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Noninvasive mechanical ventilation in the weaning of patients with

respiratory failure due to COPD. A RCT

Stefano, N., Ambrosino, N., & Clini, E. etc. (1998). Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease:

a randomized controlled trial. American College of Physicians, 128(9), 721-728.

Abstract

Discussion

Article 1 and Evidence

Article 2 and Evidence

Conclusion

Results

Clinical Significance

Summary

Lightowler, J. V., Wedzicha, J. A., & Elliot, M. W. (2002). Non-invasive positivepressure venitlation to treat respiratory failure from exacerbations of chronicobstructive pulmonary disease: Cochrane systematic review and meta-analysis.British Medical Journal, Retrieved fromhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC140272/?tool=pmcentrez

•NIV positive pressure has less complicationwith treatment and shorter length of stay

•An outcome this systematic review did notdetermine was if the NIV decreaseddeveloping nosocomial pneumonia like theoriginal article.

•Systematic literature review that reviewedonly RCTs. Articles reviewed by two usingCochrane database

•Specific inclusion and exclusion criteria

Purpose

Background/Intro

•Weaning failure rate is often high in patientswith COPD

•Prolonged mechanical ventilation canpotentially increase complications

Methods and Materials

•Acute relapse of COPD randomly assignedfrom three hospitals

•Random assignment performed usingopaque envelopes. 50 patients weredivided according to assignment, survivaland successful and unsuccessful weaning

•Criteria for accessing weaning:: SaO2 of90% or more, FiO2 of 40% or less, pH of7.35 or more, respiratory rate less than 35breaths/min, hemodynamic stability,absence of severe dyspnea, and depressedneurologic state

•25 patients were extubated and 25 wereintubated

•Day 60, 88% NIV weaned successfully, 68%successful weaned invasively

•Time in ICU was shorter in patients withnoninvasive technique

•No NIV developed pneumonia, 7 invasivelydeveloped pneumonia

•92% survival with noninvasive technique72% with invasive

•NIV technique can shorten stay in ICU,decrease incidence of pneumonia, andincrease survival

•Study was conducted on a certain group ofseverely hypercapnic patients with COPD

•NIV technique is more time consuming andcostly Success of NIV technique is likely dueto avoiding complicated artificial airways

•Excluded if known prior medical condition

•Different types of ventilation techniques totreat acute COPD patients

•NIV technique shows greater results inweaning patients off the ventilator

• Physical therapists need to be aware tomonitor patients arterial blood gases, bloodpressure, and signs of pneumonia.

•Patients with acute COPD can have NIVintubation which can decrease weaningtime, duration in ICU, likelihood ofpneumonia and higher survival rate

•Physicians and PT’s need to be aware thatpeople who have IMV may responddifferently to exercise compared to NIV

•Results were statistically significant.

•NIV had more benefits, but used on acuteCOPD

•NIV benefits: improved endurance,decreased LOS, pneumonia, mortality, pH,improved RR and arterial gases

DESIGN: Multicenter, randomized trial.

SETTING: Three respiratory intensive care units.

PATIENTS: Intubated patients with chronic obstructive pulmonarydisease and acute hypercapnic respiratory failure.

INTERVENTION: A T-piece weaning trial was attempted 48 hoursafter intubation. If this failed, two methods of weaning werecompared: 1) extubation and application of noninvasive pressuresupport ventilation by face mask and 2) invasive pressure supportventilation by an endotracheal tube.

MEASUREMENTS: Arterial blood gases, duration of mechanicalventilation, time in the intensive care unit, occurrence ofnosocomial pneumonia, and survival at 60 days.

RESULTS: At admission, all patients had severe hypercapnicrespiratory failure (mean pH, 7.18+/-0.06; mean PaCO2, 94.2+/-24.2 mm Hg), sensory impairment, and similar clinicalcharacteristics. At 60 days, 22 of 25 patients (88%) who wereventilated noninvasively were successfully weaned comparedwith 17 of 25 patients (68%) who were ventilated invasively. Themean duration of mechanical ventilation was 16.6+/-11.8 days forthe invasive ventilation group and 10.2+/-6.8 days for thenoninvasive ventilation group (P = 0.021). Among patients whoreceived noninvasive ventilation, the probability of survival andweaning during ventilation was higher (P = 0.002) and time in theintensive care unit was shorter (15.1+/-5.4 days compared with24.0+/-13.7 days for patients who received invasive ventilation; P= 0.005). Survival rates at 60 days differed (92% for patients whoreceived noninvasive ventilation and 72% for patients whoreceived invasive ventilation; P = 0.009). None of the patientsweaned noninvasively developed nosocomial pneumonia,whereas 7 patients weaned invasively did.

CONCLUSIONS: Noninvasive pressure support ventilation duringweaning reduces weaning time, shortens the time in the intensivecare unit, decreases the incidence of nosocomial pneumonia, andimproves 60-day survival rates.

•To determine whether noninvasiveventilation (NIV) improves the outcome ofweaning from invasive mechanicalventilation (IMV)

Schonhofer, B., Wallstein, S., Wiese, C., & Kohler, D. (2001). Noninvasivemechanical ventilation improves endurance performance in patients with chronicrespiratory failure due to thoracic restriction. American College of Chest Physicians,119, 1371-1378.

•NIV mechanical ventilation improved gasexchanges in COPD

•Results similar to original article despite itspeaking more of endurance performance

•Prospective case control study, level 4 onevidence

•Experimental design with manipulations ofvariables and data collection prospective

Presentation by: Kayla Klope, PT student

Bellarmine Univeristy