EBQ:NIPPV in COPD: Difference between revisions
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==Clinical Question== | ==Clinical Question== | ||
Can NIPPV be used to avoid endotracheal intubation in acute COPD exacerbation? | Can NIPPV be used to avoid endotracheal intubation in acute [[COPD]] exacerbation? | ||
==Conclusion== | ==Conclusion== | ||
NIPPV avoids endotracheal intubation, reduces the length of the hospital stay, and reduces the in-hospital mortality rate in selected patients. | NIPPV avoids endotracheal [[intubation]], reduces the length of the hospital stay, and reduces the in-hospital mortality rate in selected patients. | ||
==Major Points== | ==Major Points== | ||
*In acute COPD exacerbation, noninvasive ventilation helps avoid endotracheal intubation and complications associated with mechanical ventilation | *In acute COPD exacerbation, noninvasive ventilation helps avoid endotracheal [[intubation]] and complications associated with mechanical ventilation | ||
*The use of | *The use of [[Noninvasive Ventilation]] significantly reduced the need for [[intubation]] as compared in the standard-treatment group (5 liters/min, nasal canula) | ||
*The frequency of complications was significantly lower in the noninvasive ventilation group. | *The frequency of complications was significantly lower in the [[noninvasive ventilation]] group. | ||
*Hospital stay was significantly shorter for the noninvasive ventilation group compared to the standard group. | *Hospital stay was significantly shorter for the [[noninvasive ventilation]] group compared to the standard group. | ||
==Guidelines== | ==Guidelines== | ||
{{quote|NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (pH < 7.35, PaCO2 > 6 kPa [45 mm Hg]) is present. | sign=British Thoracic Society<ref>Roberts CM, Brown JL, Reinhardt AK, et al. Non-invasive ventilation in chronic obstructive pulmonary disease:management of acute type 2 respiratory failure. Clin Med.2008;8(5):517-521</ref>}} | {{quote|NIV should be considered in all patients with an acute exacerbation of COPD in whom a [[respiratory acidosis]] (pH < 7.35, PaCO2 > 6 kPa [45 mm Hg]) is present. | sign=British Thoracic Society<ref>Roberts CM, Brown JL, Reinhardt AK, et al. Non-invasive ventilation in chronic obstructive pulmonary disease:management of acute type 2 respiratory failure. Clin Med.2008;8(5):517-521</ref>}} | ||
{{quote|NIV improves respiratory acidosis (increases pH and decreases PaCO2) and decreases respiratory rate, severity of breathlessness, and length of hospital stay in patients with acute exacerbations of COPD. | sign=Global Initiative for Chronic Obstructive Lung Disease (GOLD)<ref>GOLD Science Committee Methodology and summary of new recommendations. Global strategy for diagnosis, management and prevention of COPD: 2010 update. 2010</ref>}} | {{quote|NIV improves [[respiratory acidosis]] (increases pH and decreases PaCO2) and decreases respiratory rate, severity of breathlessness, and length of hospital stay in patients with acute exacerbations of COPD. | sign=Global Initiative for Chronic Obstructive Lung Disease (GOLD)<ref>GOLD Science Committee Methodology and summary of new recommendations. Global strategy for diagnosis, management and prevention of COPD: 2010 update. 2010</ref>}} | ||
{{quote|Bi-level NIV is a beneficial support strategy that decreases the risk for invasive mechanical ventilation and possibly improves survival in selected hospitalized patients with respiratory failure | sign=ACCP, ACP-ASIM<ref>Bach PB, Brown C, Gelfand SE, et al. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med. 2001;134(7):600-620.</ref>}} | {{quote|Bi-level NIV is a beneficial support strategy that decreases the risk for invasive mechanical ventilation and possibly improves survival in selected hospitalized patients with respiratory failure | sign=ACCP, ACP-ASIM<ref>Bach PB, Brown C, Gelfand SE, et al. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med. 2001;134(7):600-620.</ref>}} | ||
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==Population== | ==Population== | ||
Adult patients with known or suspected COPD (by history, exam or CXR). | Adult patients with known or suspected [[COPD]] (by history, exam or CXR). | ||
===Inclusion Criteria=== | ===Inclusion Criteria=== | ||
Respiratory acidosis/elevated HCO3 with exacerbation of dyspnea lasting less than two weeks. | [[Respiratory acidosis]]/elevated HCO3 with exacerbation of dyspnea lasting less than two weeks. | ||
And at least two of the following: | And at least two of the following: | ||
#a respiratory rate above 30 bpm | #a respiratory rate above 30 bpm | ||
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===Exclusion Criteria=== | ===Exclusion Criteria=== | ||
*RR < 12 bmp or need for immediate intubation (as defined below) | *RR < 12 bmp or need for immediate intubation (as defined below) | ||
*tracheotomy or endotracheal intubation performed before admission | *tracheotomy or endotracheal [[intubation]] performed before admission | ||
*the administration of sedative drugs within the previous 12 hrs | *the administration of sedative drugs within the previous 12 hrs | ||
*CNS disorder unrelated to hypercapnic encephalopathy or hypoxemia | *CNS disorder unrelated to hypercapnic encephalopathy or hypoxemia | ||
*cardiac arrest (within previous 5 days) | *[[cardiac arrest]] (within previous 5 days) | ||
*cardiogenic pulmonary edema | *cardiogenic pulmonary edema | ||
*kyphoscoliosis as the cause of chronic respiratory failure or a neuromuscular disorder | *kyphoscoliosis as the cause of chronic respiratory failure or a neuromuscular disorder | ||
*upper airway obstruction or asthma | *upper airway obstruction or asthma | ||
*a clear cause of decompensation requiring specific treatment (e.g., peritonitis, septic shock, acute myocardial infarction, pulmonary thromboembolism, pneumothorax, hemoptysis, severe pneumonia, or recent surgery or trauma); a facial deformity; or enrollment in other investigative protocols. | *a clear cause of decompensation requiring specific treatment (e.g., peritonitis, [[septic shock]], [[acute myocardial infarction]], [[pulmonary thromboembolism]], [[pneumothorax]], [[hemoptysis]], severe [[pneumonia]], or recent surgery or trauma); a facial deformity; or enrollment in other investigative protocols. | ||
*Refusal to undergo endotracheal intubation | *Refusal to undergo endotracheal [[intubation]] | ||
==Interventions== | ==Interventions== | ||
Both groups received: | Both groups received: | ||
*subcutaneous heparin | *[[subcutaneous heparin]] | ||
*antibiotics | *[[antibiotics]] | ||
*bronchodilators (subcutaneous terbutaline, aerosolized and intravenous albuterol, and corticosteroids or intravenous aminophylline or both) | *bronchodilators (subcutaneous terbutaline, aerosolized and intravenous albuterol, and corticosteroids or intravenous aminophylline or both) | ||
*electrolyte corrections | *electrolyte corrections | ||
'''Standard group:''' | '''Standard group:''' | ||
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'''NIPPV group:''' | '''NIPPV group:''' | ||
*At least 6 hours daily of NIPPV by ARM 25 machine keep arterial O2Sat >90% ''(Duration of noninvasive ventilation was determined on the basis of clinical criteria and arterial-blood gas levels.)'' | *At least 6 hours daily of NIPPV by ARM 25 machine keep arterial O2Sat >90% ''(Duration of [[noninvasive ventilation]] was determined on the basis of clinical criteria and arterial-blood gas levels.)'' | ||
'''Hard criteria for intubation in either group:''' | '''Hard criteria for intubation in either group:''' | ||
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===Primary Outcomes=== | ===Primary Outcomes=== | ||
Need for endotracheal intubation and mechanical ventilation at any point in the study: | Need for endotracheal [[intubation]] and mechanical ventilation at any point in the study: | ||
Thirty-one of the 42 patients (74 percent) in the standard-treatment | Thirty-one of the 42 patients (74 percent) in the standard-treatment | ||
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**Since the numbers of patients requiring intubation were different in the two groups, they compared mortality rates after adjustment for endotracheal intubation, using the Mantel–Haenszel test. After adjustment, they found no significant difference, suggesting that the number of patients requiring intubation was the main factor explaining the difference in mortality | **Since the numbers of patients requiring intubation were different in the two groups, they compared mortality rates after adjustment for endotracheal intubation, using the Mantel–Haenszel test. After adjustment, they found no significant difference, suggesting that the number of patients requiring intubation was the main factor explaining the difference in mortality | ||
== | ==Review Questions== | ||
<quiz display=simple> | <quiz display=simple> | ||
{What is one group that was excluded from the study that might benefit from NIPPV? | {What is one group that was excluded from the study that might benefit from NIPPV? | ||
|type="[]"} | |type="[]"} | ||
-COPD patients with 1 week of shortness of breath. | -[[COPD]] patients with 1 week of shortness of breath. | ||
+DNI patients with COPD exacerbation. | +DNI patients with COPD exacerbation. | ||
-Patients with hypoxia and hypercapnea. | -Patients with hypoxia and hypercapnea. | ||
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</quiz> | </quiz> | ||
==Sources== | ==Sources== | ||
<references/> | <references/> | ||
[[Category:EBQ]][[Category: | [[Category:EBQ]][[Category:Pulmonary]] |
Latest revision as of 16:12, 22 March 2016
PubMed Full text PDF
Clinical Question
Can NIPPV be used to avoid endotracheal intubation in acute COPD exacerbation?
Conclusion
NIPPV avoids endotracheal intubation, reduces the length of the hospital stay, and reduces the in-hospital mortality rate in selected patients.
Major Points
- In acute COPD exacerbation, noninvasive ventilation helps avoid endotracheal intubation and complications associated with mechanical ventilation
- The use of Noninvasive Ventilation significantly reduced the need for intubation as compared in the standard-treatment group (5 liters/min, nasal canula)
- The frequency of complications was significantly lower in the noninvasive ventilation group.
- Hospital stay was significantly shorter for the noninvasive ventilation group compared to the standard group.
Guidelines
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (pH < 7.35, PaCO2 > 6 kPa [45 mm Hg]) is present.
—British Thoracic Society[1]
NIV improves respiratory acidosis (increases pH and decreases PaCO2) and decreases respiratory rate, severity of breathlessness, and length of hospital stay in patients with acute exacerbations of COPD.
—Global Initiative for Chronic Obstructive Lung Disease (GOLD)[2]
Bi-level NIV is a beneficial support strategy that decreases the risk for invasive mechanical ventilation and possibly improves survival in selected hospitalized patients with respiratory failure
—ACCP, ACP-ASIM[3]
Design
Multicenter prospective randomized trial at five hospitals
Population
Adult patients with known or suspected COPD (by history, exam or CXR).
Inclusion Criteria
Respiratory acidosis/elevated HCO3 with exacerbation of dyspnea lasting less than two weeks. And at least two of the following:
- a respiratory rate above 30 bpm
- PaO2 <45 mm Hg
- Arterial pH < 7.35 after 10min RA
Exclusion Criteria
- RR < 12 bmp or need for immediate intubation (as defined below)
- tracheotomy or endotracheal intubation performed before admission
- the administration of sedative drugs within the previous 12 hrs
- CNS disorder unrelated to hypercapnic encephalopathy or hypoxemia
- cardiac arrest (within previous 5 days)
- cardiogenic pulmonary edema
- kyphoscoliosis as the cause of chronic respiratory failure or a neuromuscular disorder
- upper airway obstruction or asthma
- a clear cause of decompensation requiring specific treatment (e.g., peritonitis, septic shock, acute myocardial infarction, pulmonary thromboembolism, pneumothorax, hemoptysis, severe pneumonia, or recent surgery or trauma); a facial deformity; or enrollment in other investigative protocols.
- Refusal to undergo endotracheal intubation
Interventions
Both groups received:
- subcutaneous heparin
- antibiotics
- bronchodilators (subcutaneous terbutaline, aerosolized and intravenous albuterol, and corticosteroids or intravenous aminophylline or both)
- electrolyte corrections
Standard group:
- Supp O2 to max 5L NC to keep arterial O2Sat >90%
NIPPV group:
- At least 6 hours daily of NIPPV by ARM 25 machine keep arterial O2Sat >90% (Duration of noninvasive ventilation was determined on the basis of clinical criteria and arterial-blood gas levels.)
Hard criteria for intubation in either group:
- respiratory arrest
- respiratory pauses with loss of consciousness or gasping for air, psychomotor agitation
- making nursing care impossible and requiring sedation
- HR ≤ 50 bpm with loss of alertness
- Hemodynamic instability with systolic arterial blood pressure below 70 mm Hg.
In NIPPV group if a criterion was present after the withdrawal of ventilatory support, it could be reintroduced. If the criterion persisted after ventilation had been resumed, intubation was performed
Outcomes
Primary Outcomes
Need for endotracheal intubation and mechanical ventilation at any point in the study:
Thirty-one of the 42 patients (74 percent) in the standard-treatment group required endotracheal intubation, as compared with only 11 of the 43 patients (26 percent) in the noninvasive-ventilation group (P < 0.001).
Secondary Outcomes
- Complications:
- The proportion of patients with one or more complications was significantly higher in the standard-treatment group (20 of 42 patients, or 48 percent) than in the noninvasive-ventilation group (7 of 43, or 16 percent; P_ 0.001).
- Duration of ventilator assistance:
- In the standard-treatment group, the 31 patients who required endotracheal intubation were ventilated for a total of 17_ 21 days.
- In the noninvasive- ventilation group, the 11 patients who underwent endotracheal intubation were intubated for a total of 25+ 17 days; the other 32 patients were ventilated with a face mask fora mean of 4 +4 days.
- Mortality rate during hospitalization:
- The proportion of patients who died in the hospital was also significantly higher in the standard-treatment group (12 of 42 patients, or 29 percent, vs. 4 of 43, or 9 percent; P_ 0.02).
- Ten of the 12 deaths in the standard-treatment group and 3 of the 4 in the noninvasive-ventilation group occurred during mechanical ventilation.
- Since the numbers of patients requiring intubation were different in the two groups, they compared mortality rates after adjustment for endotracheal intubation, using the Mantel–Haenszel test. After adjustment, they found no significant difference, suggesting that the number of patients requiring intubation was the main factor explaining the difference in mortality
Review Questions
Sources
- ↑ Roberts CM, Brown JL, Reinhardt AK, et al. Non-invasive ventilation in chronic obstructive pulmonary disease:management of acute type 2 respiratory failure. Clin Med.2008;8(5):517-521
- ↑ GOLD Science Committee Methodology and summary of new recommendations. Global strategy for diagnosis, management and prevention of COPD: 2010 update. 2010
- ↑ Bach PB, Brown C, Gelfand SE, et al. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med. 2001;134(7):600-620.