIV for Pulmonary Edema Giacomini et al (Chest 2003;123:2057) Patients with cardiogenic hypoxemic respiratory failure (n=58) Treated with NIV in the ED Weaning trial after 90 min Responders (74%) did not require ICU admission 10

Acute Pulmonary Edema Can use CPAP or NIV If CPAP used, change to NIV with dyspnea or significant hypercapnia Monitoring is important Pneumonia Confalonieri et al. (AJRCCM 1999;260:1585) 21% vs 50% required intubation Benefit only in COPD Jolliet et al. (Intensive Care Med 2001;27:812) 22/24 initially improved 66% required intubation NIV in Pneumonia Comparison in patients (without COPD) with pulmonary edema and pneumonia PO 2 /FiO 2 No decrease in RR --Domenighetti, et al. Inten Care Med 2002;28:1226 11

Pneumonia* Outcome NIV Control p (n=51) (n=54) Intubation 25% 52% 0.010 Pneumonia 26% 73% 0.017 Mortality, ICU 18% 39% 0.028 Pneumonia 16% 53% 0.030 *Excluded PCO 2 >45 mm Hg --Ferrer et al. AJRCCM 2003;168:1438 NIV in Pneumocystis Pneumonia Prospective study, case-control in patients with ARDS Used 2 levels of pressure Avoided intubation in 67% Less days in ICU and hospital Improved ICU survival 75% vs 38% --Confalonieri et al. Inten Care Med 2002;28:1233 NIV in Pneumonia Less success Condition usually slower to improve More success with interstitial pneumonias Consider NIV in patients with COPD and pneumonia Use with caution in lobar pneumonia 12

Immunocompromised Patients Prospective, randomized study --Hilbert et al, NEJM 2001;344:481 ALI/ARDS No studies in ARDS alone No benefit on intubation or ICU mortality* May consider in mild ALI Monitor for deterioration Routine use not recommended *Agarwal et al. Respir Med 2006;100:2235 NIV in Postoperative Patients Respiratory failure Respiratory rate and dyspnea Reintubation Mortality rate Prophylactic use of NIV Lung resection Gastroplasty 13

Prophylactic NIV in Obese Postoperative Patients NIV (n=62) Control (n=62) Resp. failure 10% 26% 0.03 Intubation 10% 21% 0.14 ICU stay 11.8 dys 18.2 dys <0.001 Hosp. stay 20.6 dys 26.0 dys 0.007 Mortality 13% 24% 0.17 P --El Solh AA, et al. Eur Resp J 2006;28:588 NIV for Failed Extubation Respiratory distress within 48 hrs of extubation NIV did not prevent reintubation Keenan et al. JAMA 2002;287:3238 Esteban et al. NEJM 2004;350:2452 NIV can delay reintubation Evidence for Use of NIV Strong Less Strong Weak COPD exacerbation and extubation Cardiogenic pulmonary edema Immunocompromised patients Asthma Pneumonia Postoperative respiratory failure Trauma Extubation failure Neuromuscular disease ARDS 14

Initiation of NIV Location of treatment Equipment Ventilator Mask Ventilator settings Locations for Use of NIV Intensive care unit Intermediate care unit Emergency department Postoperative care unit General floor Which ventilator is preferred for NIV by the Respiratory therapist? Nurse? A. B. C. D. 15

Bilevel vs Critical Care Ventilators Bilevel CC Modes ++ +++ Alarms, monitoring ++ +++ Leak compensation +++ ++ Cost ++ +++ Efficacy ++ ++ Which one of the following is not an option as an interface for NIV in a patient with severe pulmonary edema and hypoxia? A. Nasal mask B. Face mask C. Nasal pillows D. Helmet Patient-Ventilator Interface Masks Helmet Harness --Intensive Care Med 2003;29:1671 16

Interface Selection Patient tolerance: NM > FM Higher tidal volume: FM > NM Decrease in PaCO 2 : FM > NM --Navalesi et al. Crit Care Med 2000;28:1785 Patient tolerance: FM > NM Similar dyspnea scores and intubation rates --Kwok et al. Crit Care Med 2003;31:468 Which of the following are the best initial NIV settings for a patient with a COPD exacerbation? A. IPAP 6 cm H 2 O, EPAP 3 cm H 2 O B. IPAP 10 cm H 2 O, EPAP 5 cm H 2 O C. IPAP 12 cm H 2 O, EPAP 4 cm H 2 O D. IPAP 15 cm H 2 O, EPAP 5 cm H 2 O Initiation of NIV Pressure settings Inspiratory pressure 8-12 cm H 2 O Expiratory pressure 4-5 cm H 2 O Back up rate of 12/min FiO 2 100% for hypoxemic failure Lower for ventilatory failure 17

Other Considerations Head of bed at 45º Humidification Nasal patch Eye lubricant Gastric decompression if high risk of aspiration Caution with sedation Adaptation of NIV Make changes every 5-10 min Hypoxemic failure Expiratory pressure 1-2 cm H 2 O Ventilatory failure Inspiratory pressure 2-3 cm H 2 O Auto-PEEP Expiratory pressure 1-2 cm H 2 O Adaptation of NIV Coaching Minimize air leaks Change mask type/size Optimize rise time Lower inspiratory pressure if intolerant Consider sedation cautiously 18

Adaptation of NIV Goals Respiratory rate <25/min V T 6-7 ml/kg Improved gas exchange Patient comfort Continuous or Intermittent NIV? Condition Duration Holly, 2001 Asthma 4-18 hrs/dy Soroksky, 2003 Asthma 3 hrs Giacomini, 2003 Pulmonary 77-118 min edema Nava, 2003 Pulmonary 11.4 hrs edema Plant, 2003 COPD 8 hrs on dy 1 Monitoring Patient comfort Vital signs Pulse oximetry Level of consciousness Tidal volumes ABG (baseline, 1 hr) 19

Which one of the following patients is most likely to fail NIV? A. 60 y/o with pneumonia and PO 2 /FiO 2 120 after 1 hr of NIV B. 65 y/o with COPD and RR 20/min after 1 hr of NIV C. 35 y/o with sepsis and ARDS with PO 2 /FiO 2 250 after 1 hr of NIV D. 70 y/o with pulmonary edema and HR 98/min and RR 18/min after 1 hr of NIV Predictors of Success Improved ABG in 1-2 hrs Improved level of consciousness after 1 hr Respiratory rate 20/min Exhaled tidal volume Patient-ventilator synchrony Predictors of Failure Age > 40 yrs SAPS II 35 or high APACHE II Response after 1 hr PaO 2 /FiO 2 146 High heart rate High PaCO 2 Baseline 1 Hour Diagnosis of ARDS or pneumonia PaO 2 /FiO 2 Success Failure Support discontinuation --Antonelli, et al. Intensive Care Med 2001;27:1718 --Phua, et al. Intensive Care Med 2005;31:533 20

Weaning of NIV Clinical stability >6 hrs Respiratory rate <24-30/min Heart rate <110/min ph >7.35 Adequate oxygenation Techniques Trials off NIV Pressures by 2-3 cm H 2 O Protocol for NIV Patient selection NIV initiation Adaptation Monitoring Weaning 21