2. Controversial Issues in
Non-Invasive Ventilation
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases
,Assiut University

5. The normal ventilatory balance
Ventilatory drive
Respiratory load
Respiratory muscles
capacity

6. Respiratory Failure
Abnormal Ventilatory drive

 Respiratory muscles
capacity

 Respiratory load


7. Mechanical ventilation unloads the
respiratory muscles
Respiratory load
Mechanical
ventilation
Respiratory muscles

9. NPPV: definition
Any form of ventilatory support applied without
the use of an endotracheal tube considered to
include:
*CPAP with or without pressure support
*Volume- and pressure- cycled systems
*Proportional assist ventilation (PAV).
AJRCCM 2001; 163:283-91

10. Ventilators for NIV: Not all are
useful in each indication

11. Standard interfaces
Facial masks
advantages:
– sufficient ventilation also
during mouth breathing
– sufficient ventilation in patients
with limited co-operation
disadvantages:
– coughing is difficult
– skin lesions (bridge of the nose)

12. Standard interfaces
Nasal masks
advantages:
– better comfort
– good seal
– coughing is possible
– communication is possible
disadvantages:
– effective in nose breathing only
– good co-operation is necessary

13. Standard interfaces
Nasal prong/nasal pillow systems
* for patients with
claustrophobia
*for patients with allergies
against straps
*for low to moderate
pressures only
(< 20 cmH2O)

14. Standard interfaces
total-face masks
• Safe interface for acute
respiratory
insufficiency with high pressures
• well tolerated by the patients

15. Standard interfaces
helmet
• well tolerated by the patient
• no direct contact to the skin of
the face
• large dead space
• may influence the triggering of
the patient; use with CPAP
• very noisy

16. Standard interfaces
Custom-made masks
• for long-term
ventilation
• if standard masks are
not tolerated
mouthpieces
• simple and cheap
• short-interval alternative
interface for long-term
ventilated patients

17. Physiologic evaluation of three different
interfaces
cohort: 26 stable patients with hypercapnic COPD or interstitial lung disease.
intervention: three 30 minute tests in two ventilatory modes with
Conclusions: NIPPV was effective with all interfaces
.
patients‘ tolerance: nasal mask > facial mask or nasal prongs
pCO2 reduction:
facial mask or nasal prongs > nasal mask
Navalesi P et al. Crit Care Med 2000;28:2139-2140

18. Frequency of adverse effects and
complications of NIPPV
% occurrence
Mehta et al. Am J Respir Crit Care Med 2001;163:540-577

19. Interfaces available for adults
Acute
respiratory
failure
Chronic
respiratory
failure
Facial mask
63%
6%
Nasal mask
31%
73%
Nasal prongs
6%
11%
Mouth piece
0%
5%

21. THE RATIONALE

22. LV failure
 PaCO2
 CO
 DaO2
Pulmonary
edema

Pulmonary
compliance
+
 Airway
resistance
 PaO2
 Negative
Intrathoracic
Pressure Swing
Respiratory
muscle
fatigue

Work of
breathing

23. LV failure
 LV afterload
Pulmonary
edema
 Pulmonary
compliance
+
 Airway
resistance
 LV
transmural
pressure
 Negative
Intrathoracic
Pressure Swing
 O2
Cost of
breathing

24. Negative intrathoracic pressure swings during CPE
Pes
(cmH20)
0
-20
Rasen et al: Chest 1985; 87: 158-162

25. IntraThoracicPressure
and
LV function
AO
ITP
Ptm = 100-(-20) = 120
 effort =  ITP = Ptm

 LV afterload
LV
100
-20

26. Pes
(cmH20)
CPAP IN CPE
Spontaneous breathing
CPAP 15 cmH20
0
-20
Rasen et al: Chest 1985; 87: 158-162

27. IntraThoracicPressure
and
LV function
AO
ITP
Ptm = 100-(-5) = 105
 effort =  ITP =  Ptm

 LV afterload
LV
100
-5

28. Rationale of positive pressure
ventilation in CPE
Positive Pressure
 ITP
Pre-load
 Venous return
 FRC
 LVafterload
 PaO2
 PTM
 Cardiac performance
 pulmonary congestion
 WOB

30. CPAP vs. standard treatment in acute pulmonary oedema
CPAP
total
Rasasen,
1985
Bersten,
1991
Lin, 1995
intubated died
Standard treatment
total
intubated
died
mortality
intubation
rate
20
6
3
20
12
6
-15%
-30%
19
0
2
20
7
4
-9.5%
-35%
50
8
4
50
18
6
-4%
-20%
89
14
9
90
37
16
-6.6%
-26%
Pang D et al.: Chest 1998; 114: 1185-92

31. Noninvasive Ventilation in Cardiogenic Pulmonary Edema
A Multicenter Randomized Trial
Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437
• Multi-centre, randomized, prospective study with
130 patients with respiratory insufficiency.
• Setting: emergency room.
• Intervention: standard treatment with drugs and
high flow oxygen versus
standard treatment and NIV (nPSV).

32. Noninvasive Ventilation in Cardiogenic Pulmonary Edema
A Multicenter Randomized Trial
Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437

33. Noninvasive Ventilation in Cardiogenic Pulmonary Edema
A Multicenter Randomized Trial
Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437
Results:
• Similar intubation rate in both arms.
• Patients receiving NIV had a significantly better improvement
of PaO2/FiO2 within the first 30 minutes and within the first 3
hours of treatment.
• Hypercapnic patients: Significantly shorter time to
normalisation of PaCO2; lower intubation rate with NIV (2/33
vs. 9/33).
• Hypocapnic patients: Significantly higher intubationfrequency.

34. Noninvasive Ventilation in Cardiogenic Pulmonary Edema
A Multicenter Randomized Trial
Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437
Pi 14,5 ± 21,1 mbar; Pe 6,1 ± 3,2 mbar
mean ventilation time: 11,4 ± 3,6 hrs

35. Multicentre clinical trial:
Noninvasive ventilation in
acute cardiogenic pulmonary edema.
Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51.
primary endpoint:
death within 7 days
primary endpoint:
death or intubation within 7 days

36. Multicentre clinical trial:
Noninvasive ventilation in
acute cardiogenic pulmonary edema.
Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51.

38. Intervention
*Standard nitrate, diuretic and opioid therapy
*Consent + Randomised for 2 hours to:
-Standard oxygen therapy (by facial mask)
-CPAP (5 cmH2O  to a max 15 cmH2O)
-NIPPV (8/4 cmH2O  to a max 20/10 cmH2O)
*Fi02 0.6

39. Primary Outcome: Mortality
Standard
Therapy
NonInvasive
Ventilation
OR
95% CI
P Value
7-Day
9.8%
9.5%
0.97
0.63 1.48
0.869
30Day
16.7%
15.4%
0.93
0.65 1.32
0.685
7-day mortality, non-recruited 9.9%
No interaction with disease severity

40. NIV in Stable COPD:
Pro

41. BGA
(m m H g A
BG )
mmHg
PaC O 2
(m m H g )
100
PaO 2
100
9 00
9
8
8 00
70
70
NPPV (assPCV)
60
- mean IPAP 30
50
50
40
±4
mbar
- mean bf
60
±2
/min
23
3
4 00
1
2
30
3
5
9
Z e it ( T a g e )
1
2
3
5
ZDays e)
eit (T ag
9
Windisch W. et al. Respir Med 2002; 96:572-5

42. PaCO2
[m m H g]
NPPV
Controls
P a C O 2 d u rin g s p o n ta n e o u s b re a th in g
58
P = 0.26
56
54
NPPV (assPCV)
- mean IPAP 31
±7
mbar
- mean bf
52
±2
/min
21
50
P < 0.001
48
46
baseline
0
0,5
1
3
7
11
15 [hours]
T im e after cessatio n o f n o ctu rn al N P P V
Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260

43. Tidal
volume
[L]
V T d u rin g s p o n ta n e o u s b re a th in g
0,70
P < 0.05
NPPV
Controls
0,65
P = 0.28
0,60
NPPV (assPCV)
- mean IPAP 31
±7
mbar
- mean bf
0,55
±2
/min
21
0,50
baseline
0
0,5
1
3
7
11
15 [hours]
T im e after cessatio n o f n o ctu rn al N P P V
Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260

44. NPPV (assPCV)
- mean IPAP 28
±6
mbar
- mean bf
±3
/min
21
N = 34
2-year survival: 86%
Windisch W. et al. Chest 2005; 128:657-6

45. N = 141
NPPV (assPCV)
- mean IPAP 20
±4
mbar
- mean bf
±4
/min
20
BMI <20 kg/m2 = 21%
Budweiser S. et al. Respir Care 2006; 51:126-132

46. Windisch W. et al. J Clin Epidemiol 2003; 56:752-759
Windisch W. et al. J Clin Epidemiol 2008; 61:848-853
Severe Respiratory
Insufficiency Questionnaire
SRI
ATS homepage:
http://www.atsqol.org/sections/instruments/pt/pages/sri.html

47. • Multicenter Study (N = 135)
• Outcomes:
- Quality of life (SF-36; SRI)
- Side effects
- Hospitalisations
- Compliance
- Physiological parameters
T0 (baseline)
T1
Months
T12
Windisch W. Eur Respir J 2008; 32:1328-1336

48. SRI-Summary Scale (SRI-SS)
65
IPAP/EPAP
(mbar)
P < 0.001
restrictive thoracic
20/3
19/4
P < 0.001
neuromuscular
25/1
P < 0.001
COPD
55
kulär
Changes in SRI-SS
independent from the underlying disease
MANOVA; F=0,62; P=0,65.
45
T0
T1
T0
COPD
T12
T1
RTD
T12
NMD
Windisch W. Eur Respir J 2008; 32:1328-133

49. suppl. O2 (2.3 L/min)
suppl. O2 (2.3 L/min) +
NPPV (29/4 mbar, 20/min)
Dreher M. et al. Eur Respir J 2007; 29: 930-936

50. Six-minute walking test
suppl. O2
suppl. O2 + NPPV
P < 0 .0 0 1
85
P < 0 .0 0 1
110
80
100
90
70
P a O 2 (m m H g )
P a O 2 (m m H g )
PaO2 (mmHg)
75
65
60
55
80
70
60
50
50
45
m ean
PaCO22
(mmHg)
50
BDS
Walking
distance (m)
b e fo re
a fte r
P < 0.001
m ean
53
m ean
50
6
P < 0.001
209
P < 0.05
b e fo re
a fte r
N.S.
m ean
51
4
252
Dreher M. et al. Eur Respir J 2007; 29: 930-936

51. Rehab
Rehab + NPPV
Duiverman ML. et al. Thorax 2008; 63:1052-10

52. ERS Congress 2008 in Berlin
A randomised trial of home non-invasive ventilation vs. sham
ventilation in survivors of acute hypercapnic respiratory failure
in COPD.
Chu CM et al. Eur Respir J 2008; 32(Suppl.52):38s.
•42 COPD patients were randomised to receive either NPPV or sham
ventilation following acute NIV
• At days 120 patients were free of acute hypercapnic respiratory failure:
• 81% NPPV group
• 33% sham ventilation
Nocturnal non-invasive positive pressure ventilation (NIPPV) in
stable hypercapnic COPD patients – a randomized controlled
trial.
Funk GC et al. Eur Respir J 2008; 32(Suppl.52):37s.
• 26 COPD patients received NIPPV over 6 months following mechanical ventilation on
the ICU
• After 6 months patients were randomised to stop NIPPV or to continue NPPV
• Discontinuation of NIPPV caused clinical worsening (resumption of NPPV or ICU
admission)

53. NIV in Stable COPD:
con

54. Home NIV not recommended

55. (Casanova et al Chest 2000;118:1582-90)

56. Hospitalisation
following NPPV-establishment
LTOT:
+27%
NPPV + LTOT: -45%
ICU-Admission
n.s
following NPPV-establishment
LTOT:
-20%
NPPV + LTOT: -75%
n.s
Clini E. et al. Eur Respir J 2002; 20:529-538

57. LTOT
SURVIVAL
NPPV
THE ITALIAN MULTICENTRE STUDY ON
NONINVASIVE POSITIVE PRESSURE VENTILATION
IN COPD PATIENTS
mesi
Clini et al ERJ 2001

58. COPD

59. HOSPITAL ADMISSIONS
Total hospital admissions (nr/pt/year)
ICU admissions (nr/pt/year)
2
4
3,5
Follow-back
3
Follow-up
1,5
2,5
1
2
1,5
0,5
1
0,5
0
0
LTOT
NPPV
LTOT
Clini et al ERJ 2001
NPPV

60. Nocturnal NIPPV for at least three months in hypercapnic patients
with stable COPD had no consistent clinically or statistically
significant effect on lung function, gas exchange, respiratory muscle
strength, sleep efficiency or exercise tolerance.

61. Annane, D; Chevrolet, JC; Chevret, S; Raphael, JC
Nocturnal mechanical ventilation for chronic
hypoventilation in patients with neuromuscular and chest
wall disorders.
Cochrane Database of Systematic Reviews. Issue 1, 2001
Current evidence about the therapeutic benefit of
mechanical ventilation is weak, but consistent,
suggesting alleviation of the symptoms of chronic
hypoventilation in the short term, and in two small
studies survival was prolonged. Mechanical ventilation
should be offered as a therapeutic option to patients
with chronic hypoventilation due to neuromuscular
diseases.

71. IPS 15 cmH2O
PEEP 3 cmH2O
IPS 16 cmH2O
PEEP 3 cmH2O
v
v

75. K. Marquis et al. AJRCCM 2002; 166:809-813

76. NORMAL
Surface 118.5 cm2
COPD
Surface 79.6 cm2
S. Bernard et al. AJRCCM 1998; 158:629-634

77. Exercise in COPD patients: PSV reduces inspiratory effort
Maltais et al. Am J Respir Crit Care Med, 1995; 151:1027

78. PSV 10 cmH2O ( )
PSV 5 cmH2O ( )
van 't Hul et al ERJ 2006

79. Lack of additional effect of adjunct of assisted ventilation to
pulmonary rehabilitation in mild COPD patients
L. Bianchi, K. Foglio, R. Porta, P. Baiardi, M. Vitacca, N. Ambrosino
(% Peak Work rate)
PAV
110
Training intensity
120
SB
100
90
80
70
60
50
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Training session (days)
Respiratory Med, 2002; 96:359-367
“Assisted ventilation
during training
sessions…., was not well
tolerated by all patients
and gave no additional
physiological benefit in
comparison with exercise
training alone.“

80. No clinically or statistically significant effect on survival,
hospital admission, lung function, respiratory muscle strength
As an adjunct to exercise training in selected patients with
severe COPD, NIV may produce modest additional
improvements in exercise performance
Future research should primarily focus on adequate patient
selection and recognition of the mechanisms through which NIV
may work

82. Severe acute hypoxemic respiratory
failure
Severe AHRF  Often need ETI-IMV
IMV   morbidity and mortality
Main goal of NIV: Avoid ETI
Avoidance of endotracheal intubation
Improved morbidity and mortality?
• Heterogeneous clinical condition
• Results of studies on NIV unrelated to CPE are
inconsistent

83. Severe Community-Acquired Pneumonia
Major criteria
Minor criteria
• Mechanical ventilation
• Septic shock
•
•
•
•
•
•
•
•
•
Respiratory rate >30 min-1
PaO2/FiO2 <250
Bilateral or multilobar
SBP <90 mmHg *
BUN >25
Platelets <100,000
Leukocytes <4,000
Confusion
Hypothermia
1 Major or 3 Minor Criteria
Clin Infect Dis. 2007;44 Suppl 2:S27-S72
Pneumonia is associated with
poor outcome in patients
receiving NIV

84. NIV in acute COPD: correlates for
success
N IV failure
 Retrospective analysis
 59 episodes of ARF in 47
COPD patients
• NIV success: 46
• NIV failure: 13
 Predictors for NIV
failure:
n=5
60
40
%
20
• Higher PaCO2 at admission
• Worse functional condition
• Reduced treatment
compliance
• Pneumonia
p=0.019
n=8
0
O ther
Pneum onia
Ambrosino N. Thorax 1995;50:755-7

85. NIV failure in acute hypoxemic respiratory
failure
• Eight ICUs
• n=354:
• Success: 246
• Failure: 108
Antonelli M. Intensive Care Med 2001; 27: 1718-28

86. Non-invasive ventilation and
pneumonia
Conclusion:
 Patients with pneumonia causing ARF and
needing NIV are among those with worst
outcome
but, …..
is NIV effective in patients with pneumonia?
???

87. NIV in severe community-acquired
pneumonia
 Prospective, randomised, controlled
 Severe CAP (ATS criteria).
 Standard treatment vs ST + NPPV. n: 28 + 28 = 56
In tu b atio n rate
O verall population
60
p=0.03
N on-C O PD +
N on-hypercapnia
C O PD +
H ypercapnia
n=14
60
p = 0.005
n=6
p = 0.73
60
n=8
40
40
%
40
20
n=6
20
%
n=6
20
n=0
0
0
N IV
C ontrol
N IV
C ontrol
0
N IV
C ontrol
Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91

88. NIV in severe community-acquired
pneumonia
 Shorter length of stay only in COPD patients with hypercapnia
2-m o n th m o rtality
60
p =0.05
p=N S
n=5
60
n=6
%
n=7
p =0.71
60
n=10
40
%
N on-C O PD +
N on-hypercapnia
C O PD +
H ypercapnia
O verall population
40
20
40
n=1
n=5
20
20
0
0
N IV
C ontrol
N IV
C ontrol
0
N IV
C ontrol
Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91

89. CPAP in severe hypoxemic ARF

250
123 patients: 54% pneumonia, 34% cardiac disease
• 34/62 CPAP + O2
• 33/61 O2 alone
P aO 2 /F iO 2
C PA P + O 2
Intubation
O 2 alone
200
p< 0.001
150
100
B aselin e
40
60' after
R esp irato ry rate
30
p< 0.001
Delclaux C. JAMA 2000;284:2352
20
B aselin e
60' after

90. NIV in severe AHRF: Intubation
rate
 Prospective, randomised, controlled, 3 centres
 N=105. Pneumonia: 34 (32%)
A LI/A R D S
Pneum onia
O verall population
p = 0.467
100
100
p = 0.017
n= 11
80
80
p=0.010
%
60
40
60
100
60
40
n= 5
20
0
%
0
40
N IV
n = 13
100
20
80
%
0
N IV
C ontrol
n= 6
80
20
n = 28
n= 8
C ontrol
100
C ardiogenic
pulm onary edem a 80
60
p > 0.999
40
20
C ontrol
Thoracic traum a
p = 0.333
60
n= 5
40
n= 1
n= 2
0
Ferrer M et al. Am J Respir Crit Care Med 2003;168:1438
N IV
20
n= 1
0
N IV
C ontrol
N IV
C ontrol

91. NIV in severe AHRF: ICU mortality
A LI/A R D S
Pneum onia
O verall population
p = 0.569
100
100
p = 0.030
80
80
%
p=0.028
40
n= 3
100
80
%
0
N IV
C ontrol
60
60
20
C ontrol
N IV
100
C ardiogenic
pulm onary edem a 80
p > 0.999
40
20
n= 5
0
N IV
n=9
n= 7
40
0
n = 21
20
n= 8
60
20
%
80
40
60
100
60
Thoracic traum a
p = 0.515
40
n= 1
n= 2
0
20
C ontrol
n= 3
n= 0
0
N IV
C ontrol
N IV
C ontrol
Ferrer M et al. Am J Respir Crit Care Med 2003; 168:1438

92. NIV as an alternative to ETI in severe
AHRF
Intubated patients
 Patients with ETI predefined
criteria
 NIV vs intubation+IMV
ETI-IM V
Patients w ith com plications
80
p < 0.05
p < 0.001
n= 11
N IV
n= 32
0
20
40
60
80
100
%
30
n = 21
n=8
p < 0.01
60
%
40
N IV
E T I-IM V
20
n = 12
(% )
10
20
n=2
n=1
0
n=0
0
N IV
E T I-IM V
Pneum onia
Sinusitis
Antonelli M et al. N Engl J Med 1998;339:429-35

93. NIV in immunosuppressed
patients with pulmonary
infiltrates and AHRF

94. NIV in immunosuppressed patients
with pulmonary infiltrates and ARF
• Early administration of NIV: 26 NIV vs 26 control
– Haematological + neutropenia (BMT, chemotherapy)
– Immunosuppressor therapy (transplant, steroids)
– AIDS
Intubation
100
p = 0 .0 3
H o sp ital m o rtality
100
80
(% )
80
60
60
40
40
20
20
0
p = 0 .0 2
0
N IV
C o n tro l
NIV vs control:
• Faster improvement of
hypoxemia
• Less severe complications
N IV
C o n tro l
Hilbert G. N Engl J Med 2001;344:481

95. NIV in ARF after solid organ
transplant
• Solid organ transplant: lung, liver, renal
• Incidence of ARF in postop. period: 21%
• Patients: 20 NIV vs 20 control
Intubation
100
p = 0 .0 0 2
IC U m ortality
100
p = 0 .0 5
NIV vs control:
80
(% )
80
60
60
40
40
• Less severe complications
20
20
• Hospital mortality unchanged
0
0
N IV
C o n tro l
• Faster improvement of
hypoxemia
N IV
C o n tro l
Antonelli M. JAMA 2000;283:235

96. NIV in AHRF: A systematic review
•
RCTs on standard treatment with and without NIV
• Not due to cardiogenic pulmonary oedema
Endotracheal intubation
Absolute risk reduction: 23% (10-35%)
Keenan S. Crit Care Med 2004;32:2516
ICU mortality
Absolute risk reduction: 17% (8-26%)
Trial results significantly heterogeneous

97. Why is NIV more
effective than CPAP in
severe hypoxemic ARF?

98. Physiologic effect of CPAP and NIV in ALIARDS
 10 patients with indication for NIV
 Short-term effects of:
• CPAP 10 cmH2O
• 2 combinations of NIV: PSV 10–PEEP 10; PSV 15-PEEP 5
R espiratory rate
34
PaO 2 /FiO 2
270
240
32
210
30
180
*
28
*
150
26
*
120
In it
ia l
PCPA
10
0 -1 0 V 1 5 -5
V1
PS
PS
F in
al
In it
ia l
P
CPA
-1 0
0 -1 0 V 1 5 -5
V1
PS
PS
F in
al
L’Her E. Am J Respir Crit Care Med 2005;172:1112-8

99. CPAP and NIV in ALI-ARDS: Work of
breathing, neuromuscular drive and dyspnea
PTPdi
400
300
200
*
*
100
In it
ia l
CPA
P -1
0
0
-5
1 0 -1 S V 1 5
SV
P
P
F in
al
P 0.1
4
3
 PSV + PEEP is needed to reduce inspiratory
muscle effort
*
2
*
1
In it
ia l
P
CPA
-1 0
0 -1 0 V 1 5 -5
V1
PS
PS
F in
al
 CPAP improves oxygenation but fails to unload
the respiratory muscles
 PSV levels of 10 and 15 cmH2O provide similar
L’Her E et al.
unloading but differ in their effects on
Am J Respir Crit Care Med 2005;172:1112-8 dyspnea

100. Different efficacy of NIV in severe
pneumonia (no hypercapnia, no COPD)
200
A rterial hypoxem ia
40
B aseline severity
25
100
15
20
10
50
10
0
0
Ferrer'03
80
60
%
20
30
C onfalonieri'99
ET Intubation
5
0
Ferrer'03
60
p<0.05
C onfalonieri'99
H ospital m ortality
p<0.05
40
40
20
20
0
0
Ferrer'03
C onfalonieri'99
Ferrer'03
C onfalonieri'99
A P A C H E -II
150
S A P S -II
P a O 2 /F iO 2
p=0.05
NIV G roup
Control G roup

101. Don’t forget contraindications for
NIV
 Need for immediate intubation:
•
•
•
•
•
Cardiac or respiratory arrest
Respiratory pauses +  alertness + gasping
Psychomotor agitation  sedation
Massive aspiration
Inability to manage secretions
•
•
•
•
Severe non-respiratory organ failure
Face surgery, trauma or deformity
Upper airway obstruction
Inability to cooperate/protect the airways
 Other limitations for NIV:
Am J Respir Crit Care Med 2001;163:283-91

102. Ventilators for NIV: Not all are
useful in each indication

103. Summary
 Lower likelihood to need ETI when NIV is added to
standard medical treatment in severe AHRF
 Effects of NIV on mortality are less evident
 Different efficacy of NIV among different
populations:
 Pneumonia with severe hypoxemia and causing COPD
exacerbation
 The routine use of NIV in all patients with severe
AHRF is not supported
 CPAP: No evidences on benefits in AHRF (post-op
excluded)
 Facilities for close monitoring and rapid intubation
are advised

104. NIV in Acute Respiratory Failure
CONTRA
• Acute Respiratory Failure could have
different pathophysiology
• Clinical Studies does not reflect real life and
exclude the more severly ill patients
• NIV in hypoxemic patients cause potential
harm, the risk-benefit-ratio is not positive
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105. ERS Postgraduate Course NIV
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106. Crit Care Med 2004; 32:2516 –2523
• Conclusion:
Randomized trials suggest that patients with acute
hypoxemic respiratory failure are less likely to
require endotracheal intubation when NPPV is added
to standard therapy. However, the effect on mortality
is less clear, and the heterogeneity found among
studies suggests that effectiveness varies among
different populations.
As a result, the literature does not support the
routine use of NPPV in all patients with acute
hypoxemic respiratory failure.
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107. NIV in Acute Respiratory Failure
• Meta-Analysis of RCT of
patients with acute hypoxemic
respiratory failure not due to
cardiogenic pulmonary edema
• interventions compared
noninvasive ventilation and
standard therapy with
standard therapy alone
• outcomes included
– need for endotracheal
intubation,
– length of intensive care unit or
hospital stay
– intensive care unit or hospital
survival.
Keenan SP. Crit Care Med 2004; 32:2516 –2523
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Author
Year
No.of pts
Wysocki
1995
41
Confalioneri
1999
33 (out of 56)
Martin
2000
32 (out of 61)
Antonelli
2000
31 (out of 40)
Hilbert
2001
52
Ferrer
2003
75 (out of 105)
Auriant
2001
48

108. Risk of Endotracheal Intubation
Keenan SP. Crit Care Med 2004; 32:2516 –2523
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Length of ICU Stay

109. ERS Postgraduate Course NIV
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110. NIV in immunosuppressed patients
• Randomized trial in 52 immunosuppressed patients
with pulmonary infiltrates, fever and hypoxemic
respiratory failure
• Group A: Standard treatment (Antimicrobial agents,
diuretics, bronchodilators, immunosuppressive
agents, heparine s.c.)
• Group B: Standard + NIPPV
NIPPV Setting: Vt 7 ml/kg, PEEP til 10 cm H2O
duration of NIPPV: at least 45 min. every 3 hours
Hilbert G et al. N Engl J Med 2001; 344: 481-7
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111. NIV in immunosuppressed patients
Outcome
NIV
Standard
p
RR
Intubation
12/26
20/26
0.03
0.60
12
4
0.02
initial improve in
pO2 / FiO2
sustained improve in
pO2 / FiO2
death on ICU
13
5
0.02
10/26
18/26
0.03
0.56
death in hospital
13/26
21/26
0.02
0.62
Death in the hospit al
Hilbert G et al. N Engl J Med 2001; 344: 481-7
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112. NIV in immunosuppressed patients
• Exclusion Criteria
– hemodynamic instability (RRsyst < 80 mmHg)
– ECG: Ischemia or ventricular arrhythmia
– cardiac failure
– COPD
– pCO2 > 55 mmHg, pH < 7.35
– multiorgan failure
– deterioration in neurological status (GCS < 8)
Hilbert G et al. N Engl J Med 2001; 344: 481-7
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113. Severe Hypoxemic Respiratory Failure
Basic Disease
Patient Demographics:
• Pneumonia (34)
• Cardiogenic Pulmonary Oedema (30)
• Thoracic trauma (17)
• ARDS (15)
• others (9)
Ferrer M, et al. Am J Respir Crit Care Med 2003;168:1438-1444
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114. NIV Failure
Antonelli M. Intensive Care Med 2001;27:1718-28
100
120
80
100
No. of patients
70
80
60
50
60
40
30
40
20
20
10
0
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Pu lmF ib r/PE
Fibrosis
ARDSe x
p
ARDSexp
CAP
CAP
ARDSp
ARDS p
NP
Nosok.
Pneum
Ate le c t
Atelektasis
In h PN
Inhalation
Pneuomitis
Pu lmc o n t
Thoracic
trauma
CPE
CPE
0
Failure Rate in %
90

115. NIV in transplantation patients
• 40 pts. undergoing solid organ transplantation with
acute respiratory failure
• Design: prospective, randomised
• Group A: Standard Therapy
Group B: Standard Therapy + NIPPV
• Primary Endpoint:
Need for Endotracheal Intubation
• Secondary Endpoint: ICU mortality, Length of ICU
stay and ventilatory assistance
Antonelli M. JAMA 2000; 283: 235-41
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116. NIV – Real Life
•
Evaluation of all 449 patients receiving
NPPV for a 1-yr period for acute or acute
on chronic respiratory failure
–
–
–
–
–
•
•
•
•
cardiogenic pulmonary edema (n = 97)
AECOPD (n = 87)
non-chronic obstructive pulmonary
disease acute hypercapnic respiratory
failure (n = 35)
postextubation respiratory failure (n = 95)
acute hypoxemic respiratory failure (n =
144)
Intubation rate was 18%, 24%, 38%, 40%,
and 60%,
respectively,
Hospital mortality for patients with acute
hypoxemicrespiratory failure who failed
NPPV was 64%.
Variables associated with NPPV failure
–
–
–
–
SAPS II (OR 1.07)
Glasgow Coma Scale (OR, 0.76)
PaO2/FIO2 ratio (OR, 0.98)
serum albumin (OR, 0.30)
Schettino G. Crit Care Med 2008; 36:441 –447
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117. Schettino G. Crit Care Med 2008; 36:441 –447
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118. Conditions associated with NIV failure
in acute hypoxemic ARF
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119. NIV in ARDS
•
•
•
•
•
•
Prospective, multiple-center cohort
study
Three European intensive care units
having expertise
with NPPV
147 patients on NPPV
NPPV improved gas exchange and
avoided intubation in 79 patients (54%)
Avoidance of intubation was associated
with
–
–
•
Intubation was more likely
–
–
–
•
less VAP (2% vs. 20%)
lower ICU mortality rate (6% vs. 53%)
in patients who were older
had a higher SAPS II
needed a higher level of PEEP and PSV
SAPS II >34 and a PaO2/FIO2 <175 after
1 hr of NPPV were independently
associated with NPPV failure and need
for ETI
Antonelli M. Crit Care Med 2007; 35:18 –27
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120. Postextubation ARF
•
•
•
•
Randomised, controlled study
37 centres, 8 countries
MV < 48h
Respiratory Failure in between
48 h after extubation
• NIV
– Vt 5ml/kg BW
– Goal: SaO2 > 90%
• Vs. Standardtherapie
– O2-Insufflation
– Physiotherapy
Esteban A. NEJM 2004; 350: 2452-60
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121. Postextubation ARF
Mortality 25 %
(NIV) vs. 14 %
(O2)
RR for death for
NIV 1,78 (95%
CI 1,03 – 3,20)
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Esteban A. NEJM 2004; 350: 2452-60

122. Non invasive Ventilation in ALI
• Prospective cross over study
• 10 pts. with acute lung injury
– paO2/FiO2 < 300 mmHg (mean
132, PCO2 41 mmHg)
– SaO2> 92% under NIV
– RRsyst > 90 mmHg
• Objective:
To assess the short term
efffects of non invasive
ventilation and CPAP
L´Her E. AJRCCM 2005; online August 4
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123. Non invasive Ventilation in ALI
• Prospective cross over study
• 10 pts. with acute lung injury
– paO2/FiO2 < 300 mmHg (mean
132, PCO2 41 mmHg)
– SaO2> 92% under NIV
– RRsyst > 90 mmHg
• Objective:
To assess the short term
efffects of non invasive
ventilation and CPAP
L´Her E. AJRCCM 2005; online August 4
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124. ARMA trial - major outcome parameters
ARMA trial, 2000
NEJM 342:1301,
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125. ALVEOLI trial - outcome
ALVEOLI trial, 2004
NEJM 351:327,
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126. NIV in ARDS
Antonelli M. Crit Care Med 2007; 35:18 –27
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127. ILA in ARDS
• Retrospective analysis of
extracorporal interventional
lung assist (ILA)
• 90 pts. with ARDS in a
tertiary university center
• Before, 2 and 24 hrs after
implementation
–
–
–
–
Improvement in Oxygen
Normalisation of pCO2
73 of 90 pts. survived
Complication Rate 24.4%
Bein T. CCM 2006: 34: 1372-77
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128. ILA in Postoperative ARDS
• 7 Patients with postoperative
ARDS in Barcelona, Spain
– 5 pneumonectomy
– 2 lobectomy
• 29% of CO perfuse ILA
• No Change in Hemodynamics
• Improvement in Respiratory
Function
• Decrease in Il-6
• 6 of 7 pts. survived in
comparision to 2 of 9 in a
historical cohort
Iglesias M. Ann Thorac Surg 2008: 85: 237-44
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