Antonio M Esquinas Editor Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Key Topics and Practical Approaches 123 Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Antonio M Esquinas Editor Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Key Topics and Practical Approaches Editor Antonio M Esquinas Hospital Morales Meseguer Intensive Care Unit Murcia Spain ISBN 978-3-319-04258-9 ISBN 978-3-319-04259-6 DOI 10.1007/978-3-319-04259-6 (eBook) Library of Congress Control Number: 2015960386 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) To wife Rosario, my daughters and Rosana Alba, inspiration and meaning To the memory of my father Preface Ideally all strategies directed toward decreasing the duration of invasive mechanical ventilation (IMV) and reducing or avoiding its complications are useful in patients receiving IMV for different medical or surgical reasons In the past decade advancement in protocols focusing on weaning from mechanical ventilation and new ventilation modes such as neutrally adjusted ventilatory assist (NAVA) and airway pressure release ventilation (APRV) has been developed along with improving the patient-ventilator interaction, advance monitoring, and strategies for early diagnosis and prevention of ventilator-associated pneumonia However, there still remain a significant proportion of those who are dependent on IMV and develop difficulty in weaning from it even after their underlying acute respiratory failure (ARF) and other organ failure have resolved This population represents weaning failure and ventilator dependence More and more advanced surgical procedures and medical management in the elderly population and those with multiple comorbidities also lead to failure to wean from IMV and impact healthcare delivery both due to persistent long-term illness and increasing cost of care Currently, noninvasive mechanical ventilation (NIV) is considered one of the alternatives to endotracheal intubation in selected patients who develop ARF of diverse etiology Its establishment as a suitable, effective, and rational alternative is based not only for its strong and positive action on the respiratory muscles and gas exchange but also due to its positive influence on short- and long-term outcome in critically patients This influence is significant particularly in patients with exacerbation of COPD and acute cardiac pulmonary edema and who are immunodepressed In the past decade there has been significant development in NIV equipment and interfaces and in the understanding of the patient-NIV interaction This has led to physicians considering NIV as an alternate to endotracheal intubation and IMV, in the management of not only ARF but also failure to wean from IMV and extubation failure The latter is defined as a condition where the patient is unable to sustain respiratory status postextubation from IMV Is NIV a recognized alternative to IMV in these conditions? Will this strategy change patient outcomes and IMV-related complications? Will NIV influence healthcare delivery by improving quality of care and reduce cost of care? In this book, sections and chapters are structured in response to these questions based on evidence, clinical practice, and expert recommendations vii viii Preface The recognized chapters that we have contemplated on NIV have been divided into clinical conditions such as persistent weaning failure from prolonged mechanical ventilation, extubation post acute respiratory failure, and unplanned extubation and its use as alternative to short- and long-term IMV including those with tracheotomy The use of NIV in these clinical conditions will look at the diverse medical and surgical (thoracic, cardiac, abdominal, lung transplants) population Additionally, determinants of NIV response, comorbidities, equipments and interfaces, ventilatory modes, patient-ventilator interaction, and clinical monitoring will also be covered in this book We consider that this book represents a valuable tool for a practical approach by the rational use of NIV in prolonged mechanical ventilation, difficult weaning, and postextubation failure Murcia, Spain Antonio M Esquinas, MD, PhD, FCCP Contents Part I Weaning From Mechanical Ventilation Determinants of Prolonged Mechanical Ventlation and Weaning Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients Dimitrios Lagonidis and Isaac Chouris Prolonged Weaning from Mechanical Ventilation: Pathophysiology and Weaning Strategies, Key Major Recommendations Vasilios Papaioannou and Ioannis Pneumatikos Automated Weaning Modes F Wallet, S Ledochowski, C Bernet, N Mottard, A Friggeri, and V Piriou Neurally Adjusted Ventilatory Assist in Noninvasive Ventilation B Repusseau and H Rozé Recommendations of Sedation and Anesthetic Considerations During Weaning from Mechanical Ventilation Ari Balofsky and Peter J Papadakos Weaning Protocols in Prolonged Mechanical Ventilation: What Have We Learned? Anna Magidova, Farhad Mazdisnian, and Catherine S Sassoon Evaluation of Cough During Weaning from Mechanical Ventilation: Influence in Postextubation Failure Pascal Beuret 15 21 29 37 43 51 ix Noninvasive Ventilation and Weaning Outcome 55 Karen E.A Burns and Neill K.J Adhikari Abbreviations CI COPD CPAP FEV1 GRADE I2 ICU MD NIV PS RR Confidence interval Chronic obstructive pulmonary disease Continuous positive airway pressure Forced expiratory volume in s Grading of Recommendations Assessment Development and Evaluation Measure of heterogeneity Intensive care unit Mean difference Noninvasive ventilation Pressure support Relative risk K.E.A Burns, MD, FRCPC, MSc (*) Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada Division of Critical Care Medicine, St Michael’s Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada e-mail: burnsk@smh.ca N.K.J Adhikari, MDCM, MSc Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada e-mail: neill.adhikari@utoronto.ca © Springer International Publishing Switzerland 2016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-04259-6_55 451 452 55.1 K.E.A Burns and N.K.J Adhikari Introduction Guidelines recommend noninvasive ventilation (NIV) for severe exacerbations of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema to prevent intubation and enhance survival [1, 2] However, clinicians apply NIV to a broader array of clinical conditions to provide partial respiratory support and to limit intubation-related complications, including pneumonia and prolonged mechanical ventilation Regardless of the indication, the clinician’s goal in using NIV is to reduce patient morbidity and mortality In the weaning and peri-extubation period, NIV has been used to decrease the duration of invasive weaning, prevent recurrent respiratory failure in at-risk patients who are extubated, and rescue patients with a failed attempt at extubation [3] (Fig 55.1) In the first case, clinicians extubate selected patients who are ready for weaning, but who have failed a spontaneous breathing trial, directly to NIV The objectives are to reduce the duration of invasive ventilation, limit intubation-related complications, and minimize failed attempts at extubation In the second case, clinicians prophylactically apply NIV to patients at risk of reintubation, such as in the intensive care unit (ICU) or postoperative setting, with the goal of reducing extubation failure Finally, by applying NIV to rescue patients who fail extubation, clinicians aim to avoid reintubation and reduce further exposure to invasive ventilation and its complications In 2001, an International Consensus Conference stated that the use of NIV to “shorten weaning time and avoid reintubation represents a promising indication for NIV” but made no recommendation [4] The authors of this statement also noted that, although NIV holds potential to improve physiologic outcomes without serious side effects in postoperative patients, the ability of NIV to “modify relevant clinical outcomes in these patients is less clear” [4] In 2002, a British Thoracic Society guideline stated that “NIV has been used successfully to wean patients from invasive ventilation, and should be used when conventional Initial Treatment Phase of care Respiratory failure Role of noninvasive ventilation Avoidance of intubation in COPD, CPE, other indications Weaning from invasive ventilation and and peri-extubation Intubation (no ninvasive ventilation failed or not indicated) Resolution of primary process and/or failed SBT Weaning strategy (COPD vs non-COPD) Elective Extubation Prevention of respiratory failure (high risk vs all patients) Post-extubation respiratory failure Treatment of recurrent respiratory failure Fig 55.1 Roles for NIV in the weaning and peri-extubation period COPD chronic obstructive pulmonary disease, CPE cardiogenic pulmonary edema, SBT spontaneous breathing failure 55 Noninvasive Ventilation and Weaning Outcome 453 weaning strategies fail.” The authors assigned a level B evidence grade to this recommendation and cited support from two randomized controlled trials (RCTs) [5] Subsequently, the statement of the Sixth International Consensus Conference in Intensive Care Medicine on weaning from mechanical ventilation stated that “NIV techniques to shorten the duration of intubation should be considered in selected patients, especially those with hypercapnic respiratory failure and should not be routinely used as in the event of extubation failure” [6] A more recent Canadian Clinical Practice Guideline [7] developed comprehensive recommendations for NIV use in weaning and extubation First, it suggested that “NIV be used to facilitate early liberation from mechanical ventilation in patients who have COPD, but only in centers that have expertise.” This statement was designated as a Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2B recommendation [8, 9] Because of insufficient evidence, there was no recommendation regarding NIV for weaning in patients without COPD Second, the guideline suggested “that NIV be used after planned extubation in patients who are considered to be at high risk of recurrent respiratory failure, but only in centers that have expertise in this type of therapy” (GRADE 2B recommendation) and suggested that NIV not be used after planned extubation in patients considered to be at low risk of respiratory failure (GRADE 2C recommendation) Finally, in the setting of post-extubation acute respiratory failure, it suggested that noninvasive positive pressure ventilation not be routinely used in patients who not have COPD (GRADE 2C recommendation) and made no recommendation for patients with COPD because of a lack of evidence In this chapter, we summarize current RCTs and meta-analyses pertaining to the application of NIV to wean patients from invasive ventilation, prevent extubation failure in at-risk patients, and to treat post-extubation respiratory failure 55.2 Analysis 55.2.1 NIV to Prevent or Treat Post-extubation Respiratory Failure In 2007, Agarwal and colleagues [10] published the first meta-analysis to examine the effect of NIV in patients with post-extubation respiratory failure (Table 55.1) They identified trials, of which trials evaluated patients “at risk” for postextubation failure and examined patients with established post-extubation respiratory failure In 259 patients at high risk of post-extubation respiratory failure, NIV applied after extubation, compared with standard therapy, significantly decreased reintubation (relative risk (RR) 0.46, 95 % confidence interval (CI) 0.25–0.84) and ICU mortality (RR 0.26, 95 % CI 0.10–0.66) but not hospital mortality (RR 0.71, 95 % CI 0.42–1.20) Conversely, in 302 patients with post-extubation respiratory failure, NIV had no effect (RR for reintubation 1.03, 95 % CI 0.84–1.25; RR for ICU mortality 1.14, 95 % CI 0.43–3.00) The authors concluded that NIV 454 K.E.A Burns and N.K.J Adhikari appeared promising to prevent reintubation in patients “at risk” for post-extubation respiratory failure but should be used judiciously, if at all, in patients with established post-extubation respiratory failure In 2014, Lin and colleagues [11] published an updated meta-analysis of NIV in the prevention or management of post-extubation respiratory failure (Table 55.1) They identified 10 randomized or quasi-randomized trials enrolling 1,382 patients, including trials in the setting of prevention and the same trials found by Agarwal et al [10] in the setting of established post-extubation respiratory failure Early application of NIV to prevent respiratory failure did not reduce reintubation (RR 0.75, 95 % CI 0.49–1.15); however, in the subgroup of patients extubated after passing a spontaneous breathing trial, NIV reduced reintubation (RR 0.65, 95 % CI 0.46–0.93), ICU mortality (RR 0.41, 95 % CI 0.21–0.82), and hospital mortality (RR 0.59, 95 % CI (0.38–0.93) Tests of interaction required for the correct interpretation of subgroup analyses were not reported There was no effect of NIV in patients with established post-extubation respiratory failure on reintubation or ICU mortality, similar to the earlier meta-analysis [10] In 2013, Olper and colleagues [12] conducted a meta-analysis of randomized trials of NIV for patients after cardiac, thoracic, and thoracoabdominal vascular surgery (Table 55.1) They identified 14 randomized trials (n = 1,211) of which used continuous positive airway pressure (CPAP), used noninvasive pressure support (PS), and used both Two trials used NIV to treat post-extubation respiratory failure, and 12 used NIV to prevent it Of the trials of prophylactic NIV, included patients with impaired preoperative pulmonary function (forced expiratory volume in s (FEV1)