Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure: Intubation Rate in an Experienced Unit

BACKGROUND: Failure of noninvasive ventilation (NIV) is common in patients with COPD admitted to the ICU for acute hypercapnic respiratory failure (AHRF). We aimed to assess the rate of NIV failure and to identify early predictors of intubation under NIV in patients admitted for AHRF of all origins in an experienced unit. METHODS: This was an observational cohort study using data prospectively collected over a 3-year period after the implementation of a nurse-driven NIV protocol in a 24-bed medical ICU of a French university hospital. RESULTS: Among 242 subjects receiving NIV for AHRF (PaCO2 > 45 mm Hg), 67 had cardiogenic pulmonary edema (CPE), 146 had acute-on-chronic respiratory failure (AOCRF) (including 99 subjects with COPD and 47 with other chronic respiratory diseases), and 29 had non-AOCRF (mostly pneumonia). Overall, the rates of intubation and ICU mortality were respectively 15% and 5%. The intubation rates were 4% in CPE, 15% in AOCRF, and 38% in non-AOCRF (P < .001). After adjustment, non-AOCRF was independently associated with NIV failure, as well as acidosis (pH < 7.30) and severe hypoxemia (PaO2/FIO2 ≤ 200 mm Hg) after 1 hour of NIV initiation, whereas altered consciousness on admission and ventilatory settings had no influence on outcome. CONCLUSIONS: With a nurse-driven NIV protocol, the intubation rate was reduced to 15% in patients receiving NIV for AHRF, with a mortality rate of only 5%. Whereas the risk of NIV failure is associated with hypoxemia and acidosis after initiation of NIV, it is also markedly influenced by the presence or absence of an underlying chronic respiratory disease.

[1]  A. Torres,et al.  Noninvasive ventilation in acute hypercapnic respiratory failure caused by obesity hypoventilation syndrome and chronic obstructive pulmonary disease. , 2012, American journal of respiratory and critical care medicine.

[2]  D. Mannino,et al.  Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008. , 2012, American journal of respiratory and critical care medicine.

[3]  J. Barker.  A multicenter, randomized trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease , 2011 .

[4]  S. Nouira,et al.  Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department , 2011, Intensive Care Medicine.

[5]  T. Lim,et al.  Noninvasive and invasive ventilation in acute respiratory failure associated with bronchiectasis , 2010, Intensive Care Medicine.

[6]  R. Kacmarek,et al.  Noninvasive positive-pressure ventilation in acute respiratory failure outside clinical trials: Experience at the Massachusetts General Hospital* , 2008, Critical care medicine.

[7]  Paolo Pelosi,et al.  Evolution of mechanical ventilation in response to clinical research. , 2008, American journal of respiratory and critical care medicine.

[8]  G. Bernard,et al.  Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial , 2008, The Lancet.

[9]  R. Balk.  Increased use of noninvasive ventilation in French intensive care units , 2008 .

[10]  E. Wijdicks,et al.  Noninvasive ventilation in myasthenic crisis. , 2008, Archives of neurology.

[11]  J. Grady,et al.  Outcomes of morbidly obese patients requiring mechanical ventilation for acute respiratory failure* , 2007, Critical care medicine.

[12]  L. Brochard,et al.  Benefits and risks of success or failure of noninvasive ventilation , 2006, Intensive Care Medicine.

[13]  L. Brochard,et al.  Increased use of noninvasive ventilation in French intensive care units , 2006, Intensive Care Medicine.

[14]  S. Nava,et al.  Time of non-invasive ventilation , 2006, Intensive Care Medicine.

[15]  R. Fernandez,et al.  Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. , 2005, JAMA.

[16]  S. Nava,et al.  Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness. , 2005, Chest.

[17]  T. Lim,et al.  Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure , 2005, Intensive Care Medicine.

[18]  N. Hill,et al.  Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failure. , 2005, Chest.

[19]  M. Antonelli,et al.  A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation , 2005, European Respiratory Journal.

[20]  S. Nava,et al.  Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. , 2003, American journal of respiratory and critical care medicine.

[21]  Theodore Speroff,et al.  Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). , 2003, JAMA.

[22]  D. Cook,et al.  Which Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Benefit from Noninvasive Positive-Pressure Ventilation? , 2003, Annals of Internal Medicine.

[23]  J. Chevrolet,et al.  Helium-oxygen versus air-oxygen noninvasive pressure support in decompensated chronic obstructive disease: A prospective, multicenter study* , 2003, Critical care medicine.

[24]  E. Guérot,et al.  Effectiveness of non-invasive positive pressure ventilation differs between decompensated chronic restrictive and obstructive pulmonary disease patients , 2003, Intensive Care Medicine.

[25]  J. Wedzicha,et al.  Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis , 2003, BMJ : British Medical Journal.

[26]  P. Plant,et al.  Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial , 2000, The Lancet.

[27]  J. Carrasco,et al.  Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with chronic airflow limitation. , 2000, Chest.

[28]  J. Bach,et al.  Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. , 1997, Chest.

[29]  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.

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

[31]  S. Nava,et al.  Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. , 1995, Thorax.

[32]  C. Sullivan,et al.  Effects of short-term NIPPV in the treatment of patients with severe obstructive sleep apnea and hypercapnia. , 1994, Chest.

[33]  L. Brochard,et al.  Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. , 1990, The New England journal of medicine.