Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study.

Prolonged duration of endotracheal mechanical ventilation (ETMV) is associated with an increased morbidity and mortality in intensive care unit (ICU) patients. The aim of this study was to assess the usefulness of noninvasive ventilation (NIV) as a systematic extubation and weaning technique to reduce the duration of ETMV in acute-on-chronic respiratory failure (ACRF). Among 53 consecutively intubated patients admitted for ACRF, we conducted a prospective, randomized controlled trial of weaning in 33 patients who failed a 2-h T-piece weaning trial (2 h-WT) although they met simple criteria for weaning. Conventional invasive pressure support ventilation (IPSV) was used as the control weaning technique in 16 patients (IPSV group), and NIV was applied immediately after extubation in 17 patients (NIV group). The two weaning groups were similar for type of chronic respiratory failure (CRF), pulmonary function data, age, Simplified Acute Physiology Score (SAPS II), and severity of ACRF on admission. The characteristics of the two groups were also similar at randomization. In the IPSV group, 12 of 16 patients (75%) were successfully weaned and extubated, versus 13 of 17 (76.5%) in the NIV group (p = NS). NIV like IPSV significantly and similarly improved gas exchange in relation to that achieved during 2 h-WT (p < 0.05). The duration of ETMV was significantly shorter in the NIV (4.56 +/- 1.85 d) than in the IPSV group (7.69 +/- 3.79 d) (p = 0. 004). NIV also reduced the mean period of daily ventilatory support, but increased the total duration of ventilatory support related to weaning (3.46 +/- 1.42 d, versus 11.54 +/- 5.24 d with NIV; p = 0. 0001). Most patients in the IPSV group developed complications related to ETMV and/or the weaning process, but the difference was not significant (nine of 16 versus six of 17). The durations of ICU and hospital stays and the 3-mo survival were similar in the two groups. In conclusion, NIV permits earlier removal of the endotracheal tube than with conventional IPSV, and reduces the duration of daily ventilatory support without increasing the risk of weaning failures. NIV should be considered as a new and useful systematic approach to weaning in patients with ACRF who are difficult to wean.

[1]  J. Wedzicha,et al.  Nasal intermittent positive-pressure ventilation in weaning intubated patients with chronic respiratory disease from assisted intermittent, positive-pressure ventilation. , 1993, Respiratory medicine.

[2]  P. Pasquis,et al.  Physiological effects and optimisation of nasal assist-control ventilation for patients with chronic obstructive pulmonary disease in respiratory failure. , 1997, Thorax.

[3]  C F Donner,et al.  Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. , 1994, American journal of respiratory and critical care medicine.

[4]  S K Pingleton,et al.  Complications of acute respiratory failure. , 1988, The Medical clinics of North America.

[5]  N Ambrosino,et al.  Survival and prediction of successful ventilator weaning in COPD patients requiring mechanical ventilation for more than 21 days. , 1994, The European respiratory journal.

[6]  R. L. Rosen,et al.  Economics of mechanical ventilation. , 1988, Clinics in chest medicine.

[7]  J. Goldstone,et al.  Assisted ventilation. 4. Weaning from mechanical ventilation. , 1991, Thorax.

[8]  J. Dumon,et al.  Effect of ventilator-associated pneumonia on mortality and morbidity. , 1996, American journal of respiratory and critical care medicine.

[9]  A. Esteban,et al.  A COMPARISON OF FOUR METHODS OF WEANING PATIENTS FROM MECHANICAL VENTILATION , 1995 .

[10]  M. Prato,et al.  Noninvasive Mechanical Ventilation in the Weaning of Patients with Respiratory Failure Due to Chronic Obstructive Pulmonary Disease , 1998, Annals of Internal Medicine.

[11]  M. Wysocki,et al.  Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. , 1995, The New England journal of medicine.

[12]  R. E. Turner,et al.  Noninvasive positive pressure ventilation via face mask , 1996 .

[13]  J. May,et al.  Successful discontinuation of ventilation via tracheostomy by substitution of nasal positive pressure ventilation. , 1992, Chest.

[14]  R. Wunderink,et al.  Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure. , 1991, Chest.

[15]  S. Gottfried.  The Role of PEEP in the Mechanically Ventilated COPD Patient , 1991 .

[16]  Economics of mechanical ventilation. , 1988 .

[17]  R. E. Turner,et al.  Noninvasive positive pressure ventilation via face mask. First-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. , 1996, Chest.

[18]  S. Gottfried,et al.  Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation. , 1990, Chest.

[19]  M. Wysocki,et al.  Noninvasive pressure support ventilation in patients with acute respiratory failure. , 1993, Chest.

[20]  D. Gruson,et al.  Sequential use of noninvasive pressure support ventilation for acute exacerbations of COPD , 1997, Intensive Care Medicine.

[21]  Ose,et al.  A COMPARISON OF FOUR METHODS OF WEANING PATIENTS FROM MECHANICAL VENTILATION , 1997 .

[22]  P. Montravers,et al.  Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. , 1993, The American journal of medicine.

[23]  I. Grossbach-Landis,et al.  Weaning from mechanical ventilation , 2005, ERS practical Handbook of Invasive Mechanical Ventilation.

[24]  J. Muir,et al.  Weaning criteria from mechanical ventilation. , 1994, Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace.

[25]  J. Milic-Emili,et al.  Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. , 1990, The American review of respiratory disease.

[26]  C. Guérin,et al.  Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia , 1997, Intensive Care Medicine.

[27]  S. Benito,et al.  Which Patients Need a Weaning Technique , 1991 .

[28]  A. Simonds,et al.  Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency. , 1992, Thorax.

[29]  L. Cinotti,et al.  Acute Left Ventricular Dysfunction during Unsuccessful Weaning from Mechanical Ventilation , 1988, Anesthesiology.

[30]  M. Tobin,et al.  A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. , 1992, The New England journal of medicine.

[31]  J. Marini.  The physiologic determinants of ventilator dependence , 1986 .

[32]  S. Allen,et al.  The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation. , 2015, The American review of respiratory disease.

[33]  F. Portier,et al.  Nasal mask ventilation in acute respiratory failure. Experience in elderly patients. , 1992, Chest.

[34]  S Sauer,et al.  A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. , 1997, Critical care medicine.

[35]  W. Gibbons,et al.  Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure. , 1989, Chest.

[36]  J. Wedzicha,et al.  Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease , 1993, The Lancet.

[37]  H. Lorino,et al.  Inspiratory pressure support compensates for the additional work of breathing caused by the endotracheal tube. , 1991, Anesthesiology.

[38]  C. Guérin,et al.  Erratum: Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia , 1997, Intensive Care Medicine.

[39]  L. Brochard,et al.  Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. , 1994, American journal of respiratory and critical care medicine.

[40]  P. Pasquis,et al.  Comparative physiologic effects of noninvasive assist-control and pressure support ventilation in acute hypercapnic respiratory failure. , 1997, Chest.

[41]  C. Hörmann,et al.  Comparison of mask and nasal continuous positive airway pressure after extubation and mechanical ventilation , 1993, Critical care medicine.

[42]  E F Haponik,et al.  Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. , 1996, The New England journal of medicine.