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Noninvasive Mechanical
Ventilation and Difficult
Weaning in Critical Care
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
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 advance-
ment in protocols focusing on weaning from mechanical ventilation and new venti-
lation 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 exacerba-
tion 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 mechani-
cal ventilation, extubation post acute respiratory failure, and unplanned extubation
and its use as alternative to short- and long-term IMV including those with trache-
otomy. 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 inter-
faces, 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.
ix
x Contents
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Part I
Weaning From Mechanical Ventilation.
Determinants of Prolonged Mechanical
Ventlation and Weaning
Physiologic Determinants of Prolonged
Mechanical Ventilation and Unweanable 1
Patients
1.1 Introduction
challenges in health care [2, 3]. It is estimated that between 5 and 13 % of mechani-
cally ventilated patients require PMV [4], and that about 50 % of these will be liber-
ated from the ventilator. However, about 25 % of intensive care unit (ICU) survivors
with CCIS and PMV are not weaned at the end of first year [2]. CCIS patients have
poor prognosis and prolonged ICU and hospital stays (either in long-term acute care
facilities or in specialized weaning centers), contributing to increased costs. It has
also been estimated that 1-year mortality rates range from 48 to 68 % [3].
The ultimate goal for CCIS patients is liberation from a ventilator, because suc-
cessful weaning is associated with improved survival, better quality of life, and less
financial burden on health-care systems. Therefore, this review is intended not only
to analyze the physiologic determinants of PMV and unweanable patients in the
context of CCIS but also to guide physicians managing these patients in a compre-
hensive and structured way.
The adequacy of the respiratory function depends on the balance between the respira-
tory requirements (the load) and the capability of the respiratory pump and its com-
ponents (the respiratory motor drive and the neuromuscular system) to meet those
requirements. A practical and methodical approach to the problem of difficult-to-
wean and unweanable patients is to consider the various factors with the ability to
tip the balance, thereby slowing down or even disallowing the weaning procedure.
Control of Breathing
It has been long recognized that the hallmark of weaning failure is a rapid shallow
breathing pattern, the combination of elevated frequency ( f ) and decreased tidal
volume (VT) [57]. Weaning failure patients exhibit marked shortening of both
inspiratory and expiratory time, which results in increased breathing frequency. At
the same time, the combination of decreased inspiratory time (Ti) and normal mean
inspiratory flow leads to decreased VT [8].
Acute hypercapnia has been consistently observed in many patients who failed to
wean despite an increase, not a decrease, in respiratory drive, measured by using P0.1
or the mean inspiratory flow. The hypercapnia is not caused by decreased minute
ventilation. Instead, it is the consequence of the rapid shallow breathing pattern,
resulting in dead-space ventilation [6].
Assessment of respiratory drive is determined by P0.1, which is the airway occlu-
sion pressure at the first 100 msec of inspiration (normal values: 0.51.5 cmH2O).
Although it is available with most ventilators, it is of limited value because of the
wide normal range. The value of P0.1 depends not only on respiratory drive but also
1 Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients 5
Respiratory Mechanics
In an acute setting, Jubran and Tobin [7] demonstrated that, during a spontaneous
breathing trial (SBT), all passive respiratory mechanics (resistance, elastance,
PEEPi) became more abnormal in WF patients than in WS patients. More specifi-
cally, respiratory resistance increased up to seven times the normal value at the end
of the trial, whereas pulmonary elastance increased about five times the normal
value. Moreover, PEEPi almost doubled during the trial. The same findings were
also found by other investigators [9].
Airway resistance and respiratory load, that is, the work of breathing (WOB), are
directly related. Significantly increased airway resistance that hinders the weaning
procedure may arise from upper (obstruction of tracheotomy tube, secretions,
6 D. Lagonidis and I. Chouris
Gas Exchange
Inadequate gas exchange (hypoxemia, hypercapnia) exerts an additional load on
the respiratory muscles because increased minute volume is required to restore
gas exchange disturbances, resulting in muscle fatigue and WF. Hypercapnia
results mainly from the following mechanisms: hypoventilation (e.g., neuromus-
cular diseases), severe low ventilation/perfusion mismatch (e.g., chronic obstruc-
tive pulmonary disease (COPD)), and, to a lesser extent, increased dead space
(rapid shallow breathing, heat and moisture exchangers, connectors to the Y-point
of the circuit).
Interestingly, studies using the multiple inert gas method showed that ventila-
tion/perfusion maldistribution and hypercapnia were found in WF patients [10].
Specifically, acute hypercapnia was observed in many patients who failed to wean
despite an increased respiratory motor output, measured by P0.1 [7]. Acute hyper-
capnia is not caused by decreased minute ventilation. Instead, it is the consequence
of a rapid shallow breathing pattern resulting in dead-space ventilation. Only in a
minority of WF patients may hypercapnia be attributed to primary depression of
respiratory drive [7].
1 Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients 7
Another important task of the ventilator pump is the ability to endure, that is, to
avoid muscle fatigue. The fatigue threshold of the diaphragm can be quantified
by the tension-time index of the diaphragm (TTIdi), derived by the formula
TTIdi = (Pdi/Pdimax) (Ti/Ttot), where Pdi is the tidal transdiaphragmatic pressure,
Pdimax is the maximum transdiaphragmatic pressure, Ti is the inspiratory time, and
Ttot is the total breath duration. This equation demonstrates the importance of both
the pressure-generating effort of the diaphragm and the relative duration of inspira-
tion as determinants of diaphragmatic fatigue. Diminishing diaphragm strength
results in decreased Pdimax, whereas reduced compliance increases Pdi. Similarly,
tachypnea increases the Ti/Ttot index, thus promoting muscle fatigue.
In one study, it was reported that the majority of ICU patients had diaphragm muscle
weakness at the beginning of mechanical ventilation associated with sepsis and disease
severity [24]. The ability of the diaphragm to generate force was assessed by recording
occluded twitch tracheal pressure during twitch magnetic stimulation of bilateral phrenic
nerves. The twitch tracheal pressure (Ptawtw), measured at the proximal end of the endo-
tracheal tube, was used as a surrogate of transdiaphragmatic pressure independent of
patient effort and cooperation. More specifically, 64 % of patients had a Ptawtw less than
11 cmH2O, a value that indicates diaphragm muscle weakness.
Hypercapnia is often considered an indirect sign of respiratory muscle fatigue,
but one must be careful to take into account other mechanisms leading to it.
Nevertheless, it is probably safe to conclude that lack of hypercapnia, combined
with absence of acidbase disturbances, practically rules out the possibility of
fatigue as a cause for weaning failure.
It has been suggested that the f/VT ratio gives an estimate of the capability of
sustaining unsupported breathing and could be a surrogate of the most-difficult to
measure TTIdi or Pdi/Pdimax.
For the first time, Jubran et al. [7] showed that, in patients with COPD, the major
determinant between a successful and failed weaning trial was a change in the
breathing pattern rather than an intrinsic derangement of pulmonary mechanics. In
another study, Vassilakopoulos et al. [9] reported that, compared with WS patients,
WF patients had greater total resistance, intrinsic PEEP, dynamic hyperinflation,
ratio of mean to maximum inspiratory pressure, less MIP, and a breathing pattern
that was more rapid and shallow. They also found that TTI and f/VT were the only
significant parameters that predicted weaning success. Finally, in a study by
Capdevila et al. [15], the WF was associated with high breathing frequency,
increased P0.1, minute ventilation, intrinsic PEEP, and persistent hypercapnia.
Although TTI and Pdi/Pdimax. are too difficult to measure in everyday practice,
they seem to be more accurate in determining the potential reserve of the patients
during the weaning trial. On the other hand, the f/VT ratio may not give a thorough
insight into the weaning capabilities of ventilator-dependent patients because it
could be affected either by their psychological burden resulting in tachypnea or by
their tendency not to increase f to avoid dynamic hyperinflation [16].
Carlucci et al. [16], by recording active respiratory mechanics in true ventilator-
dependent patients with multiple weaning failures in the past, showed that the major
determinant of WS was associated with the significant improvement of diaphragmatic
inotropism at the time of gaining liberation from the ventilator, as expressed by
increased Pdimax. They also found that these patients on PMV have increased
1 Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients 9
The transition from the positive pressure ventilation to spontaneous breathing exerts
an additional load on the cardiovascular system and can impose or unmask cardiac
dysfunction, either systolic or diastolic. These factors may thus be causes of unsuc-
cessful weaning. The heart-lung interactions during the weaning procedure are
complex. Spontaneous breathing raises WOB and oxygen consumption by the
respiratory muscles and promotes adrenergic stress and negative swings in the
10 D. Lagonidis and I. Chouris
intrathoracic pressure. These alterations lead to increases in both preload and after-
load of right and left ventricles through the augmented venous return, resulting in
weaning-induced cardiac dysfunction.
At the end of a weaning trial, oxygen consumption is equivalent in WS and WF
patients [17]. However, the response of the cardiovascular system to the oxygen
demand differs in the two groups. In WS patients, oxygen demand is met by the
augmented oxygen delivery mediated through the expected increase in cardiac out-
put on release of positive pressure ventilation [17]. In WF patients, because they
have relatively decreased oxygen delivery, oxygen demand is met by the increase in
oxygen extraction. Under these circumstances, the greater oxygen extraction results
in a significant decrease in SvO2, contributing to hypoxemia [17].
In 2015, it was reported that, in acute critically ill patients, it was found that a
negative passive leg-raising test performed before SBT, suggesting preload inde-
pendence, was associated with weaning-induced cardiac dysfunction [23].
Diastolic dysfunction is a common and underdiagnosed entity. More than 60 % of
people over 65 years of age experience diastolic dysfunction, and in more than 50 %
of patients with heart failure, it is of the diastolic type. Moreover, differentiation
between systolic and diastolic cardiac failure is clinically important because of dis-
tinct therapeutic approaches [21]. Diastolic dysfunction with relaxation impairment
has been found to predict weaning failure. The principal feature of LV diastolic failure
is reduced compliance of the ventricle due to various causes (e.g., coronary artery
disease, myocardial hypertrophy and fibrosis, infiltrative diseases, hypoxia, or
acidosis).
There is growing evidence to advocate that transthoracic echocardiography (TTE)
plays a key role in the evaluation of patients who are difficult to wean due to cardiac
origin. However, it is not possible to use it in every critically ill patient because of cer-
tain limitations (e.g., excessive pulmonary emphysema, or thoracic trauma). In tissue
Doppler imaging TTE, the ratio of mitral Doppler inflow E velocity to annular tissue
Doppler Ea wave velocity (E/Ea) provides an accurate estimate of the degree of dia-
stolic dysfunction. Moreover, these echocardiographic measurements can also be per-
formed on patients with atrial fibrillation with reasonable sensitivity and specificity.
In 2010, Gaille et al. [20], in an unselected cohort of patients, found that weaning
failure occurred more often in patients with systolic heart failure. More precisely, in
patients with ejection fraction (EF) <50 % they found signs of diastolic dysfunction
(decreased E/A and depressed acceleration time of E wave) during a SBT. Moreover,
Moscietto et al. [18] showed that in 68 patients with sinus rhythm and atrial fibrillation
on mechanical ventilation more than 48 h, the measurement of E/Ea with Doppler tis-
sue imaging TTE could predict weaning failure as early as 10 min after the beginning
of the SBT. They also suggested that diastolic dysfunction with relaxation impairment
was strongly associated with weaning failure. Conversely, in the same study, the sys-
tolic dysfunction was not associated with weaning outcome. In another study with
similar findings [19], the authors suggested that an E/Ea >7.8 may indentify patients at
high risk of WF.
In conclusion, diastolic dysfunction of the left ventricle seems to be important in
the evolution of WF. By measuring E and Ea waves even in patients with atrial
fibrillation, TTE with Doppler tissue imaging measuring is a key examination that
1 Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients 11
can be easily applied before and after the weaning trial. It has also been demon-
strated that the transition from mechanical ventilation to sustained breathing could
lead to myocardial ischemia in patients with coronary artery disease. Ischemia can
be detected by electrocardiogram before and at the end of the SBT and the signifi-
cance of anemia as a precipitating factor should not be underestimated.
Mixed venous oxygen saturation (SvO2) can be used as a marker of cardiac perfor-
mance, with superior vena cava oxygen saturation (ScvO2) serving as a reasonable
surrogate. In difficult-to-wean patients, a decrease in SvO2 during the weaning pro-
cedure should raise the suspicion about the presence of inadequate cardiac output.
Patients with cardiac dysfunction largely rely on increasing the oxygen extraction
ratio instead of raising the cardiac output, resulting in SvO2 reduction as demon-
strated by Jubran et al. [17] in a study comparing 8 patients who failed at SBT with
11 patients who successfully completed the SBT. The decrease in SvO2 was related
to the inability to improve cardiac output and consequently oxygen transport.
Increased afterloads of the right and left ventricle were found in these patients.
It is imperative to note that reduction in ScvO2 is the normal response to increased
loading. In normal subjects on moderate exercise, it was found that ScvO2 decreases
below 50 %. Therefore, a reduction in ScvO2 should not necessarily be interpreted as a
marker of heart failure. Accordingly, in WF patients, without a reduction in ScvO2, heart
dysfunction is highly unlikely [21]. Conversely, in those patients who failed a weaning
trial and had reduced ScvO2, heart dysfunction could be a limiting factor and further
investigation with echocardiography and/or insertion of a Swan-Ganz catheter is war-
ranted [21].
Brain natriuretic peptide (BNP) is a neurohormone synthesized in the cardiac
ventricles and released from the myocardium upon stretch. It is released by the
myocytes as pre-proBNP that is cleaved into proBNP and finally into BNP and the
inactive N terminal proBNP peptide (NT-proBNP). Its release into the circulation
is directly proportional to the ventricle expansion and volume overload of the ven-
tricles. Thus, it serves as a marker of the systolic and diastolic left ventricular
dysfunction. The value of BNP or NT-proBNP as a predictor of weaning failure
due to cardiovascular reasons seems to be well established in the literature.
Nevertheless, the accepted cut-off values pose a clinical challenge for data
interpretation.
A study by Grasso et al. [22] demonstrated that serial measurements of
NT-proBNP could detect acute cardiac dysfunction during an unsuccessful weaning
trial in difficult-to-wean patients with COPD. Baseline NT-proBNP levels were sig-
nificantly higher (median, 5,000; interquartile range, 4,218 pg/mL) in patients with
cardiac dysfunction. It was also shown that levels of NT-proBNP increased signifi-
cantly at the end of the spontaneous breathing trial only in patients with acute car-
diac dysfunction (median, 12,733; interquartile range, 16,456 pg/mL).
Conclusions
The ultimate goal for CCIS patients on PMV is liberation from the ventilator.
Repeated weaning failure has been associated with an imbalance between
increased load and reduced capacity of the respiratory muscles or, to a lesser
extent, with the cardiovascular impairment. A systematic approach to the problem
12 D. Lagonidis and I. Chouris
Impaired neurotransmission
(uncommon)
Increased motor drive (very
common) Inspiratory muscle weakness or
dysfunction (very common)
rapid shallow breathing
index (f/VT) rapid shallow breathing
index (f/VT)
Resistive loads
maximal inspiratory
pressure (MIP)
Lung Elastic loads
transdiaphragmatic
elastance, resistance, pressure (Pdi)
PEEPi
Tension time index
Chest wall elastic loads (TIdi)
Respiratory Respiratory
load capacity
Fig. 1.1 Balance between load (motor drive, resistive, elastic, cardiovascular impairment) and
capacity (motor drive, neurotransmission, inspiratory muscle weakness) determines the ability
to sustain spontaneous ventilation
1 Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients 13
Key Points
In PMV and unweanable patients, the imbalance between inspiratory mus-
cle work load and inspiratory muscle capacity is of paramount
importance.
The rapid shallow breathing pattern is the hallmark of weaning failure.
In PMV patients, the major determinant of prolonged weaning is inspira-
tory muscle weakness or dysfunction, as expressed by TTIdi that is above
the fatigue threshold.
During the course of a weaning trial, most WF patients significantly
increase respiratory load as a result of severe worsening of respiratory
mechanics (e.g., resistance, elastance, or PEEPi).
In PMV patients, the recovery of inadequate inspiratory muscle force
seems to be the major determinant of WS allowing them to breathe below
the diaphragmatic fatigue threshold.
A less common cause of WF is impairment of cardiovascular
performance.
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Prolonged Weaning from Mechanical
Ventilation: Pathophysiology 2
and Weaning Strategies, Key Major
Recommendations
Abbreviations
2.1 Introduction
Advances in the management of critically ill patients in intensive care unit (ICU)
have improved mortality and morbidity as well as reduced length of stay and,
subsequently, cost of treatment. However, despite improvements in short-term
mortality and stabilization of acute organ dysfunction, a small but substantial
population of critically ill patients who survive the initial critical illness continue
to suffer from prolonged dependence on life support or to need long-term thera-
peutic interventions. These patients have been grouped under the classification of
chronically critically ill (CCI) patients. Such a group is characterized by hetero-
geneity, prolonged need for high-cost interventions, and high long-term (around
1 year) mortality rate [1]. The best characterized component of the CCI popula-
tion is patients on prolonged mechanical ventilation (PMV). In 2005, the National
Association for Medical Direction of Respiratory Care (NAMDRC) defined
PMV as the need for 21 consecutive days of mechanical ventilation (MV)
for 6 h/day [2]. According to the European Respiratory Society Task Force,
these patients constitute a particular group needing prolonged weaning from the
ventilator, defined as more than three spontaneous breathing trials (SBTs), or
more than 7 days from the first unsuccessful SBT [3]. Nevertheless, other inves-
tigators have favored Medicares definition of MV >96 h, with tracheostomy as
the marker of PMV [2].
Patients requiring PMV have clearly different needs and resource consumption
patterns in relation with patients during the acute phase of critical illness. Moreover,
these patients may represent as many as 14 % of patients admitted to the ICU for
intubation and MV, whereas it is estimated that they account for 37 % of all ICU
costs and are associated with in-hospital mortality up to 32 % [4, 5]. Finally, avail-
able data suggest that the global prevalence of PMV in Europe ranges from 2 to 30
per 100,000 population according to different countries [6], whereas different stud-
ies have demonstrated that as many as 20 % of medical ICU patients remained
dependent on ventilator support after 21 days [3].
The successful weaning process from PMV is based on the understanding of the
complexity of different causes associated with the need for prolonged ventilatory
support. In this respect, it has been suggested that the major mechanisms of weaning
failure in this group of patients include either an isolated failure of the respiratory
system or respiratory failure occurring within the context of chronic critical illness
syndrome (CCIS) [2, 3, 7].
It is estimated that pulmonary disease accounts for approximately 50 % of causes
for PMV, associated with inspiratory muscle weakness, increased work of breathing,
and reduced respiratory drive [2, 7]. Pulmonary disease results in reduced lung
2 Prolonged Weaning from Mechanical Ventilation: Pathophysiology and Weaning 17
compliance and increased load upon respiratory muscles. In this respect, ventilator-
associated pneumonia and acute respiratory distress syndrome (ARDS) are consid-
ered the main pulmonary pathologies leading to prolonged weaning from the
ventilator. Airway disease in patients with chronic obstructive pulmonary disease
(COPD) may also increase work of breathing through air-flow limitation, dynamic
hyperinflation, and auto-positive end-expiratory pressure (PEEP). Furthermore, con-
gestive heart disease has been reported in up to 26 % of patients hospitalized in long-
term acute care (LTAC) hospitals in the United States [8]. Such cardiac dysfunction
can be uncovered during SBTs due to increased venous return, end-diastolic volume
augmentation, and increased metabolic demands. In these cases, performance of car-
diac echocardiography and determination of B-type natriuretic peptide (BNP) serum
levels during SBTs can be of significant value for early diagnosis and prompt treat-
ment of possible myocardial dysfunction and/or hypervolemia [79].
Critical illness neuromyopathy (CINM) can manifest itself as ICU-acquired
weakness and subsequent PMV, usually associated with multiple organ failure,
muscle inactivity, hyperglycemia, or use of corticosteroids and neuromuscular
blockers. As a result, early mobilization, minimizing the use of deep sedation and
steroids, and avoidance of hyperglycemia have been advocated as effective preven-
tive strategies during the acute phase of critical illness [7, 10]. Ventilator-induced
diaphragm dysfunction constitutes a rapid form of skeletal muscle injury that may
occur within only 18 h of MV [7, 11]. Age, malnutrition, and continuous mandatory
ventilation have been found to promote such muscle weakness, whereas pressure
support ventilation (PSV) seems to minimize diaphragmatic ventilator-induced
injury [11]. In addition, optimal patient-ventilator synchrony through properly
adjusted ventilator settings, psychotropic medications, and delirium management
seems to reduce work of breathing and further promote earlier weaning from venti-
latory support [7].
Finally, managing PMV patients requires careful consideration and manage-
ment of all issues related to CCIS, such as severe nutritional deficits, endocrine
dysfunction, including loss of glycemic control and hypothyroidism, bone loss,
and immune and autonomic nervous system dysfunction, that usually arise between
7 and 14 days post acute illness, if the patients do not fully recover from the acute
episode [1].
Conclusions
The NAMDRC report included 12 recommendations regarding early identifica-
tion, management, and research priorities for patients requiring PMV [2]. Such
patients by definition have failed multiple SBTs and usually require the placement
of a tracheostomy tube. The first priority for the management of this subgroup of
critically ill patients is the optimization of any reversible factor contributing to
PMV. Thus, early mobilization, discontinuation of high doses of narcotics and
benzodiazepines, early recognition, and management of mental disorders, such as
delirium, are a few actions that can accelerate the weaning process, in association
with treatment of underlying causes of respiratory failure. Moreover, weekly
monitoring of proteins and albumin levels should be part of the plan to make sure
nutrition goals are met. Ensuring adequate nutrition in CCI patients improves
immune function and muscle strength, preventing excess breakdown of lean body
mass. Furthermore, a multidisciplinary rehabilitation program must be imple-
mented on an individualized basis, either in the acute care hospital, or to a special-
ized weaning center, where a team of physiotherapists and nutritionists could
manage or even restore muscle weakness and atrophy. Such therapies apart from
muscle strengthening can also facilitate the resolution of inflammation, turn off
catabolic stimuli, and restore glycemic control [3, 15]. Another important issue is
the transition from PMV to long-term MV. It seems that patients with COPD and
neuromuscular diseases are more amenable to long-term MV, with 3-year mortal-
ity more than 50 % [14]. Furthermore, patients with age >65 with sacral ulcers
and abnormal renal function constitute the group with the worse prognosis [14,
15]. In such cases, better communication between caregivers, patients, and fami-
lies and resetting of expectations regarding weaning failure can facilitate the man-
agement of such patients in different settings more effectively.
Weaning protocols may accelerate the weaning process in the acute care
setting, however, the heterogeneity of PMV patients limits their diagnostic
accuracy, prompting an individualized approach, usually in specialized
weaning centers, separate from the acute care hospitals.
The better communication between caregivers, patients, and families,
along with an advanced palliative care system, will restore confidence
between health-care professionals and relatives, resetting possibly unreal-
istic expectations for those patients needing long-term ventilation, usually
with NIV even at home.
References
1. Nelson JE, Cox CE, Hope AA, et al. Chronic critical illness. Am J Respir Crit Care Med.
2010;182(4):44654.
2. MacIntyre MR, Epstein SK, Carson S, et al. Management of patients requiring prolonged
mechanical ventilation. Report of a NAMDRC consensus conference. Chest.
2005;128:393754.
3. Boles J-M, Bion J, Connors A, et al. Task force. Weaning from mechanical ventilation.
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Respir J. 2007;29:103356.
4. Funk GC, Anders S, Breyer MK, et al. Incidence and outcome of weaning from mechanical
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tion. Crit Care Med. 2007;35:191827.
6. Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanical ventilation
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8. Scheinhorn D, Hassenpflug M, Votto J, et al. Ventilator-dependent survivors of catastrophic
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9. Zapata L, Vera P, Roglan A, et al. B-type natriuretic peptides for prediction and diagnosis of
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13. Jubran A, Brydon JB, Grant MD, et al. Effect of pressure support versus unassisted breathing
through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical
ventilation: a randomized trial. JAMA. 2013;309(7):6717.
14. Seneff MG, Wagner D, Thompson D, et al. The impact of long-term acute care facilities on the
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Automated Weaning Modes
3
F. Wallet, S. Ledochowski, C. Bernet, N. Mottard,
A. Friggeri, and V. Piriou
SmartCare/PSTM
IntelliventTM
Fig. 3.1 Positionning of different automated weaning modes from intubation to extubation
In such dire times, technological advances helping in the automation of all, or part,
of mechanical ventilation and its weaning seem to be an attractive solution. Furthermore,
automation also allows a constant application of the recommended guidelines for
efficient mechanical ventilation, thus resulting in improved care [14, 15].
The automation of mechanical ventilation can be used from intubation to extuba-
tion or only in the weaning phase [16]. It uses artificial intelligence technology that
involves feedback loops [16]. There are currently three available systems: the
SmartCare/PS from Drger, and ASV and IntelliVent-ASV from Hamilton. We
will later explain how these systems work. Their use in the course of a patients
mechanical ventilatory management is described in Fig. 3.1.
3.1 ASV
percentage of the ideal expired minute volume, ranging from 50 to 250 % (result-
ing in a greater or lesser alveolar ventilation)
level of PEEP
FiO2 level
When the patient is passive (deeply sedated with no spontaneous breathing), the
ventilator delivers pressure-controlled ventilation with Vt and RR previously
3 Automated Weaning Modes 23
Vt
Target
Patient
1600
Vt > Target Vt > Target V
ml
Target
Current
Pinsp Pinsp
MinVol
RR RR 800
6.6
I/min
400
f
b/min
0
0 10 20 30 40 50 60
RR RR
RR
calculated. Once the patient starts breathing and triggers the ventilator, the system
tries to bring the patient to the ideal Vt/RR combination, if necessary by completing
his or her ventilatory pattern with machine cycles. Spontaneous cycles triggered by
the patient are delivered in pressure support mode (PSV). Finally, when the patient
triggers spontaneously at a ventilatory rate greater than the targeted RR, the ventila-
tor applies only pressure support. It gradually reduces the level of support it offers
to shift the patients spontaneous Vt/RR combination toward the ideal curve, which
represents all the possible ideal Vt/RR combinations. The principle is shown in
Fig. 3.2.
This system is a feedback loop centered on the weaning period. Its objective is to
gradually reduce the level of pressure support while maintaining the patient in a
comfort zone. It therefore requires the patient to be in PSV. It is based on the
NeoGanesh expert system (from the Hindu god of wisdom and intelligence,
Ganesh). The comfort zone is defined as
Vt > 300 mL
RR of 1230/min
PETCO2 < 55 mmHg
24 F. Wallet et al.
Hypoventilation
PS PS
Insufficient ventilation
PS
Severe tachypnea
PS
PS PS
Tachypnea
Unexplained
hyperventilation
PS
identical
35 30 15 RR
biological signals from the patient (e.g., SpO2, EtCO2). With this system, the setting
of PEEP and FiO2 is based on an algorithm defined by Hamilton. It is based on a
combination of the lower PEEP table of the acute respiratory management (ARMA)
of acute respiratory distress syndrome (ARDS) study for incremental PEEP and FiO2
situations, and the decremental scheme used in the Assessment of Low tidal Volume
and elevated End-expiratory volume to Obviate Lung Injury (ALVEOLI) study
(faster decrease of FiO2 than PEEP) when necessary [20, 21]. Furthermore, the con-
tinuous analysis of SpO2 changes induced by the MV provides another level of feed-
back. However, when preload dependency is suspected by the analysis of the SpO2
waveform, the optimization of the PEEP level can be limited to control hemody-
namic effects of PEEP and increase safety [22]. Moreover, the measured level of
EtCO2 has a negative feedback on the level of minute ventilation applied (i.e., the
percentage of minute ventilation in the ASV setting). In addition, the latest version of
the IntelliVent-ASV has an automated SBT module (Quick Wean), which performs
an SBT according to predefined criteria by the user (as with the SmartCare/PS sys-
tem) as soon as the level of assistance of the patient is low enough. This system thus
offers a fully automated ventilatory strategy, from intubation to the SBT.
These automated systems are still poorly evaluated when compared with older con-
ventional ventilatory modes. Regarding ASV, a very modest benefit from a clinical
point of view in postoperative cardiac surgery has been identified [23, 24]. Some
studies show a reduction in the duration of ventilation ranging from 1 to 2 days in
ICU patients [25, 26]. If there is a benefit in terms of duration of MV, it seems mod-
est and of limited interest in the populations studied. The most important benefit
would be to relieve medical and paramedical teams of the management of MV in the
most simple patients. These ventilatory modes could also help enforcing the
recommended guideline in the ICU by systematically applying them. However,
more formal data are needed to confirm this.
Regarding SmartCare/PS, data from the literature are conflicting. The results of
two large studies by the team of Laurent Brochard [27, 28] found a 48-h reduction
in the duration of ventilation and a 4-day reduction in ICU length of stay without
deleterious effect in terms of reintubation. On the other hand, a large Australian
study did not find any benefit of the SmartCare/PS system when compared with a
conventional weaning protocol [29]. However, the latter team had the benefit of a
nurse-to-patient ratio of 1:1. To push the debate further, another study did not find
any benefit over the use of a written weaning protocol in a population of surgical
ICU patients [30], whereas a metanalysis by Friedrich et al. [31] found that weaning
with SmartCare/PS significantly decreased weaning time, time to successful extu-
bation, ICU length of stay, and proportion of patients receiving ventilation for
longer than 7 and 21 days.
Finally, concerning IntelliVent-ASV, clinical assessment remains poor. Two
recent studies have demonstrated the feasibility and safety of this ventilatory
26 F. Wallet et al.
modality [3133]. The authors found a much higher percentage of time spent in an
optimal range (90 % vs 12 %) in the IntelliVent-ASV group compared with man-
agement of the usual ventilation. These results were recently confirmed by
Clavieras et al. [34] in an unselected ICU population. Moreover, an abstract was
published in 2013 that included ARDS patients, thus confirming IntelliVent-ASVs
safety in critically ill patients [35].
Conclusion
Novel automated ventilatory modes in the ICU look promising. Beyond their per-
formance, their acceptance by health-care teams has yet to be evaluated [28]. Totally
automated modes have initially focused on selected aspects of MV in ICU patients
(initiation of the weaning process, or even its conclusion). They have shown a sig-
nificant reduction in the length of the weaning process and have led to a novel,
totally automated mode that needs further development and evaluation. The imple-
mentation of such modes in daily practice is a challenge for the future.
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3. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and
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4. MacIntyre NR, Cook DJ, Ely Jr EW, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based
guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated
by the American College of Chest Physicians; the American Association for Respiratory Care;
and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375S95.
5. Kollef MH, Shapiro SD, Silver P, St John RE, Prentice D, Sauer S, et al. A randomized, con-
trolled trial of protocol-directed versus physician-directed weaning from mechanical ventila-
tion. Crit Care Med. 1997;25(4):56774.
6. Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdu I, et al. Effect of spontaneous breathing
trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung
Failure Collaborative Group. Am J Respir Crit Care Med. 1999;159(2):5128.
7. Cox CE, Carson SS, Govert JA, Chelluri L, Sanders GD. An economic evaluation of prolonged
mechanical ventilation. Crit Care Med. 2007;35(8):191827.
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incidence of mechanical ventilation in Ontario to 2026: preparing for the aging baby boomers.
Crit Care Med. 2005;33(3):5749.
9. Zilberberg MD, de Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical
ventilation: implications for healthcare delivery. Crit Care Med. 2008;36(5):14515.
10. Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care.
2002;8(4):31620.
11. Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses work hours on vigi-
lance and patients safety. Am J Crit Care. 2006;15(1):307.
12. Le Gall JR, Azoulay E, Embriaco N, Poncet MC, Pochard F. [Burn out syndrome among criti-
cal care workers]. Bull Acad Natl Med. 2011;195(2):38997; discussion 978.
3 Automated Weaning Modes 27
13. Scott LD, Hwang WT, Rogers AE. The impact of multiple care giving roles on fatigue, stress,
and work performance among hospital staff nurses. J Nurs Adm. 2006;36(2):8695.
14. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of
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to reduce mortality among patients treated in intensive care units. J Crit Care.
2004;19(3):15864.
16. Lellouche F, Brochard L. Advanced closed loops during mechanical ventilation (PAV, NAVA,
ASV, SmartCare). Best Pract Res Clin Anaesthesiol. 2009;23(1):8193.
17. Laubscher TP, Frutiger A, Fanconi S, Jutzi H, Brunner JX. Automatic selection of tidal vol-
ume, respiratory frequency and minute ventilation in intubated ICU patients as start up proce-
dure for closed-loop controlled ventilation. Int J Clin Monit Comput. 1994;11(1):1930.
18. Campbell RS, Branson RD, Johannigman JA. Adaptive support ventilation. Respir Care Clin
N Am. 2001;7(3):42540.
19. Otis AB, Fenn WO, Rahn H. Mechanics of breathing in man. J Appl Physiol.
1950;2(11):592607.
20. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung
injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome
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21. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher
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22. Cannesson M, Attof Y, Rosamel P, Desebbe O, Joseph P, Metton O, et al. Respiratory varia-
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in the operating room. Anesthesiology. 2007;106(6):110511.
23. Sulzer CF, Chiolero R, Chassot PG, Mueller XM, Revelly JP. Adaptive support ventilation for
fast tracheal extubation after cardiac surgery: a randomized controlled study. Anesthesiology.
2001;95(6):133945.
24. Gruber PC, Gomersall CD, Leung P, Joynt GM, Ng SK, Ho KM, et al. Randomized controlled
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25. Chen CW, Wu CP, Dai YL, Perng WC, Chian CF, Su WL, et al. Effects of implementing adap-
tive support ventilation in a medical intensive care unit. Respir Care. 2011;56(7):97683.
26. Kirakli C, Ozdemir I, Ucar ZZ, Cimen P, Kepil S, Ozkan SA. Adaptive support ventilation for
faster weaning in COPD: a randomised controlled trial. Eur Respir J. 2011;38(4):77480.
27. Lellouche F, Mancebo J, Jolliet P, Roeseler J, Schortgen F, Dojat M, et al. A multicenter ran-
domized trial of computer-driven protocolized weaning from mechanical ventilation. Am J
Respir Crit Care Med. 2006;174(8):894900.
28. Burns KE, Meade MO, Lessard MR, Hand L, Zhou Q, Keenan SP, et al. Wean earlier and
automatically with New technology (the WEAN study): a multicentre, pilot randomized con-
trolled trial. Am J Respir Crit Care Med. 2013;187(11):120311.
29. Rose L, Presneill JJ, Johnston L, Cade JF. A randomised, controlled trial of conventional ver-
sus automated weaning from mechanical ventilation using SmartCare/PS. Intensive Care Med.
2008;34(10):178895.
30. Schadler D, Engel C, Elke G, Pulletz S, Haake N, Frerichs I, et al. Automatic control of pres-
sure support for ventilator weaning in surgical intensive care patients. Am J Respir Crit Care
Med. 2012;185(6):63744.
31. Lellouche F, Bouchard PA, Simard S, LHer E, Wysocki M. Evaluation of fully automated
ventilation: a randomized controlled study in post-cardiac surgery patients. Intensive Care
Med. 2013;39(3):46371.
32. Burns KE, Lellouche F, Nisenbaum R, Lessard MR, Friedrich JO. Automated weaning and
SBT systems versus non-automated weaning strategies for weaning time in invasively venti-
lated critically ill adults. Cochrane Database Syst Rev. 2014;9, CD008638.
28 F. Wallet et al.
33. Arnal JM, Wysocki M, Novotni D, Demory D, Lopez R, Donati S, et al. Safety and efficacy of
a fully closed-loop control ventilation (IntelliVent-ASV(R)) in sedated ICU patients with acute
respiratory failure: a prospective randomized crossover study. Intensive Care Med.
2012;38(5):7817.
34. Clavieras N, Wysocki M, Coisel Y, Galia F, Conseil M, Chanques G, et al. Prospective ran-
domized crossover study of a new closed-loop control system versus pressure support during
weaning from mechanical ventilation. Anesthesiology. 2013;119(3):63141.
35. Arnal JM, Garnero A, Novonti D, Demory D, Ducros L, Berric A, et al. Feasibility study on
full closed-loop control ventilation (IntelliVent-ASV) in ICU patients with acute respiratory
failure: a prospective observational comparative study. Crit Care. 2013;17(5):R196.
Neurally Adjusted Ventilatory Assist
in Noninvasive Ventilation 4
B. Repusseau and H. Roz
4.1 Introduction
Noninvasive ventilation (NIV) is widely used today in both acute and chronic set-
tings to avoid complications of invasive ventilation, such as infection [1, 2]. Despite
its increasing use, a significant number of patients fail NIV and require endotracheal
intubation. There are several indications for NIV, and patientventilator asynchro-
nies play a crucial role in the tolerance and success of this technique. Vignaux et al.
[3] showed in a multicenter study that 43 % of patients suffering from acute respira-
tory failure and treated by NIV demonstrated severe asynchronies. In a pneumati-
cally triggered NIV mode, optimal settings, including pressure support, positive
end-expiratory pressure, and inspiratory flow rate and expiratory cycling, achieving
the longest time of synchrony could be difficult (Fig. 4.1).
Neurally adjusted ventilatory assist (NAVA) is a new spontaneous ventilatory
mode, first described in 1999 by Sinderby et al. [4], based on electric triggering and
proportional ventilation. NAVA uses an esophageal catheter to collect the diaphrag-
matic electrical activity (EAdi) and to synchronize (in terms of timing and amount
of pressure) the assistance to the patients inspiratory effort. There has been increas-
ing use of NAVA, and a limited number of physiological studies have pointed out
the clinical potential benefit of this new ventilatory mode. First, electric triggering,
replacing pneumatic triggering, allows better synchrony between the patient and the
ventilator. For example, in a subject with dynamic hyperinflation, synchronization
of the pressure support with EAdi could increase patientventilator interaction
(Fig. 4.2). In the same way, auto-triggering, which frequently occurs with leaks,
could be resolved with electrical triggering.
0 Exp Tr Delay
0 Times (s) 1
Studies have been published on the invasive application of NAVA mode and have
shown better synchronization between the patient and the ventilator [5, 6]. Therefore,
NAVA could be an interesting alternative to pressure support ventilation (PSV) in
NIV.
In 2008, Moerer et al. [7] studied seven healthy adult volunteers receiving NIV via
the Helmet device. They showed that, compared with pneumatically triggered
NIV, neurally triggered NIV offers better patient-ventilator synchrony, better breath-
ing comfort, and less trigger effort during increasing levels of PSV and respiratory
rate.
Another clinical study by Cammarota et al. [8] used the Helmet interface to
compare NAVA versus PSV in 10 patients in acute respiratory failure (ARF). They
also showed a better synchrony in NAVA mode compared with PSV. However, the
severe asynchrony rate was relatively high in PSV mode (7080 %), which was
probably due to the interface [9].
In 2012, Piquilloud et al. [10] assessed 13 patients receiving NAVA and PSV
with an oro-nasal face mask. Without using a NIV algorithm, but with an optimized
setting in PSV, they reported a greater patient-ventilator interaction in NAVA com-
pared with PSV, mainly due to the reduction of ineffective effort. More recently,
Bertrand et al. [11] showed similar results on 13 patients with ARF (without chronic
obstructive pulmonary disease (COPD)).
Schmidt et al. [12] particularly focused on the NIV algorithm. This dedicated
software has been developed by manufacturers to take leaks into account and to
4 Neurally Adjusted Ventilatory Assist in Noninvasive Ventilation 31
Pressure (cmH2O)
0
Flow (L/sec) 5
0.8
Pdi (cmH2O) 5
16
0
5 Time (sec)
Pressure (cmH2O)
10
0
Flow (L/sec) 5
1
Pdi (cmH2O) 5
16
0
5 Time (sec)
Fig. 4.2 Asynchronies with ineffective efforts. Pressure/time, flow/time and trans-diaphragmatic/
time curves in noninvasive pressure support ventilation (upper figure) and noninvasive neurally
adjusted ventilatory assist (bottom). Black arrows represent ineffective efforts
32 B. Repusseau and H. Roz
automatically adjust the flow and the inspiratory trigger. They compared, in 17
patients receiving prophylactic post-extubation NIV, NAVA versus PSV with and
without NIV algorithm. They found that NAVA with this software offers the best
synchrony between the patient and the ventilator. Interestingly, NAVA without NIV-
mode was more effective in reducing the asynchrony index (AI) than PSV with NIV
algorithm.
4.3 Discussion
All of these physiologic studies are concordant and seem to indicate that NAVA
increases patient-ventilator synchrony compared with PSV in NIV.
The use of neural triggering is particularly interesting in NIV. Leaks frequently
occur, even with the NIV algorithm, and can alter a pneumatic inspiratory trigger.
Leaks can generate auto-triggering, which is a main source of discomfort. Based on
4 Neurally Adjusted Ventilatory Assist in Noninvasive Ventilation 33
neural triggering, NAVA does not prevent leaks but allows the reduction of the
inspiratory trigger delay and auto-triggering frequency [13]. Under NAVA, the trig-
ger can also be pneumatic as the algorithm is first arrived, first served between
pneumatic and neural triggering. However inspiratory trigger delays are important
in patients with dynamic hyperinflation, and, in these patients, neural trigger starts
before pneumatic trigger.
Ineffective effort can also affect NIV, especially with obstructive patients.
Dynamic hyperinflation (increased by a high level of pressure support) involves
intrinsic positive end-expiratory pressure (PEEP), which increases the patients
inspiratory threshold load in a pneumatically triggered mode. In NAVA, assistance
is directly synchronized to the respiratory drive, thereby reducing asynchronies and
the inspiratory effort related to intrinsic PEEP [14]. Using an automated analysis of
patient-ventilator interaction [15], Dooduin et al. [16] demonstrated in 12 COPD
patients that noninvasive NAVA improves synchrony compared with PSV, delivered
either by a dedicated or ICU ventilator.
However, with the exception of severe obstructive patients, we do not know
whether an increased patient-ventilator interaction is clinically relevant. In all of
these physiologic studies, a better synchrony between the patient and the ventilator
did not lead to a better oxygenation index. Furthermore, our group compared NAVA
versus PSV in 10 patients receiving prophylactic post-extubation NIV [17]. We
found that, despite an increased patient-ventilator synchrony in NAVA, there was no
difference in the inspiratory effort (expressed by the transdiaphragmatic pressure
time product by minute) between the two modes.
Moreover, it is somewhat a paradox to use NAVA in NIV. The NAVA catheter
insertion is, in a way, an invasive procedure. It seems to be much easier to use NIV
NAVA after extubation than during acute respiratory failure. A significant number
of critically ill ventilated patients need a nasogastric tube, and in those cases the
choice of the catheter has to be anticipated with the aim of using NAVA. It is more
difficult to propose NAVA ventilation at the beginning of acute respiratory failure
because of the difficulties and poor tolerance of NAVA catheter insertion in that
situation. In other cases, the use of NAVA has to be carefully thought through. One
argument for the use of NAVA is the simplicity of the settings. Once the EAdi cath-
eter is inserted and well positioned, NAVA ventilation can be easily started, with, in
most cases, a relatively good patient-ventilator interaction.
Another point of research is the clinical challenge represented by gastric disten-
sion under NIV. It has been highlighted that closure of the glottis with increasing
level of assist reduces the effective ventilation and diverts air toward the digestive
system [18]. In 2012, Hadj-Ahmed et al. [19] showed the absence of inspiratory
laryngeal constrictor muscle activity during NAVA in nonsedated lambs. This find-
ing may allow the improvement of the patient-ventilator interaction under NIV.
In addition to being a new ventilatory mode, NAVA offers, for the first time, in
invasive and noninvasive ventilation, neural respiratory drive monitoring at the bed-
side. EAdi monitoring might allow optimizing settings for patient-ventilator inter-
action. In addition to the clinical relevance, the educational interest is obvious. With
NAVA-preview software, under PSV it is possible to see an estimation of the
34 B. Repusseau and H. Roz
Conclusion
NAVA represents a new alternative to PSV in NIV. It might be an interesting
mode that improves synchrony between the patient and the ventilator. Further
studies are needed to assess whether this is clinically relevant. Moreover, NAVA
gives access to a new parameter at the bedside (EAdi), revealing a new era in
ventilation.
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matically triggered non-invasive helmet ventilation. Intensive Care Med. 2008;34:161523.
8. Cammarota G, Olivieri C, Costa R, et al. Noninvasive ventilation through a helmet in postex-
tubation hypoxemic patients: physiologic comparison between neurally adjusted ventilatory
assist and pressure support ventilation. Intensive Care Med. 2011;37:194350.
4 Neurally Adjusted Ventilatory Assist in Noninvasive Ventilation 35
Abbreviations
5.1 Introduction
The use of noninvasive ventilation (NIV) has gained popularity in a variety of appli-
cations, including acute respiratory failure, and it has been shown to be beneficial in
the reduction of complications and improvement in outcomes [1]. A variety of fac-
tors can lead to failure to tolerate NIV, and the use of sedation can be effective in
keeping the patient comfortable, yet awake and arousable, so as to prevent distress
while providing a suitable level of sedation. A survey of the use of sedation in
patients receiving NIV revealed that practices vary widely, likely because of a lack
of evidence, and as such its application is underused [2]. There are inconsistencies
in how often sedation and analgesia are provided, which agents are used, methods
of administration, and determination of patient requirements. This lack of consis-
tency sets up a situation in which the patient is exposed to circumstances that make
it more difficult to be successfully weaned from mechanical ventilation.
There are several considerations with regard to sedation and anesthetic use that are
essential to ensure optimal conditions for successfully weaning from mechanical
ventilation. While providing sedation, one must be cognizant of the numerous fac-
tors linked to failure of NIV. Such factors include weak cough reflex, excessive
secretions, intolerance and psychomotor agitation, patientventilator asynchrony,
oxygen impairment, increased respiratory rate and elevated rapid shallow breathing
index, hypercapnia, sleep disturbance, and delirium [3]. Failure to optimize these
factors makes it increasingly difficult to wean from mechanical ventilation. As such,
the goal is to provide adequate sedation and pain control while maintaining arous-
ability, respiratory drive, cough reflex, and airway protection, all while retaining the
ability to quickly and safely wean the patient from both sedation and mechanical
ventilation. Techniques that are beneficial to improving these conditions include
delivering an appropriate level of sedation and analgesia, integrating protocols to
guide administration, utilizing sufficient monitoring, using the practice of intermit-
tent sedation, and the proper selection of anesthetic agent.
5.3 Discussion
outcomes. Toward this end, there are several tools available to ensure adequate
levels of sedation. For example, the Ramsay Sedation Scale, the Sedation Agitation
Scale, and the Richmond Agitation-Sedation Scale can be used to monitor and
adjust the depth of sedation [5]. Although the Bispectral Index (BIS, Aspect
Medical Systems, Norwood, MA, USA) represents a novel method of measuring
depth of sedation through the use of electroencephalography, more research is
likely needed at this time before it sees routine use for this application. In addition
to sedation scales, there are also various pain scales that may be employed to guide
the administration of adequate analgesia, such as the Numeric Rating Scale, the
Behavioral Pain Scale, the Critical Care Pain Observation Tool, and the Nonverbal
Pain Scale [6].
Although the application of the above-discussed techniques creates desirable
conditions for successful weaning, ultimately, the choice of sedative and analge-
sic agents used may play the most important role in this process. There are
numerous medications used to achieve adequate and appropriate sedation and
analgesia in the mechanically ventilated patient with varying pharmacodynam-
ics, pharmacokinetics, and physiological effects. The different properties of
these commonly used drugs (particularly the effects on respiration) will dictate
which is the best for providing the desired results, as the condition and comor-
bidities of the patient must be considered when tailoring the best therapy for the
specific situation.
Dexmedetomidine is a centrally acting agonist of the 2-adrenergic receptor that
is metabolized hepatically, and has an estimated terminal elimination half-life of
2 h. Compared with other agents, dexmedetomidine is unique in that it produces
sedation, analgesia, and anxiolysis without adverse effects on respiration, is associ-
ated with a low risk for delirium, and decreases the need for alternative sedatives
[5]. In a study done by Akada et al. [7], all 10 patients who received dexmedetomi-
dine while undergoing NIV due to prior uncooperativeness achieved adequate seda-
tion, had respiratory rates decreased as intended, had and improved PaO2/FiO2 ratio
and Paco2, and were successfully weaned from NIV with none requiring endotra-
cheal intubation (ETI). The patients could cough and expectorate without assis-
tance, and none developed pneumonia. Although the properties of the drug make it
an excellent choice for use in sedation during weaning, potential side effects of
administration include hypotension and bradycardia.
Benzodiazepines such as midazolam are commonly used sedative agents that act
via the GABAA receptor. Midazolam is metabolized hepatically with renal clear-
ance of active metabolites, which can accumulate during prolonged infusion.
Benzodiazepines are strongly associated with delirium, which is in turn associated
with increased mortality, prolonged duration of mechanical ventilation, and
increased risk of cognitive impairment in critically ill patients [5]. Whereas both
midazolam and dexmedetomidine have been found to be effective in providing ade-
quate sedation during NIV, one group found dexmedetomidine to have several
advantages including decreased percentage of NIV failure requiring ETI (21.2 % vs
44.8 %) and a more prolonged mean time to ETI, more rapid weaning, decreased
overall duration of mechanical ventilation and ICU hospitalization, easier
40 A. Balofsky and P.J. Papadakos
References
1. Hilbert G, Clouzeau B, Nam Bui H, et al. Sedation during non-invasive ventilation. Minerva
Anestesiol. 2012;78(7):8426.
2. Devlin JW, Nava S, Fong JJ, et al. Survey of sedation practices during noninvasive positive-
pressure ventilation to treat acute respiratory failure. Crit Care Med. 2007;35(10):2298302.
3. Ozyilmaz E, Ugurlu AO, Nava S. Timing of noninvasive ventilation failure: causes, risk fac-
tors, and potential remedies. BMC Pulm Med. 2014;14:19.
4. Sessler CN, Pedram S. Protocolized and target-based sedation and analgesia in the ICU. Crit
Care Clin. 2009;25(3):489513.
5. Roberts DJ, Haroon B, Hall RI. Sedation for critically ill or injured adults in the intensive care
unit: a shifting paradigm. Drugs. 2012;72(14):1881916.
6. Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J Respir
Crit Care Med. 2012;185(5):48697.
7. Akada S, Takeda S, Yoshida Y, et al. The efficacy of dexmedetomidine in patients with nonin-
vasive ventilation: a preliminary study. Anesth Analg. 2008;107(1):16770.
8. Huang Z, Chen YS, Yang ZL, et al. Dexmedetomidine versus midazolam for the sedation of
patients with non-invasive ventilation failure. Intern Med. 2012;51(17):2299305.
9. Senoglu N, Oksuz H, Dogan Z, et al. Sedation during noninvasive mechanical ventilation with
dexmedetomidine or midazolam: A randomized, double-blind, prospective study. Curr Ther
Res Clin Exp. 2010;71(3):14153.
10. Battershill AJ, Keating GM. Remifentanil: a review of its analgesic and sedative use in the
intensive care unit. Drugs. 2006;66(3):36585.
11. Rocco M, Conti G, Alessandri E, et al. Rescue treatment for noninvasive ventilation failure due
to interface intolerance with remifentanil analgosedation: a pilot study. Intensive Care Med.
2010;36(12):20605.
12. Constantin JM, Schneider E, Cayot-Constantin S, et al. Remifentanil-based sedation to treat
noninvasive ventilation failure: a preliminary study. Intensive Care Med. 2007;33(1):827.
13. Clouzeau B, Bui HN, Vargas F, et al. Target-controlled infusion of propofol for sedation in
patients with non-invasive ventilation failure due to low tolerance: a preliminary study.
Intensive Care Med. 2010;36(10):167580.
Weaning Protocols in Prolonged
Mechanical Ventilation: What Have 6
We Learned?
Abbreviations
6.1 Introduction
A. Magidova, MD
Division of Pulmonary and Critical Care, Department of Medicine,
VA Long Beach Healthcare System, Long Beach, CA, USA
F. Mazdisnian, MD
Division of Pulmonary and Critical Care, Department of Medicine,
VA Long Beach Healthcare System, Long Beach, CA, USA
University of California, Irvine, CA, USA
C.S. Sassoon, MD (*)
Division of Pulmonary and Critical Care, Department of Medicine,
University of California, Irvine, CA, USA
Pulmonary, Critical Care and Sleep Medicine, VA Long Beach Healthcare System (11/111P),
5701 East 7th Street, Long Beach, CA, 90822, USA
e-mail: csassoon@uci.edu; catherine.sassoon@va.gov
PMV is 4.4 % of intensive care unit (ICU) admissions and 6.3 % of patients receiv-
ing mechanical ventilation [2]. Patients requiring PMV have adverse clinical out-
come, prolonged ICU and hospital length of stay, and high mortality [3]. To conserve
resources, weaning is commonly performed or continued at a long-term acute care
hospital (LTAC), a facility dedicated to weaning patients from mechanical ventila-
tion. The prevalence of successful weaning among these patients is approximately
50 % [4], regardless of the various definitions of weaning success, that is, the ability
to sustain spontaneous breathing for 5 [5], 7 [1, 6], or 11 [7] consecutive days. In
ICU patients, implementation of a weaning protocol by nonphysician staff (i.e.,
respiratory therapists) is effective in reducing the time spent on mechanical ventila-
tion among patients with either simple or difficult weaning [8, 9]. The application
of a weaning protocol in patients requiring PMV results in a similar favorable out-
come of increasing ventilator-free days [7]. Surprisingly, a weaning protocol is
available in only 48% of ICUs [6]. In this chapter, we discuss (1) the necessity of a
weaning protocol for patients requiring PMV; (2) integrated measures that can
potentially increase ventilator-free days and/or successful weaning rate; and (3)
what constitutes a weaning protocol for patients requiring PMV.
Scheinhorn and coworkers [7] were the first to report a significantly shortened
weaning time when a therapist-implemented patient-specific (TIPS) weaning proto-
col was used for patients requiring PMV. Patients enrolled prospectively in the TIPS
group (n = 252) were compared with a historical control group (n = 238). Median
weaning time in the TIPS group was 17 days compared with 29 days in the control
group, although the rate of successful weaning, ventilator dependence, and mortal-
ity were similar in both groups. As in ICU patients, a weaning protocol expedited
discontinuation from mechanical ventilation [8, 10]. However, others did not sup-
port this practice when substantial physician staffing was available to pay close
attention to patients [11]. Furthermore, in a national survey of 215 Canadian ICUs
with 308 patients requiring PMV, 81 % of units used individualized plans for wean-
ing. Of those units with protocols, only 25 % had a weaning protocol specific to
PMV [12].
To our knowledge, a comparison between individualized plans and protocolized
weaning on weaning duration in patients requiring PMV has not been reported.
Nevertheless, the mechanisms of successful weaning protocols are related to obli-
gating medical personnel to pay close attention to patients, perform daily screening,
order daily spontaneous breathing trials (SBTs), and wean patients who demon-
strate improvement without delay [13]. In addition, for patients who do not tolerate
SBT, a weaning protocol provides guidelines for trial termination, re-trial, and steps
to be taken to prevent overtaxing the respiratory muscles. Thus, a weaning protocol
6 Weaning Protocols in Prolonged Mechanical Ventilation: What Have We Learned? 45
A weaning protocol increases ventilator-free days but does not improve the success-
ful weaning rate [7]. The balance between inspiratory muscle capacity and load
determines a successful weaning rate. In fact, severe diaphragm muscle weakness is
common in patients transferred to LTAC [15].
In a study of 57 patients with sepsis and receiving mechanical ventilation,
Supinski and Callahan [15] measured twitch transdiaphragmatic pressure (Pditw) in
response to magnetic stimulation of bilateral phrenic nerves. Patients with Pditw of
10 cm H2O or greater (28 %, n = 16) had a better outcome than those with less than
10 cm H2O (72 %, n = 41). Seven of 41 (17 %) patients with Pditw of less than 10 cm
H2O were admitted to a LTAC compared with only 1 of 16 patients (6 %) with Pditw
of 10 cm H2O or greater. Respiratory muscle load, reflected by respiratory system
compliance and resistance, was not significantly different among groups. Severe
diaphragm muscle weakness, defined as Pditw of less than 10 cm H2O, was an impor-
tant determinant of prolonged mechanical ventilation [15]. Thus, measures to
improve diaphragm muscle strength and/or endurance would be expected to expe-
dite discontinuation from mechanical ventilation. Indeed, in a single blind, random-
ized controlled trial, Martin and coworkers [16] tested the efficacy of inspiratory
muscle strength (IMS) training on weaning outcome in patients with PMV. Patients
had received mechanical ventilation for an average of 6.5 weeks and had failed
multiple SBTs. Patients were randomly allocated into Sham and IMS training
groups. In the IMS training group, inspiratory muscle training with a threshold
training device utilizing high pressure and low repetition training (four sets of 610
inspiratory efforts daily, 5 days per week at the maximal pressure tolerated) was
implemented until weaned or for 28 days. The IMS training group improved
46 A. Magidova et al.
Table 6.1 Approach to weaning for patients with prolonged mechanical ventilation
I. Pre-daily screening at time of admission:
Evaluate for clinical stability including sedatives, analgesics requirement and delirium [24]
Glasgow Coma Scale >13
Evaluate to begin inspiratory muscle strength training
Evaluate to begin whole-body physical therapy
II. Daily screening:
Hemodynamic variables
Heart rate between 50 and 120 beats/min
Systolic blood pressure between 90 and 180 mmHg
[All variables must be met]
Respiratory variables
FIO2 <50 % with SpO2 >90 %; PEEP <8 cm H2O
The following variables measured during spontaneous breathing:
Tidal volume >5 ml/kg
Respiratory rate <35 breaths/min
Rapid shallow breathing index (f/VT) <105 breaths/min/l
Maximum inspiratory pressure less than 20 cm H2O
[4 out of 5 variables must be met]
III. Spontaneous breathing trial (SBT)
One hour SBT via tracheostomy collar and humidified O2
Assess for respiratory distress
Heart rate increased or decreased >20 % of baseline
Systolic blood pressure <80 or >180 mmHg
SpO2 <90 %
Respiratory rate >35 breaths/min
Agitation
Anxiety
Diaphoresis
Patient request
If any of the above signs are present, return patient to previous ventilator settings and
reassess the following morning.
IV. Weaning method
Tracheostomy collar with humidified O2:
If patient tolerates 1 h of SBT, increase SBT (tracheostomy collar and humidified O2) to a
total of 2 h, progressing with an increment of 2 h daily (i.e., 4, 6, 8, 10, 12 h) divided in
two separate sessions (e.g., 2 h twice a day for a total of 4 h of SBT).
If patient tolerates 12 h of SBT, increase duration with an increment of 4 h daily (i.e., 16,
20, 24 h).
Return to previous ventilator settings for any intolerance.
Pressure support:
If patient does not tolerate within the first 12 h of SBT, may use pressure support (PS) as
alternative weaning method. PS level titrated until patient does not display signs of
respiratory distress (see above) for at least 6 h before attempts to decrease PS level, or
reassess the following morning.
For PS trial, reduce PS level daily at a decrement of 2 cm H2O twice a day until patient
tolerates PS of less than 6 cm H2O for 12 h, then progress to SBT via tracheostomy collar
and humidified O2 with an increment of 4 h daily as above (i.e., 16, 20, 24 h).
48 A. Magidova et al.
therapy are integral parts of a weaning protocol and need to commence early. Daily
screening is for assessment of hemodynamic and respiratory stability. Once hemo-
dynamic and respiratory stability is achieved, a SBT, the gold standard assessment
of inspiratory muscle capacity and endurance, begins with increasing duration as
weaning progresses. Based on the study of Jubran et al. [5], a weaning method using
a tracheostomy collar with humidified O2 was superior to pressure support. Weaning
with a tracheostomy collar and humidified O2 resulted in shorter median weaning
time. However, in patients who had early weaning trial failure, defined as failed
weaning in less than 12 h, weaning time was equivalent with tracheostomy collar or
pressure support (PS). In those patients, an alternative weaning method with PS
may be employed.
6.3 Summary
A weaning protocol in patients requiring PMV leads to shortened weaning time and
expedient decision-making but not an increase in weaning success rate. Increasing
the successful weaning rate requires enhancement of inspiratory muscle capacity
and limb muscles strength. Overall weaning time is shortened with unsupported
breathing (tracheostomy collar). In patients with early weaning failure, weaning
time is similar using PS as an alternative weaning method.
There exists a paucity of studies of the effects inspiratory muscle strength training
and whole-body rehabilitation in patients requiring PMV. During cardiothoracic
surgery, brief phrenic nerve stimulation has been shown to increase force generation
in diaphragm muscle single-fiber preparation compared with unstimulated contra-
lateral hemidiaphragm [23]. This preliminary data suggests that intermittent phrenic
nerve stimulations have the potential to improve diaphragm muscle strength in
patients requiring PMV. Similarly, because upper limb muscle strength training
contributes to shorten weaning time [22], studies of physical therapy focusing on
upper limb muscle strengthening are needed.
References
1. MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged
mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128:
393754.
2. Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: epidemiology,
outcomes and modeling the potential cost consequences of establishing a regional weaning
unit. Crit Care. 2011;15:R102.
3. Leroy G, Devos P, Lambiotte F, et al. One-year mortality in patients requiring prolonged
mechanical ventilation: multicenter evaluation of the ProVent score. Crit Care. 2014;18:R155.
6 Weaning Protocols in Prolonged Mechanical Ventilation: What Have We Learned? 49
4. Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Ventilation outcomes study group. Post-ICU
mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest.
2007;131:8593.
5. Jubran A, Grant BJ, Duffner LA, et al. Effect of pressure support vs unassisted breathing
through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical
ventilation: a randomized trial. JAMA. 2013;309:6717.
6. Rose L, Fraser IM. Patient characteristics and outcomes of a provincial prolonged-ventilation
weaning centre: a retrospective cohort study. Can Respir J. 2012;19:21620.
7. Scheinhorn DJ, Chao DC, Stearn-Hassenpflug M, et al. Outcomes in post-ICU mechanical
ventilation: a therapist-implemented weaning protocol. Chest. 2001;119:23642.
8. Gupta P, Giehler K, Walters RW, et al. The effect of a mechanical ventilation discontinuation
protocol in patients with simple and difficult weaning: impact on clinical outcomes. Respir
Care. 2014;59:1707.
9. Blackwood B, Burns KE, Cardwell CR, et al. Protocolized versus non-protocolized weaning
for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane
Database Syst Rev. 2014;(11):CD006904.
10. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of
identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:18649.
11. Krishnan JA, Moore D, Robeson C, et al. A prospective, controlled trial of a protocol-based
strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med. 2004;169:6738.
12. Rose L, Fowler RA, Fan E, et al. Prolonged mechanical ventilation in Canadian intensive care
units: a national survey. J Crit Care. 2015;30:2531.
13. Hill NS. Following protocol: weaning difficult-to-wean patients with chronic obstructive pul-
monary disease. Am J Respir Crit Care Med. 2001;164:1867.
14. Ely EW, Bennett PA, Bowton DL, et al. Large scale implementation of a respiratory therapist-
driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159:43946.
15. Supinski GS, Callahan LA. Diaphragm weakness in mechanically ventilated critically ill
patients. Crit Care. 2013;17:R120.
16. Martin AD, Smith BK, Davenport PD, et al. Inspiratory muscle strength training improves
weaning outcome in failure to wean patients: a randomized trial. Crit Care. 2011;15:R84.
17. Stevens RD, Dowdy DW, Michaels RK, et al. Neuromuscular dysfunction acquired in critical
illness: a systematic review. Intensive Care Med. 2007;33:187691.
18. Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety
criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care.
2014;18:658.
19. Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144:
82547.
20. Nydahl P, Ruhl AP, Bartoszek G, et al. Early mobilization of mechanically ventilated patients:
a 1-day point-prevalence study in Germany. Crit Care Med. 2014;42:117886.
21. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically
ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care.
2015;19:81.
22. Martin UJ, Hincapie L, Nimchuk M, et al. Impact of whole-body rehabilitation in patients
receiving chronic mechanical ventilation. Crit Care Med. 2005;33:225965.
23. Ahn B, Beaver T, Martin T, et al. Phrenic nerve stimulation increases human diaphragm fiber
force after cardiothoracic surgery. Am J Respir Crit Care Med. 2014;190:8379.
24. Dale CR, Kannas DA, Fan VS, et al. Improved analgesia, sedation, and delirium protocol
associated with decreased duration of delirium and mechanical ventilation. Ann Am Thorac
Soc. 2014;11:36774.
Evaluation of Cough During Weaning
from Mechanical Ventilation: Influence 7
in Postextubation Failure
Pascal Beuret
Abbreviations
The inability to clear respiratory secretions is a major cause of extubation failure [1],
causing an increase in the resistive load imposed on the respiratory muscles. The pre-
diction before extubation of the ability of a patient to clear the secretions once extu-
bated is challenging. The International Consensus Conference 2007 on weaning from
mechanical ventilation recommended that patients who successfully pass a spontane-
ous breathing trial should be extubated if neurological status, excessive secretions,
and airway obstruction are not issues [2]. The evaluation of cough strength is not
mentioned here, but some studies emphasize its impact on extubation outcome.
The occurrence of sputum retention after extubation results in excessive secre-
tions present in the lower airway and ineffective cough. Secretions may be present
before extubation, notably in cases of bronchopulmonary infection under treatment.
However, excess secretions may also appear suddenly after extubation as a result of
glottis dysfunction caused by prolonged intubation or because of a coexisting neu-
rologic disease. This latter mechanism is clearly difficult to predict. Evaluation of
the amount of respiratory secretions and of cough strength before extubation is
important.
P. Beuret, MD
Intensive Care Unit, Centre Hospitalier Roanne, 28 rue de Charlieu, Roanne 42328, France
e-mail: pascal.beuret@ch-roanne.fr
Two criteria are used, one being the volume of secretions. This evaluation is usually
subjective mild, moderate, or copious [35] and inter-rater reliability is uncer-
tain. A more rigorous version of the method uses the mean volume of suctioned
secretions collected per hour [6, 7]. A second criteria is the frequency of suctioning:
usually the number of tracheal aspirates during the 24 h before extubation [5, 8, 9].
This evaluation is easier and more reproducible, however, the method of suctioning
is not always the same (e.g., suctioning on demand or systematic).
PCEF
6
Air flow (l/s)
patients, is uncertain. The PCEF has also been measured with an electronic flow
meter [8] (Fig. 7.2). Alternatively, involuntary PCEF may be measured after
inducing a cough reflex by dripping 2 ml of normal saline in the endotracheal
tube [11].
Some studies found an association between the volume of secretions and extubation
outcome [4, 7], whereas others did not [3, 6]. In a study with a large sample size, the
frequency of secretions during the last 24 h was associated with extubation outcome
[5]. Moreover, when focusing on patients with excessive secretions, the patients
requiring suctioning every 2 h or more were at risk of extubation failure [4, 9].
When the evaluation of cough is subjective, the results are conflicting: in some
studies the efficacy of cough is associated with outcome of extubation [4], in other
studies not [3, 5]. Similarly, the white card test was either predictive of extubation
outcome [4] or not [7]. Conversely, all studies that objectively measured cough
strength by PCEF found a significant association with extubation outcome [68,
11]: a low PCEF before extubation increases the risk of extubation failure by five- to
sevenfold. The cut-off value of PCEF differed depending on the device used.
Fig. 7.2 Measure of the peak cough expiratory flow with the PiKo-1 (E-Ness, Aix-en-Provence,
France). The patient, who was in the semi-recumbent position, was instructed to inspire deeply
through a three-way connector positioned between the proximal tip of the tracheal tube and the
PiKo-1. The external port of the connector was then occluded, and the patient was instructed to
cough as strongly as possible through the tracheal tube
54 P. Beuret
References
1. Epstein SK. Decision to extubate. Intensive Care Med. 2002;28:53546.
2. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Statement of the
Sixth International Consensus Conference on Intensive Care Medicine. Eur Respir J.
2007;29:103356.
3. Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients
following a successful spontaneous breathing trial. Chest. 2006;130:166471.
4. Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who
have successfully completed a spontaneous breathing trial. Chest. 2001;120:126270.
5. Miu T, Joffe AM, Yanez ND, et al. Predictors of reintubation in critically ill patients. Respir
Care. 2014;59(2):17885.
6. Smina M, Salam A, Khamiees M, et al. Cough peak flows and extubation outcomes. Chest.
2003;124:2628.
7. Salam A, Tilluckdharry L, Amaoteng-Adjepong Y, et al. Neurologic status, cough, secretions
and extubation outcomes. Intensive Care Med. 2004;30:13349.
8. Beuret P, Roux C, Auclair A, et al. Interest of an objective evaluation of cough during weaning
from mechanical ventilation. Intensive Care Med. 2009;35:10903.
9. Mokhlesi B, Tulaimat A, Gluckman TJ, et al. Predicting extubation failure after successful
completion of a spontaneous breathing trial. Respir Care. 2007;42(12):17107.
10. Trebbia G, Lacombe M, Fermanian C, et al. Cough determinants in patients with neuromuscu-
lar disease. Respir Physiol Neurobiol. 2005;146(23):291300.
11. Su WL, Chen YH, Chen CW, et al. Involuntary cough strength and extubation outcomes for
patients in an ICU. Chest. 2010;137(4):77782.
12. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high-risk patients. Crit Care Med. 2005;33:246570.
13. Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure
in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173:16470.
14. Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after extubation in hypercap-
nic patients with chronic respiratory disorders: randomized controlled trial. Lancet.
2009;374:10828.
15. Beuret P, Roux C, Pelletier N, et al. Detection and assistance of weak cough at extubation:
impact on outcome. Abstract ESICM Congress Intensive Care Med 2014;40(suppl 1): O114.
Implications of Manual Chest
Physiotherapy and Technology 8
in Preventing Respiratory Failure after
Extubation
8.1 Introduction
The process of discontinuing mechanical ventilation must balance the risk of com-
plications caused by unnecessary delays in extubation with the risk of complica-
tions resulting from early discontinuation and the need for reintubation [1].
Extubation failure occurs in 1020 % of patients who meet all weaning criteria [2]
and is associated with a higher mortality rate [3]. After extubation, if respiratory
failure happens, a reintubation must be performed. Therefore, strategies that can
prevent the development of respiratory failure after extubation and the need for
reintubation are necessary to reduce the percentage of extubation failure. Airway
secretion clearance and noninvasive ventilation (NIV) can be two of the most help-
ful approaches to addressing extubation failure.
Patients in the intensive care setting often have impaired airway clearance.
Studies show the importance of cough strength and the amount of secretions for a
successful extubation [4, 5]. Beuret et al. [6] showed that extubation failure was
more likely among patients who were unable to cough on command or who had a
peak expiratory flow rate during a cough of <35 l/min. Therefore, following extuba-
tion, all patients should be closely monitored and an early airway secretion clear-
ance must be performed to prevent reintubation. This may include manual chest
The effective elimination of airway mucus and other debris is one of the most
important factors that permits successful use of ventilation support (invasive and
noninvasive) for patients with either ventilator or oxygenation impairment.
Approaches to prevent airway secretion retention include pharmacotherapy to
reduce mucus hypersecretion or to liquefy secretions, and the application of chest
physiotherapy techniques. The goals of chest physiotherapy, in ventilator-dependent
patients, are to maintain lung compliance and normal alveolar ventilation at all
times and to maximize cough flows for adequate bronchopulmonary secretion clear-
ance [8]. Further studies are needed to identify the patients and circumstances that
are at risk from complications or adverse effects of manual chest physiotherapy.
Airway clearance refers to two separate, but connected, mechanisms: mucocili-
ary clearance and cough clearance.
Positioning the patient to enable gravity to assist the flow of bronchial secretions
from the airways has been a standard treatment for some time in patients with
retained secretions [9]. The combination of positioning with breathing techniques
and manual chest physiotherapy increases the effectiveness of airway clearance in
patients with different etiologies. Breathing control techniques include autonomous
breathing exercises such as forced and deep expirations and diaphragmatic breath-
ing to optimize airway mucus clearance. Positioning can also place the patient at
risk for skin and cardiac complications, cerebral blood flow or intracranial pressure
changes, and gastroesophageal reflux [8]. Manual chest percussion (clapping) and
chest wall vibration have been shown to increase in airflow obstruction and hypox-
emia [9]. Guidebooks on manual thoracic techniques are available demonstrating
the hand placements and thrusting techniques in children and adults [10].
During high-frequency chest wall oscillation, positive pressure air pulses are applied
to the chest wall through a vest or under a chest shell. This technique provides oscil-
lation at 525 Hz. Mechanical vibration is performed at frequencies up to 40 Hz.
Vibration is applied during the entire breathing cycle or during expiration only. The
adjustable inspiratory/expiratory ratio permits asymmetrical inspiratory and expira-
tory pressure changes (e.g., +36 cmH20), which favors higher exsufflation flow
velocities to mobilize secretions. The average length of time spent in each treatment
session will vary according to patient tolerance, amount and consistency of secretions,
and the phase of the patients illness (acute or chronic). Simultaneous use of an aero-
solized medication or saline is recommended throughout the treatment. This humidi-
fies the air to counteract the drying effect of the increased airflow [13]. High-frequency
chest wall oscillation may act like a physical mucolytic, reducing both the spinnability
and viscoelasticity of mucus and enhancing clearance by coughing [9, 11].
Contraindications for this therapy are mostly the same as for intrapulmonary per-
cussive ventilation, with the addition of head or unstable neck injury, burns, open
wounds, infection or recent thoracic skin grafts, osteoporosis, osteomyelitis, coagu-
lopathy, rib fracture, lung contusion, distended abdomen, and chest wall pain [9, 13].
The forced expiratory technique (FET, also known as huffing) consists of an active,
passive, or assisted increase of the expiratory flow with the glottis open. Low lung
60 M.L. Soares et al.
volumes mobilize distal secretions and high lung volumes remove tracheal and
proximal bronchial secretions [14].
Manually assisted cough has been shown to increase peak cough flow about
2030 %. During a forced exhalation, a compression is held in the zone of the epi-
gastrium with one hand while the other hand and arm are placed on the chest, pre-
venting paradoxical thoracic expansion. Abdominal thrust and thoracic thrust are
variations of this technique. This technique can be combined with air stacking to
further increase the cough flow. Air stacking is a technique that consists of deep
lung insufflations to the maximum insufflation capacity performed with a manual
resuscitator or a volumetric ventilator [15].
MI-E has been shown to increase peak cough flow (PCF) in patients with neuro-
muscular disease [19]. An increase in PCF is thought to improve the efficacy of the
cough and thus assist in secretion removal. Therefore, MI-E has been described as
an efficient technique in the acute setting for neuromuscular disorders patients in
the treatment of respiratory failure resulting from upper respiratory tract infections
[20], to avoid intubation [21], to facilitate extubation and decannulation, and to
prevent post-extubation failure [22].
Gonalves et al. [23] found that secretion management with MI-E may work as
a useful complementary technique to prevent reintubation in patients in whom acute
respiratory failure develops in the first 48 h after extubation, suggesting that MI-E
is safe and efficient in ICU respiratory patients with indications for mechanical
ventilation.
Conclusions
Hypersecretion, reduced mucus transport, and airflow obstruction are impair-
ments, while chronic coughing and expectoration of mucus or dyspnea can limit
the patient and can therefore be classified as disabilities.
There continues to be widespread debate as to which airway clearance regi-
men should be used and when. In most comparisons, bronchial hygiene physical
therapy produced no significant effects on pulmonary function, apart from clear-
ing sputum in COPD and in bronchiectasis. There is not enough evidence to
support or refute the use of bronchial hygiene physical therapy in people with
COPD and bronchiectasis. However, there is strong evidence that supports the
use of respiratory physical therapy techniques for secretion clearance in neuro-
muscular disease to improve quality of life and survival.
If one or more of the techniques are proven to be significantly more effective
and efficient, consideration would still have to be given to the technique to which
a particular patient will adhere and, in todays world, to cost implications. Long-
term studies (1 4 years) are much harder to set up and expensive, but necessary
to increase understanding of airway clearance. Efficacy studies should be per-
formed in homogeneous groups of patients with well-described characteristics in
terms of age, sex, diagnosis, baseline pulmonary function tests, and, if possible,
compliance characteristics. The effects of secretion clearance techniques are
probably determined by special characteristics of subgroups, characterized by
lung mechanics, bronchial hyperreactivity, rheological properties of mucus, and
localization of mucus in the bronchial tree.
In patients with ventilator impairment, NIV is an efficient technique in respi-
ratory management; however, in the majority of the cases, secretions are exces-
sive and NIV alone is likely to fail. The role of respiratory physiotherapy in these
cases is crucial to permit an efficient treatment.
Disclosure Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of this chapter.
62 M.L. Soares et al.
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Nutrition in Ventilator-Dependent
Patients 9
Militsa Bitzani
Abbreviations
MV Mechanical ventilation
MVV Maximum voluntary ventilation
NIV Noninvasive ventilation
NRS 2002 Nutritional Risk Screening 2002
PEG Percutaneous endoscopic gastrostomy
PEJ Percutaneous endoscopic jejunostomy
REE Resting energy expenditure
SCI Spinal cord injury
SGA subjective global assessment
VC Vital capacity
9.1 Introduction
9.2 Discussion
9.2.1 Assessment
Table 9.1 Predictive equations for REE estimation in critically ill patients
Ireton-Jones SB: REE = 629 11(A) + 25(BW) 609(O)
Energy VD: REE = 1925 10(A) + 5(BW) + 281(S) + 292(T) + 851(B)
Equations S, sex (male = 1, female = 0), T, trauma (present = 1, absent = 0), B, burn
(IJEE) 1992 (present = 1, absent = 0),
(O) BMI > 27 kg/m2 (present = 1, absent = 0).
Mifflin-St. Jeor M: REE = (9.99 BW) + (6.25 H) (4.92 A) + 5
F: REE = (9.99 BW) + (6.25 H) (4.92 A) 161
Penn State REE = Mifflin (0.96) + VE (31) + Tmax (167) 6212
Equation Used for patient of any age with BMI <30 or patients < 60 years with
(PSU 2003b) BMI > 30.
Penn State REE = Mifflin (0.71) + VE (64) + Tmax (85) 3085
Equation Used for patients with BMI > 30 and older than 60 years.
(PSU 2010)
Fasy-Fagon REE (kcal/d) = 8 BW + 14 H + 32 VE + 94 T 4,834
American REE = 25 BW
College of If BMI 1625 kg/m2, use usual BW
Chest If BMI > 25 kg/m2, use IBW
Physicians If BMI < 16 kg/m2, use ABW for the first 710 days, then use IBW
(ACCP)
ESPEN 2025 kcal/kg BW/d during the acute and initial phase of critical illness
Guidelines 2530 kcal/kg BW/d during the anabolic recovery phase
SB spontaneously breathing, VD ventilator dependent, REE resting energy expenditure, BW body
weight in kg, A age in years, H height in cm, VE minute ventilation in l/min, Tmax maximum body
temperature in degrees Celsius, M male, F female
Vaisman et al. [11] propose an equation that predicts the actual measurement of
REE in 86 % of its variability. It can be used only in malnourished patients with
documented reduced caloric intake compared with the predicted value and should
be recalculated along the disease course.
In CCIP, during the early stage of the disease, EN is better tolerated if given as a
continuous drip infusion using a pump. In later stages, when the patient is stable,
EN can be provided intermittently during the day, or cycled overnight to facilitate
mobilization of the patient or transition to oral nutrition. There is no ideal EN for-
mula for ventilator-dependent patients, as long as their protein and caloric needs are
covered. The choice of the formula is usually guided by the functional needs of the
individual patient and, as such, is under continuous reconsideration. Parenteral
nutrition is reserved for patients unable to meet their metabolic requirements with
EN, mainly due to gastrointestinal dysfunction. In most of cases it is complemen-
tary to EN and has a short duration.
Oral feeding is the ultimate goal, assuming that swallow function is intact.
Although the actual value is difficult to determine, incidence of swallow disorders
in patients requiring prolonged mechanical ventilation has been reported to range
from 29 to 34 %. Dysphagia is associated with nutrition deficiencies and weight loss
and, if misdiagnosed, exposes the patient to the risk of aspiration.
Before the initiation of oral feeding, LTMV patients should be checked for swal-
low disorders clinically and have a direct laryngoscopy. Barium swallow video fluo-
roscopy is usually ordered to confirm the diagnosis and to provide information for
the implementation of corrective measures by a multidisciplinary team.
Usually, there is a transition period from EN to oral feeding that maybe long and
challenging. The first step is to switch from continuous drip infusion to intermittent
administration, or continuous feeding only at night. ral feeding is attempted when
intermittent feeding is well tolerated. Initially, one to two oral meals per day are
attempted. Frequency and delivery amount increases gradually, with corresponding
decreases in tube feeding. Strict monitoring of oral intake is necessary to determine
whether supplemental tube feeding is warranted to ensure metabolic needs.
Various specialized products, both for liquids and solids, differing in texture and
consistency, are at the disposition of dysphagic patients so that the most appropriate
may be chosen according to individual needs. Powdered thickeners and prethick-
ened liquids are also available. In severe stages of dysphagia, PEG is a good
solution.
Oral feeding alone maybe inadequate in patients with respiratory disease placed
on NIV. There are clinical observations that patients on NIV have inadequate nutri-
tion support, because of the limited time available for eating between applications
of ventilation masks. Additionally, they have poor appetite, are breathless, and show
early chewing tiredness. Patients may benefit from a nutrition intervention in the
form of two to three portions of small-volume, high-caloric-value supplements, dis-
tributed during the day between meals. In some cases, tube feeding maybe more
appropriate.
Conclusion
The goals of nutrition support in ventilator-dependent patients should be the
preservation of LBM and the provision of the adequate energy and protein to
expedite the weaning process. The implementation of an adequate nutrition plan
in these patients is often challenging. Nevertheless, careful nutritional assess-
ment and determination of an individualized nutrition plan, with appropriate
readjustments guided by close monitoring, will help patients to meet their medi-
cal and nutrition targets.
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Predictive Models of Prolonged
Mechanical Ventilation and Difficult 10
Weaning
Juan B. Figueroa-Casas
Abbreviations
J.B. Figueroa-Casas, MD
Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences
Center at El Paso, El Paso, TX, USA
e-mail: Juan.Figueroa@ttuhsc.edu
Before reviewing results of published studies, several factors that limit the ability to
summarize, compare, and generalize their findings on this subject need to be men-
tioned. First, there has been incompleteness or significant heterogeneity among
studies in defining the different components involved in the development of the
predictive factors or models. The measurement of the outcome to be predicted,
duration of mechanical ventilation, has varied in the following several aspects: the
determination of the end-day of mechanical ventilation according to the number of
days of successful unassisted breathing to follow ventilator discontinuation; the
inclusion (or not) of subsequent days of ventilation and/or the interval days when
ventilation was discontinuous (reintubation or reinitiation of ventilation); and the
inclusion or not of days on noninvasive ventilation. The definition of prolonged
mechanical ventilation has ranged from more than 5 to more than 21 days. The
selection of candidate predictors (variables to be analyzed as potentially predictive)
and the point in time at which they were assessed (first day on mechanical ventila-
tion, first day in intensive care unit [ICU] whether a patient is intubated or not, or
other) have also differed significantly among studies. Second, there has been great
10 Predictive Models of Prolonged Mechanical Ventilation and Difficult Weaning 75
variation in accounting for the main competing risk for duration of mechanical ven-
tilation until successful liberation, which is death while still receiving mechanical
ventilation. Sicker patients may logically be at risk of requiring a longer duration of
ventilation and weaning, but they may also be at higher risk of dying early during
the course of ventilation, and some may therefore have a relatively short duration of
ventilatory support and/or never reach a weaning stage. These patients have variably
been included, excluded, or treated as a separate category in different studies.
Similar heterogeneity in the definition of duration of ventilation, here used as an
outcome to be predicted, has been described for clinical trials in which duration of
ventilation is used as outcome of an intervention [3, 4]. In addition to the above-
mentioned factors, differences in populations among studies and lack of external
validation of the predictive models published further limit their generalization.
Studies that have aimed at predicting mechanical ventilation duration have used dif-
ferent measures to test and inform the accuracy of their predictive tools. A summary
is shown in Table 10.1. In some studies, the analysis has been limited to identifica-
tion of associated or predictive factors of mechanical ventilation duration.
Sapijaszko et al. [5] suggested that the diagnosis category leading to mechanical
ventilation might be a predictive factor. In their prospective study of 145 general
ICU patients ventilated for at least 72 h, mostly nonrespiratory variables (age, Acute
Physiology and Chronic Health Evaluation (APACHE) II score, albumin, and fluid
balance) on the first ICU day were analyzed as possible predictors of duration of
mechanical ventilation. None of these variables correlated with the actual duration
by univariate analysis. When the first three variables were incorporated into a mul-
tiple regression analysis along with five mutually exclusive diagnostic categories,
only the categories of Acute Lung Injury with other organ failure and Other
Medical (which included medical nonrespiratory and non-neurologic diagnoses)
were associated with a longer and a shorter duration of ventilation, respectively.
Estenssoro et al. [6], however, did not find diagnosis category but rather hemody-
namic condition to be associated with ventilation duration. In this retrospective
study of 189 medical-surgical ICU patients that excluded those dying before day 21,
the authors aimed to identify predictors of prolonged mechanical ventilation (here
defined as > 21 days). From the candidate predictors (severity of illness scores,
demographic and physiologic variables, and cause for mechanical ventilation) that
were assessed on ICU admission, only the presence of shock on admission was
independently associated with the need for > 21 days of ventilation.
Other studies have identified factors associated with duration of ventilation, then
applied them as predictive criteria and analyzed their classic predictive performance
characteristics. With this methodology, Troche et al. [7] reported that the Lung
Injury Score may have high negative predictive value for surgical patients to need
prolonged ventilation. In a study limited to a surgical ICU population, they followed
76
Sennef et al. 5,915 intubated Operative status, location First ICU day Number of days Diagnosis category, Predictive
on first ICU day, and day prior to ICU, on ventilation APS, age, chronic lung equation:
from 42 ICUs diagnosis category, APS, disease, albumin, PaO2/ R2 0.18 in
TISS, APACHE III and its FIO2, respiratory rate, individual
individual physiology hospital type, disease patients
variables, age, physiology, location
comorbidities, hospital and days prior to ICU.
type, chronic lung disease
Papuzinski et al. 142 general ICU Age, vital signs, Not reported 7 days Age, hypernatremia, Predictive model:
comorbidities, APACHE COPD, PaO2/FiO2 < 200 AUC 0.81
II, TISS, diagnosis
category, hematology,
chemistry, CRP
Aon et al. 1,289 derivation, APACHE II, SOFA, Intubation day 7 days Not reported Predictive model:
372 validation, location prior to ICU, NIV AUC 0.64 vs
from 13 ICUs failure, comorbidities, death +
Barthel index, <7 days
vasopressors, diagnosis AUC 0.74 vs
category alive +
<7 days
ICU intensive care unit, APACHE Acute Physiology and Chronic Health Evaluation, SAPS Simplified Acute Physiology Score, TISS Therapeutic Intervention
Scoring System, GCS Glasgow Coma Scale, SS sepsis score, LIS lung injury score, OSFI number of organ system failures, APS Acute Physiology Score,
CRP C-reactive protein, BUN blood urea nitrogen, NIV noninvasive ventilation, COPD chronic obstructive pulmonary disease, Se sensitivity, Sp specificity,
PPV positive predictive value, NPV negative predictive value, AUC area under the receiver operating characteristics curve
Predictive Models of Prolonged Mechanical Ventilation and Difficult Weaning
77
78 J.B. Figueroa-Casas
195 patients and analyzed multiple candidate variables including diagnosis leading
to mechanical ventilation and severity of illness scores assessed at the time of
admission and intubation. Only the need for emergent intubation and the Lung
Injury Score were independently associated with duration of ventilation > 14 days.
In their subsequent validation cohort of 128 patients requiring emergent intubation,
a Lung Injury Score 1 predicted >14 days of ventilation with sensitivity of 0.88,
specificity of 0.28, positive predictive value of 0.24, and negative predictive value
of 0.91. In contrast, Clark et al. [8] found a high positive predictive value to require
prolonged ventilation for medical patients when four of their predictive criteria
were met. In their retrospective study of 99 medical ICU patients, excluding those
dying before day 14, 27 common clinical and laboratory variables (diagnosis not
included) were collected from the day of intubation. By multivariate analysis, intu-
bation in the ICU, heart rate >100/min, blood urea nitrogen (BUN) > 25 mg/dl, cre-
atinine> 2 mg/dl, pH < 7.25, and HCO3 < 20 mEq/l were each associated with a
duration of ventilation 14 days. A predictive model consisting of the number (04)
of these criteria met, applied to the same derivation sample, resulted on sensitivity
of 0.16, specificity of 1, positive predictive value of 1, and negative predictive value
of 0.72 when four criteria were met. Lower numbers of criteria met resulted in pro-
gressively higher sensitivity and lower specificities. The area under the receiver
operating characteristics (ROC) curve for this model was 0.75.
The largest study reported to date suggested that both diagnosis category and the
degree of physiologic derangement could be important predictors [9]. This study
not only aimed to identify predictive factors but also to use them to develop an equa-
tion to predict the precise duration of mechanical ventilation. In this retrospective
analysis of the APACHE III database prospectively collected from 40 hospitals
ICUs, 5,915 patients who were on mechanical ventilation on their first ICU day had
many variables extracted from that day. The total duration on the ventilator was
precisely measured for patients spending 7 days on the ventilator, while it was
estimated for patients with longer durations. Of 11 variables that were found to be
independently associated with mechanical ventilation duration, the primary reason
for ICU admission (selected from the 78 APACHE III disease categories) and the
Acute Physiology Score (a component of the APACHE III score) accounted for
most of the relative contributions to this association. An equation to predict precise
duration on mechanical ventilation was then developed by the authors. In internal
cross-validation, this equation was shown to be accurate (R2 0.94) to predict average
duration in patient groups classified by illness severity, but inaccurate (R2 0.18) in
individual patients.
More recent studies have used multivariate analyses to identify associated factors
and develop a model to quantify the probability of prolonged duration of ventilation
to then analyze the accuracy of its predictions, mainly by measuring the area under
the ROC curve. In a retrospective study of 142 ICU patients, Papuzinski et al. [10]
identified age, diagnosis of chronic obstructive pulmonary disease (COPD), hyper-
natremia, and PaO2/FiO2 < 200 on intubation day as associated with a duration of 7
days on the ventilator. A derived model to predict this prolonged duration indicated
an area under the ROC curve of 0.80 in this same derivation sample, but neither
10 Predictive Models of Prolonged Mechanical Ventilation and Difficult Weaning 79
other measures of accuracy nor validation of the model were reported. In a much
larger and prospective study including 1,661 patients from 13 general ICUs, An
et al. [11] assessed multiple variables on the first day of ventilation, including the
reason for mechanical ventilation. Accounting for early deaths as a competing event
for duration of ventilation, this study aimed at discriminating patients dying before
day 7 from those requiring 7 days of ventilation, as well as those surviving but
requiring < 7 days from those same ones requiring 7 days of ventilation. A derived
multivariate risk model, when applied to a validation subsample, yielded areas
under the ROC curve of 0.64 and 0.74 for those predictions, respectively. As com-
mented by the authors, these levels of accuracy seem insufficient for individual
clinical application.
Some of the above-mentioned studies performed in mixed ICU populations sug-
gest an influence of diagnosis category on duration of mechanical ventilation. In
addition, the factors that primarily determine the need of mechanical ventilation
might differ among its different etiologies. It would then be reasonable to speculate
that predictive models restricted to a diagnostic category could yield better results.
Studies that have focused on predicting prolonged ventilation duration in selected
ICU subpopulations, however, have generally reported insufficient accuracies.
These selected subpopulations by diagnosis category have been as broad as trauma,
acute respiratory distress syndrome (ARDS), and burns, and as narrow and specific
as Guillain-Barr syndrome and post-aortic arch repair. Sensitivities to predict pro-
longed ventilation in these studies have ranged from 0.56 to 0.82, always lower
than specificities. Models consisting of a point system by number of criteria met
have shown reasonable accuracy only for the minority of patients at the extremes of
the scale.
10.5 Summary
be accounted for in order for the models to be clinically useful. The intended pur-
pose and timing of the prediction need to be kept in mind in designing studies with
this aim. A recently published comprehensive review of development of predictive
models in critical care can be a useful guide for future studies [17].
Predictive models for the recently defined categories of difficult and prolonged
weaning have not been developed. A predictive tool to be used at an early point in
the course of mechanical ventilation would be most desirable but likely difficult to
find. A predictive tool to be applied at the onset of the weaning stage should focus
on the prolonged weaning category.
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tion dependency in intensive care unit patients. Crit Care Med. 1996;24:6017.
6. Estenssoro E, Gonzalez F, Laffaire E, et al. Shock on admission day is the best predictor of
prolonged mechanical ventilation in the ICU. Chest. 2005;127:598603.
7. Troche G, Moine P. Is the duration of mechanical ventilation predictable? Chest.
1997;112:74551.
8. Clark PA, Lettieri CJ. Clinical model for predicting prolonged mechanical ventilation. J Crit
Care. 2013;28:880e17.
9. Seneff MG, Zimmerman JE, Knaus WA, et al. Predicting the duration of mechanical ventila-
tion. Chest. 1996;110:46979.
10. Papuzinski C, Durante M, Tobar C, et al. Predicting the need of tracheostomy amongst patients
admitted to an intensive care unit: a multivariate model. Am J Otolaryngol. 2013;34:51722.
11. An JM, Gomez-Tello V, Gonzalez-Higueras E, et al. Prolonged mechanical ventilation
probability model. Med Intensiva. 2012;36:48895.
12. Esteban A, Frutos-Vivar F, Muriel A, et al. Evolution of mortality over time in patients receiv-
ing mechanical ventilation. Am J Respir Crit Care Med. 2013;188:22030.
13. Peuelas O, Frutos-Vivar F, Fernandez C, et al. Characteristics and outcomes of ventilated
patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care
Med. 2011;184:4307.
14. Funk G, Anders S, Breyer M, et al. Incidence and outcome of weaning from mechanical ven-
tilation according to new categories. Eur Respir J. 2010;35:8894.
15. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J.
2007;29:103356.
16. Sellares J, Ferrer M, Cano E, et al. Predictors of prolonged weaning and survival during venti-
lator weaning in a respiratory ICU. Intensive Care Med. 2011;37:77584.
17. Labarre J, Bertrand R, Fine MJ. How to derive and validate clinical prediction models for use
in intensive care medicine. Intensive Care Med. 2014;40:51327.
Part II
Non Invasive Mechanical Ventilation
in Weaning From Mechanical
Ventilation General Considerations
Noninvasive Mechanical Ventilation
in Difficult Weaning in Critical Care: Key 11
Topics and Practical Approach
11.1 Introduction
Simple weaning: Successful extubation after the first spontaneous breathing trial
(SBT)
Difficult weaning: Successful extubation after two or three SBTs, or weaning taking
fewer than 7 days from the first SBT to successful extubation
Prolonged weaning: Not weaned after more than three SBTs, or weaning taking
longer than 7 days
11.2 Discussion
In the other group, patients were extubated when invasive pressure support ventila-
tion (IPSV) pressure suport levels were below 8 cmH2O by decreasing levels with
35 cmH2O, and they were given nasal oxygen following the extubation. The
authors showed that it is possible to use NIMV as an early extubation and weaning
technique and that it can reduce the duration of invasive mechanical ventilation (i.e.,
it permits earlier removal of the endotracheal tube) compared with invasive PSV in
weaning intubated patients who are difficult to wean.
Quinnell et al. [11] performed a study on 67 patients with COPD in which inva-
sive mechanical ventilation treatment was administered. Their reason for choosing
this patient population was the greater possibility of difficult weaning. Invasive PSV
was administered to the patients during the weaning process. After patients were
extubated, NIVM was administered if they were not successful in spontaneous ven-
tilation without any support (only oxygen administration via nasal or face mask).
NIVM was administered only during the daytime. However, at night, if peripheral
oxygen saturation values dropped below 80 %, NIMV was also administered. The
authors concluded that, following extubation, use of PSV with NIVM increases
weaning success in COPD patients with difficult weaning.
In a randomized, clinical, prospective study on 43 patients with persistent wean-
ing failure (failed weaning attempts over 3 consecutive days), Ferrer et al. [12] extu-
bated patients in one group and administered NIMV and used conventional weaning
techniques in the other group. They showed that earlier extubation with NIV results
in shorter mechanical ventilation and length of stay, less need for tracheotomy, lower
incidence of complications, and improved survival in these patients.
11.3 Analysis
Most studies on NIMV during the weaning process are performed with the PSV
mode and on COPD patients who are susceptible to difficult weaning. Results
revealed can differ in different ventilation modes and patient groups (such as postop-
erative or oncological). For example, use of positive-pressure NIMV in the postop-
erative period in patients who underwent upper abdominal surgery (gastric,
esophageal, etc.) with anastomosis can damage the anastomosis line. Thus, the use of
NIMV with lower pressure support levels may not prevent early respiratory failure
occurrence. This would increase the reintubation rate and cause loss of precious time.
There are no studies evaluating the difference between continuous positive airway
pressure (CPAP) and biphasic positive-pressure ventilation (BIPAP) administration.
The differences in these modes can affect weaning process in terms of patient com-
fort. Increasing patient cooperation in difficult weaning cases can assist the weaning.
Another point that needs further attention is the time and the intervals of NIMV
administration. NIVM administration during the daytime may be insufficient. At
night, patients are more immobile, and to protect their sleep, activities such as pos-
tural drainage and physiotherapy are preferred to be administered during the day-
time. Hence, desaturation is observed more frequently at night. Regular use of
NIMV is also recommended during the night [11].
The study of Giraul et al. [9] showed that intermittent NIMV with 24 h episodes
(this being dependent on patient cooperation) is effective and comfortable.
Conclusions
NIMV may be safely and successfully used in difficult weaning in critical care to
shorten the process of liberation from mechanical ventilation in stable patients
recovering from an episode of acute respiratory failure who had previously failed
a weaning trial. Further studies are needed to assess the benefits of NIMV in
weaning in other forms of respiratory failure, such as acute respiratory distress
syndrome, postoperative respiratory failure, and cardiac impairment.
References
1. Koksal GM, Sayilgan C, Sen O, et al. The effects of different weaning modes on the endocrine
stress response. Crit Care. 2004;8:R314.
2. Jeong BH, Ko MG, Nam J, et al. Differences in clinical outcomes according to weaning clas-
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3. Tonnelier A, Tonnelier J-M, Nowak E, et al. Clinical relevance of classification according to
weaning difficulty. Respir Care. 2011;56:58390.
4. Ferrer M. Non-invasive ventilation in the weaning process. Minerva Anestesiol.
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5. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of
patients with respiration failure due to chronic obstructive pulmonary disease. A randomized
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6. Jiang JS, Kao SJ, Wang SN. Effect of early application of biphasic positive airway pressure on
the outcome of extubation in ventilator weaning. Respirology. 1999;4:11165.
7. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high risk patients. Crit Care Med. 2005;33:246570.
8. Ferrer M, Valencia M, Nicolas JM, et al. Early non-invasive ventilation averts extubation fail-
ure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):16470.
9. Ferrer M, Sellares J, Torres A. Noninvasive ventilation in withdrawal from mechanical ventila-
tion. Semin Respir Crit Care Med. 2014;35:50718.
10. Girault C, Daudenthun I, Chevron V, et al. Noninvasive ventilation as a systematic extubation
and weaning technique in acuteon-chronic respiratory failure: a prospective, randomized con-
trolled study. Am J Respir Crit Care Med. 1999;160:8692.
11. Quinnell TG, Pilsworth S, Shneerson JM, et al. Prolonged invasive ventilation following acute
ventilatory failure in COPD. Weaning results, survival, and the role of noninvasive ventilation.
Chest. 2006;129:1339.
12. Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning
failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168:706.
Noninvasive Mechanical Ventilation
in Post-extubation Failure: Interfaces 12
and Equipment
Dirk Dinjus
12.1 Introduction
Invasive mechanical ventilation can reduce the mortality of patients with acute criti-
cal illnesses. However, the procedure itself puts patients at risk for a number of
device-associated complications such as ventilator-associated lung injury, ventilator-
associated infection [1], and weakening of the respiratory muscle pump. The need
to reintubate a patient occurs in as few as 0.42 % of neurosurgical patients [2] and
as many as 23 %, with the highest rates in medical intensive care units (ICUs).
The weaning procedure is an effort to achieve termination of dependent ventila-
tion. The weaning period takes up to 50 % of the overall invasive ventilation time
[3]. Noninvasive ventilation (NIV) in intensive care medicine is a proven indication
to avoid intubation [4] and to advance extubation in the weaning procedure after
intubation [5] as well as in the treatment of post-extubation failure [6]. The use of
NIV can shorten the time on invasive ventilation [7].
Some randomized controlled trials (RCTs) have investigated the effects of preven-
tive NIV in an unselected population immediately after extubation in comparison
with standard treatment. There was no statistical difference in patient outcome,
most likely because of the unselected candidates [8]. In early studies of unselected
patients, only a few patients had previously diagnosed chronic obstructive pulmo-
nary disease (COPD), and hypercapnia was not an included criterion to define the
D. Dinjus, MD
Division of Cardiology, Pulmonology and Vascular Medicine, Department of Medicine,
University of Duesseldorf, Moorenstr. 5, Duesseldorf 40225, Germany
e-mail: dirk.dinjus@med.uni-duesseldorf.de
indication for primary NIV use after extubation. In an RCT comparing NIV versus
standard medical treatment in patients with risk factors for weaning failure, the
reintubation rate was lower in the NIV group, but there was no difference between
groups in ICU and hospital length of stay and survival [9]. Patients with risk factors
for respiratory failure after extubation were randomized to receive NIV or oxygen
mask. NIV reduced the incidence of respiratory failure and improved the hospital
survival rate. However, overall mortality was reduced only in a subgroup of hyper-
capnic patients. A study of selected hypercapnic patients reported a decreased inci-
dence of respiratory failure, reintubation, and mortality rate at 3 months [10]. This
demonstrates that preventive application of NIV in a specific targeted population is
beneficial.
Risk factors for post-extubation failure include the following [9]:
NIV was considered a promising therapy after extubation failure to avoid reintuba-
tion at a 2001 International Consensus Conference in Intensive Care Medicine. This
consideration was mainly based on information from uncontrolled studies or com-
parison with matched historical patients collective [11]. The results of RCTs
addressing the use of NIV in the management of patients with respiratory failure
after extubation were not, however, as promising as expected. One trial with more
than 300 patients included defined respiratory distress (>30 bpm or respiratory rate
>50 % from baseline) in 81 patients. These patients were randomized to NIV or
standard treatment. The study showed no significant difference in reintubation, ICU
stay, or survival [12]. Another RCT also showed no difference in reintubation rate
or ICU stay and an increased mortality rate among the NIV group patients [13]. This
was related to a longer time to reintubation in the NIV group. Both of these studies
had a patient cohort with only about 10 % of patients having COPD. NIV in both
studies was performed with active exhalation valve systems. In one study, the ven-
tilation mode was volume controlled [13].
Today, advanced devices with sophisticated algorithms using passive expiration
valves and pressure-controlled modes may have different results. The focus on ven-
tilatory failure, seen most frequently in obstructive lung diseases such as COPD,
results in beneficial use of NIV in the weaning process [14].
12 Noninvasive Mechanical Ventilation in Post-extubation Failure 93
To achieve NIV, the interface between the device and the patients airway is crucial.
Oronasal, nasal, and oral masks, mouthpiece nasal pillows, total face masks, and
helmets are commercially available. The oronasal mask is most often preferred in
studies. To perform NIV with good success, it is important to have a variety of dif-
ferent mask types available from different companies to achieve good comfort for
the patient. Special care should be given to the skin, with regular visual inspection
at least four times a day. Moderate leaks can be tolerated in NIV devices, but they
should not irritate the eyes. A ventilator with good leak compensation capacity
should be used.
Intensive care respirators usually do not work with a turbine but with compressed
air and valves. This results in a technical limitation with regard to leak compensa-
tion. NIV should be implicated with a specialized NIV-respirator. To improve
patient comfort and tolerance, a skilled and calm clinician at the bedside is
necessary.
Conclusion
Post-extubation failure is associated with an increased risk of reintubation, pro-
longed ICU and hospital stay, and mortality. Early application of NIV after extu-
bation decreased ICU and hospital mortality rates but not the reintubation rate
[8]. However, there are also data that show an increased risk to the patients if
NIV is used in the management of post-extubation failure. To avoid harm to the
patient, the post-extubation failure risk should be assessed before extubation. All
patients at risk should be directly treated with NIV to prevent post-extubation
failure. The success of the NIV should be monitored closely to avoid delay if
NIV fails to keep the patient stable. NIV should not be used to treat post-extuba-
tion failure as it has shown no conclusive benefit in a mixed population and even
excess mortality in a large RCT [13].
Disclosures The author received a 40,000 unrestricted research grant from Linde Gas
Therapeutics, Unterschleissheim, Germany.
94 D. Dinjus
References
1. Torres A, Aznar R, Gatell JM, et al. Incidence, risk, and prognosis factors of nosocomial pneu-
monia in mechanically ventilated patients. Am Rev Respir Dis. 1990;142:5238.
2. Shalev D, Kamel H. Risk of reintubation in neurosurgical patients. Neurocrit Care.
2015;22(1):159.
3. Esteban A, Ferguson ND, Meade MO, et al. Evolution of mechanical ventilation in response
to clinical research. Am J Respir Crit Care Med. 2008;177:1707.
4. Meduri GU, Abou-Shala N, Fox RC, Jones CB, Leeper KV, Wunderink RG. Noninvasive face
mask mechanical ventilation in patients with acute hypercapnic respiratory failure. Chest.
1991;100(2):44554.
5. Hess DR. The role of noninvasive ventilation in the ventilator discontinuation process. Respir
Care. 2012;57(10):161925.
6. Olper L, Corbetta D, Cabrini L, Landoni G, Zangrillo A. Effects of non-invasive ventilation on
reintubation rate: a systematic review and meta-analysis of randomised studies of patients
undergoing cardiothoracic surgery. Crit Care Resusc. 2013;15(3):2207.
7. Burns KE, Adhikari NK, Keenan SP, et al. Use of non-invasive ventilation to wean critically ill
adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574.
8. Lin C, Yu H, Fan H, Li Z. The efficacy of noninvasive ventilation in managing postextubation
respiratory failure: a meta-analysis. Heart Lung. 2014;43(2):99104.
9. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Noninvasive ven-
tilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med.
2005;33:246570.
10. Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure
in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173:16470.
11. Hilbert G, Gruson D, Portel L, et al. Noninvasive pressure support ventilation in COPD
patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J.
1998;11:134953.
12. Keenan SP, Powers C, McCormack DG, et al. Noninvasive positive-pressure ventilation for
postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287:323844.
13. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. N Engl J Med. 2004;350:245260.
14. Ornico SR, Lobo SM, Sanches HS, et al. Noninvasive ventilation immediately after extubation
improves weaning outcome after acute respiratory failure: a randomized controlled trial. Crit
Care. 2013;17(2):R39.
Monitoring and Mechanical Ventilator
Setting During Noninvasive Mechanical 13
Ventilation: Key Determinants in
Post-extubation Respiratory Failure
Extubation failure is usually defined as the need for reintubation within 4872 h
following extubation [1]. Patients may be unable to maintain spontaneous breathing
for multiple reasons: increased workload of breathing, cardiovascular dysfunction,
airway obstruction, or excessive secretions. The incidence of post-extubation respi-
ratory failure ranges between 10 and 20 % [2]. Patients who fail extubation have
higher mortality, consistently reported at about 2050 % in intensive care units
(ICUs), and longer ICU and hospital stays [3]. Reintubation is a risk factor for
ventilator-associated pneumonia [4] and is independently associated with ICU mor-
tality [3, 5, 6]. A minority of reintubated patients die in the first 24 h after reintuba-
tion, whereas mortality increases with time to reintubation [7]. Moreover,
upper-airway obstruction is the reason for reintubation in about 515 % of cases,
but no increase in mortality has been reported in this population [7]. Thus, three
scenarios explain the higher mortality rate: (1) reintubation entails risks per se, (2)
it is a marker for severity of illness, or (3) it is a consequence of a new event occur-
ring between extubation and reintubation.
Patient selection has been shown to be of paramount importance in the ICU setting.
Evidence supporting the use of NIV in a mixed population of patients with post-
extubation respiratory failure is scarce. Timing of NIV implementation is equally
important, because, after respiratory failure is fully established, no advantage in
outcome could be found. Conversely, prophylactic NIV use in high-risk patients
(i.e., chronic obstructive pulmonary disease (COPD) or hypercapnic patients)
entails the major benefit.
Two large, randomized studies were performed to test the efficacy of NIV in
patients with a diagnosis of respiratory failure within 48 h after elective extubation.
No advantage in reintubation rate or other clinical outcome was found [11, 12].
Although few COPD patients were enrolled in either study, this selected population
could benefit the most from NIV. A recent meta-analysis confirmed that, pooling
together the results of these two studies, the reintubation rate was not significantly
reduced by the use of NIV (relative risk (RR) 1.02, 95 % confidence interval (CI)
0.831.25) [2]. Esteban et al. [12] found a higher relative risk of death in the NIV
group of 1.78 (95 % CI 1.033.20). Time delay to reintubation was proposed as the
cause of the increased mortality [11, 12].
A different approach focused on the early use of NIV to prevent reintubation in
high-risk patients. Nava et al. [13] hypothesized that the early use of NIV was
effective in avoiding reintubation in patients with at least one of the following risk
factors: hypercapnia, congestive heart failure, ineffective cough and excessive tra-
cheobronchial secretions, more than one failure of a weaning trial, more than one
comorbid condition, or upper airway obstruction. NIV determined a reduction of
13 Monitoring and Mechanical Ventilator 97
16 % in the risk for reintubation (p = 0.027) and a trend toward a reduced ICU
mortality, probably due to an increased risk of death of 60 % in the reintubated
patients. The results of this study differed from a previous trial that showed no dif-
ference in reintubation rate between NIV and conventional therapy [14]. Although
in the latter study there was a high rate of unplanned extubations and an unselected
ICU population was enrolled, similar to the studies of Keenan and Esteban [11,
12]. Ferrer et al. [15] conducted a similar study and found a reduction in post-
extubation respiratory failure in high-risk patients (p = 0.029), largely during the
first day post-extubation, and a significant benefit in mortality (p = 0.015). It is
noteworthy that NIV was continuously delivered for 24 h and a large proportion
(51 %) of COPD patients was included, thus enrolling the best responders to
NIV. Reintubation rate was not different between the two groups, but NIV was
allowed as rescue therapy and could prevent reintubation in 47 % of patients in the
control group. Later, the same group designed a new randomized, controlled trial
to confirm that early use of NIV is beneficial to prevent post-extubation failure in
COPD patients [16]. This study found similar results to the previous one. NIV
reduced the incidence of respiratory distress after extubation in high-risk patients,
but no difference in reintubation rate could be detected, probably as a consequence
of the high successful use of NIV as rescue therapy in the control group (15 patients
out of 20 overt cases of post-extubation respiratory failure avoided intubation after
NIV implementation). Other studies found similar results, supporting the early
post-extubation use of NIV in patients with planned extubation and risk factors for
extubation failure [1719].
Acute respiratory failure in the postoperative period is one of the most severe respi-
ratory complications that can occur in the postoperative period. Postoperative rein-
tubation entails a higher mortality and morbidity. Continuous positive airway
pressure (CPAP) and NIV have been shown to be beneficial during the postoperative
period to prevent or treat pulmonary complications [20]. NIV increases lung vol-
umes and alveolar ventilation, decreases work of breathing, and counterbalances
diaphragmatic dysfunction to relieve the respiratory system modifications occurring
after anesthesia, surgery, and pain. Thus, postoperative NIV was shown to improve
gas exchange, minimize atelectasis formation, and increase functional residual
capacity [21].
Two different approaches have been proposed: (1) the prophylactic use of NIV to
prevent respiratory modification, thus avoiding the development of acute respiratory
failure and therefore the need for reintubation, and (2) the therapeutic use of NIV in
patients once respiratory failure is already established.
Squadrone et al. [22] studied the effects of early CPAP in hypoxemic patients
who underwent abdominal surgery. Severely hypercapnic patients were excluded.
Patients were randomized to a control group or to CPAP until resolution of
98 D. Chiumello et al.
hypoxemia. The primary outcome was reintubation within 7 days after surgery. The
study was stopped at the interim analysis because of the lower rate of reintubation
in the CPAP group (p = 0.005). Intubation occurred in 10 % of patients in the control
group versus 1 % in the treatment group, with a RR of 0.099 (95 % CI 0.010.76).
Another study assessed the prophylactic use of CPAP after thoracoabdominal sur-
gery, finding a similar reduction in reintubation rate (19 % vs. 3 %, p < 0.05) [23].
Several studies evaluated the effects of NIV in preventing respiratory failure during
the postoperative period after different kinds of surgery, often considering reintuba-
tion rate as part of a composite outcome [2426]. Evidence suggests the efficacy of
NIV in patients with postoperative respiratory failure, especially in abdominal and
thoracic surgery.
Antonelli et al. [27] studied NIV as a treatment strategy for respiratory distress
after solid organ transplantation. The primary endpoint was reintubation rate, and
20 % of patients in the NIV group versus 70 % in the control group were reintubated
(p = 0.002). NIV was used for a median time of 50 h. The benefits of NIV in immu-
nocompromised patients were reinforced by Rocco et al. [28], who enrolled patients
with lung bilateral transplant. Twenty-one patients who developed respiratory fail-
ure postoperatively were treated with NIV and intubation was prevented in 86 % of
them. Otherwise, this is a special population in which the use of immunosuppres-
sant drugs increases morbidity and mortality associated with pulmonary
infections.
Over a 2-year period, Jaber et al. [29] reported that 20 % of patients had post-
extubation respiratory failure after abdominal surgery and that 68 % of the patients
who were treated with NIV avoided reintubation. Numerous observational studies
found similar results in a mixed population of surgical patients [3032]. Among the
others, Varon et al. [30] successfully treated postoperative respiratory distress in
70 % of cases. Auriant et al. [33] used NIV after lung resection, and 50 % of patients
in the control group versus 21 % in the interventional group required reintubation
(p = 0.035). Similar results were obtained by Michelet et al. [34] in patients after
esophagectomy. Reintubation was lower in the NIV group (9/36 vs. 23/36, p = 0.008).
No differences in surgical complications, such as anastomosis air leakage, were
recorded.
NIV is a feasible and useful treatment in cases of postoperative respiratory fail-
ure. Note that NIV delivered though a helmet was associated with lower failure,
mainly because of better tolerability [35]. Moreover, different NIV techniques and
settings were used in these studies. A comprehensive knowledge of interfaces and
NIV settings is important to tailor the support to the individual patient.
Other aspects of NIV use, including patient cooperation after extubation, absence of
deteriorating mental status, absence of hemodynamic instability, and ability to
13 Monitoring and Mechanical Ventilator 99
protect airways, are crucial to the application and success of NIV. NIV presents both
absolute (e.g., facial trauma or severe upper gastrointestinal bleeding or hemopty-
sis) and relative contraindications. Finally, primarily in cases of curative (i.e., for
respiratory failure treatment) NIV or CPAP and also in cases of prophylactic (i.e.,
for respiratory failure prevention) use, tracheal intubation should never be delayed
if respiratory status worsens because delayed reintubation may increase mortality
[7, 12].
Randomized controlled trials (RCTs) suggest benefit from NIV after extuba-
tion in patients at high risk of deterioration [13, 15, 16]. In general, high-risk
patients were defined differently among the RCTs: (1) age greater than 65 years,
cardiac failure as the cause of intubation, or Acute Physiology and Chronic
Health Evaluation (APACHE) II score greater than 12 at the time of extubation;
(2) more than one of the following: failure of consecutive weaning trials, chronic
cardiac failure, arterial pressure of CO2 >45 mmHg after extubation, more than
one noncardiac comorbidity, weak cough or stridor after extubation not requir-
ing immediate intubation; and (3) history of chronic respiratory disease with
ventilation for more than 48 h and hypercapnia during the spontaneous breathing
trial. In an initial meta-analysis, the results for all patients combined showed
statistically significant reduced rates of reintubation (RR 0.42, 95 % CI 0.25
0.70), ICU mortality (RR 0.35, 95 % CI 0.160.78), and a nonsignificant reduc-
tion in the risk of hospital mortality (RR 0.66, 95 % CI 0.421.04) [36]. A more
recent meta-analysis, which included more studies, did not find a statistically
significant effect of NIV after extubation in decreasing reintubation rate (RR
0.75, 95 % CI 0.451.15) [2]; however, the same authors found NIV effective in
reducing reintubation rate, ICU mortality, and hospital mortality rate compared
with standard medical treatment in the planned extubation subgroup (i.e.,
patients who tolerated SBT). So, although controversial, accumulating evidence
suggests that this technique has a role in prevention of acute respiratory failure
after extubation, but mainly in patients with hypercapnic and congestive heart
failure who are at high risk for extubation failure and who tolerated a SBT, and
in centers with extensive experience both in the use of NIV and invasive airway
management.
For preventive and curative approaches, both CPAP and NIV have been used.
For NIV, pressure support ventilation (PSV) is the mode of ventilation most often
used. CPAP and PSV setting recommendations in post-extubation respiratory
failure prevention or treatment are based solely on clinical experience, without
any formal data to support the superiority of one technique over another. The
same is true for the type of ventilator: both ICU and portable ventilators can be
used. In the case of ICU ventilators, however, a specific NIV module is needed to
manage the presence of air leaks always present in case of a noninvasive inter-
face use.
100 D. Chiumello et al.
In general, the studies that evaluated the use of PSV and positive end-expira-
tory pressure (PEEP) after extubation do not suggest a specific approach in this
setting. Usually, PEEP is started at 35 cmH2O and increased as needed to
improve oxygenation, without adverse hemodynamic effect and with particular
caution in COPD patients to avoid the worsening of hyperinflation. Rarely does
the level of PEEP exceed 10 cmH2O. Pressure support is started at the same level
(35 cmH2O) and increased in increments of 2 cmH2O to achieve 610 ml/kg
expiratory tidal volume, a decrease in the patients respiratory rate, and a com-
fort improvement; the average pressure support level is 1215 cmH2O. The slope
of delivered pressure (i.e., speed of pressurization) is set up as maximum toler-
ated, inspiratory and expiratory trigger of 5 l/min, and 50 % of peak inspiratory
flow. FiO2 is set to achieve arterial saturation between 92 and 95 %, with an aver-
age initial level of 5060 %. It has been demonstrated that the analysis of the
waveforms generated by ventilators for the optimization of ventilator setup has a
significant positive effect on physiological and patient-centered outcomes during
acute exacerbation of COPD. Thus, in the post-extubation setting, this approach
is probably convenient, and the acquisition of specific skills in this field should
be encouraged [37].
For CPAP, a pressure of 710 cmH2O is required to keep tracheal pressure posi-
tive during the entire respiratory cycle. In the study of Squadrone et al. [22], which
demonstrated that CPAP may decrease the incidence of endotracheal intubation and
other severe complications in patients who develop hypoxemia after elective major
abdominal surgery, CPAP was generated using a flow generator with adjustable
inspiratory oxygen fraction set to deliver a flow of up to 140 l/min and a spring-
loaded expiratory pressure valve and applied using a polyvinyl chloride transparent
helmet. The CPAP level used was 7.5 cmH2O.
In the postoperative setting, Jaber et al. [21] proposed a protocol for NIV,
mainly for curative reasons. This protocol suggests the use of PSV, starting
with low pressures and gradually increasing pressure support (usually 1015
cmH2O) and PEEP (510 cmH2O) as tolerated, without major leaks, to achieve
alleviation of dyspnea, decreased respiratory rate, increased expiratory tidal vol-
ume (to achieve 610 ml/kg), and good patient-ventilator synchrony. An increase
of total inspiratory pressure (PEEP + PS) of more than 25 cmH2O is never recom-
mended [21].
As in other areas of NIV use, in the post-extubation setting there have been no
specific recommendations for NIV weaning/duration published in guidelines to
date. So far, there are three different weaning/duration approaches: (1) gradual
decrease in duration of NIV, (2) gradual decrease in ventilator support level and
duration, and (3) abrupt discontinuation of NIV when clinical and gas exchange/
pH targets have been achieved. In many cases, the approach used in the post-
extubation trials is not described; however, in clinical practice, the second approach,
gradual decrease in ventilator support level and duration, is probably most often
used.
13 Monitoring and Mechanical Ventilator 101
The interface is the defining element of NIV. Today, different types of inter-
faces, which differ in terms of shape, mechanical properties, and comfort, are
available, and their choice and fitting is a key element of NIV success [38].
Interfaces for NIV that deliver positive pressure both through the mouth and nose
(i.e., oronasal masks) are the most widely used, because patients with respiratory
failure often have a high respiratory drive and are generally mouth-breathers. In
the last decade, larger masks covering the entire face (i.e., full-face mask) and
specifically designed helmets have been developed for delivering NIV, theoreti-
cally improving comfort and patient tolerance. The full-face or total face mask
covers the entire face, including the eyes; thus, this interface has a large inner
volume that could increase dead space. The main advantage of a full-face mask is
that, through its large perimeter, it avoids pressure over the nasal bridge, which is
frequently exposed to pressure sores as the skin is thin and directly on the nasal
bone. However, a full-face mask is generally more expensive than an oronasal
mask, and it is single use. It is noteworthy that recent studies have shown that,
despite marked heterogeneity in mask internal volume and compliance, the
dynamic dead space and, above all, the clinical efficacy of different masks is, on
average, very similar. The helmet, originally used to deliver the desired oxygen
fraction during hyperbaric oxygen therapy, was first proposed for delivery of CPAP
and subsequently for NIV. For CPAP delivery, in some cases this interface may be
preferred, as in the study of Squadrone et al. [22]. Because it has no contact with
the face, the helmet allows the patient to cough, see, and talk with supposedly bet-
ter comfort and tolerance. However, specific problems may arise, such as the pos-
sible occurrence of axillary decubitus.
With the exception of the nasal mask and the mouthpiece, a variety of interfaces
for NIV can be used in the acute care setting. For the reasons previously discussed,
an oronasal mask is usually the first choice, and a hydrocolloid dressing can be used
to prevent nasal-bridge damage [38]. Moreover, in case of prolonged NIV, the so-
called mask rotation approach (a planned sequential utilization of different inter-
faces) can be used. This approach can reduce pressure effects by alternating the
points of highest pressure and is also useful to improve the tolerance and efficacy of
NIV [39].
In 2012, the American Association for Respiratory Care published a guideline
for humidification during invasive and noninvasive mechanical ventilation [40].
This clinical practice guideline was based on 184 clinical trials and systematic
reviews, and 10 articles, and used the Grading of Recommendations Assessment,
Development, and Evaluation (GRADE) scoring system. Authors concluded that
active humidification is suggested for noninvasive mechanical ventilation, as it
may improve adherence and comfort. Passive humidification with heat and mois-
ture exchangers (HME) was not recommended for noninvasive mechanical venti-
lation, inasmuch as they can increase the work of breathing, decrease alveolar
ventilation, and deliver less humidity in comparison with heated humidifiers
(HH). However a randomized controlled multicenter study [41], which tested the
102 D. Chiumello et al.
hypothesis that NIV delivered via ICU ventilators with HH is associated with a
reduced rate of intubation in comparison with HME, failed to show a short-term
physiological benefit of HH in comparison with HME, and no difference in intu-
bation rate was found. It is noteworthy the NIV with ICU ventilators can be par-
ticularly challenging for HME because of the specific setting (e.g., inspiratory
gases are dry, respiratory rate is high, and mouth breathing is frequent during
NIV). Thus, in the post-extubation setting, airway humidification is suggested
with both HHs or HMEs with low internal volume to avoid excess dead space.
However, it is noteworthy that HMEs must provide a minimum of 30 mg H2O/l
and are contraindicated for patients with frank bloody or thick, copious secretions
and for patients with an expired tidal volume less than 70 % of the delivered tidal
volume (e.g., those with large bronchopleurocutaneous fistulas or in cases of
intentional or unintentional large mask leaks, because the patient does not exhale
enough tidal volume to replenish heat and moisture to adequately condition the
inspired gas) [40].
13.3 Monitoring
response to NIV support but it is rarely reported in studies. Arterial blood gases
should be check within 12 h after NIV establishment to assess initial NIV response.
Studies consistently reported that early improvements in terms of oxygenation, pH,
or PaCO2 are good predictors of NIV success [4648]. Subsequent timing of ABGs
is determined by patients clinical course. If little improvements are shown after 1 h
of treatment, a second tight control is advisable to avoid any delay in reassessment
of patient status and possible intubation. Commonly, a second ABG analysis is
performed 46 h after the patient starts NIV and is a reasonable time to reach gas
exchange stability. Obviously, a new evaluation must be performed after any venti-
lator setting change. Other criteria suggesting NIV failure are worse encephalopa-
thy or agitation, inability to clear secretions, inability to tolerate any of the interfaces,
and hemodynamic instability [48].
Numerous studies have evaluated the predictors of NIV failure, finding that more
severely ill patients, those with poor nutritional status or altered mental status, and
patients with evidence of pneumonia, abundant secretions, or with large air leaks
should be monitored more closely because they are at higher risk of NIV failure [5].
In general, the ability of clinicians to select patients with a high likelihood of suc-
cess is poor and NIV failure rates are high [42, 48]. Two observational studies found
that approximately one-third of patients who received a trial of NIV failed [47, 49]
(Tables 13.1 and 13.2).
N of Type of
Author Intervention Population Study type patients ventilation Interface Conclusion
ICU Jiang Preventive General ICU RCT 93 NPPV Face mask No difference in intubation rate
et al. (1999)
[14]
Keenan Treatment General ICU RCT 81 NPPV Face mask No difference in intubation rate
et al. (2002)
[11]
Esteban Treatment General ICU RCT 221 NPPV Face mask No difference in intubation rate
et al. (2004)
[12]
Nava et al. Preventive High-risk RCT 97 NPPV Face mask Lower intubation rate in the NPPV
(2005) [13] group
Ferrer Preventive High-risk RCT 162 NPPV Face mask Lower incidence of post-extubation
et al. (2006) respiratory failure in the NPPV group
[15]
Ferrer et al. Preventive COPD RCT 106 NPPV Face mask Lower incidence of post-extubation
(2009) [16] respiratory failure in the NPPV
group
Girault Preventive COPD RCT 208 NPPV Face mask No difference in intubation rate
et al. (2011)
[17]
Khilnani Preventive COPD RCT 40 NPPV Face mask No difference in intubation rate
et al. (2011)
[18]
Su et al. Preventive General ICU RCT 406 NPPV Face mask No difference in intubation rate
(2012) [19]
D. Chiumello et al.
13
Postoperative Varon et al. Treatment Cancer patients Observational 60 NPPV Face mask NPPV prevented intubation in 70 % of
(1998) [30] patients
Antonelli Treatment Solid organ RCT 40 NPPV Face mask Lower intubation rate in the NPPV
et al. (2000) transplant group
[27]
Kindgen- Treatment Thoracoabdominal Observational 20 CPAP Nasal NPPV prevented intubation in 90 % of
Milles et al. surgery mask patients
(2000) [31]
Rocco et al. Treatment Bilateral lung Observational 21 NPPV Face mask NPPV prevented intubation in 86 % of
(2001) [28] transplant patients
Auriant et al. Treatment Thoracic surgery RCT 48 NPPV Nasal Lower intubation rate in the NPPV
(2001) [33] mask group
Fagevik et al. Preventive Thoracoabdominal RCT 70 CPAP Face mask Lower intubation rate in the CPAP
Monitoring and Mechanical Ventilator
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Noninvasive Ventilation Withdrawal
Methodology After Hypercapnic 14
Respiratory Failure
Abbreviations
14.1 Introduction
C.-T. Lun, MBChB, MRCP (UK) C.-M. Chu, MD, MSc, FRCP, FCCP (*)
Division of Respiratory Medicine, Department of Medicine and Geriatrics,
United Christian Hospital, Hong Kong, China
e-mail: lunfrankie@yahoo.com; chucm@ha.org.hk
guidelines on the use of NIV in the management of patients with COPD admitted to
hospital with acute hypercapnic respiratory failure (AHcRF) in 2008 [7]. The guide-
line suggested a 4-day weaning strategy, starting with reduction of NIV use during
the daytime. The BTS guideline adopted the above weaning strategy from a multi-
center randomized controlled trial that was planned to compare the effect of NIV
and standard medical treatment instead of comparing different methods of NIV
withdrawal [8].
In contrast to the paucity of data in NIV withdrawal, an RCT was performed in
1995 comparing different methods of weaning in patients receiving invasive
mechanical ventilation [9]. A once-daily spontaneous breathing trial led to extuba-
tion about three times more quickly than intermittent mandatory ventilation and
about twice as quickly as pressure-support ventilation.
It is important to determine the best time and the best schedule to withdraw NIV
after ARF. Premature NIV withdrawal may be followed by early recurrence of
ARF. On the other hand, NIV is labor intensive, occupies high-dependency beds, is
sometimes uncomfortable for patients, and is costly. A reduction of NIV duration
may reduce nursing care, free up NIV machines and beds, reduce patient discom-
fort, reduce cost, and facilitate early discharge. This chapter reviews the available
evidence in relation to NIV withdrawal after resolution of ARF.
14.2 Analysis
There are a number of NIV withdrawal methods being practiced. Plant et al. [8]
described a stepwise withdrawal method for AHcRF in COPD, in which patients
were encouraged to use NIV as much as possible on day 1, for 16 h on day 2,
12 h on day 3, and NIV was discontinued on day 4. Kramer et al. [2] described
immediate discontinuation of NIV once arterial blood gases were normalized
and clinical stability was achieved, with resumption of NIV if deterioration
occurred. Martin [1] described NIV withdrawal by either gradual reduction in
the levels of ventilatory support or by initiating brief periods without
NIV. However, these studies were not designed to compare different methods of
NIV withdrawal.
The BTS guideline in 2008 adopted the withdrawal method described by Plant
et al. [7, 8]. It recommends gradual withdrawal of NIV over a period for 4 days, with
an extended period of NIV-free time during daytime initially. However, BTS also
allows earlier withdrawal of NIV if patients improve rapidly and it allows some
patients to have self-determined withdrawal.
At the time of writing, there have been three clinical trials assessing NIV with-
drawal methods in COPD patients recovering from AHcRF. Damas et al. [10]
treated 78 COPD patients with AHcRF with NIV and gradually withdrew NIV if
patients were stabilized. During the first 24 h of withdrawal, patients had 1 h with-
out NIV in each 3-h period, except at night time. On the second day, they had 2 h
without NIV in each 3-h period. On the third day, they had only a night period of
NIV treatment. NIV was discontinued on day 4. In this study, all patients completed
the withdrawal protocol with no reinstitution of NIV. However, this study did not
have a comparison arm.
Sellares et al. [11] published an RCT in abstract form, comparing immediate
withdrawal of NIV with conventional oxygen therapy versus 3 additional nights of
NIV in 128 patients with AHcRF. The majority of studied subjects were COPD
patients (74 %). No statistically significant differences between immediate versus
gradual NIV withdrawal were observed, in terms of respiratory failure after NIV
withdrawal, long-term ventilator dependency, hospital stay, readmission rate, or
mortality. The authors concluded that prolongation of NIV after resolution of
AHcRF does not improve outcomes, and NIV can be directly withdrawn when
AHcRF is resolved and the patient tolerates spontaneous breathing.
Lun et al. [12] compared immediate versus stepwise withdrawal of NIV (16 h on
day 1, 12 h on day 2, 8 h nocturnal NIV on day 3) in an RCT of 60 COPD patients
recovering from AHcRF. There was no statistically significant difference in the suc-
cess rate, with NIV successfully stopped in 74.3 and 56 % in the stepwise and
immediate withdrawal groups, respectively. However, the number of subjects
recruited in this study is small, and a type II error with a false-negative result was
possible.
There has not been a study to assess whether NIV withdrawal can be accom-
plished through reduction in pressure support. There is also no study evaluating
different withdrawal methods in ARF caused by non-COPD conditions.
114 C.-T. Lun and C.-M. Chu
It is not uncommon that patients with AHcRF being treated with NIV cannot achieve
complete weaning from NIV. Cuvelier et al. [13] observed that up to 39 % non-
COPD patients and 19 % COPD patients who were treated for AHcRF by NIV were
unable to have their NIV stopped for 8 consecutive days afterwards, and they
became dependent on long-term NIV. In addition, COPD patients recovering from
AHcRF after NIV treatment have high rates of recurrence [14], and long-term domi-
ciliary nocturnal NIV may reduce the recurrence rate by about 20 % [15]. Therefore,
the decision to completely withdraw NIV needs to be individualized.
References
1. Martin TJ, Hovis JD, Costantino JP, et al. A randomized, prospective evaluation of noninvasive
ventilation for acute respiratory failure. Am J Respir Crit Care Med. 2000;161:80713.
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1799806.
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treat respiratory failure resulting from exacerbation of chronic obstructive pulmonary disease:
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14 Noninvasive Ventilation Withdrawal Methodology 115
7. BTS/RCP London/Intensive Care Society. The use of non-invasive ventilation in the manage-
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http://www.brit-thoracic.org.uk/guidelines/nippv-%E2%80%93-niv-in-acute-respiratory-
failure-guideline.aspx. Date last updated Oct 2008.
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domised controlled trial. Lancet. 2000;355:19315.
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tion: experience with progressive periods of withdraw. Rev Port Pneumol. 2008;14:4953.
11. Sellares J, Ferrer M, Bencosme C, et al. Withdrawal of non-invasive ventilation in acute hyper-
capnic respiratory failure: randomized controlled trial. Am J Respir Crit Care Med.
2012;185:A6489.
12. Lun CT, Chan VL, Leung WS, et al. A pilot randomized study comparing two methods of non-
invasive ventilation withdrawal after acute respiratory failure in chronic obstructive pulmonary
disease. Respirology. 2013;18:8149.
13. Cuvelier A, Viacroze C, Benichou J, et al. Dependency on mask ventilation after acute respira-
tory failure in the intermediate care unit. Eur Respir J. 2005;26:28997.
14. Chu CM, Chan VL, Lin AWN, et al. Readmission rates and life-threatening events in COPD
survivors treated with non-invasive ventilation for acute hypercapnic respiratory failure.
Thorax. 2004;59:10205.
15. Cheung AP, Chan VL, Liong JT, et al. A pilot trial of home non-invasive ventilation after aci-
dotic respiratory failure in COPD. Int J Tuberc Lung Dis. 2010;14:6429.
Rational Bases and Approach
of Noninvasive Mechanical Ventilation 15
in Difficult Weaning: A Practical Vision
and Key Determinants
Antonio M. Esquinas
effective comparison of the published studies and the capacity to define a suitable
strategy for the problem. When this process is established, a classical form emerges
that we define as prolonged mechanical ventilation condition.
Its clinical presentation can be revealed by two main conditions: (a) the procedure
of the type of isolation of the patient airway (orotracheal intubation or tracheostomy)
or (b) it is temporarily revealed in the immediate or precocious period (extubation or
decannulation) as acute post-extubation respiratory insufficiency (APRF) or failed
decannulation. In both instances, the majority of patients have received a basic num-
ber of variable tests evaluating their capacity for SB, from a gradual reduction of
pressure support ventilation (PSV) to periods of oxygenation using a T tube [2, 4].
Patients who are unable to overcome their incapacity for spontaneous breathing
(PSV or T tube) are described as ventilatory-dependent or unweanable [6]. The
proportion and incidence are variable according to epidemiology studies, and the
protocols and strategies used to for disconnection or weaning from mechanical ven-
tilation are also variable.
A variable proportion of unweanable patients, after a period of months or years,
can be disconnected from mechanical ventilation in special units (weaning units)
dedicated to difficult weaning. As an alternative, selected patients, such as those
with tracheostomy, can, after a prolonged tracheostomy period, become candidates
for programmed decannulation with the contribution of therapeutic or preventive
application of noninvasive mechanical ventilation [7]. A small subgroup of patients
can develop APRF in an accidental scenario (not programmed extubation) or auto-
extubation can be used [8]. Although protocols have been developed for IMV ori-
ented to shortening the duration of mechanical ventilation and to ensure the success
for disconnection, there is still a subgroup of patients for whom it is impossible to
undergo disconnection of IMV [8, 9].
protocols for weaning there should be suitable daily planning for evaluation of the
capacity of spontaneous breathing, and identification and precocious treatment of
responsible factors that maintain dependency on mechanical ventilation.
With these possible scenarios, from the first descriptions of the development of
noninvasive mechanical ventilation (NIV), we have seen in the last decade the
development of studies with different variations in their design and results that have
enabled application of NIV, in a preventive or therapeutic form, in diverse clinical
situations in medical or post-surgery patients [10]. These studies, with variations
according to their design, scenario, and criteria of indications or contraindications
of NIV, continue to present a challenge for medical staff.
Although an international consensus does not exist on the ideal profile of patients
who are candidates for NIV use, we can define the criteria of its application, follow-
ing the general recommendations for NIV [11, 15]. In a general way, the published
studies base the use of NIV on two larger objectives
The improvement of gas exchange and muscular resting, independent of the causes
of the initial indication of IMV [15], is one of the larger objectives. The objectives
on which we plan the NIV are summarized below.
In our opinion, respiratory muscular weakness is one of the key causes of prolonged
IMV or post-extubation acute respiratory failure. From its initial descriptions, there
exists consolidated information that NIV can reverse the mechanisms of muscular
fatigue of diverse origins in hypercapnic or hypoxemic acute respiratory insuffi-
ciency [10, 15, 16]. The use of NIV in patients with different forms of associated
respiratory insufficiency due to weaning from mechanical ventilation requires mul-
tidicisciplinary therapeuctic approach.
120 A.M. Esquinas
There are other factors that need to be taken into account in the NIV response [3, 7,
29, 30].
15 Rational Bases and Approach of Noninvasive Mechanical Ventilation 121
15.3.4.1 Age
Most studies exclude older patients, and this factor is usually more associated with
a greater number of comorbidities (respiratory and cardiac disease). It is not consid-
ered a limiting factor [3, 6, 7].
It is important to define scenario and strategy for NIV indications. The scenarios
might include such situations as (a) extubation without prolonged IMV, (b) extuba-
tion with prolonged IMV, (c) self-extubation, (d) programmed decannulation, and (e)
accidental decannulation. Details of these situations are summarized in Fig. 15.2 [35].
The factors discussed above are essential to developing NIV extubation protocols
for the use of NIV in the weaning process. However, there remains much heteroge-
neity and few protocols focus on this topic. A review analysis of the literature on
NIV extubation protocols is summarized Table 15.1 and Fig. 15.1.
Table 15.1 Noninvasive ventilation during the extubation process: steps and practical approach
Before extubation:
1. Patient selection and timing of extubation:
Age and body mass index (BMI)
Nutritional status (both over- and underweight)
Underlying diseases (cardiac and pulmonary conditions), previous use of NIV, home
mechanical ventilation and CPAP (continuous positive airway pressure) use
Record and assessment of ventilator parameters, PSV pressure setting
Thorough evaluation of upper airway and assessment of potential airway difficulty
Thorough evaluation of lower airways (fluid, secretions, sputum load) and cough strength
Information regarding mechanical ventilation parameters during weaning period, i.e.,
airway compliance and resistance, tidal volume, minute volume, PEEP (positive end-
expiratory pressure), and inspiratory oxygen fraction
Evaluation of respiratory muscle strength and endurance, evaluation of accessory muscle use
Early detection and recognition of high-risk extubation (warning signs present)a
Day 1. NIV extubation: immediate period
1. NIV setting and ventilatory mode
(a) Bilevel positive airway pressure (BiPAP)b
IPAP (inspiratory positive airway pressure) level: start at pressure equal to PS (Pressure Support)
before extubation; aims are to control dyspnea, respiratory rate, and accessory muscle activity
EPAP (end-expiratory positive airway pressure) level: start at pressure equal to PEEP before
extubation; aims are maintenance of adequate oxygenation and SaO2
(b) CPAP: recommended in hypoxemic respiratory failure
CPAP level: start at pressure equal to PEEP before extubation; aims are maintenance of
adequate oxygenation and SaO2
2. Interface: face mask or helmet,c nasal mask, or other interface (pipe)
3. Humidification: Heated humidifiere
4. Use of complementary respiratory techniques:
15 Rational Bases and Approach of Noninvasive Mechanical Ventilation 123
Fig. 15.1 Practical details and steps of non invasive mechanical ventilation before and after extu-
bation. These are critical for safe and effective response
Conclusion
In summary, protocols for NIV extubation require validation in a specific sce-
nario (extubation or decannulation, planned or accidental, preventive or thera-
peutic). Decisions and responses are influenced by determinant factors before
extubation (e.g., lung mechanics, underlying diseases,), appropriate interaction
among physicians and the respiratory team (i.e., nurses, respiratory therapists),
and thorough evaluation of the factors in the failure of NIV (e.g., secretions,
cough reflex, neurologic disease, and muscular weakness). In real-world prac-
tice, however, proper patient selection, weaning time (short or prolonged
mechanical ventilation stages), equipment, strict monitoring, early detection of
favorable or failure responses, and a goal of prevention and early treatment of
possible complications are accepted as essential. Training, a multidisciplinary
approach, and specific weaning units are a crucial cornerstone to successful NIV
extubation. Further large prospective clinical trials are needed to evaluate respi-
ratory and nonrespiratory determinants that influence potential impacts of NIV
in prolonged mechanical ventilation and all difficult weaning scenarios. A ratio-
nale practical approach to understand how NIV may interact during weaning
process is summarized in Fig. 15.2.
15 Rational Bases and Approach of Noninvasive Mechanical Ventilation 125
Fig. 15.2 NIV during differents steps of weaning from mechanical ventilation
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Influence of Prevention Protocols
on Respiratory Complications: 16
Ventilator-Associated Pneumonia During
Prolonged Mechanical Ventilation
16.1 Introduction
B. Mina, MD C. Kyung, MD
Department of Medicine, Division of Pulmonary and Critical Care Medicine,
Lenox Hill Hospital, New York, NY, USA
e-mail: bmina@mindspring.com; kriskyung@gmail.com
mechanical ventilation as opposed to just VAP alone. The CDC identifies VAP
using a combination of several factors, including the following:
This new terminology states that mechanical ventilation must take place for at
least 2 days to be considered a VAE. The mechanically ventilated patient must also
be stable for 2 or more days and must not have increasing requirements of positive
end-expiratory pressure (PEEP) or fraction of inspired oxygen (FiO2). After a stable
period of unchanged oxygen requirements (no change in PEEP or FiO2) for 2 or
more days, if there is an increase in the requirements of oxygen, either:
Mechanical ventilation
Ventilator associated event (VAE)
Pneumonia
Acute respiratory distress syndrome (ARDS)
Lobar atelectasis
Pulmonary edema
In the setting of a VAC, if the patient has been on mechanical ventilation for 3 or
more days or is within 2 days of worsening oxygenation, as described above, with
the following added criteria below, then it considered an infection-related ventilator-
associated complication (IVAC):
16 Influence of Prevention Protocols on Respiratory Complications 131
After all these events, if there is Gram stain evidence, inflammatory cells or cul-
ture above a certain threshold from the lungs, bronchi, or trachea, or cultures direct
from bronchoscopy, then it is classified as possible VAP. If the culture shows growth
surpassing specific thresholds or there are specific positive test findings or histopa-
thology, then VAP is considered probable.
Avoid intubation
Minimize sedation
Provide physical conditioning
Minimize secretions above the endotracheal tube cuff
Elevate the head of the bed
Maintain ventilator circuits
132 B. Mina and C. Kyung
The presence of an endotracheal tube (ETT) can interfere with the protective mech-
anism of cough, which results in pooling of secretions in the upper airways, promot-
ing micro-aspiration. Studies have shown that use of noninvasive ventilation (using
devices such as BiPAP) has decreased the need for invasive mechanical ventila-
tion, and ultimately the incidence of VAP, with a resulting decrease in length of stay
in the intensive care unit (ICU). Noninvasive mechanical ventilation can assist in
liberation from mechanical ventilation and prevent reintubation, especially in
patients with chronic obstructive lung disease (COPD). Attempts to reduce the
number of ventilation days and need for reintubation will decrease the incidence of
VAP. Strategies to avoid premature and unplanned extubation should be in place.
Strategies and development of approaches to limit the use of sedation in the ICU
have been associated with successful spontaneous breathing trials and early extuba-
tion. Efforts should be made to limit the need for sedation and should follow the
guidelines for analgesia and sedation. Other helpful tips include:
Early exercise and mobilization can prevent the development of critical muscle
weakness, expedite extubation, and improve overall quality of life for the patient.
The head of the bed should be elevated to 3045. Most meta-analyses and studies
have shown that patients whose beds are elevated to 3045 are have less risk of
aspiration compared with patients placed in a fully supine position [1]. However,
although incidence is lower, there has been no proven mortality benefit.
16 Influence of Prevention Protocols on Respiratory Complications 133
Routine change of the circulatory circuit is not required unless contaminated with
soiled secretions or if it is malfunctioning.
The following strategies may assist in the prevention of VAP but the evidence is
not as concrete.
Polyurethane-coated cuffs allow better sealing around the tracheal wall and theo-
retically decrease the incidence of micro-aspiration into the lungs. Small studies
performed by Lorente et al. [11] (n = 280 patients) and Poelaert et al. [12] (n = 134
patients post cardiac surgery) showed decreased incidence, but the studies are too
small to extrapolate the effectiveness.
A VAP prevention bundle is a group of interventions that are performed for a high-
risk patient with the goal of preventing VAP. A study by Bouadma et al. [2] com-
pared the use of a VAP bundle before and after implementation that included:
Hand hygiene
Glove and gown use
Elevation of head of bed
Oral septic prophylaxis (four times daily)
ETT cuff pressure >20 cmH2O
Use of Orogastric tube over nasogastric tube
Gastric distention prevention
Decreased tracheal suctioning (nonessential)
The results of this study showed that episodes of VAP at baseline compared with
intervention with the bundle were, respectively, 22.6 and 13.1 total episodes per
1000 ventilator days, showing statistical significance. Despite the decrease in inci-
dence and shorter length of ICU stay, there was no mortality benefit or change in
total duration of mechanical ventilation. Similar studies using different VAP pre-
vention bundles have been evaluated showing reduction in incidence, however,
these have only been cohort studies [2].
16 Influence of Prevention Protocols on Respiratory Complications 135
Other interventions that are not generally recommended or for which there is poor
data include use of silver-coated ETTs (specialized ETTs to prevent bacterial bio-
film and colonization), kinetic beds (specialized beds that continuously rotate,) and
prone positioning. However, despite the decrease in incidence of VAP, there has
been no change in mortality or duration of mechanical ventilation.
In the October 2014 issue of Chest, Hurley performed an analysis of the use of topi-
cal antibiotics in selective gastric decontamination. The results of this analysis
showed that the effects of the topical antibiotics on the incidence of VAP are confus-
ing and even paradoxical [4]. Kollef, in an editorial to the article in the same issue,
pointed out that these effects of VAP incidence were different when using different
analysis methods. Kollef points out that there could still be a role for topical antibi-
otics and even aerosolized antibiotics in VAP prevention, however, more research
136 B. Mina and C. Kyung
and information on their cost-effectiveness are required [9]. As we learn more about
these novel methods, it is important to remain focused on the basics methods for
VAP prevention: (1) VAP prevention bundles and prevention programs, (2) the prac-
tice of antibiotic stewardship, and (3) more research on VAP prevention and
treatment.
Conclusion
Ventilator-associated pneumonia is a preventable complication related to
mechanical ventilation. Morbidity and mortality related to VAP have a consider-
able economic impact on the health-care system. Although the data and research
on the methods of VAP prevention are not concrete, studies have shown that
there are various preventive measures aimed at decreasing the incidence of
VAP. The majority of these methods are generally cost-effective and easy to
implement. A summary of the recommendations is provided in Table 16.1.
References
Review Article
1. Klompas M, et al. Strategies to prevent ventilator associated pneumonia in acute care hospi-
tals. Infect Control Hosp Epidemiol. 2014;(35)8:91536.
Journal Article
2. Bouadma L, et al. Long-term impact of a multifaceted prevention program on ventilator-
associated pneumonia in a medical intensive care unit. Clin Infect Dis. 2010;51(10):111522.
3. Chan EY, et al. Oral decontamination for prevention of pneumonia in mechanically ventilated
adults: systematic review and meta-analysis. BMJ. 2007;334(7599):889.
4. Hurley JC, et al. Ventilator-associated pneumonia prevention methods using topic antibiotics:
herd protection or herd peril? Chest. 2014;146(4):8908. doi:10.1378/chest.13-2926.
5. Kalanuria AA, et al. Ventilator associated pneumonia in the ICU. Crit Care. 2014 18:208.
http://ccforum.com/content/18/2/208.
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temic review and meta-analysis. Lancet. 2011;11(11):84554.
7. Muscedere J, et al. Subglottic secretion drainage for the prevention of ventilator-associated
pneumonia: a systemic review and meta-analysis. Crit Care Med. 2011;39(8):198591.
Protocols
Editorial
9. Kollef MH. Ventilator-associated pneumonia prevention: we still have a long way to go! Chest.
2014;146(4):8734. doi:10.1378/chest.14-1066.
10. de Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and
oropharynx in ICU patients. N Engl J Med. 2009;360(1):2031.
11. Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Influence of an endotracheal tube with
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J Thorac Cardiovasc Surg. 2008;135(4):7716.
High-Flow Nasal Cannula Oxygen
in Acute Respiratory Failure After 17
Extubation: Key Practical Topics
and Clinical Implications
Rachael L. Parke
Abbreviations
17.1 Introduction
Traditionally, oxygen therapy has been provided by way of a range of devices such
as nasal prongs, face masks, and nose masks, the design of which has changed little
since the initial versions were developed more than 80 years ago. Limitations to the
provision of oxygen by conventional systems exist, including patient discomfort
and intolerance, inaccurate delivery of oxygen, failure to provide flow equivalent to
inspiratory demand, drying of the airway, and treatment failure requiring escalation
of respiratory support. Nasal high-flow oxygen therapy (NHF) has come to be used
widely in the treatment of acute respiratory failure. NHF has been demonstrated to
be easy to institute, is comfortable to the patient, and achieves excellent adherence
to therapy [1].
Commercially available NHF systems have rapidly gained popularity among the
range of respiratory support devices and oxygen administration systems available to
clinicians. Advances in the design of heated delivery tubing and the development of
uniquely designed nasal interfaces have allowed the development of systems capa-
ble of delivering high-flow rates of heated, humidified, blended air and oxygen
directly into the nares, allowing delivery of optimally conditioned gas. Systems
comprise an air-oxygen blender (capable of delivering 21100 % fraction of inspired
oxygen (FiO2)), an active heated humidifier chamber, heated single-limb inspiratory
delivery tubing (which avoids heat loss and development of condensate in the cir-
cuit), and a uniquely designed large-bore nasal interface. This allows delivery of
blended air and oxygen at flows up to 60 l/min, heated to 37 C and optimally
humidified to 44 mgH2O/l.
NHF has been suggested as an intermediate form of respiratory support posi-
tioned between traditional methods of oxygen delivery such as low-flow nasal can-
nulas and noninvasive ventilation [2]. It can be used as part of a continuum of
respiratory support, either as a tool for escalation of respiratory support in the acute
phase of illness or as a means of moving from higher support to lower support when
used during the weaning phase. NHF has been shown to reduce respiratory rate,
improve oxygenation, reduce carbon dioxide concentrations, and reduce the need
for intubation and escalation of respiratory support therapy.
The improvement in oxygenation seen with NHF may, in part, be due to less dilu-
tion of delivered oxygen. Oxygen dilution occurs in acute respiratory failure as
patients breathe with high peak inspiratory flows. As higher gas flows are achieved
with NHF, meeting or exceeding patient inspiratory demand, less entrainment of
room air and resultant dilution of oxygen concentration occurs. Studies have shown
that in healthy volunteers, the oxygen delivered by NHF systems approaches that
prescribed when the delivered gas flow rates were greater than the subjects peak
inspiratory flow rate [3, 4].
NHF removes the air contained in the nasopharyngeal cavity, reducing anatomic
dead space and enhancing alveolar ventilation and oxygenation [5, 6]. This dead
space washout also may result in higher resting oxygen saturation and potentially
enhances CO2 clearance [7]. Experiments suggest that a steady flow assumption
17 High-Flow Nasal Cannula Oxygen in Acute Respiratory Failure After Extubation 141
within the nasal cavity is invalid during natural breathing; however, it appears valid
with NHF. This may support the argument that NHF continuously flushes the naso-
pharyngeal dead space, which may enhance washout of carbon dioxide [8].
Electrical impedance tomography (EIT) has demonstrated that NHF increases both
end-expiratory lung volume (EELV) and tidal volume [13, 14]. Increases in end-
expiratory lung impedance (EELI) were significantly influenced by body mass
index (BMI), with larger increases associated with higher BMIs. Increases in EELV
may result in a reduction in the work of breathing, assist in prevention of small
airway closure, and lead to improved oxygenation due to reduced shunting [13].
142 R.L. Parke
Mouth open
0 y = 0.5050 + 0.0347* x
0 10 20 30 40 50 60
Gas flow delivered (L/min)
NHF was found to increase global EELI in both the prone and supine position,
which may represent an increase in functional residual capacity [14].
One of the perceived benefits of NHF is the enhanced patient comfort and tolerabil-
ity leading to improved compliance with the therapy [10, 15]. Tolerance of NHF has
been demonstrated in several studies and is presumed to be due to the provision of
optimal heat and humidity during the therapy to patients [10, 16, 17]. The optimal
humidity delivered by the system has been shown to reduce mouth and nasal dry-
ness when compared with dry oxygen therapy [10, 18, 19]. Also, because a nasal
interface is utilized as opposed to a face mask, patients can eat, drink, sleep, and
communicate more easily without removing the device. This has led to improved
patient comfort, fewer removals of the interface, and less oxygen desaturation when
compared with face mask oxygen therapy [20].
NHF offers a fast and sustained improvement in respiratory parameters in patients with
hypoxemic respiratory failure, ensures patient comfort over extended periods of time,
and has been shown to reduce respiratory rate, alleviate dyspnea, and improve oxygen
saturation in adult patients presenting to the emergency department and the intensive
care unit (ICU) [19, 21]. NHF can effectively be used to manage patients with mild to
moderate levels of hypoxemic respiratory failure, may prevent the need for intubation,
and can be used to provide respiratory support following extubation [22, 23].
17 High-Flow Nasal Cannula Oxygen in Acute Respiratory Failure After Extubation 143
17.3.1.2 Monitoring
It is preferable to have continuous monitoring of heart rate, respiratory rate, and
oxygen saturations. Blood gas measurements may be undertaken as per local proto-
col or as clinical need dictates.
17.3.1.3 Documentation
Staff should ensure that regular documentation of therapy includes the flow and
FiO2 delivered, respiratory rate, heart rate, and oxygen saturations. Acceptable
parameters should be prescribed describing target oxygen saturations and allowable
flow and FiO2.
17.3.2 Other
Provide regular oral care as per local protocol. Nebulizer spacers or a T piece can
be used in conjunction with NHF to deliver aerosol therapy. Patients may also be
successfully managed on some wards with NHF either in the case of deterioration
in respiratory function or following transfer from the ICU where therapy has already
been instituted. Care must be taken, however, to set realistic limits on the flow that
can be delivered in a ward environment, the FiO2 that is appropriate for ward use,
17 High-Flow Nasal Cannula Oxygen in Acute Respiratory Failure After Extubation 145
and at what point further advice and management should be sought from specialist
ICU teams. For example, call intensive care for further advice if >50 % FiO2 and/or
>40 l/min flow.
It is important to recognize that NHF may not be successful in all situations and
that an escalation protocol should be made available to staff that encourages higher-
level respiratory support in the case of increased respiratory distress, desaturation/
apnea, increased PCO2, or further clinical deterioration.
17.4 Discussion
The utilization of NHF has expanded rapidly since its introduction, and NHF is now
seen as a useful treatment option in patients with acute respiratory failure, improv-
ing oxygenation and patient comfort and reducing respiratory rate. There is growing
evidence that NHF is associated with a number of beneficial mechanisms not typi-
cally seen with traditional oxygen therapies.
Further research will help to define appropriate boundaries between nasal high
flow and traditional forms of respiratory support such as noninvasive ventilation.
Further work is also required to determine optimal patient selection, reliable indica-
tors of success and/or failure, and its place and therapeutic value in novel patient
groups such as rapid sequence induction, bronchoscopy, transesophageal echocar-
diography, and other procedures where sedation is required.
References
1. Parke R, McGuinness S. Pressures delivered by nasal high flow therapy during all phases of the
respiratory cycle. Respir Care. 2013;58:16214.
2. Chatila W, Nugent T, Vance G, Gaughan J, Criner GJ. The effects of high-flow vs low-flow
oxygen on exercise in advanced obstructive airways disease. Chest. 2004;126:110815.
3. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow
oxygen system, using oxygraphy, capnography and measurement of upper airway pressures.
Anaesth Intensive Care. 2011;39:110310.
4. Sim MA, Dean P, Kinsella J, Black R, Carter R, Hughes M. Performance of oxygen delivery
devices when the breathing pattern of respiratory failure is simulated. Anaesthesia.
2008;63:93840.
5. Ricard J. The high flow nasal oxygen in acute respiratory failure. Minerva Anestesiol.
2012;78(7):83641.
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Noninvasive Mechanical Ventilation
in Difficult Weaning in Critical Care: 18
A Rationale Approach
18.1 Introduction
Weaning, that is, withdrawal of ventilatory support, is a critical and vital step in the
care of intubated patients on mechanical ventilation. Forty to 50 % of the total dura-
tion of mechanical ventilation is the average time spent during weaning. Weaning
techniques vary among intensivists, with spontaneous breathing trials (SBTs) being
used as a diagnostic tool to estimate the probability of successful extubation.
Noninvasive ventilation (NIV) can act as bridge and facilitate the weaning process.
A patient must pass through different stages, from initiation of mechanical ventila-
tion to weaning. The process includes (1) management of acute respiratory failure,
(2) suspicion of readiness to wean, (3) assessment of readiness to wean, (4) SBT, (5)
extubation, and (6) reintubation if needed. Patients are classified into three groups
on the basis of difficulty and duration of weaning process: (1) simple weaning, (2)
difficult weaning, and (3) prolonged weaning.
Simple weaning [1]: Successful extubation in first attempt from start of weaning
with no difficulty.
Difficult weaning [1]: Initial weaning failure and requiring up to three SBTs or as
many as 7 days from initial SBT to attain successful weaning.
Prolonged weaning [1]: Three or more weaning failures or >7 days of weaning from
initial SBT.
SBT [1]: A T-tube trial or a low-level pressure support trial (8 cmH2O).
Weaning failure [1]: Failure of an SBT or the need for reintubation following extu-
bation within 48 h. There are various subjective and objective criteria for deter-
mining failure of an SBT (Table 18.1).
Numerous studies have suggested that NIV could assist in weaning patients from
invasive ventilation. A short weaning time and prevention of reintubation could be
primary end points where NIV is indicated in patients with failed weaning efforts
from mechanical ventilation. Udwadia et al. [2] evaluated the role of NIV in 22
patients with difficult weaning. Nine patients had primary lung pathology or chest
wall disease, and six had neuromuscular pathology. With nasal NIV, after a median
of 11 days, 18 patients were successfully weaned from invasive ventilation. The first
randomized controlled trial (RCT) for evaluation of NIV in weaning in patients with
acute exacerbation of COPD with severe type II respiratory failure who had recov-
ered within 48 h of mechanical ventilation, but had failed SBT, randomized the
patients into two groups [3]. The first group continued to be intubated with weaning
by pressure support ventilation mode while the second group was extubated and put
on NIV. Patient on NIV had a significantly shorter duration of ventilation, a lower
incidence of nosocomial pneumonia, increase in survival by 60 days, and were more
likely to be successfully weaned (88 % vs 68 %). The authors concluded that short-
ening the duration of endotracheal intubation was the main cause of reduced inci-
dence of ventilation-associated complications and mortality.
Another prospective randomized controlled trial evaluated the role of NIV in
patients on mechanical ventilation with persistent weaning failure who failed spon-
taneous breathing trials for 3 consecutive days [4]. Seventy-seven percent (n = 33) of
patients had chronic pulmonary diseases. Randomization was done and patients
were either extubated with noninvasive ventilation support or remained intubated
following a conventional weaning approach. The NIV group had reduced days of
invasive ventilation, shorter ICU and hospital stay, reduction in need for tracheos-
tomy to facilitate weaning, and a decrease in incidence of nosocomial pneumonia
and septic shock. An improvement in 90-day survival and ICU survival was also
152 D. Chaudhry and R. Roshan
Readiness to wean
Weaning
4872 success
SBT Success Extubation h criteria
Met
Failure
Facilitation
of weaning
COPD
hypercapnic RF
Prevention*
Post
NIV extubation
respiratory
failure
Inconclusive Treatment
evidence
Fig. 18.2 Noninvasive ventilation: current status in weaning from invasive ventilation. SBT spon-
taneous breathing trial, COPD chronic obstructive pulmonary disease, NIV noninvasive ventila-
tion, RF respiratory failure. *NIV can be applied in patients with chronic pulmonary disease,
chronic cardiac failure, old age >65 years, PaCO2 >45 mmHg, morbid obesity. Criteria for post-
extubation respiratory failure: RR >25/min for 2 h; heart rate >140/min or fall by >20 %; signs of
respiratory distress: SaO2 <90 %, PaO2 <80 mmHg on FiO2 0.5; PaCO2 >45 mmHg or 20 %
from pre-extubation; pH < .33. Weaning success criteria: SaO2 >90 %; FiO2 >0.4; pH >7.35; RR
<25/min, conscious
noted. As patients with failed weaning are likely to develop a rapid and shallow
breathing pattern, the ability of NIV to overcome hypoxemia and hypercapnia by
improving such an abnormal respiratory pattern might explain the efficacy of NIV
in these patients. Thus, NIV can be a good tool to assist the return of spontaneous
breath and alleviate the ICU requirement in patients with hypercapnic respiratory
failure requiring intubation.
Vaschetto et al. [5] evaluated role of NIV in weaning in patients of hypoxemic
respiratory failure. Twenty patients with hypoxemic failure were randomized into
two groups: weaning by conventional medical care or by NIV. In both groups, no
difference was observed in arterial blood gas after 1, 12, 24, and 48 h of NIV appli-
cation. The total number of invasive-ventilation-free days at 4 weeks was higher in
the NIV group compared with conventional weaning (20 8 vs 10 6 days). No
significant difference was present in the rate of failed extubation, ICU and hospital
mortality, ICU and hospital stay, need for tracheostomy, sepsis, and use of sedation
18 Noninvasive Mechanical Ventilation in Difficult Weaning in Critical Care 153
in both groups. In this study, around 40 % of the patients in the NIV group and
50 % in the conventional group had respiratory failure due to trauma, while the rest
had pneumonia and acute lung injury. The beneficial results of NIV in this study
may be due to the predominance of trauma patients, as they can have a good
response with NIV.
Few case reports are available regarding the use of bi-level positive pressure non
invasive ventilation in children in weaning from invasive ventilation with neuro-
muscular diseases such as Guillain-Barr syndrome and Duchene muscular dystro-
phy [6]. It can be an alternative method to tracheostomy in such patients with
neuromuscular paralysis needing prolonged ventilation.
In our experience in patients with COPD with acute or chronic hypercapnic
respiratory failure who had failed T-piece weaning trial, after randomization of
patients to receive either pressure support ventilation (PSV) or NIV as the weaning
mode, NIV was found to be equally useful as PSV. Thirty patients with acute exac-
erbation of COPD on mechanical ventilation were included in this study. No signifi-
cant difference in total duration of mechanical ventilation or ICU stay was present.
Fewer deaths among patients weaned with NIV at the time of discharge from ICU
and at 30 days were seen, though the number was not significant. Incidence of noso-
comial pneumonia was lower in the NIV compared with the PSV group (6.66 % vs
33.33 %). It was concluded that NIV is a better tool in difficult weaning, especially
in COPD, and may lead to a reduction in complications and mortality [7].
Two RCTs have shown some benefit from noninvasive positive pressure ventilation
in patients who had high risk of extubation failure [8, 9]. The risk factors were dif-
ferent between the two trials: (a) failure of more than one consecutive weaning
trial, chronic heart failure, PaCO2 45 mmHg after extubation, more than one
comorbidity, poor cough, and excessive tracheobronchial secretions [8]; and (b)
age greater than 65 years, heart failure, and APACHE (Acute Physiology and
Chronic Health Evaluation) II score greater than 12 at the time of extubation [9].
Both the trials showed a trend toward a fall in the rate of reintubation and lower
ICU mortality but minimal or no benefit in hospital mortality. Ferrer et al. [9] ana-
lyzed patients with and without CO2 retention during the spontaneous breathing
trial and reported that application of NIV lead to a drop in ICU mortality and
greater 90-day survival in hypercapnic patients only. Ornico et al. [10] did a ran-
domized controlled trial to determine the benefit of NIV applied immediately after
extubation that showed that NIV led to a reduction in intubation and hospital mor-
tality. There is still no clear-cut evidence regarding routine use of NIV to prevent
extubation failure except probably in patients with COPD. It is mandatory to moni-
tor the extubated patient after application of NIV as no sign of improvement in the
respiratory parameters warrants reintubation.
154 D. Chaudhry and R. Roshan
The benefits of NIV in the treatment of patients developing respiratory failure after
extubation is inconclusive. Few RCTs have been done that reported almost no
advantage of application of NIV in management of post-extubation respiratory fail-
ure. Esteban et al. [11] assessed the effect of NIV on mortality in patients who were
extubated after 48 h of mechanical ventilation and developed respiratory failure in
the next 48 h in a randomized controlled trial. In 221 patients, randomization was
done and they were either given NIV support (n = 114) or standard medical treat-
ment (n = 107). No difference in the rate of reintubation was reported. Mortality was
higher in the NIV group (25 % vs 14 %), with median time from onset of respiratory
distress to reintubation significantly longer in NIV group. In a post hoc analysis of
a subset of patients with COPD (n = 23), the rate of reintubation was lower in
patients who had received NIV compared with standard therapy (50 % vs 67 %).
The authors concluded that NIV is not helpful in avoiding reintubation, does not
increase the survival, and can be harmful.
Another RCT done by Keenan et al. [12] on role of NIV in patients with post-
extubation failure compared with standard medical therapy showed that there were
no differences in rate of reintubation (72 % vs 69 %), occurrence of pneumonia
(47 % vs 41 %), ICU survival (83 % vs 74 %), or hospital survival (69 % vs 67 %).
Only 11 % of patients included in this study had a diagnosis of COPD, and the
patients with COPD were excluded after 1 year of study.
Lin et al. [13] did a meta-analysis of 10 trials involving 1,382 patients on the
efficacy of NIV in treatment of post-extubation failure and reported that use of NIV
did not reduce the reintubation rate or ICU mortality compared with standard treat-
ment. Early NIV support also did not lead to a significant reduction in reintubation
rate after extubation. In the planned extubation subgroup, there was a significant
decrease in the rate of reintubation and ICU and hospital mortality rate. The authors
advocated for early use of NIV and vigilant monitoring of the patient during NIV
application in treatment of post-extubation respiratory failure.
Glossop et al. [14] analyzed the utility of NIV for weaning and prevention of
reintubation after extubation and reported that NIV reduced the duration of stay in
ICU by 5.12 days and hospital stay by 6.45 days during its use for weaning but not
post-extubation. Risk of pneumonia with NIV was also lower in weaning but not
post-extubation. No reduction in risk of reintubation or any increase in ICU survival
was seen when NIV was applied for weaning or post-extubation. Hospital survival
was greater with NIV during weaning but not post-extubation.
Burns et al. [15] performed a systematic review of the use of NIV in weaning of
mechanically ventilated critically ill patients. It included 12 trials with 530 patients,
most having COPD. Mortality, ventilator-associated pneumonia, duration of ICU
and hospital stay, and total time period of ventilation were significantly reduced
18 Noninvasive Mechanical Ventilation in Difficult Weaning in Critical Care 155
when weaned via NIV compared with invasive weaning. Weaning failure or wean-
ing time were the same, irrespective of mode of weaning. In patients with underly-
ing COPD compared with the general population, impact on the reduction in
mortality and weaning failure was relatively higher.
a. conscious
b. can protect the airway
c. good cough
d. SBT well tolerated
Monitor for the next 4872 h for post- Measure Pplat and PEEP Measure PEEP and PS above PEEP
extubation respiratory failure
Extubation NIV
Gradually decrease the IPAP and EPAP by 12 cmH2O in the daytime every 46 h
Remove the NIV initially in the daytime during feeding and for short durations of time (12 h) intermittently
NIV failure
Intubation and MV Take the patient off from NIV in the daytime, followed by its removal in night
Fig. 18.3 Weaning protocol by Non-invasive ventilation in difficult weaning. SBT Spontaneous breathing trial, Pplat Plateau pressure, PEEP Positive end
expiratory pressure, PS Pressure support, IPAP Inspiratory positive airway pressure, EPAP Expiratory positive airway pressure, NIV Non-invasive ventilation,
MV Mechanical ventilation. *IPAP and EPAP are terminologies of BiPAP (Bilevel positive airway pressure) machine. In ICU ventilators: Pressure support
D. Chaudhry and R. Roshan
above PEEP is equivalent of IPAP; PEEP is equivalent of EPAP. Set PS above PEEP = Pplat or up to 5 cmH2O less than Pplat or pre extubation PS above PEEP.
Set PEEP =pre extubation PEEP
18 Noninvasive Mechanical Ventilation in Difficult Weaning in Critical Care 157
Several benefits occur when extubation is allowed for application of NIV, such as
minimal use of sedation, early removal of the endotracheal tube, decrease in the
incidence of ventilator-associated pneumonia, improved mucociliary clearance
with reduced incidence of sinusitis, better compliance with chest physiotherapy,
and better patient comfort and communication. It improves left ventricular dys-
function and reduces cardiac failure. Also, as the duration of stay in the hospital
may be reduced, it can lead to a reduction in morbidity and is more cost effective.
NIV can be detrimental in patients where excessive secretions are present with poor
cough reflex and suctioning of the airways is needed. Chest physiotherapy and use
of mechanical insufflation/exsufflation devices can help in expectorating the secre-
tions. It can be difficult to manage agitated patients and NIV does not guarantee
mechanical ventilation. The main reasons behind the failure of NIV are the inability
of the patient to cooperate, poor tolerance, patient-ventilator asynchrony, excessive
tracheobronchial secretions, severe strength-load imbalance, hemodynamic altera-
tions, and cardiac arrhythmias. Application of NIV in patients with facial trauma or
deformity, excessive gastrointestinal bleeding, and multi-organ failure can be diffi-
cult and hazardous. Mask discomfort, skin ulceration or irritation, or claustrophobia
can be the additional factors leading to NIV failure. Persistent generation of ade-
quate tidal volume without fatigue of the respiratory pump can be difficult in patients
with critical care illness myopathy and nutritional deficiencies.
Conclusion
Increased workload on respiratory muscle, leading to fatigue, is an important deter-
minant in patients with difficult weaning from a ventilator along with cardiac and
other nutritional and biochemical factors. Ability to protect the airway and ade-
quate consciousness of the patient is vital for the success of NIV. Noninvasive
ventilation can act as a bridge between weaning failure and successful weaning. It
can be a promising tool in critically ill patients with difficult weaning. Current
evidence suggest that it should not be used routinely for patients with weaning
failure. The exception is COPD patients having hypercapnic respiratory failure,
where it can reduce the mortality and prevent ventilator-associated complications.
Early use of NIV may avert post-extubation respiratory failure in a selected group
of patients. In patients with weaning from hypoxemic respiratory failure with high
PaO2/FiO2 ratio of 200250 mmHg at FiO2 of <0.6 and mild to moderate restrictive
mechanics, a trial of positive pressure ventilation can be given, but the outcome
still remains to be determined. In selected patients with neuromuscular diseases, it
can be tried with an eye over delivery of adequate tidal volume and avoidance of
hypoventilation. Proper monitoring of the patient during a trial of NIV in weaning
is mandatory to predict the failure of NIV. Excessive secretions, asynchrony, and
strength-load imbalance are common factors for NIV failure. Clear criteria for
termination of NIV support in weaning still need to be evaluated.
158 D. Chaudhry and R. Roshan
References
1. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir
J. 2007;29(5):103356.
2. Udwadia ZF, Santis GK, Steven MH, et al. Nasal ventilation to facilitate weaning in patients
with chronic respiratory insufficiency. Thorax. 1992;47(9):7158.
3. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized,
controlled trial. Ann Intern Med. 1998;128(9):7218.
4. Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning
failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168(1):706.
5. Vaschetto R, Turucz E, Dellapiazza F, et al. Noninvasive ventilation after early extubation in
patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study.
Intensive Care Med. 2012;38(10):1599606.
6. Reddy VG, Nair MP, Bataclan F. Role of non-invasive ventilation in difficult-to-wean children
with acute neuromuscular disease. Singapore Med J. 2004;45(5):2324.
7. Prasad SB, Chaudhry D, Khanna R. Role of noninvasive ventilation in weaning from mechani-
cal ventilation in patients of chronic obstructive pulmonary disease: an Indian experience.
Indian J Crit Care Med. 2009;13(4):20712.
8. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high-risk patients. Crit Care Med. 2005;33(11):246570.
9. Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure
in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):16470.
10. Ornico SR, Lobo SM, Sanches HS, et al. Noninvasive ventilation immediately after extubation
improves weaning outcome after acute respiratory failure: a randomized controlled trial. Crit
Care. 2013;17(2):R39.
11. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. N Engl J Med. 2004;350(24):245260.
12. Keenan SP, Powers C, McCormack DG, et al. Noninvasive positive pressure ventilation for
postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287(24):
323844.
13. Lin C, Yuh H, Fan H, et al. The efficacy of non invasive ventilation in managing postextubation
respiratory failure: a meta-analysis. Heart Lung. 2014;43(2):99104.
14. Glossop AJ, Shephard N, Bryden DC, et al. Non-invasive ventilation for weaning, avoiding
reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth.
2012;109(3):30514.
15. Burns KE, Adhikari NK, Keenan SP, et al. Use of non-invasive ventilation to wean critically ill
adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574.
Noninvasive Technique of Nasal
Intermittent Pressure Ventilation 19
(NIPPV) in Patients with Chronic
Obstructive Lung Disease After Failure
to Wean from Conventional Intermittent
Positive-Pressure Ventilation (IPPV):
Key Practical Topic and Implications
19.1 Introduction
F.-M. Elkhatib
School of Medicine, American University of Beirut, Beirut, Lebanon
e-mail: fme21@aub.edu.lb
M. Khatib (*)
Department of Anesthesiology, American University of Beirut Medical Center,
P.O. Box: 110236, Beirut 1107-2020, Lebanon
e-mail: mk05@aub.edu.lb
trial when weaning was attempted, NPPV is a good alternative that resulted in better
outcome, fewer complications, and less need for tracheostomy [7]. In a prospective,
randomized and controlled study, Prasad et al. [8] evaluated the effectiveness of
NIPPV as a weaning method in patients with COPD receiving invasive mechanical
ventilation. Thirty COPD patients were randomized to be weaned with either
NIPPV or invasive pressure support ventilation (PSV). In patients who failed a
weaning trial, NIPPV resulted in faster weaning and a decrease in ICU stay, compli-
cations, and mortality [8]. Mishra et al. [9] evaluated the usefulness of NIPPV in
weaning COPD patients from invasive mechanical ventilation in a prospective, ran-
domized, and controlled study. They included 50 patients who failed an initial
weaning trial and subsequently were either extubated to be weaned with NIPPV (25
patients) or remained on invasive mechanical ventilation for further weaning with
PSV. NIPPV resulted in shorter duration of weaning and ventilation, shorter ICU
stay, less incidence of nosocomial pneumonia, and lower ICU mortality [9].
Another factor for the success of NIPPV in weaning COPD patients is the proper
utilization and adjustment of the device providing NIPPV. The mode of NIPPV as
well as other relevant parameters (i.e., inspiratory positive airway pressure (IPAP),
expiratory positive airway pressure (EPAP), back-up rate (RR) as well as fraction of
inspired oxygen (FiO2)) are parameters and variables that need to be adjusted
dynamically according to the patients needs. In general, most COPD patients are
managed with BiPAP in the spontaneous/timed (S/T) mode where the patient is trig-
gering the device except during apneas/hypopneas, where the preset back-up RR
(usually 1214 breaths/min) guarantees adequate ventilatory support [69]. Initial
levels of IPAP (1025 cmH2O) and EPAP (510 cmH2O) are usually decided on
achieving adequate tidal (approximately 56 ml/kg), total respiratory rate less than
25 breaths/min, acceptable arterial blood gas values, and patient tolerance and com-
fort. When managing and adjusting IPAP and EPAP levels during the course of
ventilatory support, clinicians should consider the difference between IPAP and
EPAP as well as their individual values. The difference between IPAP and EPAP
(sometimes referred to as PSV) per se and not the absolute values has a direct effect
on the delivered tidal volume [10]. Increasing the difference between IPAP and
EPAP usually results in an increase in tidal volume and vice versa. EPAP, however,
has a similar physiological effect as positive end-expiratory pressure (PEEP). It has
a direct effect on oxygenation by restoring functional residual capacity and partially
recruits collapsed alveoli. In addition, EPAP can stabilize recruited alveoli and pre-
vent derecruitment [10]. For patients with COPD, EPAP decreases the work of
breathing by minimizing the effect of auto-PEEP that is frequently seen and mani-
fested in COPD patients [10]. With the emerging technologies of NIPPV, clinicians
can provide accurate and adequate FiO2 with the use of oxygen-air blenders incor-
porated in the new BiPAP machines. With the old BiPAP technologies where the
FiO2 was a result of air and oxygen flows mixing, it was always a challenge to pro-
vide adequate, accurate, and stable FiO2 best suited to COPD patients.
In conclusion, NIPPV has been shown to be beneficial in the weaning of patients
with obstructive pulmonary disease. COPD patients who fail initial weaning trials
with conventional weaning techniques as well as COPD patients who are immediately
162 F.-M. Elkhatib and M. Khatib
shifted for weaning with NIPPV show shorter duration of weaning, ICU stay, less
need for tracheostomy, lower incidence of nosocomial pneumonia, lower health-care
costs, and better outcomes with NIPPV. It is essential for the success of NIPPV ther-
apy that clinicians are versed in the use and management of NIPPV.
References
1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med.
2013;369(22):212636.
2. Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive ventilation as a weaning strategy
for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review.
CMAJ. 2014;186(3):E11222.
3. Khilnani GC, Banga A. Noninvasive ventilation in patients with chronic obstructive airway
disease. Int J Chron Obstruct Pulmon Dis. 2008;3(3):3517.
4. Ferrer M, Esquinas A, Aranciba F, et al. Noninvasive ventilation during persistent weaning
failure. Am J Respir Crit Care Med. 2003;168:706.
5. Burns KE, Adhikari NK, Meade MO. A meta-analysis of noninvasive weaning to facilitate
liberation from mechanical ventilation. Can J Anaesth. 2006;53:30515.
6. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized,
controlled trial. Ann Intern Med. 1998;128:7218.
7. Trevisan C, Vieira S; The Research Group in Mechanical Ventilation Weaning. Noninvasive
mechanical ventilation may be useful in treating patients who fail weaning from invasive
mechanical ventilation: a randomized clinical trial. Crit Care. 2008;12:R518.
8. Prasad S, Chaudhry D, Khanna R. Role of noninvasive ventilation in weaning from mechanical
ventilation in patients of chronic obstructive pulmonary disease: an Indian experience. Indian
J Crit Care Med. 2009;13:20712.
9. Mishra M, Chaudhri S, Tripathi V, et al. Weaning of mechanically ventilated chronic obstruc-
tive pulmonary disease patients by using non-invasive positive pressure ventilation: a prospec-
tive study. Lung India. 2014;31:12733.
10. Hess DR. Noninvasive ventilation for acute respiratory failure. Respir Care. 2013;58(6):
95072.
Part III
Post Extubation Failure and Use of Non
Invasive Mechanical Ventilation
Use of Noninvasive Ventilation
to Facilitate Weaning from 20
Mechanical Ventilation
Scott K. Epstein
20.1 Introduction
S.K. Epstein, MD
Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center,
Tufts University School of Medicine, Boston, MA, USA
e-mail: Scott.Epstein@tufts.edu
Patients who are intubated and mechanically ventilated for acute respiratory failure
are at increased risk for complications, including upper airway injury, respiratory
muscle weakness, gastrointestinal bleeding, thromboembolism, sinusitis, and
ventilator-associated pneumonia. The latter is particularly important given its asso-
ciation with increased morbidity and possibly increased mortality. The risk for com-
plications and the risk of mortality rise with increasing duration of mechanical
ventilation. Needlessly delaying extubation in a patient who otherwise seems to be
ready also causes harm, as such patients experience increased risk for pneumonia,
length of stay, and mortality compared with patients expeditiously extubated. On
the other hand, numerous studies have found that patients who pass an SBT and
undergo planned extubation but require reintubation (extubation failure) have
increased risk for complications, prolonged hospital stay, and significantly increased
mortality [7].
Therefore, an essential task for ICU clinicians is trying to wean and successfully
extubate patients as expeditiously (and safely) as possible. A series of studies pub-
lished in the 1990s indicated that between 15 and 35 % of patients mechanically
ventilated with acute respiratory failure fail an initial trial of spontaneous breathing
and will require a more prolonged weaning process. These studies, for the most
part, relied on clinician intuition for determining readiness for weaning. More
recently, investigators have noted that, depending on the patient population studied,
4070 % of patients do not tolerate their initial SBT. This observation is likely
related to the more aggressive screening criteria used to identify the earliest time
when spontaneous breathing can be undertaken.
Given the similarities between the pathophysiology of weaning failure and that
of acute respiratory failure, NIV may have a role to play in facilitating weaning.
As with acute respiratory failure, weaning failure is often characterized by an
imbalance between respiratory muscle capacity and the respiratory load con-
fronted by those muscles (i.e., the work of breathing). The latter can result from
increased resistive or elastic work of breathing, the effects of intrinsic positive
end-expiratory pressure (PEEP), and abnormal gas exchange. When used to treat
patients with acute respiratory failure, NIV is capable of reducing the work of
breathing, providing respiratory muscle unloading (including offsetting the
effects of intrinsic PEEP), improving alveolar ventilation, and increasing oxygen-
ation. In so doing, NIV decreases the risk for intubation, reduces important com-
plications such as pneumonia, and improves survival. There is increasing
recognition that weaning failure may result from cardiovascular abnormalities
including ischemia, increased preload and afterload resulting from the negative
intrathoracic pressure that occurs during spontaneous breathing, and an inability
to adequately increase cardiac output to meet the metabolic demands of the
SBT. As demonstrated in studies of acute cardiogenic pulmonary edema, NIV can
counteract these factors and result in improved cardiac performance and decreased
cardiogenic pulmonary edema.
20 Use of Noninvasive Ventilation to Facilitate Weaning from Mechanical Ventilation 167
By exchanging the endotracheal tube for a noninvasive interface, NIV may have
additional benefits. With the removal of the endotracheal tube, any increased work
of breathing imposed by the artificial airway is eliminated. Removal of the endotra-
cheal tube improves patient comfort and the ability to communicate, reduces the
need for sedation, and restores the capacity for effective cough; all factors that could
contribute to successful weaning and extubation.
Based on the rationale above, NIV has the potential to facilitate the weaning process
in patients who are ready for spontaneous breathing but who cannot yet pass a
SBT. Observational studies, reported in the 1990s, indicated the potential of NIV to
promote successful weaning. Udwadia et al. [8] reported that 82 % of 22 difficult to
wean patients (mean duration of ventilation, 31 days), with various causes for respi-
ratory failure, could be successfully liberated from mechanical ventilation by the
use of nasal NIV. Similarly, Restrick and colleagues [9] found the use of NIV
resulted in 93 % weaning success in 14 weaning failure patients, including 8 with
COPD. In a third study, 13 of 15 patients were successfully extubated to NIV after
satisfying criteria not typically associated with satisfactory completion of an SBT
(PaO2 40 mmHg on a fraction of inspired oxygen (FiO2) of 0.21, PaCO2 55 mmHg,
pH >7.32, respiratory rate 40 breaths/min, frequency/tidal volume ratio of 190
breaths/l/min) [10].
Over the last two decades, a number of randomized controlled trials have
addressed whether NIV, when compared with invasive weaning with the endotra-
cheal tube in place, can successfully facilitate weaning in patients who are not
tolerating SBTs.
Nava and colleagues [11] randomized 50 COPD patients (40 % of whom had
failed NIV prior to intubation) with acute-on-chronic respiratory failure who had
failed a 2-h SBT to weaning with the endotracheal tube in place (using pressure
support) or direct extubation to NIV delivered with an oronasal mask. Patients
randomized to NIV experienced shorter time on mechanical ventilation,
decreased ICU stay, higher likelihood of successful weaning, and improved
60-day survival.
Using a similar study design, Girault et al. [12] randomized 33 patients with
acute-on-chronic respiratory failure and found that NIV reduced the duration of
intubation while other outcomes were unchanged. Interestingly, total mechanical
ventilation time (time intubated plus time on NIV) was more than a week greater
in the NIV group.
168 S.K. Epstein
To further analyze these randomized controlled trials, Burns and colleagues [20]
have conducted a series of systematic reviews, the most recent of which consid-
ered 16 trials (including one with a quasi-randomized approach), totaling 994
patients, who had acute respiratory failure requiring invasive mechanical ventila-
tion for a minimum of 24 h. The majority of patients in these studies had COPD;
of the 16 trials, 9 were restricted to patients with COPD and 7 studied mixed
patient populations. This analysis included the nine trials discussed above in addi-
tion to two abstracts and four investigations published in Chinese. Three of the
latter and one additional study differed significantly from the other studies ana-
lyzed in their focus on COPD patients with pneumonia. Importantly, in these stud-
ies the point of randomization was when the patient met criteria indicating control
of infection rather than after the patient had failed one or more SBTs. Four of
these additional studies also employed an SIMV weaning strategy (with or with-
out pressure support) for those in the invasive groups while NIV was delivered
using pressure mode bi-level ventilation or pressure support. In this instance, any
superiority demonstrated by the NIV groups could be attributable to the approach
to weaning (e.g., a reduction of pressure or bi-level support) rather than factors
related to the removal of the endotracheal tube or the other potential beneficial
effects of NIV.
When all 16 trials were analyzed, Burns et al. [20] found that, compared with
invasive weaning, patients weaned with NIV had reduced mortality, greater wean-
ing success, less ventilator-associated pneumonia, shorter length of stay in the ICU
and in the hospital, less need for tracheostomy, fewer episodes of reintubation, and
a shorter duration of mechanical ventilation. The reduction in mortality experienced
by patients weaning with NIV was greatest in trials that primarily or exclusively
enrolled patients with COPD.
The individual studies discussed above and the systemic review indicate that NIV
can successfully facilitate weaning, principally in patients with COPD. None of the
randomized controlled studies found NIV to be inferior to weaning with the endo-
tracheal tube in place. The reason for NIVs benefit may be attributable to the asso-
ciated reduction in complications, especially pneumonia, or the reduced need for
sedation. NIV may also improve the capacity of clinicians to detect the patients
ability to breathe spontaneously. By allowing the endotracheal tube to be removed,
any excess work of breathing imposed by that tube is alleviated. Psychological dis-
tress caused by tube discomfort, which may be misinterpreted as intolerance for
spontaneous breathing, can be alleviated by tube removal. In these cases, NIV does
not directly facilitate weaning; rather, it allows removal of the endotracheal tube
that was the proximate cause of weaning failure. The results of the second Girault
study would tend to support this hypothesis.
170 S.K. Epstein
References
1. Epstein SK. Noninvasive ventilation to shorten the duration of mechanical ventilation. Respir
Care. 2009;54:198208.
2. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. N Engl J Med. 2004;350:245260.
3. Hilbert G, Gruson D, Portel L, et al. Noninvasive pressure support ventilation in COPD
patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J.
1998;11:134953.
4. Jiang JS, Kao SJ, Wang SN. Effect of early application of biphasic positive airway pressure on
the outcome of extubation in ventilator weaning. Respirology. 1999;4:1615.
5. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high-risk patients. Crit Care Med. 2005;33:246570.
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in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173:16470.
7. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical
ventilation. Chest. 1997;112:18692.
8. Udwadia ZF, Santis GK, Steven MH, Simonds AK. Nasal ventilation to facilitate weaning in
patients with chronic respiratory insufficiency. Thorax. 1992;47:7158.
20 Use of Noninvasive Ventilation to Facilitate Weaning from Mechanical Ventilation 171
9. Restrick LJ, Scott AD, Ward EM, et al. Nasal intermittent positive-pressure ventilation in
weaning intubated patients with chronic respiratory disease from assisted intermittent,
positive-pressure ventilation. Respir Med. 1993;87:199204.
10. Kilger E, Briegel J, Haller M, et al. Effects of noninvasive positive pressure ventilatory support
in non-COPD patients with acute respiratory insufficiency after early extubation. Intensive
Care Med. 1999;25:137480.
11. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized,
controlled trial. Ann Intern Med. 1998;128:7218.
12. Girault C, Daudenthun I, Chevron V, et al. Noninvasive ventilation as a systematic extubation
and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized con-
trolled study. Am J Respir Crit Care Med. 1999;160:8692.
13. Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning
failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168:706.
14. Vaschetto R, Turucz E, Dellapiazza F, et al. Noninvasive ventilation after early extubation in
patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study.
Intensive Care Med. 2012;38:1599606.
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acute-on-chronic respiratory failure due to COPD. Egypt J Chest Dis Tuberc. 2012;61:8491.
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cal ventilation in patients of chronic obstructive pulmonary disease: an Indian experience.
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17. Trevisan CE, Vieira SR. Noninvasive mechanical ventilation may be useful in treating patients
who fail weaning from invasive mechanical ventilation: a randomized clinical trial. Crit Care.
2008;12:R51.
18. Tawfeek MM, Ali-Elnabtity AM. Noninvasive proportional assist ventilation may be useful in
weaning patients who failed a spontaneous breathing trial. Egypt J Anaesth. 2012;28:8994.
19. Girault C, Bubenheim M, Abroug F, et al. Noninvasive ventilation and weaning in patients
with chronic hypercapnic respiratory failure. Am J Respir Crit Care Med. 2011;184:6729.
20. Burns KEA, Meade MO, Premji A, Adhikari NKJ. Noninvasive ventilation as a weaning strat-
egy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review.
CMAJ. 2014;186:E11222.
Noninvasive Positive-Pressure
Ventilation in the Management 21
of Respiratory Distress in Cardiac
Diseases
21.1 Introduction
21.2 Discussion
Acute heart failure exacerbation is one of the main causes of hospitalization in the
United States, responsible for more than one million hospital admissions per year.
At least 25 % of these patients present with ACPE and a significant portion of those
require some form of ventilatory support [2].
There is strong evidence to support the use of both CPAP and BPAP in the set-
ting of respiratory distress secondary to ACPE [3, 4]. Various guidelines recom-
mend a trial of NIPPV in these patients [2]. Gray et al. [5] stated, CPAP and BPAP
safely provide earlier improvement and resolution of breathlessness, respiratory
distress, and metabolic abnormalities in severe ACPE. We recommend that nonin-
vasive ventilation (CPAP or NIPPV) should be considered as adjunctive therapy in
patients with severe ACPE in the presence of severe respiratory distress or when
there is a failure to improve with pharmacological therapy. Other meta-analyses
have found that, although neither method is superior in terms of mortality when
compared against each other, BPAP is associated with more rapid resolution of
dyspnea and better oxygenation than CPAP or standard oxygen therapy with nasal
cannula [2].
The safety and efficacy of NIPPV to limit the need for ETI is well documented.
However, many, though not all, studies fail to show a decrease in 30-day mortality
among all manner of NIV compared with ETI. However, a recent meta-analysis sug-
gests that the failure of more studies to show improved 30-day mortality is a conse-
quence of their low power to detect this outcome [3]. Of note, NIV has been shown
to significantly decrease the risk of mortality when compared with medical manage-
ment alone in the form of standard oxygen therapy [3]. Importantly, historical reports
of an increased risk of acute myocardial infarction with NIPPV use in the CHF and
ACPE populations has not been shown in multiple study populations [2, 3, 6].
21 Noninvasive Positive-Pressure Ventilation in Cardiac Diseases 175
CPAP should be started at 1015 cmH2O and titrated by 5 cmH2O every 5 min
based on the patients clinical status. If BPAP is selected, inspiratory positive airway
pressure (IPAP)/expiratory positive airway pressure (EPAP) should be started at
10/5 and titrated as for CPAP. Arterial blood gas monitoring, although not abso-
lutely required in all cases, should be performed for any patient who does not show
appropriate clinical improvement after ~10 min of therapy. A rising PaCO2 after
treatment has begun should alert the physician that the patient may be failing NIPPV
and is in danger of imminent respiratory arrest. More aggressive treatment with
ventilatory support in the form of BPAP (if CPAP had been used) or ETI (if BPAP
had been attempted) must be urgently considered in these cases. Continuous end-
tidal CO2 monitoring may also be used where available. In all cases, close monitor-
ing of patients is a necessity and transfer of these patients to a monitored unit is the
norm [5].
Major surgical procedures and the associated use of general anesthesia induce dra-
matic alterations in a patients respiratory function. This is, of course, particularly
true for surgery involving the thorax and upper abdomen. Physiologic stressors that
can develop include a significant decrease in venous return, cardiac output, and
pulmonary volumes, and can create significant atelectasis and shunt. Importantly,
these stressors are not relieved merely by the completion of the surgical procedure.
They may, in fact, be prolonged or even worsened secondary to postoperative pain
and diaphragmatic dysfunction. Thus, operative and postoperative patients are at
significant risk for developing acute respiratory failure even after an otherwise suc-
cessful surgery [7].
The data for NIPPV use in the cardiac surgical patient is far less robust than that
seen in ACPE/CHF [7]. Pinilla et al. [8] report that 4090 % of patients undergoing
cardiac surgery have pulmonary complications. Other investigators have found
corresponding rates of increased morbidity in any surgery involving cardiopulmo-
nary bypass [9].
Overall, the evidence seems to support NIPPV being used for its benefit in
improving symptomatic hypoxia and mild hypercapnia as well as for its utility in
avoiding the need for ETI [7]. In one prospective cohort of 85 patients, postopera-
tive NIPPV used to prevent or treat postoperative acute respiratory failure was use-
ful when applied in the cardiac surgical ward with 83/85 patients discharged from
hospital without requiring a higher level of care [10]. Another study in CABG
patients showed that the prophylactic use of NIPPV for 30 min after extubation
improved oxygenation in the immediate postoperative period of heart surgery com-
pared with nasal oxygen through 120 min [9].
In a large meta-analysis, CPAP reduced the incidence of pulmonary complica-
tions such as hypoxemia, pneumonia, and need for ETI compared with standard
therapy with oxygen. However, this study did not find a decrease in either intensive
care unit (ICU) or hospital length of stay. When NIPPV was studied for prophylac-
tic use in patients with evidence of radiologic atelectasis but who were otherwise
176 A.L. Miller and B. Mina
Conclusion
CPAP and BPAP are the two most commonly used modes of NIPPV. CPAP
applies a constant pressure to a spontaneously breathing patient and is physio-
logically equivalent to constant positive end-expiratory pressure. BPAP delivers
two pressure levels according to the respiratory cycle and improves ventilation,
oxygenation, and alveolar recruitment. BPAP provides both IPAP and EPAP. The
difference between these pressures is responsible for augmenting the volume of
air displaced during the respiratory cycle. Noninvasive positive airway pressure
ventilators differ among manufactures but can provide modes nearly identical to
standard ventilators used for ETI in the ICU.
Both CPAP and BPAP have been used in ACPE. High-quality data over the
last 30 years suggest that both CPAP and BPAP are superior to standard oxygen
21 Noninvasive Positive-Pressure Ventilation in Cardiac Diseases 177
therapy in improving gas exchange, patient symptoms, and reducing the need for
ETI as well as mortality in the CHF/ACPE population. Mortality benefit has not
been shown in the cardiothoracic surgical patient, although the available studies
are generally underpowered to detect this outcome. While trends exist, the supe-
riority of BPAP over CPAP for mortality has also not been conclusively shown,
even after numerous studies and meta-analyses. However, BPAP may show faster
resolution of patient symptoms and the above markers than CPAP in all of the
above populations.
Although cardiac surgery is associated with major alteration of lung function,
relatively few studies performed have evaluated the benefits of NIPPV in this
population. Notably, most of these studies examined the immediate postopera-
tive patient in the ICU soon after endotracheal extubation. While there is little
high-quality evidence examining the use of NIV in the postsurgical cardiac
patient outside of the ICU, this does not take away from its possible use and
likely benefits. However, in this setting, great care must be taken in proper patient
selection and disposition.
Before attempting use of NIV, severity of respiratory compromise and risk of
failure must be examined. The weight of evidence and long-term clinical experi-
ence make clear that treatment failure is associated with emergent need for ETI
and increased mortality. Prior to its selection as a treatment modality, thought
should be given to the patients degree of hypoxemia, hypercarbia, other comor-
bidities, as well as their degree of cooperativeness and current mental status; a
patient should be able to call for help if needed.
Used appropriately, NIPPV, in all its modalities, is a major tool in our arma-
mentarium. With more data helping to further define its benefits, it seems clear
that the populations for whom its use has shown evidenced-based utility will
only continue to grow.
References
1. Reis MS, Sampaio LMM, Lacerda D, et al. Acute effects of different levels of continuous posi-
tive airway pressure on cardiac autonomic modulation in chronic heart failure and chronic
obstructive pulmonary disease. Arch Med Sci. 2010;6(5):71927.
2. Mariani J, Macchia A, Belziti C, et al. Noninvasive ventilation in acute cardiogenic pulmonary
edema: a meta-analysis of randomized controlled trials. J Card Fail. 2011;17(10):8509.
3. Winck L, Azevedo F, Costa-Pereira A, et al. Efficacy and safety of non invasive ventilation in
the treatment of acute cardiogenic pulmonary edema a systematic review and meta-analysis.
Crit Care. 2006;10:R69.
4. Pang P, Masood Z. Airway management and assessment of dyspnea in emergency department
patients with acute heart failure. Curr Emerg Hosp Med Rep. 2013;1:1225.
5. Gray AJ, Goodacre S, Newby DE, et al. A multicentre randomised controlled trial of the use
of continuous positive airway pressure and non-invasive positive pressure ventilation in the
early treatment of patients presenting to the emergency department with severe acute cardio-
genic pulmonary oedema: the 3CPO trial. Health Technol Assess. 2009;13(33):1106.
6. Masip J, Roque M, Sanches B, et al. Noninvasive ventilation in acute cardiogenic pulmonary
edema systematic review and meta-analysis. JAMA. 2005;294(24):312430.
7. Cabrini L, Zangrillo A. Non-invasive ventilation after cardiac surgery. HSR Proc Intensive
Care Cardiovasc Anesth. 2011;3(1):57.
8. Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients:
a systematic review. Intensive Care Med. 2011;37:91829.
9. Lopes CR, Brandao CMdA, Nozawa E, et al. Benefits of non-invasive ventilation after extuba-
tion in the postoperative period of heart surgery. Rev Bras Cir Cardiovasc.
2008;23(3):34450.
10. Olper L, Cabrini L, Landomi G, et al. Non-invasive ventilation after cardiac surgery outside
the Intensive Care Unit. Minerva Anestesiol. 2010;77(1):4045.
11. Cabrini L, Plumari VP, Nobile L, et al. Non-invasive ventilation in cardiac surgery: a concise
review. Heart Lung Vessels. 2013;5(3):13741.
12. Guarracino F, Cabrini L, Baldassarri R, et al. Non-invasive ventilation-aided transoesophageal
echocardiography in high-risk patients: a pilot study. Eur J Echocardiogr. 2010;11:5546.
Postoperative Continuous Positive
Airway Pressure (CPAP) 22
Elisabet Guerra Hernndez
and Zoraya Hussein Dib Gonzlez
Abbreviations
22.1 Introduction
The combination of surgery and anesthesia can be associated with a number of seri-
ous complications that may impair patient recovery. In particular, postoperative pul-
monary complications (PPCs), including respiratory complications such as
atelectasis, pneumonia, and reintubation, are the leading cause of prolonged hospi-
tal stay, morbidity, and mortality in surgical patients [1]. PPCs are common, serious,
and expensive. Health-care costs associated with the treatment of PPCs are 50 %
greater than costs for treating postoperative cardiac complications. The incidence of
PPCs varies depending on the clinical treatment setting, the kind of surgery studied,
and the definition of PPC used. For all these reasons, incidence rates vary from 2 to
40 % [2, 3]. The actual incidence of important PPCs seems to be 25 % in patients
undergoing thoracic or upper-abdominal surgery.
In a general sense, a PPC is any event that occurs in the postoperative period that
produces physiologic dysfunction or clinical disease. A PPC may be diagnosed
CPAP might have a potential role in reducing PPCs and facilitating lung re-
expansion after anesthesia and surgery by constant positive airway pressure during
inspiration and expiration. The application of a CPAP mask increases end-expiratory
lung volume without deep breathing and might be associated with less pain and
discomfort, allow alveolar recruitment, improve oxygenation and the ventilation-
perfusion relation, reduce the work of the respiratory muscles and the diaphragm,
provide dyspnea relief, and permit respiratory system muscle unloading.
22 Postoperative Continuous Positive Airway Pressure (CPAP) 181
Conclusion
The application of a CPAP mask increases end-expiratory lung volume without
deep breathing and might be associated with less pain and discomfort. It allows
alveolar recruitment, improves oxygenation and the ventilation-perfusion rela-
tion, reduces the work of the respiratory muscles and the diaphragm, provides
dyspnea relief, and permits respiratory system muscle unloading.
Knowledge of the risk factors of PPCs is important for prevention, treatment,
and choosing the most appropriate method of the noninvasive mechanical
ventilation.
References
1. Ireland CJ, Chapman TM, Mathew SF, et al. Continuous positive airway pressure (CPAP) dur-
ing the postoperative period for prevention of postoperative morbidity and mortality following
major abdominal surgery. Cochrane Database Syst Rev. 2014;(8):CD008930.
2. Branson RD. The scientific basis for postoperative respiratory care. Respir Care.
2013;58(11):197484.
3. Smetana GW, Lawrence VA, Cornell JE; American College of Physicians. Preoperative pul-
monary risk stratification for noncardiothoracic surgery: systematic review for the American
College of Physicians. Ann Intern Med. 2006;144(8):58195.
4. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal
surgery. Chest. 1997;111(3):56471.
5. Smetana GW. Postoperative pulmonary complications: an update on risk assessment and
reduction. Cleve Clin J Med. 2009;76 Suppl 4:S605.
6. Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunction: pathophys-
iology and preventive strategies. Anesthesiology. 2013;118(4):96178.
7. Canet J, Gallart L. Predicting postoperative pulmonary complications in the general popula-
tion. Curr Opin Anaesthesiol. 2013;26(2):10715.
8. Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce periopera-
tive pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline
from the American College of Physicians. Ann Intern Med. 2006;144(8):57580.
9. Tusman G, Bohm SH, Warner DO, et al. Atelectasis and perioperative pulmonary complica-
tions in high-risk patients. Curr Opin Anaesthesiol. 2012;25(1):110.
10. Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of
postoperative hypoxemia: a randomized controlled trial. JAMA. 2005;293(5):58995.
11. Zarbock A, Mueller E, Netzer S, et al. Prophylactic nasal continuous positive airway pressure
following cardiac surgery protects from postoperative pulmonary complications: a prospec-
tive, randomized, controlled trial in 500 patients. Chest. 2009;135(5):12529.
12. Barbagallo M, Ortu A, Spadini E, et al. Prophylactic use of helmet CPAP after pulmonary
lobectomy: a prospective randomized controlled study. Respir Care. 2012;57(9):141824.
13. Kindgen-Milles D, Muller E, Buhl R, et al. Nasal-continuous positive airway pressure reduces
pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery.
Chest. 2005;128(2):8218.
Noninvasive Ventilation for Weaning,
Avoiding Reintubation After Extubation, 23
and in the Postoperative Period
Alastair J. Glossop
23.1 Introduction
surgical patients [9]. This population of recently extubated patients suffers increased
morbidity and mortality should they develop respiratory failure and require reintuba-
tion, and may therefore benefit from the use of NIV to prevent this progression. Several
studies examining the use of NIV in these situations have been either inconclusive or
produced conflicting results, and debate continues within the critical care community
regarding the optimal use of NIV following extubation.
This chapter reviews the evidence for use of NIV in the following groups of
patients who have recently been extubated:
Patients weaning from MV but who are not suitable for extubation
Patients who have been recently extubated in the ICU
Patients who have been extubated following major surgery
number of studies suggest that in COPD patients NIV weaning will reduce rates of
VAP, ICU length of stay, and mortality. Therefore, the use of NIV weaning should
be considered in all patients with known COPD who are ready to wean from MV
but not suitable for extubation.
Extubation of ICU patients who have received MV for a period of time carries the
risk of extubation failure and the need for further MV. Although the reported rate of
extubation failure in the literature varies, it may be as high as 19 % [13]. It is also
widely acknowledged that failing an extubation is associated with worse outcomes
and increased risk of morbidity and mortality, although this may be a result of sicker
patients with more comorbidities having a higher risk of extubation failure rather
than a direct effect of reintubation per se. The use of NIV in recently extubated
patients is an attractive treatment option, as it has the potential to provide ongoing
respiratory support to recently extubated patients without the attendant risks of
endotracheal intubation and MV, and several studies have examined the use of NIV
in this setting.
NIV has been assessed as a preventative strategy in ventilated ICU patients who
have risk factors for post-extubation failure, such as age greater than 65, poor
cough, cardiac and respiratory comorbidity, and hypercapnia (while ventilated or
preexisting). The application of NIV immediately post-extubation for periods of
up to 48 h was demonstrated to reduce reintubation rates and mortality in one large
RCT [8]. NIV used prophylactically has also been demonstrated to reduce the inci-
dence of respiratory failure post-extubation when used for up to 24 h post-extuba-
tion [14], and a later study of 106 patients with chronic respiratory disease
demonstrated that prophylactic NIV use for 24 h following extubation reduced
respiratory failure and 90-day mortality when compared with standard medical
therapy [15].
There have been several RCTs examining the use of NIV as a rescue treatment
for post-extubation respiratory distress. Early work suggested that application of
NIV to patients with premorbid cardiorespiratory disease who developed respira-
tory failure post-extubation did not reduce reintubation rates, duration of MV
(mechanical ventilation), hospital mortality, or length of stay compared with
standard therapy [16]. A subsequent multicenter RCT reported that patients who
had been extubated following a successful SBT but then developed post-extuba-
tion respiratory failure had an increased ICU mortality if then treated with NIV
compared with standard medical therapy [17]. There has been some criticism of
this trial, and it is important to note that the patients who failed on NIV and went
on to require intubation had received long periods of ineffective NIV before rein-
tubation on average 9 h longer than the controls which is likely to have con-
tributed to their worse outcomes. Additionally, post hoc analysis of patients with
COPD in this study suggested that use of NIV may still be warranted if used
judiciously in post-extubation respiratory distress. However, in general, the onset
186 A.J. Glossop
NPPV may reduce both reintubation rates and mortality in patients who have under-
gone lung resection surgery and develop ARF in the postoperative period [24].
A recent meta-analysis of major RCTs looking at NIV as an intervention in a
mixed population of postoperative patients demonstrated an improvement in hospi-
tal mortality, rates of VAP, and reintubation rates in patients receiving NIV com-
pared with standard medical therapy, suggesting a benefit if NIV is applied to
high-risk patients in the immediate postoperative period [25].
The use of NIV following major surgery is associated with a reduction in rates of
postoperative complications, although many of the trials utilize differing regimes
for varying periods of time, and thus debate continues as to timing, duration, and
modality of NIV that should be used. Although reductions in reintubation rates and
respiratory complications have frequently been demonstrated in the literature, there
is less evidence as to the impact of NIV use on patient mortality. Additionally, the
evidence supports using NIV in selected high-risk surgical populations and, as such,
currently we are unable to extrapolate these findings to the wider surgical
population.
Although some conflict within the literature exists, the use of NIV for weaning has
been found to reduce mortality, rates of VAP, and ICU and hospital length of stay
when compared with conventional invasive weaning methods in a large Cochrane
review of trials. The benefits are more convincing in patients with COPD, in whom
the potential benefits of using NIV in many different clinical settings has been dem-
onstrated, and thus NIV weaning should be considered in all patients with COPD
who are ready to start the process of weaning from MV.
The area of use of NIV in post-ICU extubation remains a contentious area, with
earlier prophylactic use seemingly preferential to treatment of established respi-
ratory failure in this group of patients. There is also no consensus regarding the
optimal time period to provide NIV following extubation, although a stronger signal
for beneficial effects with NIV was seen in a study that utilized NIV prophylacti-
cally for 48 h post-extubation, suggesting that this longer time period may be
optimal.
Studies of NIV use in postsurgical patients have suggested that NIV may be
beneficial in treating and preventing respiratory failure in patients who have recently
undergone major surgery, but they have been very specific in the patient populations
studied and provided little mortality data. A recent meta-analysis has demonstrated
the benefits of NIV in reducing morbidity and mortality in postsurgical patients
pooled from several different surgical specialties, and provided evidence to support
the theory that NIV is perhaps underutilized in postoperative populations. Future
work should focus on determining the optimal regime in terms of modality, timing,
and duration of NIV postoperatively and also address the impact of NIV on mortal-
ity in high-risk surgical patients.
188 A.J. Glossop
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pneumonia in a large US database. Chest. 2002;122:211521.
2. Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation
on outcome for patients failing extubation. Am J Respir Crit Care Med. 1998;158:48993.
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respiratory failure. Thorax. 2002;57:192211.
4. Keenan SP, Kernerman PD, Cook DJ, Martin CM, McCormack D, Sibbald WJ. Effect of non-
invasive positive pressure ventilation on mortality in patients admitted with acute respiratory
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5. Winck JC, Azevedo LF, Costa-Pereira A, Antonelli M, Wyatt JC. Efficacy and safety of non-
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6. Kilger E, Briegel J, Haller M, et al. Noninvasive ventilation after lung transplantation. Med
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7. Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning fail-
ure: a randomized controlled trial. [see comment]. Am J Respir Crit Care Med. 2003;168:706.
8. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high-risk patients*. Crit Care Med. 2005;33:246570.
9. Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of
postoperative hypoxemia: a randomized controlled trial. JAMA. 2005;293:58995.
10. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized,
controlled trial. Ann Intern Med. 1998;128:7218.
11. Girault C, Bubenheim M, Abroug F, et al. Noninvasive ventilation and weaning in patients
with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit
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15. Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after extubation in hypercap-
nic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009;374:
10828.
16. Keenan SP. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a
randomized controlled trial. JAMA J Am Med Assoc. 2002;287:323844.
17. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. [see comment]. N Engl J Med. 2004;350:245260.
18. Lin C, Yu H, Fan H, Li Z. The efficacy of noninvasive ventilation in managing postextubation
respiratory failure: a meta-analysis. Heart Lung J Crit Care. 2014;43:99104.
19. Michelet P, DJourno XB, Seinaye F, Forel JM, Papazian L, Thomas P. Non-invasive ventila-
tion for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg.
2009;96:5460.
20. Neligan PJ, Malhotra G, Fraser M, et al. Continuous positive airway pressure via the
Boussignac system immediately after extubation improves lung function in morbidly obese
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2009;110:87884.
23 NIV for Weaning, Avoiding Reitubation and the Post Operative Period 189
Since the early days of cardiac surgery, postoperative pulmonary dysfunction has
been the subject of a considerable amount of experimental and clinical research
because it affects virtually every treated patient [1]. Both anomalies in gas exchange
and lung mechanics contribute to the expression of postoperative respiratory dys-
function, which is clinically evidenced by increased work of breathing and respira-
tory rate, shallow respirations, ineffective cough, hypoxemia, and changes in chest
radiographs. Widening of the alveolar-arterial oxygen gradient, increased lung
microvascular permeability, and increased pulmonary vascular resistance and shunt
fraction are commonly observed after cardiac surgical procedures. Accordingly,
reductions in vital capacity, functional residual capacity, and static as well as
dynamic lung compliance are usually evident. Pathogenesis of these derangements
has been extensively studied [2, 3]. It stems from a complex interplay between
patients baseline end organ function; the type, extent, and urgency of underlying
cardiovascular pathology; and the distinct features of this surgical setting. This
operative approach encompasses general anesthesia, peculiar surgical trauma
(median sternotomy, pleural dissection), cardiopulmonary bypass, topical cooling
for myocardial protection (which may cause phrenic nerve dysfunction),
transfusion of blood products, and postoperative pain, which individually and syn-
ergistically affect respiratory performance.
Despite these data, the continuum between pulmonary dysfunction and overt com-
plications has been poorly characterized. Because such complications considerably
jeopardize outcomes and imply increased health-care costs and resource utilization,
their prevention, early identification, and effective treatment is highly advisable.
Preventive measures have been authoritatively described elsewhere [4, 5].
Refinements of operative techniques and cardiopulmonary bypass and mechanical
ventilation strategies, meticulous application of ventilator care bundles, rational
and early use of antibiotics, early extubation, and judicious blood management have
all been advocated for a thorough preventive management algorithm. Acute respira-
tory distress syndrome, transfusion-related lung injury, and ventilation associated
pneumonia, though infrequent, are the most dreaded of these complications because
of inherent dismal outcomes.
Weaning from mechanical ventilation is essential to the success of the cardiac surgi-
cal procedure and a key step toward recovery and rehabilitation. The combination of
several respiratory and cardiovascular parameters is known to improve the accuracy
of prediction of successful weaning from ventilator support. Nevertheless, the same
parameters perform poorly in the prediction of late extubation failure. Today, pul-
monary complications account for 54.9 % of intensive care unit (ICU) recidivism
and reintubation is needed in at least 6.6 % of the patients [6]. Causes of post-
extubation failure include both airway (such as upper-airway obstruction, aspira-
tions, and excess pulmonary secretions) and non-airway-related factors (including
cardiogenic dysfunction). Pathophysiology of post-extubation failure usually
includes two distinct pathways: (1) alveolar hypoventilation and ventilation-
perfusion mismatch, due to increased respiratory rate and decreased tidal volume,
and (2) a failure to increase cardiac output, which leads to an enhanced tissue oxy-
gen extraction with critically low mixed venous oxygen saturation [7]. Reintubation
prolongs the duration of invasive mechanical ventilation and increases the need for
tracheostomy. Loss of airway-protecting mechanisms, airway trauma, intense seda-
tion, and the potential for aspiration are some of the drawbacks of invasive ventila-
tion that predispose to the development of ventilator-associated pneumonia and
extend the length of the ICU and hospital stay, implying higher morbidity and mor-
tality. A pivotal study by Hein and coworkers [8] on a contemporary series of car-
diac surgery patients disclosed that hospital mortality in the event of respiratory
failure is as high as 38 % and the chance of 3-year survival is lower than 45 %.
24 Noninvasive Mechanical Ventilation in Cardiac Surgery 193
Actually, NIV might be implemented according to two different strategies: (1) pro-
phylactically, in patients who are deemed at increased risk of developing respiratory
failure, and (2) curative, as an alternative to invasive reintubation, in the event of
overt post-extubation failure. The role of NIV in the surgical post-extubation setting
is under active investigation. A meta-analysis involving patients treated after differ-
ent types of major surgical procedures demonstrated that a judicious usage in
selected patients effectively reduces both morbidity, namely reintubation and pneu-
monia, and ICU stay. This review added to the currently available literature under-
scoring that earlier prophylactic use seems more effective than treatment of
established respiratory failure. Optimal timing and duration of NIV after extubation
is still uncertain. Although CPAP is being used more prominently after operation,
little is known about the individual merits of CPAP against NPPV [11].
Despite an evident widespread adoption, there are few data on the real pattern of
NPPV usage in the cardiac surgery setting. An international survey tried to fill this gap
in knowledge. The lack of a standardized and homogeneous use is clearly reported.
Preventive prescription, especially in high-risk patients, proved the main indication
with satisfactory outcomes, while the curative approach, though increasingly
addressed, had success rate lower than 50 % for 68 % of the respondent centers [11].
Several authoritative reviews and one meta-analysis updated the current evidence in
this setting [1215]. A detailed analysis of individual studies is beyond the scope of
this chapter, and readers might refer to the above-mentioned papers. However, several
limits must be disclosed for a thorough comprehension of the inherent clinical bottom
line. Available studies are still few, usually involved small patient samples, only a
minority had a randomized design, and the overall quality might be rated from moder-
ate to low. The heterogeneous mix of comparators and anomalies relating to therapeu-
tic protocols, terminology, and reporting of results also represents a considerable bias.
24 Noninvasive Mechanical Ventilation in Cardiac Surgery 195
Overall, available data demonstrate that NIV significantly reduces the reintubation
rate, hospital length of stay, and mortality with a highly satisfactory safety profile. As
a preventive tool, NIV effectiveness was maximized by selection of highly vulnerable
patients, inasmuch as routine usage had no evident clinical impact on hard outcomes.
As a treatment tool in overt acute respiratory failure, success rate as high as 94 % may
be anticipated in correctly selected patients.
An in-depth reading of published data discloses several key steps for successful
NIV implementation:
In conclusion, there is enough evidence to support NIV as a safe and effective tool
in reducing the burden of post-extubation failure in cardiac surgery. Available evi-
dence should be confirmed by large randomized trials. Optimization of patient
selection criteria, timing, modalities, and location of NIV along with evaluation of
cost-effectiveness are fields of future research.
196 L.S. De Santo et al.
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3. Stephens RS, Shah AS, Whitman GJ. Lung injury and acute respiratory distress syndrome
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outcome after cardiac surgery. Crit Care Med. 1999;27:3407.
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2013;110:896914.
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reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth.
2012;109:30514.
12. Guarracino F, Cabrini L, Ferro B, et al. Noninvasive ventilation practice in cardiac surgery
patients: insights from a European survey. J Cardiothorac Vasc Anesth. 2013;27:e635.
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Anestesiol. 2011;77:73441.
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review. Heart Lung Vessel. 2013;5:13741.
15. Olper L, Corbetta D, Cabrini L, et al. Effects of non-invasive ventilation on reintubation rate:
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racic surgery. Crit Care Resusc. 2013;15:2207.
Noninvasive Ventilation
in Postextubation Failure in Thoracic 25
Surgery (Excluding Lung Cancer)
Abbreviations
25.1 Introduction
Thoracic surgery operations play a significant part and are a wide-range weapon
in the confrontation and treatment of serious lung and heart conditions, lung cancer,
or severe traumatic injuries involving the anatomy and integrity of the chest cavity
and the underlying vital organs and tissues, such as the trachea and esophagus. In
the past two decades, thoracic surgery has also evolved as an accurate diagnostic aid
in the histological identification of tumors or other granulomatous, autoimmune,
and inflectional diseases involving the organs of the thorax. Depending on the
access in the thoracic cavity, great progress has been achieved against serious diag-
nostic issues that previously prevented or delayed the desired therapeutic evolution
of the patient. Today, pleural biopsy, chest wall biopsy, and pleural effusion drain-
age are performed in everyday practice with a high percentage of success [1].
The evolution of thoracic surgery has led to the performance of operative proce-
dures such as a radical video-assisted thoracic surgery, thymectomy, minimally
invasive excisions of mediastinal tumors, and even lung transplantation. On the
other hand, the demands against the management of the manifestation of an acute or
chronic cardiac disease, a situation that usually demands urgent attention, have
required such procedures as percutaneous transluminal coronary angioplasty and
coronary artery bypass grafting to be established as routine. These operations can be
performed through long chest incisions, such as thoracotomy or sternotomy, or
through one to three small chest incisions with the additional use of a camera (tho-
racoscope), a minimally invasive procedure called video-assisted thoracic surgery.
The level of difficulty, the usual presence of high-risk patients, and the need to
maintain constant focus and emphasis on every detail require optimum pre-, intra-,
and postoperative cooperation between the surgeon and anesthesiologist.
A patient who is undergoing this kind of an operation can be expected to present
a wide spectrum of medical history and additional chronic diseases, which may or
may not receive the proper treatment. This is a challenge that thoracic surgeons and
anesthesiologists must always confront with great responsibility and a degree of
vigilance, especially in terms of an emergency incident or during the admission of
the patient to an emergency department. Additional brief examination procedures,
such as a spirometry, can indicate the degree of an individuals respiratory function-
ality when the time potentiality is given. A detailed and careful documentation of
their medical record is a good start for the thoracic surgeon to anticipate and over-
come possible undesirable complications along the way.
25.2 Discussion
One of the most important issues that requires continuous observation and proper
management is the satisfaction of the patients respiratory needs. The regulation of
postoperative analgesia is an additional variable that must be managed efficiently. It is
25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 199
intrapulmonary contributing factors. This severe stage of acute lung injury is clini-
cally presented as increased respiratory rate and respiratory distress, progressive
hypoxemia, and diffuse infiltrations on chest X-ray [5].
Chronic obstructive pulmonary disease (COPD) has been a major health problem
for many years, and its manifestation is the result of many and variable factors and
may lead to ARF. An early diagnosis (especially in female patients), along with the
recognition of the disease with the latest guidelines and approaches in mind, may
ensure the optimum preoperative preparation for these kinds of chronic patients [6, 7].
The progressive inability of the patient to oxygenate, ventilate, or protect the air-
way, leading to weaning/postextubation failure, is a direct indication for applying
NIV as a first choice of response. The response to NIV varies from patient to patient
and with the operative procedure the patient has undergone.
A mechanical breath can be classified according to three factors: (i) The trig-
ger: This refers to the mechanism that initiates respiration. Time is considered to
be the traditional trigger, where the mechanical breath is delivered at a specific set
rate and regular time intervals, making it possible to deliver it at any time during the
patient's spontaneous respiratory cycle. (ii) Pressure ventilation or volume limited:
Pressure ventilation delivers each breath until a certain amount of peak inspiratory
pressure is reached, no matter how much tidal volume (VT) corresponds to that pres-
sure. VT can vary from mechanical breath to mechanical breath. On the contrary,
volume-limited (also called volume-controlled) ventilation delivers a set VT of air
with each mechanical breath, without the need to reach specific pressure to get that
breath in. As the lung compliance changes during the procedure, the pressure varies
from mechanical breath to mechanical breath. Nonetheless, the delivered volume of
gas always remains the same. (iii) The cycle: This is the mechanism responsible
for breath termination. Each cycle is regulated by different means, to be completed
after a set time or inhale:exhale ratio. When a certain pressure or volume is reached,
or the inspiratory flow decreases to a small percentage, the process is considered
complete.
By definition, the term NIV includes any means of ventilatory support that does
not require tracheal intubation of the patient. Although the use of NIV was intro-
duced during the 20th century (severe polio epidemics in the 1950s are recorded as
the first example of NIV application), the development of modern NIV has been
registered after the late 1980s, with the application of positive or negative pressure
NIV via a nasal mask. The aim was the treatment of respiratory failure in patients
with advanced neuromuscular disease, respiratory restrictive conditions, or even
sleep apnea. NIV is currently considered the gold standard as a first-line treatment
against serious and life-threatening respiratory complications, especially those that
accompany thoracic surgery.
In recent decades, the indications for NIV have expanded in both acute and
chronic care. NIV has decreased the need for intubation and mortality, effects that
25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 201
have been consistently observed in ICUs and respiratory wards. Noninvasive venti-
lator assistance is usually delivered using masks or nasal prongs. The flow of gas
extends to both the respiratory and gastrointestinal tracts.
NIV is often chosen as a means to avoid intubation during ARF to reduce the risk
of other complications, such as ventilation-associated pneumonia (VAP), especially
in immune-suppressed patients. The goal is to reestablish the functionality of the
poorly ventilated alveoli, achieve the unloading of the respiratory muscles, attain a
favorable hemodynamic preexisting level, and restore the normal respiratory func-
tion. The efficacy of NIV treatment depends strictly on the etiology of the estab-
lished ARF, whether or not a potentially reversible trigger (e.g., pneumonia/acute
heart failure) or an acute exacerbation of (e.g., pulmonary fibrosis) takes place.
It is generally accepted that improvement in gas exchange during the perfor-
mance of NIV treatment depends on the etiology of the ARF displayed. The hetero-
geneity of the possible etiologies of ARF demonstrates the importance of patient
selection and management with NIV. For instance, it has been demonstrated that the
application of noninvasive continuous positive airway pressure (CPAP) reduces the
risk of needing to perform in patients with severe hypoxemic ARF due to pneumo-
nia, compared with O2 therapy. It improves oxygenation in patients with pneumo-
nia. In other cases, noninvasive CPAP has been successfully introduced during ARF
caused by pneumonia in patients who underwent lung transplantation for idiopathic
pulmonary fibrosis.
NPPV can be an effective technique to improve gas exchange in order to avoid
endotracheal intubation in selected patients with ARF due to ARDS. Nevertheless,
the need for ETI via endotracheal intubation or tracheostomy is quite often neces-
sary. According to recent studies, trials and the latest guidelines, it has been regis-
tered that the success rate of the applied NPPV was measured about 50 %, and
evidently it has been suggested that NPPV can be safely be applied in specific cases
under close supervision.
It has also been concluded that the early use of NIV for mildly and moderately
COPD patients, after a thoracic surgery procedure and their return to the general
ward, results in a rapid improvement of their physiological variables. The need for
invasive mechanical ventilation, as well as in-hospital mortality, has been signifi-
cantly reduced with the application of NIV, and it has also been demonstrated to be
cost-effective. After continuing trials, the clinical usefulness of NIV has been widely
accepted for treating acute hypercapnic respiratory failure or obstructive atelectasis
due to COPD in patients who underwent a thoracic operative procedure [8].
25.2.3 Equipment
Respiratory support is achieved through the application of NIV, without the need for
a tube in the tracheal lumen. The delivery of the necessary amount of mechanically
assisted breaths is performed without an artificial airway. NIV may be performed
via negative or positive pressure. The expiration is passive until the alveolar pres-
sure reaches atmospheric level. The main goal is to improve the existing
202 D. Paliouras et al.
progression of eventual gas exchange abnormalities, and the overall clinical condi-
tions, the first few hours after the initial acute manifestation may determine their
clinical outcomes. NIV therapy of such patients requires a thorough knowledge of
both respiratory physiology (including respiratory mechanics and gas exchange
abnormalities) and existing ventilatory devices (e.g., interfaces, valves, etc.). A
minimum monitoring level is necessary for its use. In addition to traditional prog-
nostic variables, inadequate use of NIV resulting from a lack of personnel training
is detected in many cases of patients presenting with NIV. The most common prob-
lems include (i) a lack of operating knowledge by the staff; (ii) improperly fitted
equipment (e.g., a mask with excessive leaks); and (iii) the inability of the personnel
to control oxygen therapy or manage the ventilator alarms. Thus, the improper use
of NIV in non-designated areas, combined with the absence of well-trained medical
and nursing staff, may result in increased patient mortality. The presence of a well-
trained team, careful patient selection, continuous cooperation between thoracic
surgeons and anesthesiologists, and optimal choice of the impact NIV outcomes [9].
The question on where NIV should be applied during the patients postoperative
period, after their hospitalization, is currently related to the available resources of each
hospital and the knowledge and experience of the specialized staff. ICU care is com-
plex and expensive, and it is not needed as a rule for all the patients requiring NIV. In
this regard, specific intermediate locations (between the ICU and the respiratory ward)
have been implemented for the application of NIV in postoperative patients. These are
called semi-critical, intermediate, or high-dependency units, and they have emerged
especially in industrialized countries as an alternative to ICUs. Their specific goal is
to provide noninvasive respiratory support without the complex environment and the
costs of an ICU. The efficacy and cost effectiveness of such units give them the ability
to provide an ideal location for ventilator support (equipped with adequate resources
and staff) and a more comfortable environment for patients [10].
25.2.5 Prediction
NIV is currently considered the gold standard for managing respiratory failure after
a thoracic operative procedure. Significant and continuous efforts have been made
to identify the main predictors of successful NIV. The British Thoracic Society
defines treatment failure via the following guidelines: (i) deterioration in the
patients clinical condition, (ii) lack of improvement or deterioration in arterial
blood gas parameters, (iii) development of new symptoms or complications that
require ETI or ICU admission, or (iv) a decrease in the level of consciousness. If an
effective NIV treatment is performed, patients should experience improvement
within a few hours after the initiation of the ventilation.
NIV treatment failures can be divided into early (within 148 h of NIV use, with
or without an initial success) and late (48 h after initiation of NIV, following an
initial successful response). The latest international guidelines always recommend
a second complete evaluation of the patient after a few hours of NIV use. When
there is no clinical improvement, the prognosis is uncertain. In the presence of NIV
25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 205
failure, a decision concerning intubation should always be made. Thus, the severity
of the underlying disease and the operative procedure that has taken place must
always be of first concern.
Conclusion
The purpose of NIV is to achieve of a successful clinical reaction to a patients post-
operative respiratory complications, improvement of gas exchange and the work of
breathing, and, ultimately, avoid the need for ETI. NIV can be used as a first-line
treatment response because of its many advantages. Overall results have shown a
statistically significant decrease in the rate of ETI, mortality, and fatal complications
along with reduced ICU and hospital length of stay. We must not forget, however,
that it is a complementary ventilation technique and cannot replace ETI in all
instances. Although it is efficacious, the implementation of NIV remains subopti-
mal, and the availability of trained staff and sufficient resources to guarantee its
proper application must be ensured, especially for patients who have undergone a
major thoracic operation. NIV should be applied with close monitoring, and ETI
should be promptly available in possible cases of failure. An optimal team-training
experience, careful selection of patients, and special attention to the selection of
devices are critical for optimizing NIV outcomes in critically ill patients.
References
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Reanim. 2014;33:48791.
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bances. Management and expected benefits. Ann Fr Anesth Reanim. 2014;33:4846.
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acute respiratory distress syndrome following esophagectomy for esophageal cancer: a clinical
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5. Claesson J, Freundlich M, Gunnarsson I, et al. Scandinavian clinical practice guideline on
mechanical ventilation in adults with the acute respiratory distress syndrome. Acta Anaesthesiol
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6. Lopez-Campos JL, Jara-Palomares L, Muoz X, et al. Lights and shadows of non-invasive
mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations. Ann
Thorac Med. 2015;10(2):8793.
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9. AlYami MA, AlAhmari MD, Alotaibi H, et al. Evaluation of efficacy of non-invasive ventila-
tion in non-COPD and non-trauma patients with acute hypoxemic respiratory failure: a sys-
tematic review and meta-analysis. Ann Thorac Med. 2015;10(1):1624.
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during one-lung ventilation in elderly patients with poor pulmonary function. Ann Thorac
Med. 2014;9(4):2038.
Predictors of Prolonged Mechanical
Ventilation in Lung Cancer: Use 26
of Noninvasive Ventilation
26.1 Introduction
26.2 Analysis
Considering that lung cancer is the leading cause of cancer death in both men and
women and that as many as 65 % of these patients experience dyspnea, the contribu-
tion of lung cancer to dyspnea in patients with terminal cancer is substantial. It is
estimated that 30 % of patients with malignant disease will develop pulmonary metas-
tasis at some time during the clinical course of their disease. Mechanisms for acute
respiratory failure in patients with bronchogenic carcinoma include the following:
The most common cause is inspiratory respiratory muscle fatigue [3, 4], which is
almost always multifactorial in etiology. Possible causes of inspiratory respiratory
muscle fatigue are
The predictors of prolonged MV are based on the clinical judgment of the physi-
cians, for example,
26 Predictors of Prolonged Mechanical Ventilation in Lung Cancer 209
The rapid shallow breathing index as reflected by the respiratory frequency (f) to
tidal volume (Vt) ratio is the most accurate predictor of failure in weaning patients
from MV [8].
26.3 Discussion
Patients who are hypercapnic [11] tend to have better results than those
who are only hypoxemic. Patients with severe acidosis (pH 7.22 or higher)
and higher degrees of hypercapnia (PaCO2 near 100 mmHg), however, have
worse prognosis. The faster the onset of treatment, the better the outcome is.
Furthermore, the faster the gas exchange and respiratory rate improves [11],
the better the outcome is.
In the postoperative period, it is sometimes difficult to separate preventive
from curative application of NIV [15]. Further studies are needed to better
identify patients who may benefit from NIV after thoracic surgery [15] and
the optimal NIV protocol delivered.
References
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cohort of patients receiving mechanical ventilation. Chest. 2005;128:496.
2. Vassilakopoulos T, Petrof BJ. Ventilator induced diaphragmatic dysfunction. Am J Respir Crit
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3. Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med.
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4. Laghi F, Cattapan SE, Jubran A, et al. Is weaning failure caused by low-frequency fatigue of
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mechanical ventilation at a regional weaning center. Chest. 2004;126:1307.
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26 Predictors of Prolonged Mechanical Ventilation in Lung Cancer 211
7. Polkey MI, Moxham J. Clinical aspects of respiratory muscle dysfunction in the critically ill.
Chest. 2001;119:926.
8. Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of wean-
ing from mechanical ventilation. N Engl J Med. 1991;324:144550.
9. Cered M, et al. Noninvasive respiratory support in the perioperative period. Curr Opin
Anaesthesiol. 2013;26:13440.
10. Ferrer M, Esquinas A, Aranbica F, et al. Non invasive ventilation during persistent weaning
failure a randomized controlled trial. Am J Respir Crit Care Med. 2003;168(1):706.
11. Chiumello D, Chevallard G, Gregoretetti C. Non-invasive ventilation in postoperative patients:
a systematic review. Intensive Care Med. 2011;37(6):91829.
12. Auriant I, Jallot A, Herve P, et al. Non invasive ventilation reduces mortality in acute respira-
tory failure following lung resection. Am J Respir Crit Care Med. 2001;164:1231.
13. Lorut C, Lefevre A, Planquette B, et al. Early postoperative prophylactic noninvasive ventila-
tion after major lung resection in COPD patients: a randomized controlled trial. Intensive Care
Med. 2014;40(2):2207.
14. Riviere S, Monconduit J, Zarka V, et al. Failure of noninvasive ventilation after lung surgery:
a comprehensive analysis of incidence and possible risk factors. Eur J Cardiothorac Surg.
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Use of Noninvasive Mechanical
Ventilation in Lung Transplantation 27
Ana Hernandez Voth, Pedro Benavides Maas,
and Javier Sayas Cataln
Abbreviations
CF Cystic fibrosis
COPD Chronic obstructive pulmonary disease
CPAP Continuous positive airway pressure
ETI Endotracheal intubation
FEV1 Flow expiratory volume in the first second
ICU Intensive care unit
ILD Interstitial lung disease
LT Lung transplantation
NIV Noninvasive mechanical ventilation
27.1 Introduction
Many candidates for LT have a chronic domiciliary NIV indication as part of their
underlying lung disease treatment. There is evidence of NIV benefit as a bridge to
LT in two obstructive pathologies: COPD and cystic fibrosis (CF).
COPD exacerbation is a situation where the use of NIV has a higher degree of
evidence, particularly in severe exacerbations that develop respiratory acidosis.
These exacerbations are frequent in patients with COPD on the waiting list for LT,
and NIV can decrease mortality in up to 50 % cases of COPD exacerbation with
respiratory acidosis when compared with standard treatment [1]. This impact on sur-
vival is much higher than that obtained from any of pharmacological treatments used
in COPD exacerbations, and it has a high degree of evidence to be recommended.
NIV usefulness in stable COPD is more controversial. In patients with chronic
hypercapnic respiratory failure, several studies with contradictory results have been
published. Some of them show a slight increase in survival of patients with COPD
with hypercapnic respiratory insufficiency, whereas others have not found any dif-
ferences in terms of exacerbations or survival. Nevertheless, although there is no
conclusive scientific evidence about its usefulness in stable COPD, it is one of the
main indications of chronic domiciliary NIV in Europe.
Regarding the use of NIV in COPD as bridge to LT, an improvement in a pulmo-
nary function parameter (an increase of 0.20 0.18 l (liters) in FEV1) has been
described, along with a small increase in survival while on the waiting list for LT
[2]. However, these are limited data because of the absence of a control group and
the presence of important selection bias in their results. Functional improvement
has been achieved in very severe COPD by using NIV prior to an oncologic thoracic
surgery, which can be extrapolated to very severe COPD patients on the waiting list
for LT.
NIV in CF patients has shown short-term improvement in oxygen saturation and in
pCO2 levels, as well as a decrease in the work of breathing, alveolar ventilation and
exercise tolerance improvement, and pulmonary function stabilization during reha-
bilitation [3, 4]. When these patients have a severe exacerbation that requires ventila-
tory support, invasive mechanical ventilation has a bad prognosis associated with
infectious complications from frequent bronchial colonization, as ventilator-associated
pneumonia. As a bridge to LT, NIV in CF can reduce mortality from this cause.
Generally, after thoracic surgery there are strong effects on respiratory function that
relate to postoperative prolonged mechanical ventilation requirements. In the par-
ticular case of LT, there are also other associated factors: the usual myopathy that
terminal respiratory insufficiency patients present, functional alterations due to
clamshell incision in bilateral LT, and postoperative diaphragm involvement due to
phrenic nerve damage.
27 Use of Noninvasive Mechanical Ventilation in Lung Transplantation 215
NIV use has been considered in the LT early postoperative period with three
major objectives: to facilitate early extubation, to prevent reintubation due to post-
surgery ventilatory failure, and to treat ventilatory failure once it is established [5].
Table 27.1 Variables analyzed in the early postoperative period in lung transplant patients.
Hospital Universitario 12 de Octubre
Non-NIV group NIV group
Variable (N = 39) (N = 14)
Arterial blood gases (early postoperative period) 7.36/45.9 7.33/49.5
[pH/PCO2 (mean)]
Time spent in endotracheal intubation (mean) 53.52 h 43.68 h
Length of stay (mean) 10.53 days 7.10 days
NIV noninvasive mechanical ventilation, ICU intensive care unit, PCO2 carbon dioxide partial
pressure in blood
Moreover, NIV has demonstrated its usefulness in treating patients with hypox-
emic respiratory failure of different etiologies, reducing the need for ETI and
thereby decreasing infectious complications from it (nosocomial pneumonia and
septic shock) and decreasing global mortality [9].
Along with the evidence that NIV is safe and may be beneficial in hypoxemic
failure, this technique also has utility in ventilatory failure management in immuno-
suppressed patients. In these patients, when ventilatory failure requires ETI, mortal-
ity increases significantly, but NIV use enables to reduce reintubation rate and
mortality, compared with reintubated patients. Particularly in lung transplant
patients it has demonstrated an improvement in physiological parameters (arterial
blood gases analysis, breathing rate, etc.) after introducing NIV as acute respiratory
failure treatment. However, these results derive from a descriptive study without a
control group, so we can only conclude that the NIV option is safe and may be ben-
eficial to these patients [10].
Conclusion
NIV is a useful tool in lung transplant patients, where avoiding intubation is cru-
cial. It can also improve work of breathing, gas exchange, oxygenation, and exer-
cise tolerance. Its applications include all the range of complications that may be
present in the pretransplant and post-transplant period (early and late ones).
218 A. Hernandez Voth et al.
References
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obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med.
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2. Wiebel M, et al. Noninvasive self-ventilationsuccessful transition aid in the waiting period
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3. Fauroux B, et al. Long-term noninvasive ventilation in patients with cystic fibrosis. Respiration.
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4. Serra A, et al. Non-invasive proportional assist and pressure support ventilation in patients
with cystic fibrosis and chronic respiratory failure. Thorax. 2002;57(1):504.
5. Feltracco P, et al. Noninvasive ventilation in postoperative care of lung transplant recipients.
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27 Use of Noninvasive Mechanical Ventilation in Lung Transplantation 219
6. Rocca GD, et al. Is very early extubation after lung transplantation feasible? J Cardiothorac
Vasc Anesth. 2003;17(1):2935.
7. Ferrer M, et al. Noninvasive ventilation during persistent weaning failure: a randomized con-
trolled trial. Am J Respir Crit Care Med. 2003;168(1):706.
8. Hadjiliadis D, et al. Outcome of lung transplant patients admitted to the medical ICU. Chest.
2004;125(3):10405.
9. Ferrer M, et al. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized
clinical trial. Am J Respir Crit Care Med. 2003;168(12):143844.
10. Rocco M, et al. Non-invasive pressure support ventilation in patients with acute respiratory
failure after bilateral lung transplantation. Intensive Care Med. 2001;27(10):16226.
Noninvasive Mechanical Ventilation
in Postoperative Spinal Surgery 28
Eren Fatma Akcil, Ozlem Korkmaz Dilmen,
and Yusuf Tunali
28.1 Introduction
28.2 Discussion
The efficacy of NIMV has been demonstrated in postoperative ARF, including car-
diac, thoracic, thoracoabdominal, and abdominal surgery [15]. Various complica-
tions may develop following spinal surgery; the most common are cardiac
complications (3 %), pulmonary complications (1.2 %), and pneumonia (1.2 %).
Postoperative complications were reported to increase mortality; advanced age (>65),
comorbidities, and complexity of surgical interventions are contributing factors [6, 7].
It is obvious that scoliosis, trauma, and oncological spinal surgical interventions are
more invasive interventions than degenerative disc disease surgery, with higher peri-
operative morbidity and mortality rates. Moreover, in posterior lumbar fusion opera-
tions, mortality is lower than with anterior and thoracic approaches [6]. It has been
demonstrated that diabetes mellitus (particularly insulin-dependent), obesity, COPD,
and steroid use increase complications in lumbar stenosis surgery [7]. Thoracic disk
surgery is particularly associated with pulmonary complications (6.9 %) [8]. In those
undergoing anterior/anterolateral decompression and fusion, all complications and
pulmonary complications were reported to be greater than in those undergoing poste-
rior/posterolateral decompression and only disc decompression with fusion.
Although we report high mortality and morbidity rates in scoliosis surgery, surgi-
cal interventions are needed to improve the quality of life of these patients and for
the correction of the vital functions. Irreversibly affected respiratory and cardiac
functions may complicate both anesthesia and surgery. Spinal deformity progres-
sion may cause deteriorated respiratory functions. Secondary scoliosis may develop
in children with muscular dystrophies and myopathies, and, hence, spinal fusion
surgery is required. There is alveolar hypoventilation and hypercapnia susceptibility
due to respiratory muscle weakness, and inability to cough in scoliosis accompa-
nied by neuromuscular diseases.
Postoperative pulmonary function is seen to deteriorate further than preoperative
function. In a case series including eight patients, early pre- and postoperative
NIMV applications are effective in protecting the respiratory functions in these chil-
dren with restrictive respiratory failure [9]. Pre- and postoperative biphasic positive
airway pressure was performed in children with forced vital capacity (FVC) 1 L,
those undergoing scoliosis surgery, and in a case of desaturation due to hypoventila-
tion during the night, and no difference between preoperative and postoperative
respiratory functions was observed [9]. When NIMV is used in chronic respiratory
failure due to scoliosis, it may improve arterial oxygenation, increase the quality of
life, and reduce the hospital LOS. Following scoliosis surgery, acute respiratory
failure may develop, particularly in patients with poor respiratory functions in the
preoperative period. Atelectasis, depressant effects of opioids, and pain are the con-
tributing factors to the risk of postoperative respiratory failure in these patients [10].
It is established that the application of mechanically assisted cough and nasal inter-
mittent positive pressure ventilation before and after surgery ensures that extubation
will performed successfully and invasive mechanical ventilation will not be required
in patients undergoing scoliosis surgery with FVC values of < 40 % before the sur-
gery [11]. In a study of 73 patients undergoing scoliosis surgery, NIMV was applied
in 28 patients in the perioperative period, and PPC developed less often in this group
than in those who did not undergo NIMV [12].
In the pulmonary function tests of the children with muscular dystrophy, assum-
ing that the vital capacity decreases by 310 % per year and surgery is contraindi-
cated without opening tracheostomy in cases with FVC values of below 40 %,
perioperative NIMV application and early surgery seem to be advantageous [13].
28 Noninvasive Mechanical Ventilation in Postoperative Spinal Surgery 223
Conclusion
Spinal surgery particularly surgery for scoliosis could be complicated by respiratory
failure in the perioperative period, and NIMV is essential for its management.
Key Recommendations
Respiratory function tests should be evaluated in the preoperative period of
thoracic spinal and scoliosis surgery.
Short-acting anesthetic drugs should be preferred.
Postoperative pain management is essential for recovery.
References
1. Garcia-Delgado M, Navarrete I, Garcia-Palma MJ, et al. Postoperative respiratory failure after
cardiac surgery: use of noninvasive ventilation. J Cardiothorac Vasc Anesth. 2012;26:4437.
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Anaesthesiol. 2010;23:2338.
3. Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients:
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2010;112:45361.
5. Albala MZ, Ferrignio M. Short term noninvasive ventilation in the postanesthesia care unit: a
case series. J Clin Anesth. 2005;17:6369.
6. Pumberger M, Chiu YL, Ma Y, et al. Perioperative mortality after lumbar spinal fusion sur-
gery: an analysis of epidemiology and risk factors. Eur Spine J. 2012;21:16339.
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veteran population. Spine. 2013;38:1695702.
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2014;39:12338.
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isting respiratory failure. Spine. 2006;31:247883.
10. Doherty MJ, Millner PA, Latham M, et al. Non-invasive ventilation in the treatment of ventila-
tory failure following corrective spinal surgery. Anaesthesia. 2001;56:23547.
11. Bach JR, Sabharwal S. High pulmonary risk scoliosis surgery: role of noninvasive ventilation
and related techniques. J Spinal Disord Tech. 2005;18:52730.
12. Chong HS, Padua MRA, Kim JS, et al. Usefulness of noninvasive positive-pressure ventilation
during surgery of flaccid neuromuscular scoliosis. J Spinal Disord Tech. 2015. doi:10.1097
BSD.0000000000000234.
13. Mills B, Bach JR, Zhao C, et al. Posterior spinal fusion in children with flaccid neuromuscular
scoliosis: the role of noninvasive positive pressure ventilatory support. J Pediatr Orthop.
2013;33:48893.
14. Almenrader N, Patel D. Spinal fusion surgery in children with non-idiopathic scoliosis: is there
a need for routine postoperative ventilation? Br J Anaesth. 2006;97(6):8517.
Noninvasive Ventilation Following
Abdominal Surgery 29
Alastair J. Morgan and Alastair J. Glossop
Abbreviations
29.1 Introduction
Authors Disclosures Alastair Glossop has previously received a scholarship awarded by the
National Institute for Health and Clinical Excellence (NICE) but received no financial incentive.
A.J. Morgan, BSc, MRCP(Ed), FRCA, FFICM A.J. Glossop, MRCP, FRCA, DICM,
FFICM (*)
Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust,
Herries Road, Sheffield S5 7AU, UK
e-mail: alastair.glossop@sth.nhs.uk
pneumonitis, sputum plugging, lobar collapse, pneumonia, and the requirement for
mechanical ventilation (MV). The incidences of PRF and PPCs are 0.23.4 and
7.240 %, respectively, following elective abdominal surgery, with even higher
rates following emergency surgery and in patients older than 80 years [1]. Depending
on patient characteristics and demographics, associated mortality can exceed 25 %,
with substantial associated increases in health-care costs [13].
Endotracheal reintubation is required in 810 % of patients secondary to PRF
following major abdominal surgery. Although often a necessary supportive inter-
vention, endotracheal intubation is an independent predictor of hospital mortality,
prolonged intensive care, and hospital stay [15]. Noninvasive ventilation (NIV)
has been used as both a prophylactic and therapeutic treatment option in patients
with PRF after major abdominal surgery and may potentially reduce the significant
morbidity and mortality associated with reintubation. Early studies examining the
use of NIV in this patient group were inconclusive or produced conflicting results
[6, 7], but there is now growing evidence and enthusiasm for using NIV postopera-
tively to reduce the risk of complications following major surgery. This chapter
reviews the evidence for the use of NIV in open abdominal visceral surgery, thora-
coabdominal surgery, vascular surgery, and transplant surgery.
The use of NIV following major surgery is well established as both a prophylactic
and therapeutic treatment modality. Although oxygen therapy may be effective in
attenuating postoperative hypoxemia, it is only a symptomatic approach that does
not reverse the underlying pathophysiological process. There is evidence to sug-
gest that lung expansion therapy using incentive spirometry and deep-breathing
exercises reduces PPCs after abdominal surgery [8]. Compared with standard posi-
tive pressure respiratory therapy, the application of continuous NIV is associated
with an increase in functional residual capacity and reduced atelectasis and left
ventricular afterload, with a subsequent increase in cardiac output and arterial
oxygenation.
29 Noninvasive Ventilation Following Abdominal Surgery 227
Studies comparing NIV with standard therapy have generally provided positive
results supporting the use of NIV postoperatively, but they are limited by small
sample sizes, with a large variation in the modality of NIV, technical implementa-
tion, and timing of application seen between studies. The small sample sizes in
these studies has meant that atelectasis and PaO2/FiO2 (PF) ratio are commonly
assessed, which may not translate into clinically relevant end points such as reintu-
bation and mortality rates. Although reductions in rates of PPCs and reintubation
have been demonstrated in the literature, there is currently limited evidence regard-
ing the impact of NIV on mortality.
A landmark multicenter, prospective, randomized control trial (RCT) of 209
patients published in 2005 by Squadrone et al. [9] demonstrated a significant reduc-
tion in reintubation, pneumonia, and sepsis rates following early hood continuous
positive airway pressure (CPAP) in hypoxemic patients after elective major abdomi-
nal surgery. ICU length of stay was lower in the CPAP group, but there was no dif-
ference in hospital length of stay or in-hospital mortality between groups. In a
prospective observational study involving 72 patients with severe PRF after abdom-
inal surgery, reintubation was avoided in 67 % of patients treated with NIV [10].
A large meta-analysis of 654 patients pooled from nine studies of NIV use
following abdominal surgery demonstrated that NIV use was associated with a
significantly lower rate of PPCs, including atelectasis, when compared with stan-
dard medical therapy [11]. The pooled estimate of two studies using intubation as
an endpoint showed a beneficial effect of CPAP (risk reduction 0.85; 95 % confi-
dence interval (CI) 0.340.97). Two of the studies included in the analysis assessed
the effect of postoperative CPAP on mortality following abdominal surgery; how-
ever, the number of deaths was too small to allow meaningful analysis. The stud-
ies included in this meta-analysis displayed marked heterogeneity, differing in
both application and duration of CPAP use, and only included preoperatively
healthy patients in five studies and may therefore underestimate the beneficial
effects of NIV.
CPAP may be of particular benefit for patients who cannot participate with
incentive spirometry or deep-breathing exercises. In patients with obstructive air-
ways disease, CPAP decreases work of breathing by counterbalancing the inspira-
tory threshold load imposed by intrinsic positive-end expiratory pressure (PEEP).
Noninvasive positive pressure ventilation (NPPV) may be considered in patients in
whom hypercarbia coexists with hypoxemia, when there is a history of chronic
obstructive pulmonary disease, or in patients who are experiencing an increased
respiratory workload.
The optimum amount of PEEP and duration of NIV, particularly as a prophylac-
tic treatment, remains controversial, with a lack of supporting evidence and trials in
which a benefit for NIV has not been evident [7, 12]. Some authors have suggested
that immediate application of NIV post extubation may be more beneficial in
recruiting alveoli than delayed or intermittent NIV, although current practice varies
widely and is often dictated by local preferences and protocols or the need to balance
continued alveolar recruitment with patient comfort, nursing availability, and
workload.
228 A.J. Morgan and A.J. Glossop
Although few studies have examined different techniques to treat or prevent pulmo-
nary complications and large RCTs in this area are lacking, early NIV is an attrac-
tive treatment option following major abdominal surgery because it may provide
ongoing respiratory support without the risks of endotracheal intubation and
MV. When NIV is effective in avoiding reintubation, the morbidity and mortality
associated with MV are reduced. NIV may also reduce ICU length of stay, which
has substantial associated cost benefits.
There is good evidence to support the early use of NIV (CPAP) in high-risk
patients with PRF or PPCs following elective major abdominal surgery, and its use
is recommended in this group to reduce reintubation risk. The use of a risk stratifica-
tion score may assist in identifying the specific patient population for whom NIV
may be of most benefit and directing resources toward patients with the most need
[1]. When used as prophylaxis, based on limited current evidence, NIV should be
applied immediately post extubation and used continuously as tolerated by the
patient. Future research should focus on determining the optimal NIV regimen in
terms of modality, timing, and duration and also address the impact of NIV on mor-
tality in high-risk patients.
The use of NIV after gastrointestinal surgery involving formation of an anasto-
mosis is more controversial, although the available literature suggests that NIV is
safe to use in patients with respiratory failure following esophageal, gastric, and
bariatric surgery as it may reduce reintubation rates without increasing risk of anas-
tomotic dehiscence. Further work is needed in this area to clarify the mode of deliv-
ery, timing, and duration of NIV that is most beneficial in this patient group.
The use of NIV as prophylaxis following major vascular surgery has been shown
to reduce the risks of hypoxia, respiratory failure, and need for reintubation, which
are all major causes of postoperative morbidity. Although evidence of mortality
benefit in this patient group is lacking, the use of NIV to prevent such complications
is recommended. There is a paucity of evidence for the use of NIV following trans-
plant surgery, although the available evidence suggests that NIV use may be benefi-
cial in patients who develop respiratory failure postoperatively to prevent the need
for reintubation and the attendant infective risks.
Overall, it is evident that the use of NIV in patients following major abdominal
surgery is beneficial, and although there is little data pertaining to mortality benefit,
there is evidence in all patient groups of reductions in major causes of postoperative
morbidity and complications, which has important implications for patient safety
29 Noninvasive Ventilation Following Abdominal Surgery 231
and use of health-care resources. Debate continues as to whether NIV is best used
as prophylaxis or treatment in postoperative patients and also whether CPAP or
NPPV is the optimal mode of delivery to reduce postoperative complications. Future
research should focus on mortality as an endpoint, given that the morbidity benefits
are already well demonstrated, and also debate the optimum mode, timing, and
delivery of NIV in high-risk surgical patients.
References
1. Canet J, Gallert L, Gomar C, et al. Prediction of postoperative pulmonary complications in a
population-based surgical cohort. Anesthesiology. 2010;113:133850.
2. Arozullah AM, Daley J, Henderson WG, et al. Multifactorial risk index for predicting postop-
erative respiratory failure in men after major non cardiac surgery. The National Veterans
Administration Surgical Quality Improvement Program. Ann Surg. 2000;232:24253.
3. Johnson RG, Arozullah AM, Neumayer L, et al. Multivariable predictors of postoperative
respiratory failure after general and vascular surgery: results from the patient safety in surgery
study. J Am Coll Surg. 2007;204:118898.
4. Fagevik Olsn M, Wennberg E, Johnsson E, et al. Randomized clinical study of the prevention
of pulmonary complications after thoracoabdominal resection by two different breathing tech-
niques. Br J Surg. 2002;89:122834.
5. Lawrence VA, Hilsenbeck SG, Mulrow CD, et al. Incidence and hospital stay for cardiac and
pulmonary complications after abdominal surgery. J Gen Intern Med. 1995;10:6718.
6. Stock M, Downs J, Gauer P, et al. Prevention of postoperative pulmonary complications with
CPAP, incentive spirometry, and conservative therapy. Chest. 1985;87:1517.
7. Carlsson C, Sonden B, Thylen U. Can postoperative continuous airway pressure (CPAP) pre-
vent pulmonary complications after abdominal surgery? Intensive Care Med. 1981;7:2259.
8. Lawrence VA, Cornell JE, Smetana GW, et al. Strategies to reduce post-operative pulmonary
complications after non-cardiothoracic surgery: systematic review for the American College of
Physicians. Ann Intern Med. 2006;144:595608.
9. Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of
post-operative hypoxaemia: a randomized controlled trial. JAMA. 2005;293:58995.
10. Jaber S, Delay J, Sebbane M, et al. Outcomes of patients with acute respiratory failure after abdomi-
nal surgery treated with non-invasive positive-pressure ventilation. Chest. 2005;128:268895.
11. Ferrerya GP, Baussano I, Squadrone V, et al. Continuous positive airway pressure for treatment
of respiratory complications after abdominal surgery: a systematic review and meta-analysis.
Ann Surg. 2008;247:61726.
12. Denehy L, Carroll S, Ntoumenopoulos G, et al. A randomized controlled trial comparing peri-
odic mask CPAP with physiotherapy after abdominal surgery. Physiother Res Int. 2001;6:
23650.
13. Huerta S, DeShields S, Shpiner R, et al. Safety and efficacy of post-operative continuous posi-
tive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass.
J Gastrointest Surg. 2002;6:3548.
14. Ramirez A, Labor PF, Szomstein S, et al. Continuous positive airway pressure in immediate
postoperative period after laparoscopic Roux-en-Y gastric bypass: is it safe? Surg Obes Relat
Dis. 2009;5:5446.
15. Weingarten TN, Kendrick M, Swain JM, et al. Effects of CPAP on gastric pouch pressure after
bariatric surgery. Obes Surg. 2011;21:19005.
16. Michelet P, DJourno XB, Seinaye F, et al. Non-invasive ventilation for treatment of post-
operative respiratory failure after oesophagectomy. Br J Surg. 2009;96:5460.
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nal aortic aneurysms. Am J Surg. 1994;168:1525.
232 A.J. Morgan and A.J. Glossop
18. Svensson LG, Hess KR, Coselli JS, et al. A prospective study of respiratory failure after high-
risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1991;14:27182.
19. Bhner H, Kindgen-Milles D, Grust A, et al. Prophylactic nasal continuous positive airway
pressure after major vascular surgery: results of prospective randomised trial. Langenbecks
Arch Surg. 2002;387:216.
20. Kindgen-Milles D, Muller E, Buhl R, et al. Nasal-continuous positive airway pressure reduces
pulmonary morbidity and length of hospital stay following thoraco-abdominal surgery. Chest.
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Noninvasive Mechanical Ventilation
in Postoperative Bariatric Surgery 30
Michele Carron and Anna Toniolo
30.1 Introduction
Obesity has increased worldwide during the past few decades [1, 2]. Anesthesiologists
must provide care for an increasing number of obese patients in their clinical practice.
Anesthesiologists should consider that the specific respiratory problems associated
with obesity may increase the risk of postoperative respiratory complications.
Anesthesia, surgery, and postoperative pain further diminish respiratory function, pre-
disposing the obese patient to hypoxemia and acute respiratory failure (ARF) [1, 2].
Noninvasive ventilation (NIV) may be an important tool for managing obese
patients after surgery. NIV may reduce the risk of ARF, reintubation, duration of
intensive care and hospital stays, morbidity, and mortality in postoperative patients
[3]. Major issues surrounding preoperative and postoperative respiratory changes
and postoperative application of NIV in obese patient are discussed in this
chapter.
Obese patients are predisposed to upper airway obstruction and respiratory failure
[1, 2]. Patency of the upper airway is maintained by the pharyngeal dilator muscles
during inspiration, although lung inflation may also contribute to patency [1, 2].
Postoperative muscle weakness and upper airway or pharyngeal dysfunction fol-
lowing anesthesia may predispose patients to upper airway obstruction, particularly
patients with OSA [13]. Fat deposition can promote airway collapse and narrow-
ing of the upper airway. Magnetic resonance imaging studies indicate superficial fat
deposition at the neck and a greater amount of fat deposition in the lateral pharyn-
geal wall, including pharyngeal structures, such as the tongue, uvula, tonsils, tonsil-
lar pillars, and aryepiglottic folds [1]. These findings are particularly evident in the
android obesity pattern.
Obesity, particularly severe obesity, affects pulmonary function [15]. The accumu-
lation of fat tissue in the chest wall, abdominal cavity, and intrathoracic space
decreases compliance and diminishes lung volume. Cephalic displacement of the
diaphragm increases abdominal content and pulmonary blood volume, further
reducing compliance and lung volume [15].
Resting tidal volume normalized to total body weight or lean body weight is
reduced by 50 % or 20 %, respectively, in comparison with that of patients with
normal weights [1, 2]. In addition, the respiratory rate may be 40 % higher in obese
patients than in nonobese subjects [1, 2]. Forced vital capacity (FVC), forced expi-
ratory volume in 1 s (FEV1), functional residual capacity (FRC), expiratory reserve
volume (ERV), total lung capacity (TLC), and maximal voluntary ventilation are
reduced, particularly among morbidly obese patients [2]. Because both FEV1 and
30 Noninvasive Mechanical Ventilation in Postoperative Bariatric Surgery 235
FVC decrease, the FEV1 to FVC ratio often remains unchanged [1, 2]. TLC, FRC,
and ERV decline exponentially as BMI increases [1, 2]. FRC is usually reduced as
a consequence of reduced ERV, with residual volume remaining within normal limit
[1]. FVC is reduced by 1015 % in some obese patients and by 2550 % in mor-
bidly obese patients [2].
Mechanical pulmonary function is further altered by physiological changes that
are present in the obese state [1, 2]. Increased lean body weight and fat tissue
increases oxygen consumption and carbon dioxide production to satisfy metabolic
requirements. These changes increase minute ventilation [1, 2]. Oxygen consump-
tion is increased at rest by approximately 25 % in obese subjects [1, 2]. Despite
increased production of carbon dioxide, normocapnia is usually maintained by the
increased minute ventilation [1, 2]. Patients with chronic obstructive pulmonary
disease (COPD) or obesity hypoventilation syndrome are generally hypercapnic [1,
2]. Increased upper airway resistance, restrictive pulmonary pathophysiology,
increased minute ventilation, oxygen consumption, carbon dioxide production, and
respiratory muscle dysfunction due to increased cytokine levels and fatty infiltration
significantly increase the effort required to breathe [1, 2]. Normocapnic, morbidly
obese subjects exhibit increased breathing effort at rest by about 3070 %. In severe
obesity, effort required may increase up to 280 % of normal, leading to a 10-fold
increase in the energy cost of breathing [1, 2].
Altered pulmonary function in obese patients affects pulmonary gas exchange,
especially among those with BMIs that exceed 40 kg/m2 [1, 2]. Morbidly obese
patients may have reduced partial arterial oxygen concentrations (PaO2), increased
partial arterial carbon dioxide concentrations (PaCO2), and increased alveolar-to-
arterial oxygen partial pressure differences. The increased shunt fraction and the
ventilation-perfusion mismatch result in hypoxemia [1, 2].
the use of a specific patient interface device in obese patients [2, 6]. However, the use
of a helmet may improve patient comfort and compliance. Helmets are better tolerated
than masks, resulting in longer use and lower NIV failure rates [6].
Prevention and management of gastric insufflation may be achieved by placing a
nasogastric tube for intermittent air and fluid aspiration prior to NIV [2, 6]. Antacid
prophylaxis should be considered for reducing gastric content and vomiting after
gastric insufflation to avoid serious complications (i.e., pulmonary aspiration, pneu-
monia, and possibly death) [2, 6].
use of BiPAP 12/4, but not 8/4, allowed significant reduction in the magnitude of
pulmonary dysfunction after gastroplasty [12]. FVC and FEV1 were more than 50 %
greater in the BiPAP 12/4 group compared with those in the control group during 3
days of follow-up observation [12]. The peak expiratory flow rate was also increased
in the BiPAP 12/4 group (p = 0.10) [12]. Improved pulmonary function was associ-
ated with a significant increase in oxygenation in both BiPAP groups [12].
Zoremba et al. [13] prospectively studied 60 obese patients undergoing minor
peripheral surgery. Half were randomly assigned to receive short-term NPPV
(PSV + PEEP; Drger AG; Lbeck, Germany) through full face masks during their
PACU stays; the others received supplemental oxygen via Venturi masks [13].
Pulmonary function in the NPPV group was significantly better than that in the
control group (p < 0.0001) [13]. Blood gas levels and the alveolar to arterial oxygen
partial pressure difference were also improved (p < 0.03) [13]. These effects per-
sisted for at least 24 h after surgery (p < 0.05) [13] (Fig. 30.1).
a b
Fig. 30.1 Postoperative use of NIV in obese patients. (a) Prophylactic use of CPAP in an obese
patient after laparoscopic sleeve gastrectomy through a CPAP mask with integral Venturi flow
driver and adjustable PEEP valve (Ventumask; StarMed; Mirandola, Italy). (b) Therapeutic use of
NPPV (PSV + PEEP) in an obese patient with respiratory failure after gastric bypass surgery deliv-
ered by a helmet for NIV (CaStar R; StarMed; Mirandola, Italy). Written informed consent was
obtained from patients
30 Noninvasive Mechanical Ventilation in Postoperative Bariatric Surgery 239
One meta-analysis showed that NIV reduced reintubation rates (odds ratio (OR)
0.24), incidence of pneumonia (OR 0.27), and ICU length of stay (0.44 days) when
applied after major surgery [15]. There was insufficient evidence to suggest that
NIV improves ICU survival, but an increased hospital survival was observed when
NIV was used after surgery (OR 4.54) [15].
Conclusion
Obese patients present preoperative changes in respiratory function. Anesthesia
and surgery can profoundly impair respiratory function, increasing the risk of
postoperative respiratory complications and ARF. Evidence supports early
administration of NIV as a prophylactic and as a therapeutic tool after surgery in
obese patients for improving respiratory function and gas exchange. Selection of
the correct interface (face or nasal mask vs helmet) and the type of NIV (CPAP
vs NPPV) together with proper monitoring of the patient during NIV is funda-
mental for increasing the likelihood of success of NIV.
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11. El-Solh AA, Aquilina A, Pineda L, et al. Noninvasive ventilation for prevention of post-
extubation respiratory failure in obese patients. Eur Respir J. 2006;28:58895.
12. Joris JL, Sottiaux TM, Chiche JD, et al. Effect of bi-level positive airway pressure (BiPAP)
nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients under-
going gastroplasty. Chest. 1997;111:66570.
13. Zoremba M, Kalmus G, Begemann D, et al. Short term non-invasive ventilation post-surgery
improves arterial blood-gases in obese subjects compared to supplemental oxygen delivery a
randomized controlled trial. BMC Anesthesiol. 2011;11:10.
14. Jaber S, Delay JM, Chanques G, et al. Outcomes of patients with acute respiratory failure after
abdominal surgery treated with noninvasive positive pressure ventilation. Chest.
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Noninvasive Ventilation After
Extubation in Obese Critically Ill 31
Subjects
31.1 Introduction
Obesity has become a major public health problem, with recent data demonstrating
that about a third of the US population is obese [1]. The economic impact of obesity
is significant because of the associated comorbidities and the increased health-care
utilization of obese subjects [2]. This increasing proportion of obesity among the
overall population is reflected by the high proportion of obese subjects who are
admitted to intensive care units (ICUs). Some series have estimated that 1825 % of
critically ill subjects are obese [3, 4]. In this particular population, the most com-
mon reason for admission to an ICU is respiratory failure, and up to 55 % of obese
subjects who are admitted to an ICU require mechanical ventilatory support [5, 6].
This emphasizes the importance of understanding the mechanisms of respiratory
failure, ventilatory strategies, and the approach to weaning and extubation to
decrease the risk for reintubation and improve the outcomes in critically ill obese
patients. This last aspect is the focus of this chapter.
alveoli recruited may be higher than the level recommended by the guidelines to
deem the patient ready (usually the guidelines recommend a PEEP between 5 and
8 cmH2O) [14]. In general, because of the altered lung mechanics in obese subjects,
we advocate the measurement of esophageal pressures as a surrogate for the pleural
pressure, with titration of PEEP to maintain the transpulmonary pressure gradient
(pressure in the airway pleural pressure) between 0 and 5 cm H2O [16]. In our
experience, the mean end-expiratory esophageal pressure of severely morbidly
obese subjects is approximately 17 cmH2O [17], which means that these patients
should be kept on a relatively high PEEP even when considering extubation. This
requirement is one of the justifications to extubate these patients to NIV. If the
esophageal manometry is not available, it is reasonable to keep the PEEP between
10 and 15 cmH2O based on previously published observational studies [8]. These
data suggest that obese subjects can be deemed ready for extubation if they meet the
aforementioned criteria, even if the PEEP is relatively high.
Once the subject is ready for extubation, then the next step is to proceed with a
spontaneous breathing trial (SBT). Although the literature recommends the use of
either a T-piece trial or a trial under PEEP and some pressure support ventilation,
based on the lung mechanics of the obese subjects it is recommended that they
undergo a SBT maintaining the same level of PEEP used during the acute phase
with some pressure support. The criterion for failure of SBT in obese subjects does
not differ from the general population and includes tachypnea, hypoxemia, tachy-
cardia, hemodynamic instability, or signs of respiratory distress (thoracoabdominal
paradox, use of accessory muscles for respiration). If none of the criteria for failure
are present during the SBT, then extubation should follow. If a high level of PEEP
has been maintained during the weaning process, it is reasonable to extubate to
NIV. Even if the PEEP is at a low level (<8 cmH2O), NIV should still be considered
in obese subjects being liberated from invasive mechanical ventilation.
Key Points
NIV is an option when considering extubation of obese subjects.
High PEEP and ePAP is recommended when using mechanical ventilation
in obese individuals. We strongly recommend the use of esophageal
manometry to guide this decision.
Because of the advantages of tidal volume delivery and less leakage, we
recommend the use of a full face mask when using NIV in obese
subjects.
There is no consensus on how to wean patients from NIV. We recommend
the use of intermittent NIV (with naps and during sleep) for an indefinite
period of time in patients who meet criteria for OHS or sleep apnea.
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Noninvasive Mechanical Ventilation
in Patients with Neuromuscular Disease 32
Fabrizio Racca, Chiara Robba, and Maria Pia Dusio
32.1 Introduction
Respiratory failure is the most common cause of morbidity and mortality in patients
with progressive neuromuscular diseases (NMDs) [14]. The wide variety of NMDs
that can affect respiratory function are listed in Table 32.1. NMDs are often compli-
cated by progressive involvement of the respiratory muscles and can lead to both
chronic and acute respiratory failure (ARF). Reduced inspiratory muscle strength
can result in ineffective alveolar ventilation, and weakness of expiratory muscles
can lead to inadequate clearance of airway secretions. Thus, these conditions can
cause chronic respiratory failure as well as potentially life-threatening problems
[510].
Once patients with NMDs develop respiratory failure, noninvasive mechanical
ventilation (NIV) combined with techniques of manually or mechanically assisted
coughing are the main therapeutic interventions to support their respiratory function
[510]. This chapter reviews the pathophysiological mechanisms responsible for
respiratory failure in patients with slowly progressive NMDs (e.g., amyotrophic
lateral sclerosis (ALS), spinal muscular atrophy (SMA), Duchenne muscular dys-
trophy (DMD)) and the issues concerning their respiratory care during ARF. We do
F. Racca, MD (*)
Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital,
Alessandria, Italy
S.C. Anestesia e Rianimazione Pediatrica Azienda Ospedaliera SS Antonio Biagio e Cesare
Arrigo, Via Venezia 16, 15100 Alessandria, Italy
e-mail: fracca7766@gmail.com
C. Robba M.P. Dusio
Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital,
Alessandria, Italy
not consider rapidly progressive NMDs (e.g., Guillain-Barr syndrome and myas-
thenic crises) because there is currently insufficient data to support the extensive use
of NIV in these patients, and clinical issues arising from their rapid clinical evolu-
tion deserve separate remarks.
Table 32.2 Causes of acute exacerbations of chronic respiratory failure in children with NMD
Upper respiratory tracts infections
Pneumonia
Atelectasis
Aspiration
Pneumothorax
Cardiac failure
Tracheal hemorrhage (patients with tracheostomy)
Acute gastric distension (patients under mechanical ventilation)
Abuse of sedative drugs
Postoperative respiratory failure
Pulmonary embolism
Patients with NMD may require intensive care because of the progressive respi-
ratory muscle dysfunction. Their admission to the intensive care unit (ICU) is usu-
ally prompted by precipitating factors (Table 32.2). In particular, ARF usually
occurs in NMD patients as a consequence of otherwise benign upper respiratory
tract infections [1517] or as a result of more severe respiratory complications, such
as pneumonia, aspiration, atelectasis, and pneumothorax [18, 19]. During these
events, the inspiratory muscles strength cannot compensate for the increased respi-
ratory load, resulting in impaired alveolar ventilation. Moreover, weakness of expi-
ratory and bulbar muscle causes ineffective coughing and airway mucus
accumulation that further increases the work of breathing, leading to respiratory
distress [1517, 20].
Patients with NMD usually experience mild to moderate bulbar dysfunction,
with the exception of patients diagnosed with type 1 SMA and ALS, who may
develop a severe glottis functional impairment. Bulbar muscle weakness (facial,
oropharyngeal, and laryngeal muscles) can affect the ability to swallow, leading to
a risk of aspiration.
Additionally, several myopathies (DMD, limb-girdle muscular dystrophies,
myotonic dystrophies, myofibrillar myopathies, mitochondrial myopathies, and
glycogen storage diseases) are associated with cardiac dysfunctions (dilated cardio-
myopathy and/or abnormalities of the conduction system) [21, 22], which may also
contribute to the development of ARF [23].
In NMD patients with compromised respiratory function, anesthetic agents
may further decrease respiratory muscles strength and can exacerbate hypoventi-
lation, airway secretions retention, aspiration, and obstructive and central apneas
[5, 7, 24]. These conditions may lead to nosocomial infections, prolonged intuba-
tion, tracheotomy, and eventually death. Therefore, in all patients with NMDs,
preoperative pulmonary evaluation is strongly recommended to assess the risk of
respiratory complications and when respiratory function measurements and/or
sleep studies are abnormal, NIV and assisted cough techniques may be indicated
[5, 7, 24].
250 F. Racca et al.
History: rule out abuse of sedative drugs, aspiration, and anticipatory care plan
(i.e., a do not intubate order)
Physical examination: rule out signs and symptoms of:
Heart failure (pulmonary crackles, peripheral edema, elevated jugular venous
pressure, pleural effusion, hepatic congestion)
Clinical signs of pneumonia, aspiration, or atelectasis
Pneumothorax
Lab tests:
Serum B-natriuretic peptide and D-dimer (good negative predictive values for
heart failure and pulmonary embolism)
Blood and sputum culture with Gram stain if pneumonia is suspected
Imaging:
Electrocardiogram to rule out arrhythmias and conduction defects
Chest X-ray to rule out cardiomegaly, pulmonary congestion, new pulmonary
infiltrate, and pneumothorax (mandatory computed tomography (CT) scan in
case of suspected pneumothorax and non-conclusive chest X-ray)
Echocardiogram to evaluate ventricular function if heart failure is suspected
patients benefit from NIV. For patients already using nocturnal NIV, daytime NIV
may be required during acute exacerbations [34, 35].
NIV is contraindicated in patients with severe inability to swallow; uncontrolla-
ble airway secretions; life-threatening hypoxemia; severely impaired mental status;
hemodynamic instability; recent facial, upper airway, or upper gastrointestinal tract
surgery; or bowel obstruction [26, 27, 36, 37].
Invasive ventilation should be considered if, despite 612 h of NIV with optimal
ventilator settings, it proves impossible to reduce dyspnea or lethargy, to decrease
the respiratory rate, or to improve blood gas exchange (i.e., refractory arterial pH
below 7.30 or below the value on admission or failure to maintain a PaO2 > 65 mmHg
with a FIO2 0.6) [27, 36].
Hospital admission can be disruptive for these patients [38], who can often be suc-
cessfully managed at home by experienced and well-trained family members [30].
Bach and colleagues [16, 17, 29, 39] described a regimen for managing acute on
chronic neuromuscular respiratory failure at home. The patients received a 24-h NIV
during the exacerbation periods. Oxygen saturation of room air was monitored con-
tinuously and when it fell below 95 %, secretions were aggressively removed using
MI-E (mechanical insufflation-exsufflation) until oxygen saturation returned to the
95 % range. Although controlled studies establishing the efficacy of this approach are
lacking, the authors reported a dramatic reduction in the need for hospitalization and
a prolongation of life expectancy. Vianello et al. [40] showed that hospital at home
for NMD patients with respiratory tract infection for whom hospital admission had
been recommended after medical assessment is an effective alternative to hospital
admission. They treated these patients according to the following treatment protocol:
District nurses visited the subjects mornings and afternoons until recovery from
exacerbation. The nurse assessed the subjects adherence and response to treat-
ment and could request a pulmonology visit if clinical progress was
unsatisfactory.
A pulmonologist visited the subjects each morning for the first 3 days, and there-
after at the discretion of the district nurses or subjects general practitioner, to
assess the response to therapy and eventually introduce changes.
Subject telephone access to the pulmonologists was ensured.
The subjects general practitioners were informed of the subjects being random-
ized to the hospital-at-home program.
Standard antibiotic therapy was used, following guidelines for the management
of acute bronchitis or community-acquired pneumonia.
The ventilator was readjusted to obtain a tidal volume of 1012 ml/kg and a
breathing frequency of <25 breaths/min and to maintain SpO2 95 %. NIV was
initially delivered continuously, except for 3060 min periods of rest to allow
the subject to receive liquid dietary supplements, drink water, and speak. After
the first 2448 h, if clinical conditions and blood gas exchange were satisfactory,
the application of NIV was interrupted by progressively longer intervals of
spontaneous breathing. In all cases, nocturnal ventilation via nasal mask was
continued until the end of the follow-up period.
252 F. Racca et al.
compression) in synchrony with the subjects own cough effort [23]. Nevertheless,
manually assisted coughing requires patient cooperation.
The mechanical insufflator-exsufflator (MI-E or cough machine) is a device
that generates a deep insufflation by a positive pressure blower (i.e., + 3040 cm
H2O) followed immediately by a forced exsufflation in which high expiratory flow
rates are determined by a deep negative pressure (i.e., 30 to 40 cmH2O) [48]. A
range of insufflation of +15 to 40 cmH2O and exsufflation of 20 to 50 cmH2O have
been suggested for the application of MI-E for pediatric patients [49]. The MI-E
may be applied via a full face mask or via endotracheal or tracheostomy tube with
the cuff inflated. Cough flow rates delivered by MI-E were shown to be superior to
those generated by manual-assisted coughing techniques alone [50]. The use of a
MI-E via a face mask increases peak cough flow and aids airway clearance. This
device has been demonstrated to be more effective than other techniques to clear
secretions from the respiratory tract in patients with NMDs [28, 4951]. Treatment
with the MI-E can be required as frequently as every few minutes around the clock
until no further secretions are present [26, 27].
Bronchoscopy should be considered only in cases of persistent atelectasis after
all noninvasive airway clearance techniques have proven to be unsuccessful [23].
After recovery from the acute illness, patients who do not have severe bulbar impair-
ment should be promptly extubated and started immediately on NIV [10, 52, 53].
Unfortunately, because of the weakness of the inspiratory muscles, inadequate
cough, and inability to handle oropharyngeal secretions, a substantial proportion of
patients with NMD who undergo invasive mechanical ventilation fail to pass spon-
taneous breathing trials after recovery from the acute illness and are at high risk for
extubation failure [2, 38, 54, 55]. It should be emphasized that extubation failure is
an outcome to be avoided because it is independently associated with increased
hospital mortality, prolonged ICU and hospital stay, higher costs, and greater need
for care. Therefore, strategies preventing this occurrence are required.
NMD patients are considered at high risk of extubation failure in the presence of
one or more of the following conditions:
Ineffective cough, defined as peak cough expiratory flow less than 160 l/min
Hypercapnia during spontaneous breathing trials
History of extubation failure
Failed multiple spontaneous breathing trials
Table 32.3 Extubation criteria for patients with NMD at high risk of extubation failure
Afebrile and normal white blood cells count
PaCO2 40 mmHg at peak inspiratory pressures < 35 cmH2O on full-setting assist/control
mode
SpO2 95 % for 12 h or more in ambient air
All oxyhemoglobin desaturations <95 % reversed by cough machine and suctioning via
translaryngeal tube
Fully alert and cooperative, receiving no sedative medications
Chest radiograph abnormalities cleared or clearing
Air leakage via upper airway sufficient for vocalization upon cuff deflation
SpO2 pulse oxyhemoglobin saturation
the results of a large uncontrolled study performed on a NMD population that also
included patients with acquired critical care myopathy, showing that the standard-
ized use of NIV and cough assistance leads to successful extubation in almost all
cases of NMD patients.
Bach et al. [52] developed a NMD-specific extubation protocol and NMD-
specific extubation criteria. While intubated, ventilatory support was used to main-
tain normocapnia and normal respiratory rates. A cough machine was used at 40
to + 40 cmH2O or greater with exsufflation-timed abdominal thrusts. The cough
machine sessions were up to every 20 min to maintain or return the pulse oxyhemo-
globin saturation (SpO2) to 95 % in ambient air. Once extubation criteria
(Table 32.3) were met, the orogastric or nasogastric tube was removed to facilitate
post-extubation nasal NIV. The patient was then extubated directly to NIV on assist/
control on room air. NIV was provided via a combination of nasal, oronasal, and
mouthpiece interfaces. For episodes of SpO2 < 95 %, ventilator setting, interface air
leakage, CO2 retention, and cough machine were considered. The therapists, nurses,
and, in particular, the family and personal care attendants provided Mechanical
assisted cough via oronasal interfaces up to every 20 min until the SpO2 no longer
dipped below 95 % and the patients felt comfortable and clear of secretions.
Tracheostomy may be required, but it should not be considered in the acute
phase. Tracheotomy would be recommended if the extubation criteria (Table 32.3)
could not be met within 2 weeks of application of the protocol [52].
Conclusion
In conclusion, when patients with NMDs develop respiratory failure, a noninva-
sive approach is preferred where feasible. For patients who do not have severe
bulbar impairment, the use of NIV in combination with assisted coughing is an
effective alternative to invasive ventilation. Moreover, ARF is usually prompted
by precipitating factors, whose identification is essential because they are ame-
nable to therapy. If a noninvasive approach fails, patients can be intubated and
mechanically ventilated as a short-term measure. After recovery from the acute
illness, patients without severe bulbar impairment should be promptly extubated
and treated with NIV combined with assisted coughing. Finally, tracheotomy can
be considered, but not as an acute intervention.
256 F. Racca et al.
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Dysphagia in Post-extubation
Respiratory Failure: Potential 33
Implications of Noninvasive Ventilation
33.1 Introduction
cerebrovascular stroke have been reported in which 94 % of the subjects were seen
to suffer some degree of dysphagia, in an important number of cases with a good
response to conventional rehabilitation therapy. The persistence of dysphagia in
these patients was associated with a poorer prognosis, a prolonged hospital stay, and
increased admission to homes for the elderly, worsening of quality of life, and
dependency for activities of daily living [1].
The incidence of pharyngeal and laryngeal incompetence (typically in the intra-
glottic/subglottic region) in patients requiring an artificial airway has not been
clearly established. Some studies suggest an incidence range from 3 to 62 % in
recently extubated patients, that is, post-extubation dysphagia (PED) [2-4]. In a
large cohort of critically ill patients, dysphagia (non-neurologic) was present in
84 % of patients and between 50 and 84 % of patients required tracheotomy [1, 2].
Translaryngeal intubation can affect the laryngeal structures as a result of direct
impact during intubation, in the course of prolonged intubation, in restless patients,
as a consequence of abrasion of the laryngeal mucosa, or secondary to the mere
presence of the orotracheal tube. Common findings are vocal cord edema and swell-
ing of the supraglottic space (Fig. 33.1), with a less frequent observation of granu-
lomas at this level. Other infrequent findings are arytenoid subluxation or luxation
(Fig. 33.2) or vocal cord paralysis secondary to direct damage or involvement of the
recurrent nerves. The orotracheal (translaryngeal) tube keeps the glottis open for
prolonged periods of time, abolishing the natural movements of the larynx and of
pharyngeal muscles. This, in turn, leads to muscle atrophy, weakness of the pharyn-
golaryngeal muscles, and stiffness of the tongue, pharynx, hypopharynx, and lar-
ynx. The intrinsic movements of the larynx, such as reflex glottic closure during
swallowing, are affected. The edema produced as a result of the indwelling foreign
body (translaryngeal tube) and the absence of correct stimulation of the laryngeal
and hypopharyngeal mechanoreceptors cause a decrease in sensitivity to the pres-
ence of secretions, altering the complex swallowing mechanism, which in turn can
facilitate laryngeal penetration or tracheal aspiration. The length of time intubated
is the most deleterious condition for the development of PED because of muscle
atrophy, and impairment of the nerve endings in the glottic and subglottic region,
interruption of air passage through the glottis, and the loss of pressure in the sub-
glottic region directly affect the cough reflex, laryngeal adduction, and glottis clos-
ing capacity. The glottic and subglottic muscles are affected not only by
polyneuropathy in the critical patient but also largely by a lack of use. In fact, restor-
ing air passage through the glottis after extubation or using fenestrated cannulas
and/or speaking valves facilitates rehabilitation and posterior recovery from such
alterations, in addition to correction of the swallowing and speech mechanisms.
The studies conducted to date in relation to laryngeal PED comprise a limited
number of heterogeneous patients [4]. In such studies, it is important to note that,
hours after intubation, patients may develop laryngeal alterations that can persist
for prolonged periods of time. A recent series has reported that in the first 24 h after
extubation, 44 % of the patients suffered aspirations not accompanied by cough
reflex. In one of the largest series the incidence of PED was 84 %, 17 % of them
were classified as severe dysphagia, and moderate 23 %; mild an severe PED was
associated independently with the composite outcome of pneumonia, reintubation
and death agreeing with other series [3, 4]. The use of simple screening methods or
protocolization of the study of such disorders has been shown to be useful, allow-
ing the identification of patients at high risk, with a view to adopting appropriate
management measures.
262 A.F. Carmona et al.
Conclusion
PED is a high-prevalence pathology in the ICU and should be suspected and
treated in all patients needing prolonged mechanical ventilation. Although it
often is an underestimated pathology, it has serious implications and carries
higher morbidity and mortality rates.
NIVs incorporation in weaning protocols does not avoid the appearance of
PED, although it probably improves its recovery by shortening invasive mechan-
ical ventilation time and decreasing the reintubation rate, as well as restoring
anatomical airway flow and rehabilitation. New applications or designs of this
technology might allow better dysphagia rehabilitation and a precocious begin-
ning of safe oral nutrition during the critical care weaning process.
The development of secretion encumbrance can be a determinant of NIV fail-
ure. It should be monitored and correctly treated, including in protocols the use
of technologies such as MI-E in case of impaired airway secretion clearance.
264 A.F. Carmona et al.
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Agitation During Prolonged Mechanical
Ventilation and Influence on Weaning 34
Outcomes
34.1 Introduction
E. Tobar (*)
Internal Medicine Department North, University of Chile Clinical Hospital,
University of Chile School of Medicine, Santiago, Chile
e-mail: eduardotobar@med.uchile.cl
D. Gusmao-Flores
Universidade Federal da Bahia, Instituto de Ciencias da Saude,
Edgar Santos University Hospital, Salvador, Bahia, Brazil
Over the past 15 years, awareness of the importance of managing delirium in the
ICU has increased. The condition is acute, fluctuating, and multifactorial in origin
and is characterized by disturbances in attention and other brain functions. Delirium
is common, with an incidence of 5085 % in MV patients. Although hypoactive
symptoms are the most typical, mixed or hyperactive forms of delirium occur in
540 % of cases, making delirium the main cause of agitation in the ICU [13].
However, it should be noted that agitation is sometimes attributable to causes
other than delirium; therefore, it is important to systematically monitor for these
other factors. Other causes include pain and withdrawal from illicit drugs or pre-
scription medications. We revisit this point below.
Diagnosis of agitation is simple, based on clinical observation of the patient. The
nurse is typically the first professional to recognize agitation. It is important to use
a valid scale to rate the severity of agitation and to evaluate the need for urgent mea-
sures according to severity. Current guidelines for managing pain, sedation, agita-
tion, and delirium recommend the use of the following scales to monitor sedation
level and agitation: Sedation-Agitation Scale (SAS) and the Richmond Agitation-
Sedation Scale (RASS) [47].
(a) Withdrawal associated with illicit or prescription drugs: Similar symptoms have
been reported for withdrawal from recreational and therapeutic drugs. These
cases are typically recognized in the emergency room, where the most severe
cases are labeled excited delirium syndrome (EXDS), characterized by severe
agitation, hyperthermia, and acidosis [15].
(b) Withdrawal associated with sedatives or opioids used in the ICU: An incidence
of 32 % has been reported for patients on MV for more than 1 week, but there
are few studies in this topic. This condition is associated with higher doses of
sedatives, the use of neuromuscular blockers, and the presence of acute respira-
tory distress syndrome [16]. These cases are particularly complex, given the
difficulty in differential diagnosis of hyperactive delirium without withdrawal
and the theoretically different management of the two situations (standard by
protocol administration of sedatives versus minimizing benzodiazepines).
(c) Withdrawal associated with chronic alcohol abuse: Alcohol-use disorders
(AUD) are common in the ICU. In these patients, the use of sedatives is impor-
tant. Agitation develops as part of the withdrawal syndrome in 18 % of patients
with AUD [17, 18]
(d) Withdrawal associated with chronic tobacco abuse: Recent studies have reported
an association between nicotine withdrawal and agitation in the ICU [19].
The presence of any of these four withdrawal syndromes should always cue the
team to monitor for agitation in the ICU. If possible, withdrawal symptoms should be
addressed before the onset of agitation in the ICU. If there is no documented history
of alcohol, tobacco, or drug use, it may be advisable to re-interview the family and
document any newly reported history if severe, difficult-to-control agitation occurs.
Adverse events related to agitation are numerous: First, deleterious physiological
consequences of agitation include elevated oxygen consumption, increase in intra-
cranial pressure, hemodynamic instability secondary to both the agitation itself and
the pharmacological interventions used to manage its symptoms, increase in the
work of breathing, and patient ventilator asynchrony. Agitation can develop or
worsen during a spontaneous breathing trial (SBT) and is a common contraindica-
tion for SBT and/or cause of SBT failure.
From the point of view of relevant outcomes, agitation is associated with longer
duration of MV, prolonged ICU stay, higher risk of nosocomial infection, higher
rate of unplanned extubation (UE), and unplanned removal of central venous line
[911]. UE is the most-documented adverse event associated with agitation.
Incidence of UE is related to the sedation strategy and the monitoring level used by
268 E. Tobar and D. Gusmao-Flores
Start of Exitous
MV extubation
Delirium /
Agitation
Can I
MV controlled Is the SBT Succesfull
extubate to
(if needed) feasible ? Extubation
my patient ?
Agitation is one of the subjective criteria for failure of a SBT; however, agitation
is a continuum, with mild and severe types, and sometimes isolated mild agitation
can be controlled with nonpharmacological measures and medication. However, in
other cases a new agitation during a SBT is a symptom of cardiovascular or respira-
tory failure and the patient must be reconnected to MV This difference is not always
easy to detect and it requires a global evaluation of whether mental symptoms of
failure are alone or with other objective or subjective failure criteria. There are no
studies to help to make this decision and a good clinician is needed.
Sometimes agitation begins following extubation. Extubation failure happens in
618 % of patients and is associated with increased ICU mortality, so it is important
to detect it and to quickly determine whether the patient needs to be reintubated.
Similar to agitation during SBT, the new agitation after extubation is a bad sign and,
after a global evaluation for other criteria of failure, the decision must be made
whether to offer noninvasive ventilation (NIV) or a fast reintubation. In our opinion,
significant agitation is in this setting a contraindication for NIV. Only in mild agita-
tion without other signs of failure can we offer NIV with close observation.
The incapacity to follow orders has been studied in neurocritical patients as a risk
factor for extubation failure [25], but another more recent study did not show an
association between delirium and extubation failure [26]. This research area looks
controversial and more studies are needed looking for the association of delirium
and/or agitation with extubation failure.
(a) Complete history of risk factors for agitation, including medication list and his-
tory of illicit drug, alcohol, or tobacco use.
(b) Serial evaluation or pain, using instruments validated for mechanically venti-
lated patients such as the behavioral pain scale [27] or the Critical-Care Pain
Observation Tool (CPOT) [28].
(c) Serial monitoring of sedation level and agitation using the SAS or RASS, men-
tioned above. Chanques et al. [29] reported that systematic monitoring for pain
and agitation alone reduced the incidence of agitation.
(d) Daily monitoring of delirium. As with pain, sedation, and agitation, valid instru-
ments should be used to monitor delirium, such as the Confusion Assessment
method for the ICU (CAM-ICU) or Intensive Care Delirium Screening Checklist
(ICDSC) scales.
(e) Adherence to recommendations for pain and delirium management. Severe
pain is also recognized as a causal factor in agitation; therefore, optimal analge-
sia is important. To manage hypoactive delirium, early intervention with non-
pharmacological therapy should be deployed, including occupational therapy
and multimodal management.
(f) Use of dexmedetomidine as a sedative in MV patients. There is evidence from
clinical trials as well as level IIB evidence suggesting that dexmedetomidine
reduces the risk of delirium compared with benzodiazepines. Given that delir-
ium is the main cause of agitation, it is reasonable to assume that reducing the
incidence of delirium may reduce the incidence of agitation, although this idea
has not been systematically evaluated.
At onset of agitation, the first priority is to minimize risk to the patients physical
integrity (falls, accidental removal of breathing tube, catheters, drains, or other
equipment), and, in parallel, to protect the hospital staff from physical injury. Severe
agitation in a young patient may require the strength of three or four team members
to apply physical restraints.
It is crucial to evaluate the severity of the condition, as appropriate management
of mild cases can often prevent the onset of severe agitation. Mild cases will respond
to verbal direction, allowing time for appropriate diagnostic and pharmacological
intervention. The diagnostic process should also include evaluation of pain, delir-
ium, and withdrawal syndromes, as previously noted. If these scales suggest the
presence of pain, an opiate bolus is recommended; in our center, we use 25100 g
of fentanyl, depending on body weight, titrating according to clinical response. If
CAM-ICU or ICDSC scores indicate delirium, the use of neuroleptic agents is rec-
ommended. Worldwide, the most commonly used drug of this type is haloperidol.
The recommendation is to begin with 0.51.0 mg administered enterally, keeping in
mind that the onset of action is about 20 min. Intravenous administration is discour-
aged, due to the higher risk of prolonged QT interval and arrhythmias. If no other
administration route or drug is available, we suggest using 0.51 mg of intravenous
haloperidol in 50100 of saline over 30 min, performing an electrocardiogram as
soon as possible to evaluate for QT. It is important to consider that neuroleptics have
potential adverse cardiac and neurological effects (such as extrapyramidal symp-
toms), and the level of evidence supporting their use is low.
Given their more favorable safety profile, recent studies have evaluated atypical
neuroleptic agents such as risperidone, quetiapine, and olanzapine. One small-scale
study of the use quetiapine in critical care patients suggested a reduced duration of
delirium as compared with a control group [30].
34 Agitation During Prolonged Mechanical Ventilation 271
For more severe cases, a bolus of sedative may be necessary during the acute
phase to control agitation.
Dexmedetomidine should be considered the sedative of choice for managing agi-
tation during weaning. The goal is not only to control agitation but also to avoid
returning to profound levels of sedation that would delay or limit the application of
the SBT. Dexmedetomidine is a promising candidate for this application due to its
characteristics, although, again, evidence for its use is limited to clinical series and
extrapolations from clinical trials comparing this drug to benzodiazepines as the
sedative of choice during weaning [3133].
Other therapeutic strategies that have been studied at the level of clinical series
or small clinical trials include music therapy and electroconvulsive therapy in
refractory cases.
Conclusion
Agitation is common among mechanically ventilated patients, typically occur-
ring during the weaning period. Agitation limits both the application and the
likelihood for success of the SBT and increases the chance of weaning failure. In
addition to accurately diagnosing agitation, it is important to measure the sever-
ity of the condition and monitor for etiologies other than delirium. Using best
practices for managing pain, sedation, and delirium improves outcome and
reduces the impact of agitation during the weaning process.
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34 Agitation During Prolonged Mechanical Ventilation 273
35.1 Introduction
Bi-level positive airway pressure (BiPAP) allows the application of two levels of
positive airway pressures: expiratory positive airway pressure (EPAP) and inspira-
tory positive airway pressure (IPAP) [7]. EPAP has similar physiological effects to
continuous positive airway pressure (CPAP)/PEEP, whereas IPAP acts as pressure
support ventilation (PSV) on top of EPAP (Fig. 35.1). The toggling between these
two pressure levels is controlled by the patients spontaneous pattern of breathing.
BiPAP therapy can improve oxygenation and relieve respiratory distress by one of
the following mechanisms [7]. First, the use of positive airway pressure during the
expiratory phase of BiPAP (i.e., EPAP) serves as a CPAP/PEEP. The beneficial
effect of CPAP/PEEP contributes to the recruitment of collapsed alveoli, and hence
can increase the FRC and decrease the degree of shunt with a consequent improve-
ment of oxygenation. Also, EPAP can stabilize recruited alveoli and prevent dere-
cruitment. Second, the implementation of positive airway pressure during the
inspiratory phase of the BiPAP therapy (i.e., IPAP) functions as PSV. This not only
35 BiPAP for Preoxygenation in Acute Postoperative Respiratory Failure 277
+3 E E E E
Spont 0
3 I I I I I
E E E E
5
CPAP I I I I I
0
IPAP
10
BiPAP
5
EPAP
0
Fig. 35.1 Airway pressure versus time with spontaneous breathing, continuous positive airway
pressure (CPAP), and bi-level positive airway pressure (BiPAP)
can contribute to resolving atelectasis, but can improve alveolar oxygenation by the
increase in alveolar ventilation resulting in increase of tidal volume with the use of
IPAP, and will lead to a decrease in the work and oxygen cost of breathing [7].
BiPAP is being more frequently used for acute postoperative respiratory failure as it
provides several advantages over traditional invasive mechanical ventilation. BiPAP is
a form of noninvasive ventilatory support that minimizes the risks of ventilator-
induced lung injuries, reduces the need for excessive sedation, and preserves the upper
airways reflexes and functions for better protection against aspiration and for better
humidification of inspired gas. Two separately adjusted pressure levels, EPAP and
IPAP, allow the clinician to independently maintain upper-airway patency and pre-
vent airway/alveolar collapse/derecruitment during exhalation, thereby preventing
atelectasis and increasing the FRC that is the main oxygen store as well as augmenting
tidal volume and alveolar ventilation and subsequently alveolar oxygenation [7].
BiPAP as a preoxygenation method has been shown to be more effective at reducing
arterial oxyhemoglobin desaturation than conventional preoxygenation techniques
during intubation in hypoxemic patients [8]. Furthermore, the levels of oxygenation
achieved with BiPAP are usually sustained for longer duration after intubation than
conventional preoxygenation techniques with a non-rebreather bag-valve mask [8].
This reflects the possible significant linear correlation between oxyhemoglobin satu-
ration at the end of the preoxygenation period with BiPAP and the minimal oxyhemo-
globin saturation during endotracheal intubation.
278 F.-M. ElKhatib et al.
References
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Hagbergs airway management. Philadelphia: Elsevier; 2013. p. 28097.
2. Taha S, Siddik-Sayyid S, El-Khatib M, et al. Nasopharyngeal oxygen insufflation following
pre-oxygenation by the four deep breath technique. Anaesthesia. 2006;61:42730.
3. Taha S, El-Khatib M, Siddik-Sayyed S, et al. Preoxygenation by 8-deep-breaths in 60 seconds
using Mapleson A (Magill) or the circle system versus Mapleson D system. J Clin Anesth.
2009;21(8):5748.
4. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the dif-
ficult airway: an updated report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology. 2013;118(2):25170.
280 F.-M. ElKhatib et al.
5. Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emer-
gency department. J Emerg Med. 2011;40:6617.
6. Imberger G, McIlroy D, Pace NL, et al Positive end-expiratory pressure (PEEP) during anaes-
thesia for the prevention of mortality and postoperative pulmonary complications. Cochrane
Database Syst Rev. 2010;(9):CD007922.
7. Hess DR. Noninvasive ventilation for acute respiratory failure. Respir Care.
2013;58(6):95072.
8. Baillard C, Fosse JP, Sebbane M, et al. Noninvasive ventilation improves preoxygenation
before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;174:1717.
9. Jean-Marc Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pres-
sure ventilation to enhance preoxygenation in morbidly obese patients: a randomized con-
trolled study. Anesth Analg. 2008;107:170713.
10. El-Khatib M, Kanazi G, Baraka A. Noninvasive bilevel positive airway pressure for preoxy-
genation of the critically ill morbidly obese patient. Can J Anesth. 2007;54(9):7447.
11. Herriger A, Frascarolo P, Spahn DR, et al. The effect of positive airway pressure during pre-
oxygenation and induction of anaesthesia upon duration of non-hypoxic apnoea. Anaesthesia.
2004;59:2437.
12. Baraka A, Mariane Aouad M, Maalouli J, et al. BiPAP. Management of hypoxemia associated
with unilateral phrenic nerve palsy following surgery for thoracic outlet syndrome. Middle
East J Anesth. 2002;16(5):53542.
13. Hillberg RE, Johnson DC. Noninvasive ventilation. N Engl J Med. 1997;337:174652.
Determinant Factors of Failed
Extubation and the Use of Noninvasive 36
Ventilation in Trauma Patients
Abbreviations
36.1 Introduction
Trauma patients are frequently admitted to the intensive care unit (ICU) requiring
intubation and prolonged ventilator support. These interventions are necessary and
life-saving but also carry with them potential complications that include but are not
limited to laryngeal and pulmonary trauma, hemodynamic compromise, and pneu-
monia. For these reasons, patients should be liberated from a ventilator as soon as
feasibly possible. This can be accomplished either by extubation or tracheostomy.
Balancing the need for early liberation from a ventilator is the risk of failed extu-
bation or prolonged ventilator dependence. Patients who require reintubation often
require it in emergent, less than ideal conditions. These patients have higher rates of
E. Bui, MD (*)
Division of Acute Care Surgery, Los Angeles County + USC Medical Center, Los Angeles,
CA, USA
e-mail: ehbui81@gmail.com
J. Aydelotte, MD B. Coopwood, MD C.V.R. Brown, MD
Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX, USA
adverse outcomes as well, including pneumonia, increased ICU and hospital days,
increased rate of tracheostomy, and increased mortality.
In the general population of ICU patients, risk factors for failed extubation include
duration of ventilation, advanced age, severity of illness at the time of extubation,
anemia, semirecumbent position, intravenous sedation, and unexplained extubation.
The reported rate of failed extubation in the literature ranges from 2 to 25 % across
variable patient populations [1]. However, little is published about risk factors and
outcomes specific to failed extubation in trauma patients.
In 2011, Daigle et al. [1] looked specifically at trauma patients as a population to
identify risk factors for reintubation. A prospective, observational study was per-
formed of all adult trauma patients who required endotracheal intubation admitted
to the ICU over an 18-month period. Failed extubation was defined as unplanned
reintubation within 24 h. Cause of failure of extubation was determined (airway
obstruction, respiratory failure, secretions, hemodynamic instability, and deteriora-
tion of neurologic status). All patients were extubated after a spontaneous breathing
trial per institutional protocol.
The two groups (successful vs failed extubation) had similar demographics with
regards to age, gender, body mass index, injury severity score, or need for opera-
tions (craniectomy, laparotomy, thoracotomy).
The statistical analysis identified several independent risk factors for failed extu-
bation (Table 36.1). The presence of spine fractures, initial intubation for airway
issues, delirium tremens, and lower Glasgow Coma Scale (GCS) at the time of
extubation (GCS of 9 vs 10) were all associated with need for reintubation [1].
Patients who failed extubation also, interestingly, have a higher initial GCS on
admission than those that did not.
Patients who failed extubation were found to more often require prolonged ven-
tilation (>48 h). Compared with those who tolerated extubation, those who failed
remain intubated for 4 2 days longer [1].
The use of noninvasive ventilation (NIV) techniques, that is, continuous positive
airway pressure (CPAP) in post-extubation respiratory failure has been described in
the literature. Several randomized controlled trials (RCT) have shown mixed results.
pneumothorax [8]. ICU length of stay was also lower in patients who were treated
with NIV. Interestingly, there was no difference when comparing the different
modalities of NIV (CPAP, bi-level positive airway pressure, or noninvasive pressure
support ventilation) [8].
36.4 Discussion
Key Recommendations
1. Patients who have spine fractures, were intubated for an airway issue, have
a depressed GCS at the time of extubation, or have delirium tremens are at
higher risk for failed extubation. These patients should be closely moni-
tored following extubation.
2. NIV is safe in patients with chest trauma who are appropriate candidates
for it and can potentially prevent the need for initial intubation.
3. NIV should not delay endotracheal intubation if intubation is indicated.
4. The exact subset of trauma patients who will best benefit from NIV is yet
to be defined.
36 Determinant Factors of Failed Extubation 285
References
1. Brown CV, Daigle J, Foulkrod K, et al. Risk factors associated with early reintubation in
trauma patients: a prospective observational study. J Trauma. 2011;71(1):3742.
2. Esteban A, Frutos-Vivar F, Ferguson N, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. N Engl J Med. 2004;350:245260.
3. Keenan S, Powers C, McCormack D, et al. Noninvasive positive-pressure ventilation for
postextubation respiratory distress. JAMA. 2002;287(24):323844.
4. Ferrer M, Valencia M, Nicolas M, et al. Early noninvasive ventilation averts extubation failure
in patients at risk. Am J Respir Crit Care Med. 2006;173:16470.
5. Agarwal R, Aggarwal A, Gupta D, et al. Role of noninvasive positive-pressure ventilation in
postextubation respiratory failure: a meta-analysis. Respir Care. 2007;11:14729.
6. British Thoracic Society Standard of Care Committee. Non-invasive ventilation in acute respi-
ratory failure. Thorax. 2002;57:192211.
7. Hernandez G, Fernandez R, Lopez-Reina P, et al. Noninvasive ventilation reduces intubation in
chest trauma-related hypoxemia. Chest. 2010;137(1):7480.
8. Chiumello D, Coppola S, Froio S, et al. Noninvasive ventilation in chest trauma: systematic
review and meta-analysis. Intensive Care Med. 2013;39:117180.
Noninvasive Mechanical Ventilation
in Tetraplegia 37
Michael A. Gaytant and Mike J. Kampelmacher
Abbreviations
37.1 Introduction
Spinal cord injury (SCI) is prevalent worldwide, with an estimated 1540 cases per
million population [1]. Injury to the cervical and upper thoracic cord may disrupt
the function of the diaphragm, intercostal muscles, accessory respiratory muscles,
and abdominal muscles. This causes reduction in spirometric parameters and static
mouth pressures and results in ineffective cough and difficulty in clearing secretions
37.2 Pathophysiology
In the case of an intact central nervous system, respiration occurs via two systems
[3, 5]:
(a) A coordinated activity of the somatic nervous system, which controls the inspi-
ratory and expiratory muscles
(b) The autonomic nervous system, which controls the bronchial tone and
secretion
The diaphragm is the main inspiratory muscle and is innervated by the phrenic
nerve. It receives primary innervation at the C4 level, often with contribution from
C3 and C5. The diaphragm provides 65 % of the tidal volume during normal breath-
ing. Other inspiratory muscles are the external intercostal muscles and the accessory
muscles (scalene, sternocleidomastoid, trapezius, and pectoralis). The intercostal
muscles are innervated by segmental spinal nerves (T111) and assist inspiration by
elevating the ribs, which expands the chest wall. The scalene muscles receive inner-
vation by segmental nerves C48, the trapezius and sternocleidomastoid by C14
and the accessory nerves.
Expiratory muscles are the abdominal muscles and the lateral internal intercos-
tals (T112) and are important for the expulsive force needed for an effective cough
and to clear secretions.
there is a high degree of variability of the ability to wean in the C3 and C4 popula-
tion [9]. In patients with SCI C56 or below, there is a probability to recover suffi-
cient spontaneous ventilation.
As atelectasis, pneumonia, and ventilatory failure are the most common respira-
tory complications in the acute hospitalization phase of cervical SCI patients, moni-
toring and early treatment of these patients is of significant importance.
Consortium guidelines on respiratory management recommend that initial
assessment should include investigations like an arterial blood gas (ABG) and chest
X-ray [10]. ABG can show respiratory dysfunction: PaCO2 is used to evaluate ven-
tilation abnormalities and PaO2 is a sensitive tool for evaluation of atelectasis. In the
first few days after injury, one can monitor respiratory function by serial ABG (e.g.,
4 times per 24 h) or by end-tidal CO2 measurements and continuous pulse oximetry.
Serial chest X-rays assess for atelectasis, pulmonary edema, and aspiration. In addi-
tion to these investigations, tachypnea, progressive desaturation, and rapid decline
of vital capacity are important signs of impending respiratory failure.
For secretion management and optimal ventilation, suctioning is essential.
However, possible complications like hypoxia, hypotension, infection, tracheal
mucosa damage, and increased bronchial mucous production can occur [3, 11].
In cases of impaired cough, peak cough flow may be augmented by means of
performing an abdominal thrust and/or squeeze over the chest wall in coordination
with either the patients spontaneous breath, an assisted breath, or by airstacking
(insufflation of air in the lungs after maximal inspiration with the use of a manual
resuscitation bag) combined with an abdominal thrust [4, 12].
In cases of chest trauma, internal abdominal trauma, or unstable spine traction,
this is, however, contraindicated. In these circumstances a mechanical insufflation-
exsufflation device or cough-assist machine might be used for mechanically assisted
coughing (MAC). This is a therapy that simulates the cough cycle through mobiliz-
ing secretions by gradually applying a positive pressure to the airways and then
rapidly shifting to negative pressure, generating a high expiratory flow simulating a
natural cough. It may also clear the left airways (which are often not cleared well by
invasive suctioning) and can be used in intubated, tracheotomized, and nonventi-
lated patients [11, 13].
To clear the airways, MAC may be combined with Intrapulmonary Percussive
Ventilation (IPV, Percussionaire Corp., Sandpoint, ID, USA). This is a combina-
tion of high-frequency ventilation and intrapulmonary chest percussion. It is used to
mobilize and clear retained secretions and to assist in the resolution of atelectasis by
means of high-frequency ventilations (up to 300 breaths per minute), which loosen
retained secretions and deliver aerosol to hydrate viscous mucous plugs [3, 11].
37.5.1 Ventilators
Although any ventilator can be used for NPPV, increasingly ventilators are used that
are designed specifically for NPPV. There are two types that are specifically used:
bi-level positive airway pressure (BiPAP) and intermediate ventilators.
BiPAP ventilators are designed specifically for NPPV and use a single-limb cir-
cuit. A leak port, which serves as a passive exhalation port for the patient, is incor-
porated into the circuit near the patient or into the interface to prevent rebreathing.
Intermediate ventilators use a single-limb circuit with an exhalation valve near the
patient. Some of the intermediate ventilators can also be used with a leak system
like the BiPAP ventilators.
A number of modes can be used with NPPV, and there are advantages and disad-
vantages of each. The BiPAP ventilators typically provide pressure support or
pressure-controlled ventilation. The newer generations of the intermediate ventila-
tors provide volume-controlled ventilation (VCV), pressure-controlled ventilation
(PCV), and pressure support ventilation (PSV).
PSV This mode is used most commonly for NPPV. With bi-level ventilators, the
difference between inspiratory positive airway pressure and expiratory positive air-
way pressure is the level of pressure support (PS). With a critical care ventilator, the
level of PS is applied as a pressure above the baseline positive end-expiratory pres-
sure (PEEP).
PCV This is similar to PSV in that the ventilator applies a fixed level of support
with each breath, but there are two differences: there is a back-up rate and the inspi-
ratory time is fixed.
VCV With VCV, the ventilator delivers a fixed tidal volume (TV) and inspiratory
flow with each breath. VCV has been used during NPPV for home mechanical ven-
tilation (HMV) with intermediate ventilators and requires a non-vented interface. It
can also be used to provide mouthpiece ventilation and for breath-stacking
maneuvers.
PCV or PSV will compensate for leaks better than VCV. With VCV, flow and
volume delivery from the ventilator are fixed, so any leak will reduce the TV. To
compensate for a leak, the set TV may be increased but this will usually increase the
leak as well. In case of PSV or PCV, the ventilator targets a constant inspiratory
pressure. Thus, if a leak occurs, there will be a drop in pressure, at which point the
ventilator increases the flow to restore the pressure.
37.5.2 Interfaces
by air leaks, claustrophobia, facial skin erythema, rash, irritation of the eyes, and
skin breakdown (especially of the nose bridge).
The following masks are used:
Air leaks may reduce patient tolerance and the effectiveness of NPPV, increase
patient-ventilator asynchrony (loss of triggering sensitivity), and cause discomfort
during sleep.
Nasal masks/pillows have less interference with speech and eating, and allow
coughing and vomiting. Nasal pillows have less dead space than face masks, are less
likely to produce claustrophobia, and allow for wearing glasses. Pillows can be
alternated with oronasal and nasal masks to minimize friction and pressure on the
skin, which could improve tolerance of NPPV and therefore allow for more hours
of ventilation per day. Contraindications are leaks from the mouth during sleep, for
example, due to bulbar pathology.
Oral interfaces are used by patients who have severe chronic respiratory failure
and have to be ventilated during daytime for many hours. During the night they use
a nasal or oronasal mask.
Oronasal masks: The advantages compared with nasal masks are that they cause
less air leaks. They are, however, contraindicated in patients with claustrophobia
and in patients with impairment in arm movement who cannot remove their mask in
case of vomiting.
Full face masks are often used in acute NPPV but not often in long-term NPPV. In
case of severe skin problems of the nose bridge, a full face mask can be used tem-
porarily to let the skin heal.
For patients with motor complete SCI at the C5 level and below, spontaneous respi-
ratory effort may initially be supported by BiPAP [14]. Positive airway pressure
improves ventilation because of a better gas exchange and improves resting lung
ventilation by increasing the TV. It is also useful in preventing and treating atelec-
tasis. Applying PEEP will generate resistance on exhalation, which may increase
oxygenation and treat atelectasis [3].
If the patient is able to grab a mouthpiece that is fixed near the mouth by a
flexible metal support arm attached to the wheelchair and keep it between his or
her teeth all day, ventilation during daytime is available whenever needed by the
37 Noninvasive Mechanical Ventilation in Tetraplegia 293
patient. Alternatively, nasal pillows or a nasal mask may be used for daytime
ventilation [4].
The standard ventilator settings of 68 ml/kg of ideal bodyweight (BW) do not
apply for patients with SCI. In patients with complete tetraplegia, high TVs up to
20 ml/kg of ideal BW have been beneficial in stabilizing their ventilation [11]. Low
TVs delivered to patients with acute tetraplegia can lead to atelectasis, mucous
plugging, and decreased production of surfactant [11]. High TV ventilation recruits
distal airways, stimulates surfactant production, and improves oxygenation. Peak
airway pressures with these higher TVs rarely exceed 30 cm H2O because of flaccid
muscle tone in patients with complete tetraplegia, thus taking away the fear of baro-
trauma [11].
In a retrospective review of 28 patients with acute SCI, BiPAP was successfully
used in 10 of 17 patients to prevent the need for full-time ventilation [14]. In these
10 patients, vital capacity (VC) on admission measured 1.1 l (range 0.71.8 l) and
decreased to a mean of 0.9 l immediately before starting BiPAP. In the seven patients
in which BiPAP did not prevent ventilatory failure, the mean vital capacity fell to
0.6 l before beginning BiPAP. Bach [3] recommends the use of NPPV, either nasally
or by mouthpiece ventilation, in case of dyspnea or if the VC falls below 1500 ml
over a relative short time, or less than 1200 ml at any time. Reasons to initiate treat-
ment with BiPAP, according to Tromans et al. [14], included respiratory fatigue and
exhaustion with falling oxygen saturation and decreasing vital capacity. Both stud-
ies are retrospective and had a limited number of cases.
37.8 Discussion
Respiratory complications are still the leading cause of morbidity and mortality in
patients with SCI. In patients with cervical SCI above the C3 level, immediate and
24-h mechanical ventilation is required to sustain life. In practice, this almost always
294 M.A. Gaytant and M.J. Kampelmacher
will lead to tracheostomal ventilation. There are, however, experiences with imme-
diate NPPV after extubation [4] and transition to NPPV after a period of tracheos-
tomal ventilation in patients with very high SCI injuries [15].
In case of cervical injury at C35, respiratory insufficiency results as a conse-
quence of significant respiratory muscular dysfunction, which will lead to inade-
quate VC and inadequate cough. In these patients, there may be a role for NPPV
over the long term instead of invasive ventilation. The success of the transition to
NPPV will depend on knowledge of NPPV techniques and familiarity with tech-
niques like airstacking, MAC and IPV. Without adequate experience of these tech-
niques, failure of NPPV is likely to happen.
In patients with SCI at C56 or below, there is a probability to recover sufficient
spontaneous ventilation. However, they remain at risk for the development of respi-
ratory failure and SDB. Consequently, regular follow-up is recommended with
assessment of respiratory function, nocturnal gas exchange, and symptoms that
would indicate respiratory insufficiency. Noninvasive techniques like airstacking
and MAC may prevent respiratory insufficiency. When respiratory insufficiency
will occur, despite all efforts, NPPV can be initiated.
In recent years, the use of NPPV has been proposed for patients with SCI as respi-
ratory support both in acute conditions, in respiratory weaning, and as long-term noc-
turnal support for patients with hypoventilation [7]. Most publications, however, are
case reports or retrospective studies with low numbers of patients. According to Bach
[4], the only indication for tracheotomy in SCI patients is when saliva aspiration
occurs to the degree that the oxyhemoglobin saturation (SpO2) decreases and remains
below 95 % irrespective of optimal use of MAC or NPPV. Thus, NPPV in combina-
tion with MAC, airstacking, and close monitoring could become the therapy of choice
in SCI patients, either following intubation or instead of intubation but also for SCI
patients who stay ventilator dependent. There remains, however, a need for prospec-
tive randomized controlled trials to support the use of NPPV as a substitute for inva-
sive mechanical ventilation, both in the acute setting and over the long term.
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on respiratory parameters for patients with chronic airway secretion encumbrance. Chest.
2004;126:77480.
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Spinal Cord. 1998;36:4814.
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Noninvasive Mechanical Ventilation
in Sleep-Related Breathing Disorders 38
Stefanie Keymel, Volker Schulze, and Stephan Steiner
Abbreviations
S. Keymel, MD V. Schulze, MD
Medical Faculty, Division of Cardiology (Prof. Dr. M. Kelm), Pneumology and Angiology,
Department of Medicine, University Hospital Duesseldorf, Duesseldorf, Germany
S. Steiner, MD (*)
Division of Cardiology, Pneumology and Intensive Care Medicine, Department of Medicine,
St. Vincenz Hospital, Auf dem Schafsberg, Limburg/Lahn 65549, Germany
e-mail: s.steiner@st-vincenz.de
38.1 Introduction
Sleep-related breathing disorders (SRBDs) are common in the general public and
can be differentiated by miscellaneous diseases, for example, neuromuscular disor-
ders, obesity-hypoventilation, or sleep apnea syndromes. The latter comprise
obstructive, central, and mixed forms according to different pathomechanisms. As a
result of increasing pathophysiological insights, further definitions, including the
so-called complex sleep apnea or the overlap syndrome, were established. In
addition to improvement of symptoms such as daytime sleepiness and depression,
effective treatment enhances the prognosis, presumably as a result of a reduction in
cardiovascular complications [1]. There are different therapeutic approaches, most
of which include application of positive airway pressure (PAP).
This chapter discusses the different types of PAP (for definitions, see
Table 38.1) and their use is summarized with respect to sleep apnea syndromes.
Although there is a challenging evolution of devices, it should be kept in mind
that the proper choice of ventilation mode depends on an adequate diagnosis and
pressure titration [2].
Most evidence concerning indications for ventilation therapy and outcome exists for
patients with OSA. Patients with an AHI 15/h or symptomatic patients with an
AHI 5/h should be considered for treatment of OSA [4]. OSA should be approached
as a chronic disease requiring long-term multidisciplinary management [4]. PAP is
the treatment of choice for mild, moderate, and severe OSA and should be offered
as an option to all patients. Continuous PAP (CPAP) is the first choice of treatment
and is recommended as standard for patients with moderate to severe disease and as
an option for patients with mild disease [4, 5]. Other modalities such as bi-level PAP
(BPAP), autotitrating PAP, or pressure relief may be considered in patients with
CPAP failure [4].
For nonobstructive sleep apnea, the evidence of treatment and outcome is rather
limited. In patients with CSA, CPAP therapy targeted to normalize AHI is indicated
for the initial treatment of CSA related to congestive heart failure. If suppression of
AHI is not sufficient by CPAP, adaptive servo-ventilation (ASV) or BPAP therapy
in a spontaneous timed mode may be applied [6]. In case of hypoventilation/hypox-
emia syndrome with proven hypercapnia, BPAP therapy as noninvasive positive
pressure ventilation with true ventilatory support should be considered.
the upper airway during sleep in OSA syndrome. Thus, the pathophysiologic cas-
cade, which includes hypoxemia, intrathoracic pressure swings, repetitive arousals,
and adrenergic stimulation, is avoided. However, there are other, mostly positive
hemodynamic effects, especially in heart failure patients, and an unloading of the
respiratory system. Because end expiratory lung volume rises, there are beneficial
effects on gas exchange. Beyond these acute effects, it should be kept in mind that
CPAP is known to reduce cardiovascular risk [1] and has positive effects on clinical
course of coronary artery disease [7], restenosis after coronary stent implantation
[8], and ventricular remodeling after myocardial infarction [9].
Auto CPAP (APAP) is a particular form of CPAP. Specific algorithms were
evolved to detect variations of airway obstruction and adjust pressure level. In
clinical practice, areas of application developed: APAP could be used to titrate
CPAP pressure to save costs. Moreover, it could be used in patients with sleep
apnea only during rapid eye movement sleep or respiratory events related to
position [10]. Because APAP allows adaption of pressure to current require-
ment, median nocturnal pressure is lower compared with conventional CPAP
[11]. This might contribute to better acceptance and, therefore, higher adher-
ence to therapy. If exhalation against positive pressure is associated with patient
discomfort, some devices allow an expiratory pressure contour modification
[12]. APAP should not be used in patients with severe comorbidities such as
heart failure, chronic obstructive pulmonary disease (COPD), or hypoventila-
tion syndromes [12].
Although OSA can be treated effectively by CPAP in most patients, problems can
occur under some conditions. In this context, it should be considered that sleep
apnea is associated generally with increased work of breathing, especially in hyper-
capnic patients [13]. There are three main reasons to step up CPAP to noninvasive
ventilation (NIV) in patients with SRBDs:
1. Patients require high pressure, 1015 cmH2O, to eliminate collapse of the upper
airways. Exhalation against high pressures can be uncomfortable, furthering
problems with the interface such as leaks. The need for high pressures is associ-
ated with a reduced adherence to therapy [4].
2. Predominantly central apnea, Cheyne-Stokes ventilation, or change from
obstructive to central apnea under CPAP application. As has been emphasized,
OSA syndrome is a matter of upper airway collapse but not a problem of respira-
tory drive. In contrast, central apnea is characterized by a cessation of central
respiratory drive, often associated with stroke or congestive heart failure.
Therefore, it is not surprising that CPAP attenuates central apnea only for about
50 % of patients [14, 15]. A post hoc analysis of the Canadian Continuous
38 Noninvasive Mechanical Ventilation in Sleep-Related Breathing Disorders 301
It has been recognized for more than 30 years that several respiratory diseases
(e.g., COPD, lung fibrosis, and sleep apnea) can occur in the same patient [17].
Beyond coexistence, diseases might influence each other, mostly negatively. The
common combination of OSA syndrome and COPD (overlap syndrome),
which occurs in about 1 % of the general adult population [18], has been shown
to be associated with a more severe nocturnal hypoxemia and greater risk of
morbidity and mortality [19]. In these patients, CPAP is still a therapeutic option,
with the additional application of nocturnal oxygen if necessary. Nevertheless, to
optimize oxygenation and minimize respiratory workload, NIV might be helpful.
In a review, McNicholas [18] proposed a pragmatic approach: in cases where
OSA syndrome predominates, CPAP might be appropriate; whereas in patients
with significant nocturnal hypoventilation and sustained hypoxemia, NIV may be
advantageous.
Table 38.2 Major Alveolar ventilation resulting from inspiratory pressure change
advantages of NIV
Unloading of respiratory muscles
compared with
CPAP/APAP in Decrease work of breathing
sleep apnea Mandatory support in case of central apnea
302 S. Keymel et al.
or who are overweight. To minimize work of breathing, the use of a timed mode
might be beneficial.
In cases of central apnea, Cheyne-Stokes respiration, or hypoventilation, BPAP
use is reasonable. In this setting, it is recommended to use the backup rate option.
Other forms of NIV include ASV, which adapts pressure to maintain more consis-
tency of respiration over time. In addition to suppression of hypopnea/apnea, ASV
is designed to promote uniform ventilation and a reduction of arousal [22]. Average
volume-assured pressure support ventilation (AVAPS) combines gains of pressure
support ventilation and volume-controlled ventilation. Because this mode ensures a
delivered tidal volume, it might be utilized in hypoventilation syndromes or in CSA.
References
1. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with
obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive air-
way pressure: an observational study. Lancet. 2005;365:104653.
2. Force PAPTT, American Academy of Sleep Medicine. Clinical guidelines for the manual titra-
tion of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med.
2008;4:15771.
3. Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update
of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. J Clin Sleep Med.
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4. Force AOSAT, American Academy of Sleep Medicine. Clinical guideline for the evaluation,
management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med.
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bilevel positive airway pressure devices to treat adult patients with sleep related breathing
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6. Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in
adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep.
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nary artery disease: a long-term follow-up study. Eur Heart J. 2004;25:72834.
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rence of restenosis after elective percutaneous coronary intervention in ischemic heart disease.
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38 Noninvasive Mechanical Ventilation in Sleep-Related Breathing Disorders 303
Abbreviations
Intubations are among the most common invasive interventions performed in the
intensive care unit (ICU), and most ICU patients who require mechanical ventila-
tion are intubated. Unplanned extubation (UE), an intubation-associated complica-
tion, is defined as the removal of an endotracheal tube by a patient or its accidental
removal. The reported frequency of UE ranges between 3 and 16 % among patients
on mechanical ventilatory support [13]. A previous study in our center showed a
similar rate of extubation (11 %) [4]. Among its main causes are inadequate seda-
tion and insufficient nursing care during positioning. Nevertheless, UE may occur
even under optimal conditions where sedation is adequate and all necessary precau-
tions are taken. Successful management of UE may result in shortened duration of
intubation and reduced rate of complications associated with mechanical ventila-
tion. On the other hand, failure to do so may lead to the need for reintubation, lead-
ing to an increased risk of complications.
In a case-control study by Epstein et al. [5], a total of 75 patients with UE were
compared with 150 controls. In their center, the incidence of UE was 11 %. Patients
with UE had a longer duration of stay in the ICU as well as prolonged hospitaliza-
tion. However, patients with UE who did not require reintubation had similar mor-
tality, ICU and hospital stay, and mechanical ventilation duration as controls. In that
study, controls and patients with UE did not significantly differ in terms of in-
hospital mortality. Furthermore, patients who did or did not require reintubation
after UE had similar rates of in-hospital mortality. Thus, UE emerged as a risk factor
associated with prolonged duration of intensive care and hospitalization.
In another study, by Atkin et al. [6], the clinical outcomes in 50 patients with UE
and 100 controls were compared, whereby the frequency of nosocomial infections
before the occurrence of UE was higher among patients with UE than among con-
trols. However, these authors did not report on the infection incidence following the
occurrence of UE. Similar to the previously mentioned study, patients with UE had
longer hospital and ICU stay, despite the absence of a significant difference in in-
hospital mortality rates from controls (38 % vs 25 %; p = 0.14).
Krinsley and Barone [7] compared 100 patients with UE and 200 control sub-
jects and observed an increased duration of hospital and ICU stay, in addition to a
prolonged requirement for mechanical ventilation in UE cases. However, there was
a significantly higher mortality rate in controls. As compared with patients with UE
who did not require reintubation, those who required reintubation had an increase in
hospital and ICU stay, requirement for mechanical ventilation, frequency of infec-
tions acquired during intensive care, costs associated with intensive care, laboratory
work-up, and diagnostic imaging studies, and, most importantly, they had increased
mortality. In the same study, a multiple logistic regression analysis showed that age
was the single most important determinant of the need for reintubation, while rein-
tubation was the most important determinant of mortality after UE. In that study,
reintubation was not only associated with an increased occurrence of intensive care-
acquired infections but also with increased mortality.
Between 22 and 74 % of patients require reintubation after UE and most studies
reported increased mortality in patients requiring reintubation after UE. The
reported rate of reintubation was 56 % in the study by Epstein et al. [5]. Risk factors
for UE and factors associated with the need for reintubation were explored by
Chevron et al. [8], who found that a Glasgow Coma Scale score below 11 and a
PaO2/FiO2 ratio below 200 correlated with a higher frequency of the need for rein-
tubation in patients in whom UE occurred during weaning.
Despite the clear association between UE and life-threatening complications,
most institutions still lack standard procedures to be implemented in the case of
UE. While the need for reintubation is immediately evident in a certain proportion
of patients (e.g., inability to maintain an airway, significant oxygen requirement,
unconsciousness) who require prompt reintubation after UE, others may not be in
the need of reintubation despite the continued need for mechanical ventilation at the
time of the occurrence of UE. The need for intubation is not synonymous with the
need for mechanical ventilation, and in a certain group of patients noninvasive
mechanical ventilation may be considered as an alternative to re-intubation.
Invasive mechanical ventilation is a safe method in ICU patients when noninva-
sive positive-pressure ventilation (NPPV) is contraindicated or not applicable.
39 Impact of Noninvasive Positive-Pressure Ventilation in Unplanned Extubation 307
Conclusion
Based on previous studies, the reported rate of UE in most ICUs is approxi-
mately 710 %. Approximately half of all patients with UE will require reintuba-
tion. NPPV may be an option in patients with UE during the weaning period.
However, when the UE occurs before weaning criteria are met, NPPV contrain-
dications should be rapidly reviewed and patients not eligible for NPPV should
be reintubated without delay.
39 Impact of Noninvasive Positive-Pressure Ventilation in Unplanned Extubation 309
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9. Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia
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10. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure
after extubation in high risk patients. Crit Care Med. 2005;33:246570.
11. Ferrer M, Valencia M, Nicolas JM, et al. Early non-invasive ventilation averts extubation fail-
ure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173:16470.
12. Jiang JS, Kao SJ, Wang SN. Effect of early application of biphasic positive airway pressure on
the outcome of extubation in ventilator weaning. Respirology. 1999;4:1615.
13. Keenan SP, Powers C, McCormack DG, et al. Noninvasive positive-pressure ventilation for
postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287:323844.
14. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for
respiratory failure after extubation. N Engl J Med. 2004;350:245260.
Part IV
Non Invasive Mechanical Ventilation
and Decannulation in Tracheostomized
Patients
Tracheostomy Decannulation:
Key Practical Aspects 40
Antonello Nicolini, Ines Maria Grazia Piroddi,
Sofia Karamichali, Paolo Banfi, and Antonio M. Esquinas
Heffner [15] proposed the following checklist to determine whether the patient
might be decannulated: (1) Is MV no longer required? (2) Are airway secretions
controlled? (3) Is aspiration nonexistent or minimal and well tolerated? (4) Does the
patient have an effective cough? An important point is the absence in Heffners
checklist of judgment about severity of disease (PaCO2, prognosis, and stability).
Studies are needed to evaluate accepted criteria for safely closing tracheostomy.
The common opinion is that tracheostomy decannulation is a multidisciplinary
team decision, made either in the ICU or in step-down units following patient dis-
charge from the ICU [3]. The four most important determinants are clinician-rated
level of consciousness, ability to tolerate tracheostomy tube capping, cough effec-
tiveness, and secretions. Patient comorbidities, etiology of respiratory failure, swal-
lowing function, respiratory rate, adequate nutritional state, absence of delirium or
psychiatric disorders, patent upper airway, and oxygenation were judged to be of
moderate importance [16].
Although the ability to tolerate tracheostomy capping was judged to be an impor-
tant determinant of tracheostomy decannulation for patients with paralytic condi-
tions, peak cough flow (PCF) can be significantly increased by providing maximal
insufflations. Flows can be further increased by appropriately timing an abdominal
thrust to glottic opening (manually assisted coughing) [17]. All patients for whom
greater than 160 l/min of PCF could be achieved were successfully extubated or
decannulated, whereas no patients with PCFs under 160 l/min were successfully
extubated or decannulated [17].
Though decannulation is not risk free, there are clear-cut benefits to tracheos-
tomy tube removal. The tracheostomy tube is a foreign body that may cause bron-
chorrhea or excessive cough. The tracheostomy tube impairs normal tracheal
elevation during swallowing. Diverting breathing away from the upper airway and
through the tracheostomy lumen has substantial deleterious effects. The physiologic
benefit of pursed-lips breathing is eliminated. The vocal cords are bypassed, and
there is no laryngeal blast to facilitate effective cough. Partial closure of the vocal
cords maintains a subglottic pressure referred to as physiologic PEEP (positive
end-expiratory pressure). Most importantly, patients are unable to speak when the
tracheostomy tube bypasses the larynx. There are profound consequences of inabil-
ity to speak. Care is further compromised when the patient is unable to express
symptoms that would normally prompt further investigation or intervention. Clinical
assessment is compromised when mental status cannot be appropriately assessed
because of the lack of verbal communication. For patients with long-term tracheos-
tomy, it is common practice to take an intermediate step prior to completely remov-
ing the tracheostomy tube, using a speaking valve [7].
During the post-mechanical ventilation period, patients are predisposed to respi-
ratory muscle fatigue, abnormal ventilatory drive, and another episode of respira-
tory failure. Individuals with a long-term tracheostomy are at risk for upper-airway
obstruction due to complications of tracheostomy. Additionally, there may be
upper-airway abnormalities that were initially unappreciated or unrecognized at the
time of decannulation. Patients may subsequently experience life-threatening air-
way compromise requiring emergency reinsertion of the tracheostomy tube [7].
316 A. Nicolini et al.
After decannulation, continuous telemetry and oximetry are important for at least
24 h to monitor for unexpected airway compromise.
A patient may exhibit reduced voice quality due to air-flow diversion through
the healing stoma on exhalation. Vocalization may be enhanced by gently placing
two fingers over the gauze-covered stoma during speech to minimize leak and
maximize air flow to the vocal cords. Vocalization will usually return to normal
once the stoma has closed completely. The tracheostomy stoma heals by secondary
intention within 57 days in the majority of patients. However, tracheostomy stoma
closure rates are variable and closure may occur in a single day or may take weeks.
A persistent tracheocutaneous fistula may remain in some patients and may require
surgical closure [5].
Conclusion
A review by Santus et al. [23] provides a hypothetical score for practical use
with objective quantitative parameters, major criteria, and semiquantitative or
subjective parameters, minor criteria, to help clinicians in choosing decan-
nulation timing. If all main criteria are satisfied, regardless of minor criteria,
decannulation with high probability of positive outcome can be assumed, but
40 Tracheostomy Decannulation: Key Practical Aspects 319
Table 40.1 Protocol criteria for tracheostomy decannulation from prolonged mechanical
ventilation
Absence of distress and stable ABG values on prolonged mechanical ventilation for 5 days
Stable clinical conditions (hemodynamic stability, absence of fever or active infection)
PaCO2 < 60 mmHg
Normal endoscopic examination or revealing stenotic lesions occupying <30 % of the airways
Adequate swallowing evaluated by gag reflex, blue dye, and video fluoroscopy
MEP >40 cmH2O or PCF > 160 l/min (NMD patients)
Tube capping >24 h
ABG arterial blood gases, PaCO2 partial pressure of carbon dioxide, MEP maximum expiratory
pressure, PCF peak cough flow
this requires discussion and a prospective validation study. Table 40.1 provides
our proposed practical protocol criteria for tracheostomy decannulation from
PMV.
In conclusion, decannulation is usually well tolerated by the patient, but a
systematic approach to patient evaluation is needed. Following decannulation,
patients require close monitoring to identify signs of airway compromise.
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decannulation using a tracheostomy retainer in patients with prolonged weaning and persisting
respiratory failure. Respiration. 2012;84:46976.
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Transfer to Noninvasive Ventilation
as an Alternative to Tracheostomy 41
in Obstructive Pulmonary Disease:
Key Practical Topics
Gerhard Laier-Groeneveld
Abbreviations
Noninvasive ventilation has widened both the indications and use of mechanical
ventilation to outside the intensive care unit (ICU), to early and preventive use, to
therapy to improve ventilator function [1], and as an alternative to invasive ventila-
tion. Noninvasive ventilation can replace invasive ventilation at almost any stage of
disease. This extends weaning, which originally meant termination of (invasive)
mechanical ventilation, to also include avoidance of intubation by noninvasive ven-
tilation, to transfer from intubation to continuing mechanical ventilation by nonin-
vasive means, to arrange home mechanical ventilation for those who require
continuous intermittent ventilator support, and, if life quality cannot be restored, to
terminal weaning to noninvasive ventilation, retaining the option of reintubation in
G. Laier-Groeneveld
Medical Clinic II, Pneumology, Thoracic Oncology, Ventilatory Support and Sleep,
Klinikum Niederrhein, Steinbrinkstrasse, D44160 Oberhausen, Germany
e-mail: laier-groeneveld@t-online.de
Mechanical ventilation may be started during surgery and continued thereafter for
complications following the surgical procedure. Patients may wean completely with
the techniques available after they have stabilized. Awareness and withholding sed-
atives helps allow extubation as early as possible. If patients have been intubated for
a minor reason but the underlying disorder is considerably severe, they do not wean
completely with the strategies available, and they are considered difficult to wean.
The patients history should be extensively explored, first, for the severity of the
acute condition under which intubation has been performed and, second, for a
chronic impairment present before the deterioration occurred. Chronic obstructive
pulmonary disease (COPD) with severe airflow obstruction, emphysematous lung
destruction, hypoxemia, or hypercapnia is the most common underlying disorder. In
addition, neuromuscular disorders, scoliosis, severe heart failure, and severe sleep
41 Transfer to Noninvasive Ventilation as an Alternative to Tracheostomy 323
apnea predispose for weaning difficulties. Minor complications at the time of intu-
bation together with a severe underlying chronic disorder should immediately call
alternative weaning procedures into place.
If an underlying chronic disease is less severe or absent, alternative weaning
strategies should be sought as soon as the patient does not readily wean for any of
the possible reasons. The problem may become evident when the patient is extu-
bated, awake, and breathing spontaneously. We see patients being weaned within a
few days but requiring months to recover from sequelae of long-term mechanical
ventilation. Immobility, muscular weakness, and mental disorders contribute. Time
is a critical factor in invasively ventilated patients.
One alternative weaning strategy is the transfer from intubation directly to non-
invasive ventilation. Mechanical ventilation is continued but the airway access is
changed from the endotracheal tube to a well-fitting mask. This separates mechani-
cal ventilation from intensive care treatment. Invasive ventilation and transfer to
noninvasive ventilation requires the resources of an ICU. However, once noninva-
sive ventilation is performed safely, the patient can be discharged from the ward to
regular care, rehabilitation, or even home, despite being on mechanical ventilation.
An early decision can first be made regarding how to ventilate and where. Then, the
decision regarding whether the patient needs to be ventilated at all can be postponed
until physical recovery is complete.
During invasive mechanical ventilation, if there is no clear history, tests to
explore for a chronic disease and for breathing capacity are limited and leave con-
siderable uncertainty. We therefore prepare any patient for transfer and are happy if
noninvasive ventilation after extubation is not needed.
strategy, which requires sufficient volume to unload the patients ventilatory pump
to sufficient hyperventilation to suppress respiratory drive and, thus, rest the mus-
cles and relieve dyspnea. These strategies have not been compared in studies.
During weaning, the unloading strategy is more advantageous and is the strategy of
choice. In COPD, the lung-protective strategy has not been shown to have a place.
Patients with COPD are excluded because, in COPD, there is airway over-distention
and a positive alveolar end-expiratory pressure called intrinsic PEEP. Airway col-
lapse is not present and lung protection, therefore, is not needed.
With the unloading strategy, sedative requirements should be questioned immedi-
ately after intubation or after transfer. Most patients are exhausted at the time of
intubation or after struggling with the ventilator. They do not need sedatives for a
considerable period thereafter, especially if dyspnea is absent as a consequence of
the unloading strategy. Removal of sedatives under these conditions is safe. Only
rarely are bolus applications required. It has been shown that tube mechanical venti-
lation can be performed without any sedatives and, once the tube is in place, is well
tolerated, similar to tracheostomal ventilation [5, 6]. Considerable time usually
elapses after intubation or removal of sedation until the patient experiences discom-
fort and the decision either to extubate or to sedate is inevitable, providing sufficient
time to explore the patients cooperation and ability for spontaneous breathing to
allow extubation.
Simultaneously with the introduction of the unloading strategy and the with-
drawal of all sedatives, other conditions should be addressed. Excessive fluid should
be removed as it impairs spontaneous breathing capacity. Underlying diseases
should be treated. Airway obstruction is frequently involved. If airway obstruction
is present or cannot be clearly ruled out, appropriate treatment is necessary.
Corticosteroids and agonists may be necessary, first intravenously and then by
inhalation. Secretions should be removed. In COPD, secretions may accumulate in
the peripheral airways, as suctioning only clears the central airways in sedated
patients. The secretions may be viscous or purulent and contribute to hypoxemia
and difficulties in spontaneous breathing. Bronchoscopic lavage is often helpful in
successful weaning. If no pulmonary disease is present, hypoxemia or atelectasis
require clearance of secretions, especially in patients with neuromuscular disease.
In patients with COPD, in contrast, hypoxemia is a consequence of their disease. A
decrease in oxygen saturation can be caused by several pulmonary complications,
such as airway obstruction, fluid overload, pleural effusions, pulmonary embolism,
hypersecretions, purulent bronchitis, or pulmonary infiltrations or may be persistent
as a result of advanced disease. Such complications should be actively investigated
during the weaning process (Table 41.1).
There is no evidence that spontaneous breathing trials train the patient and his or her
muscles. In fact, it is unlikely that spontaneous breathing trials result in increasing
the strength of respiratory muscles. It has been clearly shown that, if intensity of
41 Transfer to Noninvasive Ventilation as an Alternative to Tracheostomy 325
load is not monitored and guaranteed, no training effect can be expected [6].
Spontaneous breathing trials do not improve the patients condition but provided
information about how to continue. Spontaneous breathing capacity reflects the
impact of the disease and the necessity of mechanical ventilation. Frequently, the
spontaneous breathing capacity displayed is much better than anticipated before the
trial is performed. This allows more rapid weaning to proceed. Impacts on pCO2 and
dyspnea reveal whether spontaneous breathing is safe or risks resulting in muscular
fatigue if unduly prolonged. The evolution of oxygen saturation during spontaneous
breathing reveals whether hypoxemia can be managed without intubation. In addi-
tion, physical and behavioral ability to cooperate and tolerate an unpleasant respira-
tory load without panic or anxiety can be tested during a spontaneous breathing
trial. Some patients who have experienced life-threatening episodes during their
intensive care stay may become anxious about any change that is made. Explaining
the process to the patient and staying him or her, asking about discomfort, and ter-
minating the trial as soon as adverse events occur may be prerequisites for success.
There are two approaches to spontaneous breathing trials: (a) breathing sponta-
neously while on the ventilator, with minimum support by continuous positive air-
way pressure (CPAP) and pressure support, and (b) T-tube breathing, with the tube
in place but not connected to the ventilator and with an oxygen adaptor inserted to
apply additional oxygen as required.
Supporters of the CPAP trial argue that the patient is still monitored by the ven-
tilator. However, as previously mentioned, the spontaneous breathing trial should be
monitored by an experienced therapist to recognize and avoid any adverse event and
to motivate the patient. Thirty minutes of spontaneous breathing have been shown
to be sufficient, with no additional information gained if the trial is prolonged
beyond that point [7]. A well-supervised T-piece trial does not require any monitor-
ing by the ventilator. Perfect interaction with the ventilator during CPAP and pres-
sure support can be difficult to accomplish in a spontaneous breathing, swallowing,
and coughing subject, and we worry that breathing against the machine may impair
the patient. Additionally, ventilator support, although minimal, may mask some
consequences of spontaneous breathing [9, 10] because of muscle overload or non-
compensable hypoxemia and, as a consequence, the risk for reintubation. In severe
COPD, CPAP must be kept low, at least below the intrinsic PEEP, if increased
hyperinflation might further aggravate. Because intrinsic PEEP is variable with time
and not homogenously distributed in the lung, we prefer the T-tube trial [11].
326 G. Laier-Groeneveld
As soon as the patient is extubated and the endotracheal tube is replaced by a nasal
or naso-oral interface, mechanical ventilation can be performed intermittently
according to the patients spontaneous breathing capacity. Until complete stabiliza-
tion is reached, spontaneous breathing periods may be kept short to avoid exhaus-
tion and rapid shallow breathing followed by difficulties to readapt to noninvasive
ventilation. Thereafter, prolongation of spontaneous breathing and reduction of the
time on the ventilator may follow the overall improvement. Noninvasive ventilation,
in contrast to endotracheal ventilation, allows the patient to be transferred to the
normal ward, to a rehabilitation center, or to home even if the patient is not com-
pletely weaned. Sufficient care and cooperation to continue with intermittent venti-
lation and stability are the only requirements (Table 41.2).
Noninvasive ventilation can be successfully performed in the totally ventilator
dependent patient. However, the more spontaneous breathing is preserved, the lower
the risk for reintubation. Thirty minutes of a stable T-piece trial with stable pCO2
and oxygen saturation should be achieved prior to extubation and transfer to nonin-
vasive ventilation. However, with sufficient expertise and the support of well-trained
specialists, most of our patients are extubated after a shorter T-piece trial [5]. Full
cooperation and perfect adaptation are the major determinants of failure or success
[12]. If the patient is fully cooperative and adapts well to invasive tube ventilation
without the need of sedatives, mask ventilation can be expected to work equally
effectively. Uncooperativeness or the necessity to apply sedatives considerably
increase the risk of failure.
The best patient for extubation can cooperate in closing his or her mouth and follow
the commands of the therapist. The patient should be able to breathe spontaneously for
up to 30 min. The best parameters of success are the patients tolerance, comfort, and
progressive improvement. In patients with healthy lungs, which is the case in those
We support the high intensity or better physiological strategy in the setting of the
ventilator [1]. This means that mechanical ventilation should restore the pCO2 to the
normal healthy range below 40 mmHg and, in addition, unload the ventilator pump
completely. We could add evidence to this strategy with a randomized controlled study
in chronic hypercapnic COPD patients [2]. The physiological strategy showed a sig-
nificant improvement in survival and quality of life, together with a decrease in pCO2
on spontaneous breathing compared with the control group. Several controlled studies
did not improve pCO2 by the ventilator setting and, during spontaneous breathing, did
not show any substantial benefit [15]. Achieving the goal of a pCO2 below 40 mmHg
and of unloading the ventilator pump is usually feasible in patients with neuromuscular
disease because they require lower tidal volumes and pressures. In COPD, many more
options must be used. In some cases, the goal can only achieved with time.
During spontaneous breathing, COPD patients develop an intrinsic PEEP. This is
variable from breath to breath with the tidal volume, the expiratory time, and breath-
ing frequency. Respiratory muscles have to enlarge the thorax until the intrinsic
PEEP has been reached and positive alveolar pressure becomes negative. It is not
until then that inflow of air starts and the trigger of the ventilator is activated. Most
work of breathing may be done to overcome intrinsic PEEP and only minor work is
added to inflate the lung [10]. In this case, an elevated pressure at end expiration
(PEEP) will prevent the thorax from settling below and relieve the respiratory mus-
cles from the initial part of work.
If the patient is passively ventilated and all breaths are totally ventilator initiated,
setting a PEEP on the ventilator is not necessary. The ventilator can easily provide
the additional work required to overcome intrinsic PEEP. The alveoli never collapse
in COPD because the alveolar pressure always remains positive because of the
intrinsic PEEP in this disorder. We therefore use little or no PEEP in mechanically
ventilated patients with COPD, whether ventilated invasively and noninvasively.
As the driving pressure is required to reach the tidal volume necessary, the intro-
duction of PEEP increases the peak inspiratory pressure. Higher pressures increase
the risk of leaks during noninvasive ventilation. The air flow from the ventilator
during expiration may interfere with speaking and swallowing in noninvasively ven-
tilated patients, further reasons not to use PEEP.
During pressure preset ventilation, the inspiratory time can be used to increase
tidal volume. The longer the pressure is applied during inspiration, the more the
328 G. Laier-Groeneveld
lungs are inflated. In patients with COPD, care should be taken that expiration is
fully completed before the following inspiration starts, but an inspiratory-expiratory
ratio of 1:1.4 can be reached in most of patients without any air trapping. During
volume preset ventilation, a prolonged inspiratory time will help to decrease peak
inspiratory pressure and can equally be used to provide more comfort to the patient.
Despite these additional measures to increase tidal volume, the major determi-
nant is the inspiratory pressure in pressure preset ventilation and the adjusted tidal
volume in the volume preset setting. As much as 30 or 40 mbar may be needed to
normalize the arterial pCO2 [1, 3]. During invasive ventilation, normocapnia can
usually be instantly achieved with this setting, whereas during noninvasive ventila-
tion, as a consequence of leaks, several days may be needed and different masks and
settings tried until the adaptation is free from leaks and complete. The study of
Khnlein et al. [3] and other work, however, show that an improvement in pCO2 can
be reached in patients with COPD once a goal is set.
COPD is a broad spectrum of disease, from the least to the most severe, from the less
affected lung to the completely emphysematous lung, from severe bronchospasm to
irreversible airflow limitation, from hypersecretion to severe obstruction by secretions,
from occasional to total ventilator dependency, from severe hypoxemia to extreme
hypercapnia. Any of these may cause failure of noninvasive or invasive ventilation. One
after the other should be evaluated and treated once the normocapnic goal is not readily
achieved. Different intensities of mechanical ventilation in volume or pressure, in time,
and in the acceptable leakage may be sufficient depending on the patient. Nevertheless,
the best unloading should be chosen during transfer from intubation to noninvasive ven-
tilation because reintubation has been shown to be a major determinant of adverse out-
come and complications and, by any preventive measures, should be avoided [1, 4].
Key Recommendations
Weaning should start immediately after intubation or after admission to the
weaning unit.
Intubated patients can be prepared for transfer to noninvasive ventilation,
although some do not require noninvasive ventilation after extubation.
The more minor the complication prior to intubation and the more severe
the chronic underlying disease, the more transfer to noninvasive ventila-
tion is needed to avoid the hazards of tracheotomy.
An unloading strategy of mechanical ventilation, a setting to normalize
pCO2, and ventilation that is comfortable and passive for the patient while
intubated and while ventilated noninvasively is recommended.
Full patient cooperation during a spontaneous T-tube breathing trial with a
tolerable increase in pCO2 and stable oxygen saturation of up to 30 min
may prove that noninvasive ventilation will succeed after extubation.
All possible complications should be ruled out, corrected, and treated to
rapidly reach a stable situation after transfer from intubation to noninva-
sive ventilation.
41 Transfer to Noninvasive Ventilation as an Alternative to Tracheostomy 329
References
1. Laier-Groeneveld G, Schucher B, Crie CP. Die Ursache der chronischen Hyperkapnie. Med
Klin. 1997;92:339.
2. Burns KE, Adhikari NK, Meade MO. A meta-analysis of noninvasive weaning to facilitate
liberation from mechanical ventilation. Can J Anaesth. 2006;53:30515.
3. Khnlein T, Windisch W, Khler D, Drabik A, et al. Non invasive positive pressure ventilation
for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multi-
centre, randomized, controlled clinical trial. Lancet Respir Med. 2014;9:698705.
4. Keenan SP, Kerneman PD, Cook DJ, Martin CM, et al. Effect of noninvasive positive pressure
ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis.
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5. Laier-Groeneveld G, Abazed Y, Bauer JU. Noninvasive ventilation during weaning. J Physiol
Pharmacol. 2007;58:3358.
6. Strom T, Martunissen T, Toft P. A protocol of no sedation for critically ill patients receiving
mechanical ventilation: a randomized trial. Lancet. 2010;375:47580.
7. Hill K, Jenkins SC, Philippe DL, Cecins N, et al. High intensity inspiratory muscle training in
COPD. Eur Respir J. 2006;27:111928.
8. Esteban A, Alia I, Gordo F, Fernandez R, et al. Extubation outcome after spontaneous breath-
ing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative
Group. Am J Respir Crit Care Med. 1997;156:45965.
9. Rasche K, Laier-Groeneveld G, Weyland W, Braun U, et al. Sauerstoffverbrauch der
Atemmuskulatur unter kontrollierter bzw. assistierter Beatmung bei Patienten mit chronischer
Ateminsuffizienz. Med Klein. 1994;89:436.
10. Weyland W, Schuhmann M, Rathgeber J, Weyland A, et al. Oxygen cost of breathing for
assisted spontaneous breathing modes: investigation into three states of pulmonary function.
Intensive Care Med. 1995;21:2117.
11. Marini JJ. Dynamic hyperinflation and auto-positive end-expiratory pressure: lessons learned
over 30 years. Am J Respir Crit Care Med. 2011;184:75662.
12. Laier-Groeneveld G, Crie CP. Weaning by transfer to nasal ventilation. Eur Respir
J. 1997;10:268S.
13. Alberts CH, Hanau S, Laier-Groeneveld G. Properatives weaning versus postoperatives pro-
longiertes weaning. Pneumologie. 2012;67:P474.
14. Cabrini L, Landoni G, Oriani A, Plumari VP, et al. Noninvasive ventilation and survival in
acute care setting: a comprehensive systematic review and metaanalysis of randomized con-
trolled trials. Crit Care Med. 2015;43:8808.
15. Clini E, Sturani C, Rossi A, Vioggi S, et al. The Italian multicentre study on noninvasive ven-
tilation in chronic obstructive pulmonary patients. Eur Respir J. 2002:52938.
Extubation and Decannulation
of Unweanable Patients 42
with Neuromuscular Weakness
Abbreviations
J.R. Bach, MD
Department of Physical Medicine and Rehabilitation, Rutgers University
New Jersey Medical School, Newark, NJ, USA
Department of Physical Medicine and Rehabilitation, University Hospital B-403,
150 Bergen Street, Newark, NJ 07103, USA
e-mail: bachjr@njms.rutgers.edu
42.1 Introduction
The three respiratory muscle groups include the inspiratory muscles, expiratory mus-
cles, and bulbar-innervated muscles. The inspiratory and expiratory muscles can be
assisted or supported indefinitely by applying pressure to the body or airways such
that no extent of dysfunction should result in respiratory failure or require resorting to
tracheotomy [1]. Inspiratory and expiratory muscle aids are devices and techniques
that involve the manual or mechanical application of forces to the body or pressure
changes to the airway to assist or substitute for inspiratory or expiratory muscle func-
tion. Negative pressure applied to the airway during expiration assists the expiratory
muscles during coughing, just as positive pressure applied to the airway during inhala-
tion (noninvasive intermittent positive-pressure ventilation (IPPV)) assists inspiratory
function [1]. A manual thrust applied to the abdomen during expiration or exsuffla-
tion, especially when combined with mild chest compression, assists expiratory mus-
cle function to increase cough flows. Patients with little or no measurable vital capacity
(VC) or any ability to autonomously sustain alveolar ventilation or cough can be man-
aged without invasive tubes using these methods. However, even when inspiratory and
expiratory muscles are functional, patients with bulbar-innervated muscle dysfunction
and spasticity or other irreversible airway obstruction, for whom continuous aspira-
tion of airway secretions results in decrease in an O2 sat baseline below 95 %, need to
undergo tracheotomy to survive [2]. When this occurs, the patient has usually already
lost the ability to speak and swallow food. This usually occurs only in patients with
advanced bulbar amyotrophic lateral sclerosis (ALS) and some patients with spinal
muscular atrophy type 1 (SMA1).
Inspiratory and expiratory muscle aids can be used at home or in the hospital to
prevent episodes of pneumonia and respiratory failure that would otherwise occur
during intercurrent upper respiratory tract infections (URIs) and episodes of bron-
chitis due to ineffective coughing. Both mechanical insufflation-exsufflation (MIE)
and continuous noninvasive ventilatory support (CNVS) are often needed during
these episodes when, quite possibly, they are not required at other times [26]. The
feedback obtained by using an oximeter during acute URIs to guide in the use of
noninvasive ventilatory support (NVS) and, especially MIE, is important in keeping
the O2 sat over 94 % or returning it to over 94 % quickly if it should decrease below
95 %. This is because O2 sat is only normal when it is 95 % or greater. It is impos-
sible to develop respiratory failure with O2 sat greater than 94 % in ambient air. Any
O2 sat below 95 % must indicate some combination of hypoventilation, airway
secretion congestion, and intrinsic lung disease such as atelectasis or pneumonia.
When the O2 sat cannot be kept above 94 %, patients usually require hospitalization
for pneumonia and possible acute respiratory failure [3].
42 Extubation and Decannulation of Unweanable Patients 333
Typically, the dyspneic patient arrives at the emergency room of a local hospital
and immediately receives supplemental oxygen. The patients already-elevated CO2
further increases and CO2 narcosis results in ventilatory arrest, intubation, and then
failure to wean from invasive ventilatory support via a translaryngeal tube. A tra-
cheotomy is performed and the patient is left with a lifetime of invasive ventilatory
support. Once a tracheostomy tube is placed, the patient often loses all ventilator-
free breathing ability. This occurs most often because the tracheostomy tube causes
airway secretions that block the respiratory exchange membrane, ventilation via the
tube causes inspiratory muscle deconditioning [7], and chronically and invasively
ventilated patients tend to be hypocapnic and therefore tolerate less ventilator-free
breathing [8]. Their demand for increased ventilator volumes or pressures may be
related to bypassing the upper airway sensory input.
Supplemental oxygen should not be given until attempts have been made to nor-
malize O2 sat (>94 %) by using full-setting NVS to normalize ventilation (PaCO2)
and MIE to clear the airways of secretions. Intubation becomes appropriate when
optimal use of NVS and MIE fail to maintain normal O2 sat and the patient develops
respiratory distress, most often as a result of pneumonia.
Intubated patients who fail spontaneous breathing trials are usually told that trache-
ostomy is their only option. Conventionally, unweanable intubated patients are only
extubated following tracheotomy. Once a tracheostomy is placed, the majority of
patients will eventually die from complications directly attributable to the tube,
including hemorrhage, tracheoesophageal fistulae, respiratory infection, trachecta-
sis, pneumonia, accidental disconnection from the ventilator, and ventilator failure.
In a review of four papers discussing outcomes of tracheostomy ventilation for
Duchenne muscular dystrophy (DMD), 17 patients survived more than 2 years,
including 1 for 18 years; 3 died from complications of the tube in less than 2 years;
and 2 died after 2 years of use [912]. In a relatively large study, Bach et al. [13]
reported mean survival for 17 DMD tracheostomy IPPV users of 7.3 8 years
(range, 7 days to 12 years). At least 4 of the patients died from complications associ-
ated with the tube. Likewise, 32 of our 40 ALS patients using tracheostomy mechan-
ical ventilation (TMV) died as a result of complications caused by the tracheostomy
tube after about 5 years of continuous TMV [14].
Fig. 42.1 Ten-year-old girl with neurofibromatosis status post spinal cord tumor resection, extu-
bated with a vital capacity of 180 ml and no ventilator-free breathing ability, using a 15-mm angled
mouthpiece (Malincrodt-Puritan-Bennett, Pleasanton, CA, USA) for ventilatory support
Any patient with an indwelling tracheostomy tube who has understandable speech
when the tube cuff is deflated is evaluated for decannulation. Patients without severe
speech and swallowing impairment are usually good candidates. The ability to
effect glottic closure and maintain airway patency during a cough is critical for suc-
cessful decannulation. Unweanable patients for whom CPF can approach 160 l/m
336 J.R. Bach
Fig. 42.2 Twenty-six-year old man with Duchenne muscular dystrophy transferred for extubation
after failing three extubations over a 26-day period. He used a 15-mm angled mouthpiece, as in
Fig. 42.1, for daytime ventilatory support and a lip seal phalange with nasal prongs (Hybrid,
Teleflex Medical, Research Triangle Park, NC, USA) for nocturnal ventilatory support
the event of ventilator malfunction or loss of access to the NVS interface [22, 23,
27]. The need to decannulate TMV users to NVS can be avoided, however, if
unweanable patients are extubated without resort to tracheotomy. We have decan-
nulated more than 200 continuously ventilator-dependent patients without a sin-
gle failure [3, 16, 20, 22, 23]. In some cases, our decannulated and extubated
continuously ventilator-supported cases have depended on NVS for more than 60
years for prolonged survival [28]. Unfortunately, few centers decannulate con-
tinuously ventilator-dependent patients [2325].
Finally, after years of debate and consensus conferences of experts whose
knowledge of noninvasive ventilation is limited to CPAP and the use of low-span
bi-level PAP for patients with sleep-disordered breathing, a Centers for Disease
Control panel of respiratory experts and other consensus groups have recommended
that NVS be used long term for up to 24 h per day ventilator dependence [29, 30].
Despite the fact that our center has managed more than 100 CNVS dependent DMD
patients and has not needed to resort to tracheotomy to prevent respiratory mortality
for DMD patients in more than 30 years, it has taken this long for recognition of the
fact that, even in the absence of inspiratory or expiratory function, these patients can
be managed noninvasively. No informed NMD patient, trained in NVS and MIE,
prefers to undergo tracheotomy [15]. However, family and caregiver involvement in
providing NVS and MIE is important for long-term success. The only appropriate
indications for tracheotomy are failure of NVS and MIE to maintain normal O2 sat
because of continuous saliva aspiration and irreversible upper airway obstruction
resulting from upper motor neuron lesions. In our experience, this only occurs in
patients with advanced bulbar ALS or severe central nervous system disease.
References
1. Bach JR. Update and perspectives on noninvasive respiratory muscle aids: part 1 the inspira-
tory muscle aids. Chest. 1994;105:123040.
2. Bach JR, Bianchi C, Aufiero E. Oximetry and indications for tracheotomy for amyotrophic
lateral sclerosis. Chest. 2004;126:15027.
3. Gomez-Merino E, Bach JR. Duchenne muscular dystrophy: prolongation of life by noninva-
sive respiratory muscle aids. Am J Phys Med Rehabil. 2002;81:4115.
338 J.R. Bach
4. Bach JR, Saltstein K, Sinque D, Weaver B, Komaroff E. Long term survival in Werdnig-
Hoffmann Disease. Am J Phys Med Rehabil. 2007;86:33945.
5. Bach JR, Baird JS, Plosky D, Nevado J, Weaver B. Spinal muscular atrophy type 1: manage-
ment and outcomes. Pediatr Pulmonol. 2002;34:1622.
6. Bach JR. Amyotrophic lateral sclerosis: prolongation of life by noninvasive respiratory aids.
Chest. 2002;122:928.
7. Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R,
Sonnad S, Kaiser LR, et al. Rapid disuse atrophy of diaphragm fibers in mechanically venti-
lated humans. N Engl J Med. 2008;358:132735.
8. Haber II, Bach JR. Normalization of blood carbon dioxide levels by transition from conventional
ventilatory support to noninvasive inspiratory aids. Arch Phys Med Rehabil. 1994;75:114550.
9. Gatin G. Inret de la ventilation assise dans les dystrophies musculaires. Ann Readapt Med
Phys. 1983;26:11128.
10. Splaingard ML, Frates RC, Harrison GM, Carter RE, Jefferson LS. Home positive pressure
ventilation: twenty years experience. Chest. 1984;4:37682.
11. Baydur A, Gilgoff I, Prentice W, Carlson M, Fischer DA. Decline in respiratory function and
experience with long term assisted ventilation in advanced Duchennes muscular dystrophy.
Chest. 1990;97:8849.
12. Fukunaga H, Okubo R, Moritoyo T, Kawashima N, Osame M. Long term follow up of patients
with Duchenne muscular dystrophy receiving ventilatory support. Muscle Nerve. 1993;16:
5548.
13. Bach JR, OBrien J, Krotenberg R, Alba A. Management of end stage respiratory failure in
Duchenne muscular dystrophy. Muscle Nerve. 1987;10:17782.
14. Bach JR. Amyotrophic lateral sclerosis: communication status and survival with ventilatory
support. Am J Phys Med Rehabil. 1993;72(6):3439.
15. Bach JR. A comparison of long term ventilatory support alternatives from the perspective of
the patient and care giver. Chest. 1993;104:17026.
16. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with
ventilatory failure. A different approach to weaning. Chest. 1996;110:156671.
17. Bach JR, Gonalves MR, Hamdani I, Winck JC. Extubation of unweanable patients with neu-
romuscular weakness: a new management paradigm. Chest. 2010;137(5):10339.
18. Bach JR, Sinquee D, Saporito LR, Botticello AL. Efficacy of mechanical insufflation-
exsufflation in extubating unweanable subjects with restrictive pulmonary disorders. Respir
Care. 2015;60:47783.
19. Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via the mouth as an
alternative to tracheostomy for 257 ventilator users. Chest. 1993;103:17482.
20. Bach JR, Saporito LR, Shah HR, Sinquee D. Decanulation of patients with severe respiratory muscle
insufficiency: efficacy of mechanical insufflation-exsufflation. J Rehabil Med. 2014;46:103741.
21. Bach JR, Goncalves M. Ventilator weaning by lung expansion and decanulation. Am J Phys
Med Rehabil. 2004;83:5608.
22. Bach JR, Alba AS. Noninvasive options for ventilatory support of the traumatic high level
quadriplegic. Chest. 1990;98:6139.
23. Bach JR. New approaches in the rehabilitation of the traumatic high level quadriplegic. Am
J Phys Med Rehabil. 1991;70:1320.
24. Viroslav J, Sortor S, Rosenblatt R. Alternatives to tracheostomy ventilation in high level SCI
[abstract]. J Am Paraplegia Soc. 1991;14:87.
25. Viroslav J, Rosenblatt R, Tomazevic SM. Respiratory management, survival, and quality of
life for high level traumatic tetraplegics. Respir Care Clin N Am. 1996;3:31322.
26. Bach JR, Intintola P, Alba AS, Holland I. The ventilator-assisted individual: cost analysis of
institutionalization versus rehabilitation and in-home management. Chest. 1992;101:2630.
27. Bach JR, Bianchi C, Vidigal-Lopes M, Turi S, Felisari G. Lung inflation by glossopharyngeal
breathing and air stacking in Duchenne muscular dystrophy. Am J Phys Med Rehabil.
2007;86:295300.
42 Extubation and Decannulation of Unweanable Patients 339
28. Bach JR, Mehta AD. Respiratory muscle aids to avert respiratory failure and tracheostomy: a
new patient management paradigm. J Neurorestoratal. 2014;2:2535.
29. Birnkrant DJ, Bushby KM, Amin RF, Bach JR, Benditt JO, Eagle M, Finder JD, Kalra MS,
Kissel JT, Koumbourlis AC, Kravitz RM. The respiratory management of patients with
Duchenne muscular dystrophy: a DMD care considerations working group specialty article.
Pediatr Pulmonol. 2010;45(8):73948.
30. Bach JR, Gonalves MR, Hon AJ, Ishikawa Y, De Vito EL, Prado F, Dominguez ME. Changing
trends in the management of end-stage respiratory muscle failure in neuromuscular disease:
current recommendations of an international consensus. Am J Phys Med Rehabil.
2013;92(3):26777.
Tracheostomy Decannulation
After Cervical Spinal Cord Injury 43
Erik J.A. Westermann and Mike J. Kampelmacher
Abbreviations
43.1 Introduction
comparing early (i.e., within 7 days after intubation) with late tracheostomy, which is
performed 21 days after intubation. A retrospective study suggested a policy favoring
early tracheostomy over a later procedure because of earlier discontinuation of
mechanical ventilation, shorter ICU stay, and less frequent complications of pro-
longed intubation (tracheal stenosis and granulomas) in patients who were operated
on within 7 days [2]. Because of the length of time already spent in the ICU, the
removal of the tracheostomy tube may be left to be performed outside the safe and
monitored environment of the ICU, which may carry additional risks for the patient
within the first 1236 h after decannulation [3]. Caution is advised to avoid inappro-
priate discontinuation of mechanical ventilation in patients with severely restrictive
respiratory syndromes and their discharge with artificial airways to the nursing ward
while breathing spontaneously but insufficiently and in a hypercapnic state [4]. These
patients are at high risk of erroneously being treated with oxygen to resolve desatura-
tions, resulting in respiratory arrest during the night and subsequent cardiopulmonary
resuscitation or even death.
For most SCI patients who have adequate ventilator-free breathing ability to pass
an SBT, the removal of the tracheostomy tube may not be as straightforward as in the
general ICU population. These patients usually have marginal or even absent ventila-
tory reserves and swallowing dysfunction from long-term tracheostomy tube cannula-
tion. Their ventilatory reserve may just enable them to sustain or prohibit them from
handling an increased respiratory load by increasing respiratory rate or tidal volume,
maintaining eucapnia or causing hypercapnia, respectively. If followed by aspiration,
impaired swallowing may, in fact, be the cause of such an increased respiratory load,
possibly or definitely rendering these patients hypercapnic. Periodic hypercapnia,
whatever its cause, is especially treacherous if it occurs only during sleep, which may
be regarded as a stress test for a depleted ventilatory reserve. Ventilatory reserve may
be further compromised by neuromuscular abnormalities associated with critical ill-
ness in addition to the multiple medical comorbidities also present in the general
medico-surgical ICU population. Therefore, monitoring of ventilatory sufficiency
during sleep after discontinuing mechanical ventilation should be routinely performed
in the ICU, especially before the patient is transferred to the nursing ward. During an
European Respiratory Society online lecture series on neuromuscular diseases in
November 2012, with topics on noninvasive and invasive mechanical ventilation,
44 % of attending international colleagues would discontinue mechanical ventilation
even if patients could not maintain eucapnia. In practice, such a policy may put
patients at risk for recurring episodes of ventilatory failure, which obviously should be
prevented.
The patient should be assessed for a patent upper airway, cough effectiveness, and
the ability to protect the airway from aspiration of saliva. Patency of the upper air-
way may be checked by temporarily blocking the artificial airway after deflation of
the cuff. The patient then should be able to breathe alongside the endotracheal tube
344 E.J.A. Westermann and M.J. Kampelmacher
Table 43.1 Decannulation criteria for patients who can breathe (conventional)
Prerequisites Recommendation
Alert and cooperative No sedative medications to improve sleep
Clinical hemodynamic stability No vasoactive medications
Normal gas exchange on room air PaCO2 < 45 mmHg (6.0 kPa), PaO2 > 94 %
Ventilator-free breathing ability Perform an SBT; if successful, discontinue mechanical
ventilation
Preferably, absence of aspiration ENT swallow evaluation assessment by speech
pathologist
Perform Evans blue dye test
Exclusion of upper airway ENT endoscopic evaluation of larynx and upper trachea
abnormalities caused by
endotracheal intubation or
tracheostomy
Ability to tolerate deflation of Perform endotracheal suctioning during cuff deflation
tracheostomy tube cuff
Ability to tolerate capping of the Perform a capping trial [7]. Subsequently, monitor for
tracheostomy tube respiratory distress caused by increased airway
resistance for 1224 h
Ability to maintain airway patency Evaluate voice quality during temporary occlusion of
tube with cuff deflated
Measure involuntary CPF while intubated (should
exceed 58.5 l/min [5]); measure voluntary CPF with
capped tracheostomy tube (should exceed 130 l/min [8])
Decannulate
PaCO2 partial pressure of arterial carbon dioxide, SBT spontaneous breathing trial, ENT ear, nose,
and throat, CPF cough peak flow
be performed as a screening tool for decannulation [7]. This test showed a high
sensitivity (90 %) and positive predictive value (100 %) for successful decannula-
tion among 57 patients screened over a 12-month period. Patients were enrolled
from eight different clinical services and included four neurological patients and
only one patient from the ICU. One patient failed the capping trial and was decan-
nulated but reintubated to manage secretions. Unfortunately, this study did not men-
tion how secretions were routinely managed other than by conventional invasive
methods or spontaneous coughing.
In the study of Pandian et al. [7], the following criteria for eligibility for capping
were defined:
The patient should have a small tracheostomy tube, preferably size four cuffless.
While occluding the tube with a finger for 1 min, the breathing pattern should
remain comfortable without release of positive pressure from the tracheostomy
tube upon removal of the finger as a sign of air trapping.
The patient should be able to tolerate a speaking valve without respiratory distress.
Coughing should be adequate to mobilize airway secretions.
Airway suctioning should be required less frequently than every 4 h.
Capping of the tracheostomy tube should be tolerated without respiratory distress.
The patient should maintain stable oxygen saturation at all times.
The patient should be alert and sufficiently dexterous to remove the cap from the
tracheostomy tube within 30 s without assistance from healthcare personnel.
During capping, sedation must be avoided. Those patients already known to have a
difficult airway according to their medical history or anesthesiology assess-
ment upon prior intubation were evaluated by a ear, nose, and throat (ENT) spe-
cialist, who then could advise whether to proceed with or withhold a capping
trial. SCI patients will not be able to satisfy a number of the above-mentioned
criteria because of their tetraplegia. Therefore, nursing attendance should be
continuous and an adequate call bell should be provided and its effective opera-
tion by the patient should be ascertained.
Next, because of the increased risk of dysphagia in SCI patients, an ENT inves-
tigation evaluating swallowing is recommended. Tracheostomy tubes should be
removed early in the morning, preferably at the beginning of the week, to allow for
close monitoring by as many knowledgeable professionals as possible over the fol-
lowing 2448 h.
During this period patients should be continuously monitored by pulse oximetry
and checked every 30 min for the need for suctioning or assisted coughing. Forced
vital capacity should be assessed every 4 h to identify respiratory deterioration or
signs of exhaustion. Respiratory rate should also be monitored, counting for 30 s
once every 15 min for the first 4 h and consecutively every 30 min for the next 20 h
and once hourly for the following 24 h. A spare tracheostomy tube of the same size
and one size smaller should be kept in readiness to recannulate the patient if the
need should arise [9].
346 E.J.A. Westermann and M.J. Kampelmacher
Patients with high-level cervical SCIs for whom mechanical ventilation cannot yet
be discontinued either will or will not pass an SBT, depending on the recurrence of
some ventilator-free breathing ability. They usually remain cannulated for pro-
longed periods of time, often indefinitely. They remain at increased risk of airway
damage from suctioning procedures, complications associated with the tracheos-
tomy, airway microbial colonization, pulmonary infection, and recurrent ICU
admission. Because they cannot breathe, a capping trial may seem inappropriate or
even dangerous for the simple reason of interrupting invasive mechanical ventila-
tion. Often, the presumed permanent dependence on the artificial airway is accepted
by physicians because of the continuous necessity for removal of bronchial secre-
tions. It is rarely appreciated that these artificial airways cause and increase secre-
tions and impair the ability to cough. Many tracheostomized patients, however,
choose to be decannulated or to forgo tracheostomy if noninvasive techniques are
available [10].
The question then arises regarding whether and how to remove the tracheostomy
tube for these patients. In the 1990s, Bach and coworkers [11, 12] showed that
patients with high-level cervical SCIs without ventilator-free breathing ability could
be extubated and decannulated by converting them from invasive to noninvasive
ventilation using facial interfaces during the night and mouthpiece ventilation dur-
ing the day. It was extremely important that patients were able to manage their
bronchial secretions, which were the main reason for oxygen desaturation, atelecta-
sis, retention pneumonia, and hospitalization. When using assisted coughing tech-
niques following aggressive lung volume recruitment (LVR), a cough peak flow
(CPF) of > 160 l/min could usually be achieved, and this proved enough to safely
permit the removal of the tracheostomy tube. Bach et al. proposed continuing LVR
techniques following decannulation every day to prevent airway secretion encum-
brance. Patients could use air (or breath) stacking or glossopharyngeal breathing
(GPB) to augment lung volume, improve voice volume, improve respiratory com-
pliance, facilitate noninvasive mechanical ventilation, and improve CPFs. In addi-
tion, they could regain ventilator-free breathing ability by using GPB as a breathing
method. McKim and coworkers [8] demonstrated that, using LVR and assisted
coughing techniques, CPFs measured after decannulation were some 3040 l/min
greater than during coughing with the capped cannula in place using these tech-
niques, probably because of the surplus airway resistance of the endotracheal part
of the tube. They suggested that, in cannulated patients, these findings might lower
the CPF threshold of 160 l/min with this flow difference as an indication for safe
decannulation.
For the high cervical SCI patient who cannot pass an SBT, discontinuing invasive
mechanical ventilation often seems impossible. In the ICU it may go unnoticed that
one of the main reasons for failure to discontinue invasive ventilation is airway
43 Tracheostomy Decannulation After Cervical Spinal Cord Injury 347
secretion encumbrance. During their training, intensivists have been taught to rely
on artificial airways to invasively remove airway secretions and they have seldom
been trained in using LVR techniques, which are necessary to effectively resolve
retention of bronchial secretions. Hence, they may be reluctant to remove the tra-
cheostomy tube because they think the patients depend on them for mucus removal.
Of note, contrary to what is seldom considered, these patients often can be success-
fully liberated from their artificial airways [13]. In these patients, the aims are to
discontinue invasive ventilation, proceed with mechanical ventilation noninvasively,
and remove the artificial airway. The latter goal cannot be achieved without effec-
tive airway clearance techniques [13, 14].
For SCI patients in the ICU, early treatment with LVR techniques is recom-
mended. For an effective tution of air stacking or GPB, the patient should be awake,
alert, cooperative, and highly motivated to achieve the maximum insufflation capac-
ities necessary to enhance CPFs for mucus removal. Training in these techniques is
time consuming and requires a dedicated and patient teacher. In the early post-
injury phase it is more prudent to use mechanical insufflation-exsufflation (MI-E)
with a cough-assist device, which can also be operated on a cuffed tracheostomy
tube for unresponsive patients. Only after lungs and airways have been completely
cleared of secretions, which in our experience can never be achieved with invasive
suctioning procedures only, training in noninvasive mechanical ventilation may be
initiated. Starting invasive LVR techniques early in the course of recovery may pre-
vent pulmonary complications and can shorten ICU stay and length of hospital
admission [14].
In clinical practice, patients in the ICU grow accustomed to regular bagging
procedures with a manual resuscitator prior to cuffed artificial airway suctioning.
They should again be acquainted with airflow through the upper airways to toler-
ate capping of the tracheostomy tube and to be safely converted to noninvasive
(mouthpiece) ventilation during the day. The difference between closed-circuit
mechanical ventilation via a cuffed tracheostomy tube and the air leakage cus-
tomary to noninvasive ventilation should be thoroughly explained to the patient.
While still on the ventilator, which should be able to perform in noninvasive
mode, the cuff is deflated and the patient is given mechanical ventilation by hand
with a manual resuscitator connected by a length of corrugated tubing to a
mouthpiece, which is presented to the patient. While being ventilated by hand
through the mouthpiece in sync with the ventilator equipment, its minute volume
is gradually dialed down until the patient is ventilated completely by hand. At
this point, the ventilator can be disconnected from the tracheostomy tube, which
subsequently can be capped. The patient is then adjusted to a mechanical ventila-
tor in volume-controlled mode using the mouthpiece. The same procedure applies
when adjusting the patient to noninvasive ventilation by nasal or oronasal inter-
faces. Table 43.2 lists prerequisites and recommendations as a stepwise approach
for tracheostomy tube removal in patients with high-level SCIs who have limited
or no ventilator-free breathing ability.
Table 43.2 Decannulation criteria for patients with limited or without ventilator-free breathing ability
348
Prerequisites Recommendation
Awake, alert, and cooperative Avoid sedative medications
Clinical hemodynamic stability No vasoactive medications
Maintain SpO2 > 94 % on an FiO2 = 0.21 Decrease FiO2; use pulse oximetry as biofeedback
Complete clearance of airway secretions Use invasive MI-E with exsufflation timed abdominal thrusts
Normal gas exchange Check blood gas analysis regularly, PaCO2 < 45 mmHg (6.0 kPa)
Any desaturations < 95 % resolved by MI-E or other LVR technique If SpO2 < 95 %, continue MI-E until SpO2 > 94 %
Absence of infectious (pulmonary) disease Normal white blood cell count and absent serum variables of infection; normal chest X-ray
Prevent stomal air leakage alongside tube Tight-fitting tracheostomy tube by PDT or Lipkin tracheostomy surgical technique
Ability to tolerate cuff deflation Deflate tracheostomy tube cuff; rule out aspiration
Tolerance of mouthpiece noninvasive ventilation while on Train patient in using mouthpiece noninvasive ventilation, teach to get used to
tracheostomy mechanical ventilation oropharygeal and laryngeal airflow; increase airflow to at least 90 l/min
Discontinue tracheostomy tube ventilation during the day Use mouthpiece ventilation only; cap tracheostomy tube. Check blood gas analysis and
adjust ventilation accordingly. Teach to master air stacking as LVR technique
Discontinue invasive MI-E
Tolerance of tracheostomy tube being capped Perform capping trial and monitor for respiratory distress during either spontaneous or
mouthpiece ventilation, check gas exchange, apply LVR as necessary to maintain SpO2
> 94 % on room air
Tolerance of noninvasive mask ventilation during the night with Check blood gas analysis or monitor nocturnal PCO2 transcutaneously or by
capped tracheostomy tube oxicapnometry
Ability to sustain noninvasive positive pressure ventilation day Exclude anxiety related to NPPV; fear of going to sleep with NPPV
and night
Ability to sustain noninvasive MI-E by oronasal mask Decannulate. Apply pressure dressing
Maintain normal gas exchange for 2448 h using NPPV, MPPV, Monitor gas exchange, triggering frequency, VC and CPF, MIC, and CPF after MIC
and LVR Discontinue noninvasive MI-E; continue air stacking with abdominal thrusts thrice daily
Prepare for ICU discharge Consult home mechanical ventilation service
SpO2 pulse oximetry saturation, FiO2 fraction of oxygen in inspired air, PaCO2 partial pressure of arterial carbon dioxide, MI-E mechanical insufflation-exsuf-
E.J.A. Westermann and M.J. Kampelmacher
flation, PDT percutaneous dilatational tracheostomy, LVR lung volume recruitment, NPPV noninvasive positive pressure ventilation, MPPV mouthpiece posi-
tive pressure ventilation, VC vital capacity, CPF cough peak flow, MIC maximum insufflation capacity, ICU intensive care unit
43 Tracheostomy Decannulation After Cervical Spinal Cord Injury 349
43.5 Summary
In high-level SCI patients for whom airway management has resulted in tracheos-
tomy tube placement during their ICU course, decannulation can be achieved for
most of them by using a stepwise approach (Tables 43.1 and 43.2), and if executed
by an experienced and dedicated health-care team. Also, the selected patient with an
aspiration hazard may be liberated from an artificial airway. With the aggressive use
of different LVR techniques accompanied by timed abdominal thrusts it has been
clearly shown that decannulation is feasible, even if not initially considered because
of complete ventilator dependency or prolonged airway secretion encumbrance. By
gaining experience in the application of LVR techniques and mechanical-assisted
coughing, intensivists can liberate SCI patients from invasive mechanical ventila-
tion and from their tracheostomy tubes during their ICU stay. Thus, they can shorten
admission times, reduce health-care costs, and generally improve the quality of life
of their patients, who now can be managed at home using noninvasive ventilation
and noninvasive LVR techniques for ventilatory support and airway clearance,
respectively.
350 E.J.A. Westermann and M.J. Kampelmacher
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2. Romero J, Vari A, Gambarrutta C, et al. Tracheostomy timing in traumatic spinal cord injury.
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spinal cord injury. Paraplegia. 1993;31:4308.
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patients in an ICU. Chest. 2010;137(4):77782.
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the patient and the care giver. Chest. 1993;104:17026.
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Part V
Discharge Ventilator Depend Patients
Criteria for Discharging Patients
with Prolonged and Difficult Weaning 44
from Intensive Care Unit to Weaning
Center
Abbreviations
44.1 Introduction
During the past two decades, an abundant literature on weaning from mechanical
ventilation (MV) has permitted a better understanding of this process, which may
account for about 40 % of the total time spent on MV [1]. The majority of patients
can be weaned easily, as soon as the first trial [13], provided that clinicians
promptly detect the ability to be weaned, avoid excess sedation, and perform a spon-
taneous breathing trial (SBT) [1]. For some patients, weaning is difficult and they
require a potentially complex pathophysiological analysis to diagnose and treat the
etiology of failure before resuming an SBT. Finally, a smaller proportion of patients
recovering from catastrophic illness and/or having severe underlying comorbidities
require a long time before being separated from the ventilator. They constitute the
prolonged weaning group, with a usually poor outcome [1]. For these patients,
weaning from MV could depend on specific measures; among them, transfer to a
specialized weaning unit could be discussed [4]. In this chapter, we consider criteria
for discharging these particular patients in such a structure.
44.2 Discussion
Length of intensive care unit (ICU) stay is a classical and important tool to evaluate
quality of care and activity of the ICU. For clinicians, ensuring optimal care with a
short length of stay is important because of the association between prolongation of
ICU stay and complications, with an effect in terms of morbidity and mortality [5].
To our knowledge, no consensus exists that defines when a stay is considered to be
prolonged; moreover, these settings might be different, depending on the character-
istics of the ICU (surgical or not, and type of surgical ICU) [6]. However, an ICU
stay of 14 days seems to be relatively consensual for a nonspecific ICU [7]. Over the
years, probably related to patient evolution (with increasing comorbidities) and
progress in intensive care, a new category of patients has appeared and is expected
to increase: They experience a catastrophic illness and survive after a long ICU stay
and aggressive therapy, but they remain dependent on a ventilator. Moreover, these
patients suffer from consequences of multiple organ failure, including renal insuf-
ficiency, acquired weakness, malnutrition, and colonization with multidrug-resistant
bacteria. We can designate them as chronic critically ill patients [8, 9].
We can find many definitions for prolonged weaning. Thus, in the United States,
when a patient is ventilated more than 21 days, he or she can be systematically con-
sidered as a prolonged ventilated patient, regardless of the weaning process issue.
This definition is directly related to economic considerations [10]. Indeed, some
patients may not benefit from weaning attempts, because of the severity and persis-
tence of the underlying disease that lead to prolonged invasive MV. Thereby, in
2007, an international consensus conference [1] proposed a classification of the
weaning process according of the number of spontaneous breathing trials performed
44 Criteria for Discharging Patients with Prolonged and Difficult Weaning 355
and the success of extubation. The third group in this new classification is referred
to as prolonged weaning, defined as requiring more than three weaning attempts
or 7 days to be separated from the ventilator. Although these prolonged weaning
patients represent fewer than 10 % of the whole population of ICU patients, they
paradoxically require a prolonged ICU stay, accounting for up to 40 % of ICU
expenditures [11, 12].
The concept of a specialized weaning unit (SWU) was developed in the United
States [13], based on epidemiologic (an increase of patients with difficult and pro-
longed ventilation) and economic (lower operating costs of these units and preser-
vation of ICU bed availability) arguments. The notion of a SWU was also introduced
by the international consensus conference on weaning, and discharge of these
patients in specific units should now be encouraged [1]. Several modalities of orga-
nization have been described [4]. Schematically, a SWU could be supported by an
ICU or located in a specific long-term care hospital.
The concept of chronic critically ill patients emerged in the last decade from
cohort studies and can be applied to many ICU patients [14]. Recent studies confirm
that prolonged weaning is associated with a higher mortality, longer ICU stay, and
longer duration of MV [3]. This finding has led to the development of the SWU
because of the high cost of conventional ICU wards and because ICUs may lack the
necessary organization and specialized staff to manage prolonged weaning patients
[15]. These specific units also facilitate more efficient use of critical care resources
by increasing the availability of acute ICU beds. Thus, in their retrospective study,
Lone et al. [16] showed that an SWU could decrease by 810 % the number of ICU
day-beds occupied and permit a savings of nearly $500,000/year.
SWUs also offer expertise in prolonged weaning and specialized multidisci-
plinary teams composed of clinicians, physiotherapists, nurses, nutritionists, and
psychotherapists. Moreover, these units are characterized by a suitable environ-
ment, with less noise and less activity, especially at night, both of which are sleep
promoting. Thus, they can provide more specifically adapted care with reference to
the patients needs, together with cost savings related to the reduced nurse-to-patient
ratio, specific monitoring, and technical equipment.
To our knowledge, no study has compared different ICU criteria to define those used
for discharging patients to an SWU. In relation to the purpose of such a unit, patients
must be classified in the prolonged weaning category, provided that a well-
conducted weaning from MV has been initiated but resulted in weaning failure.
Consequently, a real weaning project should exist and be planned. Therefore, patients
with persistent coma, spinal cord injury with diaphragmatic impairment, or terminal
356 G. Beduneau et al.
chronic respiratory failure do not appear to be good candidates for SWU admission.
At the stage of prolonged weaning from MV, eligible patients for an SWU should
have already been tracheostomized to facilitate their global and ventilatory manage-
ment [15]. Recent studies have demonstrated that performing a tracheostomy does
not alter outcome in terms of mortality or duration of MV [17]. It is generally
acknowledged, however, that performing a tracheostomy in these ventilator-
dependent patients permits reduction of the work of breathing and sedation level and
more easily restores mobilization, nursing, swallowing, oral nutrition, and speech
[18, 19]. In addition, no other vital organ failure than ventilatory dependence should
persist, even though patients may present some consequences of multiple-organ fail-
ure (e.g., denutrition, renal failure). Thus, there are benefits from a transfer to an
SWU for such patients: the patients benefit by the different conduct of their specific
management, and the community benefits as it frees up some ICU beds.
In sum, we must carefully select patients for admission into an SWU, but, of
course, results and outcome will depend on the severity of the criteria used. To our
knowledge, criteria used for SWU admission have been poorly reported, excepted in
the study of Rose et al. [20]. Their admission criteria were as follows: MV for more
than 21 days, clinical stability, tracheostomy performed, appropriate nutritional
intake, ability to decide, and advance directives collected. Exclusion criteria were as
follows: fatal disease, dementia, and progressive neurological disease. We also devel-
oped a six-bed SWU in our French teaching hospital, linked to our medical ICU. Our
specific admission criteria are as follows: prolonged weaning defined as group III
(prolonged weaning) of the international consensus conference classification [1], tra-
cheostomy being performed, clinical stability (specifically no catecholamine drugs),
no central neurological or cognitive disorders making weaning out-of-hand hopeless,
and good functional autonomy prior to ICU hospitalization [21].
median time to be weaned was 15 days, and 54 % had weaning success, 21 % had
persistence of ventilator dependence, and 25 % of patients died. One year after
discharge, 30 % of patients were still alive [8, 15]. Finally, these cohort studies
clearly illustrate the need for prolonged weaning of chronic critically ill patients
in terms of human and technical resources.
Although ventilatory management remains essential, no specific protocol has
been demonstrated to outperform other strategies in this difficult-to-wean patient
group [23]. Interestingly, much attention must be paid to the decannulation proto-
col. For instance, decannulation can greatly interfere with the patients work of
breathing [24] and it seems to us important to wait until the appropriate time before
removing the cannula. To our knowledge, only one study has reported and outlined
the need for a step-by-step clinical protocol for weaning these patients from the
tracheostomy [25].
Conclusion
Characteristics of patients with prolonged weaning from MV illustrate the con-
cept of chronic critically ill patients. They need very specific care, with the main
objectives of MV weaning and ICU discharge but also rehabilitation and return
to functional autonomy for hospital discharge. The management of these patients,
dependent on MV and also on ICU resources, represents, therefore, a true chal-
lenge for the clinician. Specific units, such as an SWU, dedicated to weaning
from MV and global rehabilitation, must provide sufficient human resources and
technical skills to achieve these different objectives. Patients discharged to these
units must have initiated but failed the weaning process. Finally, there is still a
need for scientific research in this field, focusing particularly on criteria for SWU
admission, modalities of management and outcome, and populations that are
more susceptible to benefit.
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otomy on sedative administration, sedation level, and comfort of mechanically ventilated
intensive care unit patients. Crit Care Med. 2005;33(11):252733.
44 Criteria for Discharging Patients with Prolonged and Difficult Weaning 359
20. Rose L, Fraser IM. Patient characteristics and outcomes of a provincial prolonged-ventilation
weaning centre: a retrospective cohort study. Can Respir J. 2012;19(3):21620.
21. Beduneau G, Ardanuy C, Clabault K, Richard JCM. Prolonged weaning from mechanical ven-
tilation: impact of a specialised weaning unit. Intensive Care Med. 2008;34 Suppl 1:S80.
22. Ambrosino N, Venturelli E, Vagheggini G, Clini E. Rehabilitation, weaning and physical ther-
apy strategies in chronic critically ill patients. Eur Respir J. 2012;39(2):48792.
23. Vitacca M, Vianello A, Colombo D, Clini E, Porta R, Bianchi L, et al. Comparison of two
methods for weaning patients with chronic obstructive pulmonary disease requiring mechani-
cal ventilation for more than 15 days. Am J Respir Crit Care Med. 2001;164(2):22530.
24. Chadda K, Louis B, Benassa L, Annane D, Gajdos P, Raphal JC, et al. Physiological effects
of decannulation in tracheostomized patients. Intensive Care Med. 2002;28(12):17617.
25. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, et al. Weaning from
tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flow-
chart and clinical outcome. Intensive Care Med. 2003;29(5):8458.
Discharge Planning of Neuromuscular
Patients with Noninvasive Mechanical 45
Ventilation After Difficult Weaning
from Invasive Mechanical Ventilation:
From ICU to Home Care
45.1 Introduction
About 5 % of patients under mechanical ventilation longer than 7 days are difficult
to wean after 4 weeks and have been classified as chronic ventilator-dependent
patients (VDPs) [1]. The presence of a neuromuscular disease is one of the most
important reasons for this weaning failure.
After the resolution of an acute episode in a neuromuscular patient (NMP), it is
important to consider such questions as, How and when can noninvasive mechani-
cal ventilation (NIV) be implemented? Will NIV avoid invasive mechanical venti-
lation forms such as tracheostomy? What is the most appropriate site for optimal
long-term care that will allow greatest independence, function, and quality of life?
When and how can the patient be transferred from the intensive care unit (ICU) to
home?
Today, it is recognized that NIV has an important impact on the care of
VDPs, particularly in those with neuromuscular disorders and thoracic skeletal
disorders. The purpose of this chapter is to provide principles and guidelines
for the selection and treatment of VDPs with neuromuscular diseases in non-
ICU sites.
Recommendations are provided regarding the continued care of VDPs at avail-
able sites, the criteria for discharge to a general ward from an ICU, and steps for
making decisions on the most appropriate site for an individual patient until it is
possible to consider their transfer to home. At this point, it is relevant to explore
planning for discharge, care, and rehabilitation of ventilator-assisted patients needed
after discharge and the necessary equipment and resources.
Advances in medical care and the acute application of invasive mechanical ventila-
tion have resulted in increased survival of critically ill patients, some of whom may
become dependent on long-term mechanical ventilation. In a study by Bach et al.
[2], most long-term ventilator-assisted patients (62 %) were in acute care hospitals,
22 % were in chronic care hospitals, and only 20 % were at home. Other studies [3]
have demonstrated that most long-term ventilator-assisted patients continue to be
located in acute care hospitals, consuming most of the available resources [4].
Determining objectives and goals for the management of VDPs not only contributes
to the best possible care but also enables decisions on sites and resources that will
best enhance the patients lives and make care more cost effective. Three objectives
guide the management of VDPs: (1) treat the patients acute illness, (2) wean the
patient from mechanical ventilation when possible, and (3) enhance the patients
quality of life.
A 1986 American College of Chest Physicians Consensus Conference included
the following goals for the management of VDPs: provide an environment that
enhances the individuals potential, improve physical and physiologic function,
reduce morbidity, extend life, and provide cost-effective care [5]. These goals may
be applied equally to each of the objectives for treatment. For example, improve-
ment of physical and physiologic function is an appropriate goal for acutely ill
patients (to reverse the pathophysiologic aspects of the presenting disease), and also
for long-term VDPs with limited physical function (such as NMPs or patients with
spinal cord injury).
New information suggests that the ICU environment is not needed for long-term
ventilator care and may even interfere with optimization of functional potential.
Patients requiring long-term ventilation may reach a state of relative clinical stabil-
ity and not require ICU nursing or invasive monitoring. Furthermore, most, if not
all, long-term ventilator-assisted patients require significant rehabilitation, and a
multidisciplinary treatment plan focusing on rehabilitation is difficult to implement
in an ICU.
Decisions on the most appropriate non-ICU setting for long-term mechanical
ventilation must be individualized, but regardless of the site chosen, several
364 E. Barrot-Corts et al.
essential criteria for patient stability must be met to ensure that discharge to an
alternative site is safe, logistically possible, and cost saving. Clinical criteria for
stability of a VDP transferred to a more intensely supervised site (such as a special-
ized respiratory care unit in an acute care facility) are less rigid than for patients
discharged to an intermediate care facility (such as a rehabilitation hospital) or to a
long-term facility or home.
Patients should also meet the criteria for respiratory stability. They should have
a secure airway or be stabilized on a regimen of NIV. They should not have epi-
sodic severe dyspnea or desaturations, and oxygenation needs should be met easily
without requiring high supplementary oxygen concentrations or high levels of
positive end-expiratory pressure. Respiratory secretions should be manageable
outside of the ICU environment, and variations in airway resistance should be min-
imal. In addition, the patient should not be undergoing frequent ventilator setting
changes, other than for weaning, and should not require sophisticated ventilator
modes.
For VDPs who are being considered for transfer home, additional psychological
and social stability criteria should also be met to ensure that the patient presents a
successful psychological adaptation to home and will have sufficient human and
financial resources to sustain that success. It is also advantageous to have a family
that fully comprehends the situation, is capable and desirous of participating in the
patients care, and has sufficient support from an experienced multidisciplinary
team of health-care professionals.
All members of the health-care team should evaluate these factors as they relate
to the individual requiring assisted ventilation. Should the current level of care be
continued? Or is an alternate site now appropriate? The patient and the patients
family should be asked to provide input. The physician, as the individual responsi-
ble for ordering services and care, has a key role in this process and should deter-
mine the amount of medical care, monitoring, and intervention required by listing
the needs and goals of the VDP.
The discharge planning process should ensure a smooth transition and safety in
addition to an optimal outcome in the new site both when planning the patients
discharge from the hospital to home and when transferring the patient from an ICU
to non-ICU acute care. The patients goals and a list of patient needs, including
personnel requirements and specific equipment, should be clearly defined.
Guidelines for the discharge planning process have been written by the American
Medical Association [8], the American Association of Respiratory Care [9], and a
group of health-care professionals at a university medical center [10].
Successful transition of a VDP from the ICU to an intermediate or long-term
care site outside the traditional hospital setting, particularly to the home, requires
the collaborative efforts of a discharge team [11]. The team identifies all patient care
issues that must be resolved prior to discharge and develops a plan to facilitate the
45 Discharge Planning of Neuromuscular Patients with NIV 365
transfer. The team, which includes the patient and his or her family, should be com-
prised of key hospital and community-based personnel, many of whom will play an
ongoing role in the patients care once he or she is discharged. Discharge planning
team members should include the following:
Patient and family: The most essential members of the discharge team, mainly
transferring to home, are the patient and his or her family.
Physicians: Those responsible for the VDPs transition and care are the pulmo-
nary or rehabilitation medicine specialist and the primary care physician, who
should have experience in the management of long-term mechanical ventilation.
Because a VDP at home imposes a significant burden on the family, the physician
should inform the patient and family of the burdens as well as the benefits of home
mechanical ventilation.
Discharge coordinator: One team member should be designated as the coordina-
tor who will serve as a liaison among the multiple disciplines involved. This person
is usually a nurse, preferably specialized in pulmonary care, who will collaborate
with a respiratory care practitioner.
The patient and their family need to learn skills about care, and on this way
the role of doctors and nurses is crucial. The coordinator usually selects the spe-
cific types of home respiratory care equipment and ensures that the patient, fam-
ily, and other caregivers have a detailed understanding of the equipment. When
patients are discharged to long-term care sites, including the home, the home
care company should be responsible for equipment maintenance and should also
provide personal trained in NIV management when necessary. A social worker
can also provide an evaluation of the alternate site as well as of community and
home resources and support available for long-term care. In addition, beds,
wheelchairs, and other general medical equipment must be provided or their
acquisition facilitated (see the checklist in Table 45.2 for equipment and supplies
required).
Occupational therapist: Occupational therapists should be consulted if the
patient must learn new skills to facilitate discharge or rehabilitation. This specialist
may participate in home assessment, especially if the patient is wheelchair bound,
evaluate the need for assistive devices that increase patient function and enhance
performance of daily activities, and train the patient in work simplification and
energy conservation.
Physical therapist: Many patients require consultation by a physical therapist.
Rehabilitation prior to discharge and as an intermediate step before home discharge
is frequently needed to increase the patients strength, endurance, and function. The
physical therapist also assists the patient in choosing the appropriate wheelchair,
especially when a motorized chair is needed.
The discharge plan should contain three components: assessment, education and
training, and a plan of care. The assessment should include three different aspects:
(1) patient stability (Table 45.1); (2) resources available where long-term care will
be performed; and (3) caregiver skills, education, and training. The discharge plan
tries to provide the patient and family the tools necessary for the VDP management
at home.
366 E. Barrot-Corts et al.
Table 45.2 Checklist of equipment and supplies that should be considered for ventilator-dependent
patients (<4 h with spontaneous ventilation and/or tracheostomy) planning to discharge to home
Mechanical ventilator
Primary
Secondary or backup system (portability)
Battery and connecting cable for emergency (power source)
Ventilator circuit
Exhalation valve
Noninvasive patient interfaces (face mask, nasal mask or nasal pillows, mouthpiece)
Humidifier and heater
Head gear, chin straps
Tracheostomy supplies
Tracheostomy tube adapter/connector, T-tube adapter
Tracheostomy tube (including next smaller size)
10-ml syringe, used only to inflate or deflate cuff
Heat and moisture exchanger
Disinfectant solution
Tracheostomy dressings or Velcro tracheostomy tube strap
Manual resuscitator
Oxygen supply system (stationary and portable), nasal cannulas
Suction machine (stationary and portable), suction catheters
Manual and mechanical secretion clearance aids such as cough in-exsufflator
Compressor for aerosolized medications
Monitors and alarms for ventilator and patient (when needed)
Others supplies:
Patient communication system
Wheelchair
Hospital bed and mattress
Commode, bedpan, urinal, or elevated toilet seat
Patient lifter
Safety bars in bathroom
Hand-held shower
Shower chair
Modified from ODonohue et al. [5]
The physician plays an essential role in the non-ICU acute care sites, including
home. He or she should be in contact with those responsible for the patients. Based
on the information the physician receives, the physician should be able to adjust the
patients treatment when an acute problem occurs, aiming to avoid unnecessary
hospital visits.
The identified caregivers should be able and willing to undergo the extensive
training required to perform all the patient care procedures and must be able to
dedicate the time required to learn these procedures while the patient is still in an
acute or intermediate care facility. Not all caregivers are willing to learn
45 Discharge Planning of Neuromuscular Patients with NIV 367
Conclusion
A patient-specific discharge plan should be developed and implemented by a dis-
charge planning team. Discharging a VDP from an ICU requires a coordinated
team of health-care providers, including the individual and his or her family, a
physician, nurse/discharge planner, social worker, respiratory therapist, and home
care company. It should contain three components: assessment, education and
training, and a plan of care.
References
1. Knaus WA. Prognosis with mechanical ventilation: the influence of disease, severity of dis-
ease, age, and chronic health status on survival from an acute illness. Am Rev Respir Dis.
1989;140(suppl):S813.
2. Bach JR, Intintola P, Alba AS, et al. The ventilator-assisted individual: cost analysis of institu-
tionalization vs rehabilitation and in-home management. Chest. 1992;101:2630.
3. Milligan S. AARC and Gallup estimate numbers and costs of caring for chronic ventilator
patients. AARC Times. 1991;15:306.
45 Discharge Planning of Neuromuscular Patients with NIV 369
Abbreviations
Once the precipitating cause of their acute episode of respiratory failure has been
solved, these chronically ill patients are often discharged from the ICU but still
require MV. Post-discharge care for PMV requires transfer to a long-term care or
46 Organization of a Weaning Unit 375
These consists of several CVFs going under names such as regional weaning cen-
ters, prolonged respiratory-care units, long-term acute-care units, and respiratory
ICUs inside rehabilitation hospitals. These units were established either as free-
standing hospitals, as in the case of most regional weaning centers, or within an
acute-care hospital but operating with total independence. As such, their gover-
nance is independent of the host hospital, and reimbursement is not based on a
diagnosis-related group system. Unlike CVFs located within acute-care hospitals,
CVFs located outside appear to have a rather heterogeneous organization and staff-
ing. This heterogeneity occurs despite the facilities espousing a program based on
the common ideal of providing comprehensive medical, nursing, and respiratory
care to ventilator-dependent patients.
In Europe, CVFs outside acute-care hospitals are run mainly by full-time attend-
ing physicians who are specialists in respiratory and/or critical-care medicine.
These physicians are in charge of the admission and discharge of patients and the
weaning protocols. They are on duty 24 h a day. The doctor-patient ratio is at least
1:8. The nurse-patient ratio is usually similar to that of North American centers (the
nurse-patient ratio is about 1:4 during the day and 1:8 at night and on weekends).
Respiratory therapists in Europe are involved mainly in specific rehabilitation pro-
grams, for about 8 h a day (excluding Sundays and holidays), rather than in the
weaning process. Indeed, they provide physical and pulmonary rehabilitation,
which has been shown to help in freeing patients from MV and restoring them to an
acceptable level of autonomy. CVFs located outside acute-care hospitals are
intended to provide privacy, rest, and longer visiting hours for relatives and friends.
Fig. 46.1 Bedside attended session of muscular active training involving the upper limbs
program with better physical function recovery, better control of emotional status,
low rate of readmission, and lower costs. Weaning from PMV is a complex and
time-consuming process that involves not only the selection of the best ventilation
method for a particular patient, but also comprehensive procedures such as protocol-
driven weaning, including management of the ventilator and tapering sedation.
Severe disability following acute illness onset, psychiatric symptoms, frequent
sleep disturbances and disruptions, and swallowing problems are common prob-
lems in these patients with prolonged weaning. Therefore, several activities and
facilities in these units aim to restore maximal functions for each individual patient.
Given the nature of critical illness and the modalities used to manage it, pro-
longed bed rest, with well-known adverse physiological effects, is a common fea-
ture of the ICU. Physiotherapy has the important potential to restore the lost
peripheral muscle function. Moreover, it traditionally does not start until ICU dis-
charge. Critically ill patients are often viewed as too sick to tolerate physical
activity in the early phase of their illness and, therefore, immobilization is frequently
prolonged. Physiotherapy is the process of restoring health or normal life by train-
ing and therapy after illness, but it would be preferable to do it proactively by opti-
mizing and preserving physiological reserve in earlier stages of acute disease, as
well as trying to restore it in the later phases of chronic critical illness. Figure 46.1
shows bedside active muscular training involving the arms in the very early phase
of stay. Sometimes, recovery of muscular function can succeed earlier than wean-
ing; patients are thus encouraged to move actively while still needing ventilatory
assistance (see an example in Fig. 46.2).
378 E.M. Clini et al.
Fig. 46.2 An advanced recovery phase: patients flat walking using a rollator but still needing the
ventilatory assistance
Patients who survive the acute phase of critical illness experience has a wide
range of physical disabilities, including: neuromyopathies with muscle wasting,
weakness, and fatigability; joint deformities and contractures; and additional resid-
ual disease-related damage to specific organ systems. Patients who remain ventilator-
dependent in ICUs may suffer from additional burdens of continuing systemic
inflammation and catabolism combined with limited mobility and suboptimal nutri-
tion, and this particularly affects the neuromuscular system. In addition to neuro-
muscular disorders, patients experience other physical and psychosocial effects,
like changes to skin and hair, endocrine impairment, sleep, mood and libido disor-
ders, and chronic pain.
Open visiting hours for family members and comfort among patients and care-
givers may be enhanced by return to a more physiologic circadian rhythm as
opposed to that found in a typical ICU. Sleep deprivation can have significant con-
sequences and has been shown to impair cognitive function, increase protein catab-
olism, decrease immune function, and alter respiratory mechanics that might
eventually impact weaning from MV. A more natural environment like a CVF
may minimize the number and intensity of some critical factors involved in the
genesis of poor sleep, such as noise and light intensity.
Aspiration is common in patients with tracheostomies receiving prolonged
ventilation, and with advanced age the risk of aspiration increases. Swallowing
46 Organization of a Weaning Unit 379
problems are seldom assessed with the appropriate technique (i.e., video fluoros-
copy) in the ICU, and the most important specific rehabilitative therapy is rarely
started. A less stressed environment than of ICUs, combining less sedative drugs
and more comprehensive teamwork by nurses, respiratory therapists, psycholo-
gists, and clergy, typical for a CVF, may improve the patient-clinician relation-
ship. In this view, the expectations and outcomes may be better defined and
discussed.
Therefore, organization of a weaning unit requires interaction among different
health professionals with specific competence [11]. A medical doctor is gener-
ally referred as the most prominent managing figure of the team, often involved
in the difficult patient care decision algorithm and in communication with the
relatives. Overall, the optimal physician-to-patient ratio in these units is about
1:6. Nurses should assist each patient more than 135 min/day and physiothera-
pists for 60 min/day or 360 min per week. Other professional figures such as the
psychologist and the nutritionist should be involved for at least 10 and 3 h per
week, respectively.
Although advances in intensive care have enabled more patients to survive an acute
critical illness, they also have created a large and growing population of chronically
critically ill patients with prolonged dependence on MV and other intensive care
therapies. The American College of Critical Care Medicine states in its guidelines
for admission to and discharge from adult intermediate-care units that medically
stable ventilator patients for weaning and chronic care are the ideal candidates for
these environments. The hallmark of chronic critical illness is respiratory failure
requiring prolonged dependence on MV. Besides prolonged ventilator dependence,
evidences point out that chronic critical illness is a syndrome comprising additional
characteristic features. These include profound weakness attributed to myopathy,
neuropathy, and alterations of body composition including loss of lean body mass,
increased adiposity, and anasarca; distinctive neuroendocrine changes including
loss of pulsatile secretion of anterior pituitary hormones, contributing to low target
organ hormone levels and impaired anabolism; increased vulnerability to infection,
often with multiresistant microbial organisms; brain dysfunction manifesting as
coma or delirium that is protracted or permanent; skin lesions and breakdown; all
associated with nutritional deficiencies, edema, urinary incontinence, and prolonged
immobility. Patients report significant distress from symptoms like pain, thirst, dys-
pnea, depression, and anxiety, and from inability to communicate during endotra-
cheal intubation [12]. Chronic critical illness is uniquely characterized by the
presence of these features as a clinical constellation in association with prolonged
dependence on MV. Between 5 and 10 % of patients who require MV for acute
conditions develop chronic critical illness. Between 30 and 53 % of chronically
critically ill patients are liberated from MV in the acute-care hospital. Better out-
comes are reported by some SWUs, but they often select patients with higher
380 E.M. Clini et al.
46.5 Conclusion
Over the past 15 years, the availability of ICU beds, new technology, and improved
levels of care have produced a new population of patients called survivors of cata-
strophic illness. These patients often require prolonged weaning. The rate of achiev-
ing complete ventilator independence in specific and dedicated weaning units is
generally high. It has been demonstrated that these units are cost-saving alternatives
to an ICU for carefully selected patients and survivors have an acceptable long-term
quality of life. The different international medical systems need to adopt new orga-
nizational innovations and highlight the need for a diverse program of comparative
effectiveness research to determine the optimal organization of care for patients
recovering from critical illness, including the best way to maximize survival and
control costs for this high-risk patient group [14]. Chronic critical illness is a devas-
tating condition: mortality exceeds that for most malignancies, and functional
dependence persists for most survivors. Most chronically critically ill patients are
older adults who have underlying comorbid conditions and develop sepsis and other
acute comorbidities with treatment for acute medical, surgical, neurologic, or car-
diac critical illness. Beyond prolonged ventilator dependence, which is its hallmark,
increasing evidence indicates that chronic critical illness is a syndrome encompass-
ing other characteristic clinical features and affecting multiple systems and organs.
Long-term acute-care hospitals play an increasingly important role in patients with
chronic critical illness.
With increased efforts to reduce health-care costs, patients will be shifted away
from ICUs toward other clinical settings, such as dedicated weaning facilities, to
care for more and increasingly complex patients. The main benefits of chronic ven-
tilator facilities are the possibility of relieving congestion of ICU beds, maintaining
a high level of nursing assistance, responding to sudden changes in a patients clini-
cal condition, allowing enough time for a multidisciplinary rehabilitation approach,
and acting as a bridge to home-care programs or other forms of continuous chronic
assistance.
Notwithstanding, few data exist to guide decision making about transfer or
discharge to these facilities [15], and more research is needed to assess the
46 Organization of a Weaning Unit 381
References
1. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from
mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med.
1995;332:34550.
2. Vitacca M, Vianello A, Colombo D, et al. Comparison of two methods for weaning patients
with chronic obstructive pulmonary disease requiring mechanical ventilation for more than 15
days. Am J Respir Crit Care Med. 2001;164:22530.
3. Ferrer M, Esqinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning
failure. Am J Respir Crit Care Med. 2003;168:706.
4. Brochard L (2005) Pressure support is the preferred weaning method. As presented at the 5th
international consensus conference in intensive care medicine: weaning from mechanical ven-
tilation. Hosted by ERS, ATS, ESICM, SCCMand SRLF, Budapest, 2829 Apr 2005.
5. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation Statement of the
Sixth International Consensus Conference on Intensive Care Medicine. Eur Respir J.
2007;29:103356.
6. Funk GC, Anders S, Breyer MK, et al. Incidence and outcome of weaning from mechanical
ventilation according to new categories. Eur Respir J. 2010;35(1):8894.
7. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-
term functional recovery. Crit Care Med. 2009;37:2499505.
8. Nava S, Vitacca M. Chronic ventilator facilities. In: JTobin M, editor. Principles and practice
of mechanical ventilation. 3rd ed. New York: McGraw-Hill; 2013. p. 77792.
9. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical
ventilation. Chest. 1997;112(1):18692.
10. Seneff MG, Wagner D, Thompson D, et al. The impact of long-term acute-care facilities on the
outcome and cost of care for patients undergoing prolonged mechanical ventilation. Crit Care
Med. 2000;28:34250.
382 E.M. Clini et al.
11. Vitacca M, Clini E, Nava S, et al. High complexity rehabilitation in prolonged weaning patient:
role of pneumologist. Rass Patol App Respir. 2013;28:17987.
12. Nelson JE, Cox CE, Hope AA, et al. Chronic critical illness. Am J Respir Care Med.
2010;182:44654.
13. Nelson JE, Meier DE, Litke A, et al. The symptom burden of chronic critical illness. Crit Care
Med. 2004;32:152734.
14. Kahn JM, Benson NM, Appleby D, et al. Long-term acute care hospital utilization after critical
illness. JAMA. 2010;303(22):22539.
15. Vitacca M, Nava S. Incomplete network for survivors of catastrophic illness after release from
ICUs. Respir Care. 2013;58(2):3845.
16. Kahn JM. The evolving role of dedicated weaning facilities in critical care. Intensive Care
Med. 2010;36:810.
Difficult and Prolonged Weaning:
The Italian Experience 47
Raffaele Scala
47.1 Introduction
47.2 Mission
The mission of RICUs that function as weaning centers [9] is crucial in the context
of clinical governance of ARF/ACRF because they work as a strategic node for (1)
the quick discharge of critically ill patients from the ICU, where they failed repeated
attempts of disconnections from the ventilator, to these units dedicated to weaning
with an optimization of the limited health resources; (2) the achievement of a greater
rate of success in totally or partially liberating ventilator-dependents patients from
IMV through protocol-driven, multidisciplinary, intensive rehabilitative interven-
tions; and (3) the delicate transitional process at home of chronically critical patients
(e.g., with chronic obstructive pulmonary disease (COPD), end-stage heart failure,
advanced neuromyopathy, pluri-comorbidities, postsurgical sequelae), thanks to the
activation of integrated pathways between hospital and territory.
a
2007 (n.44)
Weaning
IMV
NIV
Monitoring
0 10 20 30 40 50 60
b %
60
RMU (n = 13)
RIICU (n = 24)
50 RICU (n = 7)
40
Percent of patients
30
20
10
0
Monitoring NIV Invasive Weaning Decannulation
ventilation
Fig. 47.1 (a) Interventions performed in the Italian RICU according to the two national surveys
in 1997 and 2007. Differences for each intervention were statistically significant (p <0,05) between
1997 and 2007 (Modified from [14]). (b) Distribution of interventions in the surveyed RICUs in
2007 according to the level of care (modified from [5]). Differences between the three levels of
RICU care were statistically significant for all interventions (p <0.05) except weaning in RIICUs
vs RICUs. RMU respiratory monitoring unit, RIICU respiratory intermediate intensive care unit,
RICU respiratory intensive care unit
care hospitals. These RICUs act as weaning and rehabilitative centers for prolonged
invasively ventilated patients, most of them having a tracheostomy tube [5, 6]. In
accordance with these data is the 1-year experience of one expert RICU showing a
rehabilitative vocation that analyzed the interventions performed on 96 patients:
65 % of them came from ICUs and 42 % of them were admitted for prolonged
386 R. Scala
weaning [11]. Likewise, according to a retrospective study [12] including more than
3,000 patients in the period 19902005 in five Italian RICUs working as step-down
units, the management of prolonged weaning was the cause of the admission in
66 % of cases.
47.4 Models
In Italy, there are two main organizational patterns for the management of patients
with prolonged weaning within the pulmonologists rehabilitative critical area
(Fig. 46.2).
The first clinical pathway involves the transfer of ventilator-dependents patients
into the eight RICUs with rehabilitative attitude where long-term (>30 days)
multidisciplinary interventions may be applied. The role played by these units is
oriented first to recovering as much as possible of the patients functional auton-
omy, from ventilation to neuromotor activities, and, then, to activate home-care
programs for patients who remain partly or totally dependent on mechanical ven-
tilation [1214]. The weakness of this model is due to the small number of these
rehabilitative RICUs scattered throughout the national territory and their location
in institutions lacking ICU facilities. The latter may have negative implications
for safety in case of multiorgan deterioration of the patient during the weaning
process.
The second clinical option is based on the transfer of patients with difficult/
prolonged weaning into the 36 RICUs located inside acute care hospitals, where
the strategy followed to achieve the maximum ventilatory autonomy could be
applied for a shorter period of time (<30 days) [5, 14]. In case of failure of fur-
ther weaning attempts in these acute RICUs, patients could be transferred, if one
is available in their regional area, to a rehabilitative RICU. Otherwise, the length
of stay in the acute RICU is likely to be extended with the consequence of a
reduced turnover of beds available for the admission of new ARF/ACRF patients.
The integrated sequential activity of a RICU located in an acute care hospital
with that of a weaning center implemented in a close rehabilitative center was the
Home
nursing-home
Rehabilitative
RIICU PW
centers
Fig. 47.2 Different clinical models for the care of patients with weaning problems in Italy. ICU
intensive care unit, RIICU respiratory intermediate intensive care unit, RICU respiratory intensive
care unit, DW difficult weaning, PW prolonged weaning
46 Difficult and Prolonged Weaning: The Italian Experience 387
47.5 Resources
11.6
12 1997
Ratio between MD/N and patients
2007
10
8
*
average
6 4.5 * 4.4
3.2
4
0
Doctors(MD) Nurse(N)
Fig. 47.3 Changes in the average ratio between medical doctors (MD) and nurses (N) to patients
in RICUs according to the two national surveys in 1997 and 2007 (Modified from [6]) (* p <0.005
1997 vs 2007)
388 R. Scala
47.6 Diseases
The AIPO survey highlighted that the pattern of diseases treated in the Italian
RICUs changed from 1997 to 2007, with a contraction of the admissions for acute
exacerbation of COPD, largely treated with NIV, in favor of an increase in patients
with ventilatory decompensation in neuromuscular diseases and severe hypoxemia
de novo, who are more likely to require IMV and tracheostomy [5, 6]. Similarly, the
experience of some rehabilitative RICUs showed an increase in admissions for neu-
romuscular diseases, mainly due to problems of weaning, and a significant increase
in the impact of comorbidity [12]. Another type of patient referred more often to
Italian RICUs for difficult/prolonged weaning is one with postoperative ARF, often
complicating cardiac surgery, which represents a quarter of the total number of
admissions of a typical step-down unit [11].
47.7 Training
Training and expertise of the team working in an RICU are the crucial ingredi-
ents for achieving the success of the treatments, with the inclusion of weaning
from IMV. A recent survey of the respiratory intensive care unit study group of
AIPO [16] showed that the professional education pathway of the pulmonologist
in terms of RICU procedures is disappointing during the postgraduate course.
According to the data from this survey, the training for most of the procedures
required in the RICU (NIV, intubation, bronchoscopy, chest drainage, etc.) coin-
cides with the employment of the pulmonologist in the hospital. These are the
same procedures pulmonologist use to deal with difficult/prolonged weaning.
The same survey [16] showed that about 20 % of the nurse staff working in the
RICUs had never received any training course and more than 20 % of them had
never attended a course of retraining. Other worrying concerns are the limited
use (in less than 20 % of cases) of weaning protocols in more than 40 % of the
sample interviewed [16].
Conclusions
The Italian snapshot of the current role of the pulmonologist in the clinical care
of patients with prolonged/difficult weaning brings forth the following points:
1. The the growth of RICUs has stimulated the interest of Italian pulmonologists
in critical respiratory medicine and, hence, weaning strategies.
2. There is insufficient training of medical and nursing staff in RICU procedures
resulting from a still-inadequate university educational program.
3. The heterogeneous mission of the Italian RICUs results from the prevalent
rehabilitative or acute vocations, location, human resources, organiza-
tional and structural models, and integration with the territory.
4. Regional networks need to be set up according to the logic of hubs and spokes
that are able to create sequential links between the various existing structures
46 Difficult and Prolonged Weaning: The Italian Experience 389
to optimize the limited health-care resources and direct them toward the
common goal of giving the best response in terms of expertise and rapid solu-
tions to patients with weaning problems.
References
1. Corrado A, Ambrosino N, Rossi A, et al. Gruppo di Studio AIPO Riabilitazione e Terapia
Intensiva Respiratoria. Unit di Terapia Intensiva Respiratoria. Rass Patol App Respir.
1994;9:11523.
2. Corrado A, Ambrosino N, Cavalli A, et al. Unit di Terapia Intensiva Respiratoria: update.
Rass Patol App Respir. 2004;19:1834.
3. Confalonieri M, Mollica C, Nava S, et al. Censimento delle Unit di Terapia Intensiva
Respiratoria in Italia. Rass Patol App Respir. 1998;13:18692.
4. Confalonieri M, Gorini M, Mollica C, et al. Scientific Group on Respiratory Intensive Care of
the Italian Association of Hospital Pneumonologists (AIPO). Respiratory intensive care units
in Italy: a national census and prospective cohort study. Thorax. 2001;56:3738.
5. Scala R, Corrado A, Confalonieri M, et al. Gruppo di Studio AIPO Terapia Intensiva
Respiratoria. Increased number and expertise of Italian Respiratory High-Dependency Care
Units: the second national survey. Respir Care. 2011;56:11007.
6. Scala R, Confalonieri M, Corrado A, et al. Il secondo censimento AIPO delle UTIR in Italia
tra certezze scientifiche e criticit organizzative. Rass Pat App Respir. 2011;26:2429.
7. Marchese S, Corrado A, Scala R, et al. Tracheostomy in patients with long-term mechanical
ventilation. Respir Med. 2010;104:74953.
8. Corrado A, Roussos C, Ambrosino N, et al. European Respiratory Society Task Force on epi-
demiology of respiratory intermediate care in Europe. Respiratory intermediate care units: a
European survey. Eur Respir J. 2002;20:134350.
9. MacIntyre NR, Epstein SK, Carson S, et al. National Association for Medical Direction of
Respiratory Care. Management of patients requiring prolonged mechanical ventilation: report
of a NAMDRC consensus conference. Chest. 2005;128(6):393754.
10. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J.
2007;29(5):103356.
11. Ceriana P, Delmastro M, Rampulla C, et al. Demographics and clinical outcomes of patients
admitted to a respiratory intensive care unit located in a rehabilitation center. Respir Care.
2003;48(7):6706.
12. Polverino E, Nava S, Ferrer M, et al. Patients characterization, hospital course and clinical
outcomes in five Italian respiratory intensive care units. Intensive Care Med.
2010;36(1):13742.
13. Carpen N, Vagheggini G, Panait E, et al. A proposal of a new model for long-term weaning:
respiratory intensive care unit and weaning center. Respir Med. 2010;104(10):150511.
14. Scala R. Respiratory High-Dependency Care Units for the burden of acute respiratory failure.
Eur J Intern Med. 2012;23(4):3028.
15. Vitacca M, Clini E, Porta R, et al. Preliminary results on nursing workload in a dedicated
weaning center. Intensive Care Med. 2000;26(6):7969.
16. Facciolongo N, Scala R, Garuti G, et al. Gds AIPO di Terapia Intensiva Respiratoria. Survey
nazionale su formazione e pratica clinica dello Pneumologo in Terapia Intensiva Respiratoria.
Rass Patol App Respir. 2010;25:3643.
Part VII
Non Invasive Mechanical Ventilatio
in Neonatology and Pediatric
Noninvasive Ventilation Interfaces
and Equipment in Neonatology 48
Daniele De Luca, Anne Claire Servel, and Alan de Klerk
48.1 Introduction
Noninvasive respiratory support of the neonate, in the broadest sense, may include,
from least invasive up, ambient oxygen (such as via an oxyhood), low-flow nasal can-
nula, high-flow nasal cannula (delivered as heated, humidified, high-flow nasal can-
nula), continuous positive airway pressure (CPAP), phasic noninvasive ventilation,
and, more recently, nasal high-frequency ventilation (nHFV). The focus of this chap-
ter is on positive-pressure noninvasive ventilation (NIV) in neonates. Therefore, this
discussion focuses on drivers of CPAP, phasic NIV, and nHFV, and of the impact of
those drivers and modalities on the efficacy of the delivered noninvasive support.
water (or in some centers, 0.25 % acetic acid) to the depth required to generate the
desired airway pressure (e.g., 6 cm below the surface to generate 6 cmH2O pressure).
Most, if not all, modern conventional neonatal ventilators are able to provide CPAP via
a continuous gas flow source directed against a controlled resistance in the expiratory
limb of the circuit. Although some conventional ventilators are also able to provide
variable-flow CPAP, modulating the expiratory resistance valve and the circuit flow to
maintain the pressure, this technology is different from what is generally considered
true variable-flow CPAP, as described below. In addition to bubble and ventilator CPAP,
the Benveniste gas-jet valve (Dameca, Copenhagen, Denmark) has been used (pre-
dominantly in Scandinavia) as a constant-flow CPAP device that works via the Venturi
principle using two coaxially positioned tubes connected by a ring.
Variable-flow CPAP became increasingly popular in the 1990s and beyond.
A number of devices and name changes have occurred over the past two decades,
with the Infant Flow CPAP/SiPAP system (CareFusion, Yorba Linda, CA, USA)
being the dominant current device. Applying several fluidic principles of operation
(including the Bernoulli, Coanda, and fluidic flip effects), gas delivered via dual
injector jets at high velocity generates CPAP at the airway by the gas flow into the
device and the leak around the nasal prongs.
Bubble CPAP produces measurable pressure oscillations around the baseline
CPAP level. In preterm lambs, bubble CPAP may be associated with a higher pH,
better oxygenation and ventilation, and less ventilation inhomogeneity, suggesting
that the stochastic recruitment effect system may result in the need for a lower mean
airway pressure to achieve the same level of volume recruitment, with potential
reduced risk of adverse effects of higher CPAP pressures [1]. However, studies in
human neonates are conflicting as to possible beneficial effects on gas exchange
[2, 3]. Comparing the various CPAP devices in terms of efficacy, studies have shown
improved lung compliance and decreased inspiratory work of breathing (WOBI) and
its component resistive work of breathing (RWOB) with variable-flow versus con-
stant-flow CPAP via a ventilator [4]. Variable flow CPAP was also shown to reduce
RWOB (but not WOBI) and respiratory asynchrony when compared with bubble
CPAP [5]. Despite these observed differences, studies to date comparing the different
devices have not reported consistent improvements in clinically important outcomes.
Stefanescu et al. [6] showed fewer days on supplemental oxygen and shorter hospital
stay post-extubation using either Infant Flow CPAP or ventilator CPAP, but no differ-
ences in extubation failure. Comparing similar devices, Mazzella [7] demonstrated a
lower oxygen requirement and decreased respiratory rate on Infant Flow CPAP, but
no differences in successful weaning, need for mechanical ventilation, or duration of
treatment. In a study comparing variable-flow and bubble CPAP in preterm infants,
extubation failure was lower and the duration of support was shorter in infants venti-
lated less than 14 days when supported with bubble CPAP following extubation [8].
In the face of incomplete and often conflicting evidence, it seems prudent to use
bubble or variable-flow CPAP (rather than ventilator CPAP) for their potential ben-
efits on pulmonary mechanical parameters and some clinical outcomes. When
deciding between these two options, the stochastic recruitment benefits of bubble
CPAP may offer advantage in acute atelectasis-prone patients with respiratory
48 Noninvasive Ventilation Interfaces and Equipment in Neonatology 395
Increasing interest has been paid in recent years to the potential role of nHFV, in
particular noninvasive high-frequency oscillatory ventilation and nasal
396 D. De Luca et al.
In the study of Roberts et al., the use of CPAP without mechanical ventilation for
neonates increased from 2001 to 2008, with a particularly notable rise among infants
of >32 weeks of gestation and at non-tertiary hospitals following the publication of
a randomized trial showing CPAP decreased the need for neonatal transfer [24, 25].
CPAP has been applied to preterm infants using an array of devices. Its first
application to the preterm neonate with respiratory distress was via an endotracheal
tube or by enclosure of the head in a plastic pressure chamber. Subsequent CPAP
devices included a pressurized plastic bag fitted over the infants head, face cham-
bers, and face masks. The use of tight-fitting facial masks and devices requiring a
neck seal declined as a consequence of serious complications associated with their
application, including an increased incidence of cerebellar hemorrhage and post-
hemorrhagic hydrocephalus [26].
Nasal devices remained popular, as they facilitated better access to the infants:
nasal masks, nasal cannulae, and single and binasal tubes/prongs of varying lengths
[26].
The initial mode of delivery through an endotracheal tube or head chamber was
superseded by the use of nasal prongs which could deliver CPAP in a simpler and
less invasive manner.
Randomized trials have shown a reduced rate of extubation failure with the use
of double nasal prong devices compared with single nasal prongs [13]. Double nasal
prongs with sealing both nostrils certainly result in better transmission of pressure
to the upper airways and the lungs.
For preterm infants primarily treated with NCPAP soon after birth, Mazzella
found a significantly lower oxygen requirement and respiratory rate in those ran-
domized to short binasal prongs when compared with CPAP delivered via the naso-
pharyngeal prong [7]. It suggests that short binasal prongs are more effective than
nasopharyngeal CPAP in the treatment of early respiratory distress syndrome.
There is now a broad range of prongs used to deliver NCPAP.
One important characteristic of a NCPAP device is its resistance to airflow. This
determines the fall in pressure from that measured in the delivery circuit to that
transmitted to the respiratory tract. The study of De Paoli et al. [27] has measured
the pressure drop across a variety of NCPAP devices used in current neonatal prac-
tice. Devices with short double prongs had the lowest resistance to flow. In the
Cochrane Review of De Paoli in 2008, although the Infant Flow Driver appears
48 Noninvasive Ventilation Interfaces and Equipment in Neonatology 397
more effective than Medicorp prongs (in one study), the most effective short binasal
prong device remains to be determined. Indeed, the Infant Flow interface is engi-
neered to allow sufficient flow to the infant on inspiration while minimizing expira-
tory resistance and then reduced work of breathing when compared with conventional
devices [26].
Another way to deliver NCPAP is nasal mask. With the first masks developed in
the 1970s, it was difficult to obtain an adequate seal and there was a tendency to
cause nasal airway obstruction [26]. With the new generation of nasal masks, this
kind of problems is totally minimized.
In a cohort of 120 children <31 weeks of gestation, NCPAP was more effective
to prevent intubation and ventilation within 72 h of starting therapy when given via
nasal masks compared with nasal prongs [28]. Nasal trauma occurred in a small
proportion of infants, with equal frequency with each interface (prongs/mask) and
after several weeks of therapy. Trauma related to nasal prongs tends to be maximum
around the medial aspect of the nasal septum and the columella, whereas trauma
related to nasal masks is more often seen at the junction of the nasal septum and
philtrum and at the glabella. As masks and prongs cause nasal trauma in different
distribution, the interface used is alternated in many units. Kieran et al. recommend
to start CPAP on nasal mask and to alternate the interface only after 72 h.
Short binasal prongs are the most widespread, although well-known disadvan-
tages are nasal trauma and unstable pressure delivered to the airway because of
mouth opening. Insufficiently applied pressure and the babys open mouth result in
lowering of the pharyngeal pressure and may lead to failure of nCPAP.
Good tolerability has been demonstrated with hood CPAP in adults and more
recently in newborns. The potential advantage of this system is the absence of air
leakage caused by the babys open mouth, producing more stable pressure in the
airways. The study of Colnaghi in 2008 compared set CPAP values and pharyn-
geal pressure readings in premature infants with mild respiratory distress syn-
drome treated with either hood CPAP or the conventional nCPAP system [29].
This is a small study (20 patients) but the preliminary results show more effective
pressure transmission during hood CPAP compared with nCPAP, because of the
absence of the effect of the babys open mouth. The hood CPAP system may rep-
resent a potential improvement, as it allows good transmission of the applied pres-
sure without the possible dislodgement of nasal prongs thereby avoiding nasal
trauma. The risk of infection and obstructive apnea due to excessive production of
nasal secretion is also potentially reduced. This suggests high tolerability of the
hood CPAP system.
Zaramella et al. [30] assessed cerebral blood flow and relative changes in cere-
bral blood volume in infants treated with hood CPAP and nCPAP and found no
differences in relative blood volume, although cerebral blood flow was lower during
hood CPAP. No difference in the occurrence of brain lesions was observed, but fur-
ther larger randomized trials are needed to investigate potential limitations and
unknown risks. Another problem suggested by the study of Trevisanuto et al. [31] is
noise intensities generated by the neonatal helmet CPAP. The neonatal helmet CPAP
is noisier than a conventional nCPAP system. In the helmet, the noise intensity
398 D. De Luca et al.
depends on the gas flow rate and the presence of a humidifier and a filter in the
system.
Nasal cannulae are most often used in neonates to deliver supplemental oxygen
at low flows with no intention of generating significant airway pressure. Despite
their relative small caliber, nasal cannulae with an outer diameter of 3 mm and flows
up to 2 L/min were reported to increase intra-esophageal pressure and reduce thora-
coabdominal motion asynchrony [32]. But optimal flows setting, appropriate can-
nulae size, and the effect on important outcomes with this nasal interface require
further research.
References
1. Lee KS, Dunn MS, Fenwick M, et al. A comparison of underwater bubble continuous positive
airway pressure with ventilator-derived continuous positive airway pressure in premature neo-
nates ready for extubation. Biol Neonate. 1998;73:6975.
2. Pillow JJ, Hillman N, Moss TJ, et al. Bubble continuous positive airway pressure enhances
lung volume and gas exchange in preterm lambs. Am J Respir Crit Care Med.
2007;176:639.
3. Morley CJ, Lau R, De Paoli A, et al. Does underwater bubbling improve gas exchange of
babies on nasal continuous positive airway pressure: a randomized crossover trial. Pediatr Res.
2003;53:360A.
4. Pandit PB, Courtney SE, Pyon KH, et al. Work of breathing during constant- and variable-flow
nasal continuous positive airway pressure in preterm neonates. Pediatrics.
2001;108(3):6825.
5. Liptsen E, Aghai ZH, Pyon KH, et al. Work of breathing during nasal continuous positive
airway pressure in preterm infants: a comparison of bubble vs. variable-flow devices. J
Perinatol. 2005;25(7):4538.
48 Noninvasive Ventilation Interfaces and Equipment in Neonatology 399
6. Stefanescu BM, Murphy WP, Hansell BJ, et al. A randomized, controlled trial comparing two
different continuous positive airway pressure systems for the successful extubation of
extremely low birth weight infants. Pediatrics. 2003;112(5):10318.
7. Mazzella M, Bellini C, Calevo MG, et al. A randomised control study comparing the Infant
Flow Driver with nasal continuous positive airway pressure in preterm infants. Arch Dis Child
Fetal Neonatal Ed. 2001;85(2):8690.
8. Gupta S, Sinha SK, Tin W, et al. A randomized controlled trial of post-extubation bubble con-
tinuous positive airway pressure versus Infant Flow Driver continuous positive airway pressure
in preterm infants with respiratory distress syndrome. J Pediatr. 2009;154(5):64550.
9. Pillow J. Which continuous positive airway pressure system is best for the preterm infant with
respiratory distress syndrome? Clin Perinatol. 2012;39(3):48396.
10. DeMauro SB, Millar D, Kirpalani H. Noninvasive respiratory support for neonates. Curr Opin
Pediatr. 2014;26(2):15762.
11. Lemyre B, Davis PG, de Paoli AG. Nasal intermittent positive pressure ventilation (NIPPV)
versus nasal continuous positive airway pressure (NCPAP) for apnea of prematurity. Cochrane
Database Syst Rev. 2002;(1):CD002272.
12. Meneses J, Bhandari V, Alves JG. Nasal intermittent positive-pressure ventilation vs. nasal
continuous positive airway pressure for preterm infants with respiratory distress syndrome: a
systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2012;166:3726.
13. Davis PG, Lemyre B, De Paoli AG. Nasal intermittent positive pressure ventilation (NIPPV)
versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extuba-
tion. Cochrane Database of Syst Rev. 2001;(3):CD003212.
14. Kirpalani H, Millar D, Lemyre B, et al. A trial comparing noninvasive ventilation strategies in
preterm infants. N Engl J Med. 2013;369:61120.
15. Lemyre B, Millar KH, Roberts D, et al. Nasal intermittent positive pressure ventilation vs.
nasal continuous positive airway pressure for preterm neonates after extubation. Washington:
Pediatric Academic Societies; 2013.
16. De Luca D, Carnielli VP, Conti G, Piastra M. Noninvasive high frequency oscillatory ventila-
tion through nasal prongs: bench evaluation of efficacy and mechanics. Intensive Care Med.
2010;36(12):2094100.
17. De Luca D, Piastra M, Pietrini D, et al. Effect of amplitude and inspiratory time in a bench
model of non-invasive HFOV through nasal prongs. Pediatr Pulmonol. 2012;47(10):10128.
18. Colaizy TT, Younis UM, Bell EF. Nasal high-frequency ventilation for premature infants. Acta
Paediatr. 2008;97(11):151822.
19. van der Hoeven M, Brouwer E, Blanco CE. Nasal high frequency ventilation in neonates with
moderate respiratory insufficiency. Arch Dis Child Fetal Neonatal Ed. 1998;79(1):F613.
20. Mukerji A, Finelli M, Belik J. Nasal high-frequency oscillation for lung carbon dioxide clear-
ance in the newborn. Neonatology. 2013;103:1604.
21. De La Roque ED, Bertrand C, Tandonnet O, et al. Nasal high frequency percussive ventilation
versus nasal continuous positive airway pressure in transient tachypnea of the newborn. Pediatr
Pulmonol. 2011;46:21822.
22. Czernik C, Schmalisch G, Bhrer C, et al. Weaning of neonates from mechanical ventilation
by use of nasopharyngeal high frequency oscillatory ventilation: a preliminary study. J Matern
Fetal Neonatal Med. 2012;25(4):3748.
23. Mukerji A, Singh B, Helou SE, Fusch C, Dunn M, Belik J, Shah V, et al. Use of noninvasive
high-frequency ventilation in the neonatal intensive care unit: a retrospective review. Am J
Perinatol. 2015;30(2):1716.
24. Roberts CL, Badgery-Parker T, Algert CS, et al. Trends in use of neonatal CPAP: a population-
based study. BMC Pediatr. 2011;11:89.
25. Buckmaster AG, Arnolda GR, Wright IM, Henderson-Smart DJ. CPAP use in babies with
respiratory distress in Australian special care nurseries. J Paediatr Child Health.
2007;43(5):37682.
26. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration
of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database
Syst Rev. 2008;(1):CD002977. doi:10.1002/14651858.CD002977.pub2.
400 D. De Luca et al.
27. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration
of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database
Syst Rev. 2002;(4):CD002977.
28. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for nasal con-
tinuous positive airway pressure in preterm infants. Pediatrics. 2012;130(5):e11706.
29. Colnaghi M, Matassa PG, Fumagalli M, Messina D, Mosca F. Pharyngeal pressure value using
two continuous positive airway pressure devices. Arch Dis Child Fetal Neonatal Ed.
2008;93(4):F3024.
30. Zaramella P, Freato F, Grazzina N, et al. Does helmet CPAP reduce cerebral blood flow and
volume by comparison with Infant Flow driver CPAP in preterm neonates? Intensive Care
Med. 2006;32(10):16139.
31. Trevisanuto D, Camiletti L, Doglioni N, Cavallin F, et al. Noise exposure is increased with
neonatal helmet CPAP in comparison with conventional nasal CPAP. Acta Anaesthesiol Scand.
2011;55(1):358.
32. de Jongh BE, Locke R, Mackley A, et al. Work of breathing indices in infants with respiratory
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Noninvasive Ventilation Strategies
to Prevent Post-extubation Failure: 49
Neonatology Perspective
Abbreviations
Funding Support Georg M. Schmlzer is a recipient and a Heart and Stroke Foundation Canada
Scholarship/University of Alberta Professorship of Neonatal Resuscitation.
49.1 Introduction
Respiratory failure is the most common problem encountered in the neonatal inten-
sive care unit (NICU) [1]. Nearly two-thirds of infants born less than 29 weeks
gestation require endotracheal intubation and mechanical ventilation (MV) while
admitted to the NICU [1]. Although MV is often lifesaving, it is associated with
multiple short- and long-term sequelae, including subglottic injury, infection, bron-
chopulmonary dysplasia (BPD), and neurocognitive impairment [2]. As a conse-
quence, clinicians try to avoid or minimize the duration of MV and extubate infants
as early as possible. Following extubation, application of a continuous distending
pressure to the airways helps prevent alveolar collapse and maintain gas exchange [3].
Although noninvasive respiratory support has become routine for post-extubation
management in preterm infants, optimal strategies to prevent extubation failure
have not been clearly defined. This chapter aims to review the definitions of post-
extubation failure and describe the available equipment and techniques for noninva-
sive post-extubation respiratory support in preterm infants.
RCTs that studied SNIPPV used abdominal pneumatic capsules for synchronization
and the ventilators that utilize these capsules are no longer commercially available.
In a small RCT (n = 63), Moretti et al. [16] reported greater extubation success
with nasal-flow (pneumotachograph) synchronized NIPPV compared with CPAP.
However, this device is less effective if there is leak at the mouth or nose, and dif-
ficulty with its use has been reported [13]. Neurally adjusted ventilator assist
(NAVA) provides reliable synchronization for intubated infants and may be benefi-
cial in conjunction with NIPPV, although reports of its noninvasive use are limited
to adults and animal models [17].
Heated, humidified high-flow nasal cannula (HFNC) has gained considerable popu-
larity as a mode of noninvasive respiratory support in preterm infants [17]. HFNC
utilizes short, tapered binasal prongs that do not occlude the nares (in contrast to
CPAP prongs or mask that typically have minimal air leak at the nares) to provide
oxygen or blended oxygen and air at flow rates greater than 12 l/min. The higher
flow rates compared with low-flow nasal cannula are intended to provide continu-
ous distending pressure similar to CPAP. Proponents of HFNC cite reduced nasal
trauma, improved infant comfort, greater ability to maintain the nasal prongs within
the nares, and facilitation of parent bonding and developmental care as the benefits
of HFNC over standard CPAP [17]. However, a formal assessment of patient com-
fort and ease of care demonstrated no difference between HFNC and CPAP and
there are concerns about the safety and efficacy of HFNC, particularly in the most
premature infants [1719].
Several RCTs compared HFNC with CPAP for post-extubation respiratory sup-
port in preterm infants [1721]. Campbell et al. [21] reported, in a single-center
RCT (n = 40), lower reintubation rates within the first 7 days among infants treated
with CPAP of 56 cm H2O compared with HFNC of 1.41.7 l/min (RR 2.1; 95 %
CI 1.33.0). Three more recent RCTs compared CPAP with HFNC flows ranging
from 3 to 8 l/min [1820]. Manley et al. [19] used a non-inferiority trial design
(n = 303) and concluded that HFNC was non-inferior to CPAP with the treatment
effect nonsignificantly favoring extubation to CPAP (risk difference 8.4 percentage
points; 95 % CI 1.918.7). However, the upper bound of the 95 % CI approached
the arbitrarily selected 20 percentage point non-inferiority margin. Moreover, nearly
half of the infants who failed HFNC were successfully rescued with CPAP and did
not require reintubation. In the subgroup of infants with gestational ages <26 weeks
(n = 63), the risk difference was 20 percentage points, in favor of CPAP. The remain-
ing two trials reported nonsignificant differences with the opposite direction of
effect, favoring extubation to HFNC [18, 20]. A meta-analysis of these RCTs con-
cluded that there was no difference in extubation failure risk between the two thera-
pies (RR 1.05; 95 % CI 0.791.39) [17].
The primary safety concern with HFNC is the potential for high, unmeasured
distending pressures [17]. In an in vitro model, Sivieri et al. [22] recorded pressures
49 Noninvasive Ventilation Strategies to Prevent Extubation Failure in Infants 405
up 2030 cm H2O with flow rates >2 l/min. However, data compiled from the recent
HFNC trials indicated a low risk of pneumothorax (incidence <1 %) with a nonsig-
nificantly higher rate in the CPAP group [17].
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tinuous positive airway pressure versus infant flow driver continuous positive airway pressure
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8. De Paoli AG, Davis PG, Faber B, et al. Devices and pressure sources for administration of
nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database
Syst Rev. 2008;(1):CD002977.
9. Kieran EA, Twomey AR, Molloy EJ, et al. Randomized trial of prongs or mask for nasal con-
tinuous positive airway pressure in preterm infants. Pediatrics. 2012;130:e11706.
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12. Buckmaster A. Nasal continuous positive airway pressure for respiratory distress in non-
tertiary care centres: what is needed and where to from here? J Paediatr Child Health.
2012;48:74752.
406 E.A. Jensen and G.M. Schmlzer
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18. Yoder BA, Stoddard RA, Li M, et al. Heated, humidified high-flow nasal cannula versus nasal
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on generated airway pressures: an in vitro study. Pediatr Pulmonol. 2013;48:50614.
Application of Noninvasive Ventilation
in Preventing Extubation Failure 50
in Children with Heart Disease:
Key Topics and Clinical Implications
Abbreviations
50.1 Introduction
Surgery for congenital heart disease (CHD) using cardiopulmonary bypass (CPB)
usually requires postoperative mechanical ventilation [1]. However, advances in
anesthesia and surgical procedures have changed the expectations for mechanical
ventilation following cardiac surgery [2]. Some centers attempt early endotracheal
extubation as part of a fast-tracking approach, whereas others prefer extubation
from mechanical ventilation in the intensive care unit (ICU) as their standard patient
management.
Extubation failure after mechanical ventilation is relatively common. It occurs in
approximately 10 % of children after cardiac surgery (22 % in children after a
Norwood procedure). When urgent reintubation is required, this may produce sub-
stantial hemodynamic instability, excessive airway trauma, increased risk for noso-
comial infections, and prolonged mechanical ventilation and ICU length of stay
(LOS) [3].
Either by fast-tracking or by a more conservative approach, there is no doubt
that noninvasive ventilation (NIV) can play an important role as a rescue therapy. In
addition, NIV can be used as an elective or prophylactic therapy when the patient is
at high risk for extubation failure [3].
procedure, mean pulmonary artery pressure was lower and mean arterial pres-
sure was higher in the early extubation group compared with the nonearly extu-
bation group. In addition, these patients require less inotropic support and shorter
duration of thoracic drainage [4, 5].
Other institutions prefer to control mechanical ventilation in the ICU as their
standard patient management in the postoperative period [1]. Earlier studies
established that infants and young children with CHD are at risk for prolonged
mechanical ventilation and failed extubation after cardiac surgery [6]. It makes
sense to transfer the patient to the ICU, where the choice of when to extubate can
be determined in a controlled setting using objective criteria to consider hemo-
dynamic stability, coagulation status, pulmonary gas exchange, systemic oxygen
delivery, or fever. Moreover, systemic inflammatory response induced by surgery
with CPB contributes to the presence of several components that may influence
or intensify an extubation failure in the postoperative period [7].
Patients who had longer CPB times, longer aortic cross-clamp times, and
higher preoperative mean pulmonary vascular resistance and systemic ventricu-
lar end-diastolic pressure seem to be good candidates for delayed extubation in
the ICU using an organized evaluative process with continuous assessment of
patients recovery [7].
The incidence of failed extubation after pediatric cardiac surgery is greater com-
pared with that in the general pediatric population. These patients are particularly
vulnerable to the increased metabolic demands imposed by spontaneous breathing,
and cardiac output may be compromised by altered respiratory mechanics [8].
Common causes in children with heart disease that contribute to extubation failure
include lung disease, cardiac dysfunction, diaphragmatic paralysis, airway edema,
and vocal cord paralysis [3]. Cardiac dysfunction has been found to be the etiology
of extubation failure in 2765 % of children with CHD [9].
Not surprisingly, extubation is challenging in pediatric patients undergoing car-
diac procedures. Preoperative factors that may contribute to an extubation failure
are low body weight, chromosomal abnormalities, poor nutritional status, and, con-
sequently, limited body reserves and functional immaturity of organ systems [8,
10]. Intraoperative factors also should be considered as possible reasons for extuba-
tion failure, such as complex operative procedures, prolonged CPB time, balancing
pulmonary (Qp) and systemic circulation (Qs), and delayed sternal closure [10].
Once the patient is admitted to the ICU, making the decision to extubate not only
should be based on the above-described factors, but others also have to be consid-
ered, such as altered respiratory mechanics or increased multiorgan dysfunction.
Residual effects from sedative agents and neuromuscular blockade, and diaphrag-
matic paresis or paralysis, presumably from nerve injury, may affect pulmonary
mechanics [10]. Furthermore, due to complex cardiopulmonary interactions, low
cardiac output syndrome is a determining factor in extubation not being a success.
410 Y. Lpez-Fernndez and F.J. Pilar-Orive
NIV has been used as a preventive measure in patients with high risk for extubation
failure and can be effectively applied as an alternative means of respiratory support
in patients with hypoxemic or hypercarbic failure with signs of respiratory distress
who were considered likely to require reintubation after cardiac surgery. Improving
ventilation by NIV in these patients is associated mostly with reduced work of
breathing and has alleviated respiratory muscle fatigue [8].
Decreased functional residual capacity (FRC) that is repeatedly present in
patients after cardiac surgery can be improved with continuous positive airway pres-
sure (CPAP). The use of positive end-expiratory pressure (PEEP, EPAP) improves
FRC, allowing better gas exchange [12]. This improvement can be increased by
additional pressure support (PS) and/or pressure-controlled (PC) breaths, which can
help preserve good lung volume and reduce the load of the inspiratory muscles and
the work of breathing [8].
Common causes of respiratory failure after cardiac surgery were pulmonary
edema, pneumonia, and atelectasis [13]. To prevent extubation failure, NIV may be
a useful therapy in certain scenarios, such as those involving lung disease, diaphrag-
matic paralysis, and airway edema. In other scenarios, such as those related to vocal
cord paralysis, NIV may be dangerous because these patients are at high risk for
aspiration [3].
NIV can be started:
Few studies on the use of NIV in children after pediatric cardiac surgery have
been published to date, therefore, the reported clinical experience is too small to
50 Application of Noninvasive Ventilation in Preventing Extubation Failure 411
draw clear and valid conclusions [12]. There are no published studies that show an
advantage of elective NIV over rescue NIV in postoperative cardiac patients.
Accordingly, elective NIV cannot yet be recommended as a routine approach [14].
50.5.1 Indications
NIV should be considered as treatment when the patient, within 2448 h after extu-
bation, presents with:
The patient prepared for NIV should be conscious and cooperative, stable hemo-
dynamically, and at no risk for asphyxia (aspiration, gastrointestinal hemorrhage, or
abundant airway secretions) [13]. Major indications and contraindications of NIV
after cardiac surgical procedures are shown in Table 50.1.
50.5.2 Devices
Any standard ventilator with an NIV option can be used. However, there could be
limitations in the smallest children due to their inaccurate trigger systems and insuf-
ficient leak compensation. NIV-specific ventilators allow reaching programmed
pressures despite high levels of leakage, resulting in a more accurate setting of
activation and cycling-off trigger. Furthermore, newer generations of ventilators
offer more sophisticated systems to overcome some of these limitations as well as
Table 50.1 Indications and contraindications of NIV after pediatric cardiac surgical procedures
Indications Contraindications
Atelectasis Unconscious/noncooperative
Acute pulmonary edema Hemodynamic instability
Pneumonia Abundant and thick secretions
Diaphragmatic paralysis Severe respiratory failure (P/F <150; S/F
<200)
Airway edema: post-extubation laryngitis Vomiting/gastrointestinal hemorrhage
Weaning in patient with polyneuromyopathy Vocal cord paralysis
Alternative to reintubation if unplanned Facial trauma or cranial malformations
extubation
Support procedures with sedoanalgesia Pneumothorax (not drained)
412 Y. Lpez-Fernndez and F.J. Pilar-Orive
50.5.3 Modes
CPAP: may improve oxygenation, increasing lung volume derived from alveoli
recruitment and fluid redistribution. Myocardial function may be improved
through a decrease in left ventricular afterload. Low CPAP levels (56 cm H2O)
are recommended to start ventilation, increasing gradually 12 cm H2O up to
10 cm H2O according to respiratory requirements. Levels above 12 cm H2O are
usually not well tolerated [8, 14].
Bi-level positive airway pressure (BPAP): additional PS and/or PC breaths. Its
use is reserved for more distressed patients. These modes combine inspiratory
positive airway pressure (IPAP, PPI) and expiratory positive airway pressure
(EPAP, PEEP). A backup respiratory rate is added when the inspiratory effort
generated by young children is often too small to be detected by the ventilator.
To enhance comfort and compliance, ventilation settings start with PEEP (or
EPAP) at 45 cm H2O and increase as necessary, up to a maximum of 10 cm
H2O. Inspiratory positive airway pressure (PPI or IPAP) is started at 68 cm H20
and gradually increased to 1820 cm H2O. The parameters are increased gradu-
ally to appropriate clinical setting within 30120 min [8, 13].
50.5.4 Interfaces
The choice of the right interface may be challenging in young children. NIV can
be delivered by way of nasal, oronasal, and full-face masks; nasal prongs and
oropharyngeal tubes are commonly used in for infants. Full-face and oronasal
masks are best suited for hypoxemic patients and advanced hypercapnic respira-
tory failure, in particular for more dyspneic patients. Nasal-type masks are usu-
ally indicated for hypercapnic patients, but only in those who are not very
50 Application of Noninvasive Ventilation in Preventing Extubation Failure 413
dyspneic and can keep their mouth closed. The main disadvantage of most of the
interfaces is the difficulty of preserving a good seal and achieving adequate pres-
sure [8, 14].
50.5.6 Monitoring
Conclusions
NIV can be used as a preventive measure in patients with high risk for extubation
failure and can be effectively applied as an alternative means of respiratory sup-
port in patients with hypoxemic or hypercarbic failure with signs of respiratory
distress who are considered likely to require reintubation after cardiac surgery.
Improving ventilation by NIV in these patients is associated mostly with reduced
work of breathing and has alleviated respiratory muscle fatigue.
414 Y. Lpez-Fernndez and F.J. Pilar-Orive
References
1. Kin N, Weismann C, Srivastava S, et al. Factors affecting the decision to defer endotracheal
extubation after surgery for congenital heart disease: a prospective observational study. Anesth
Analg. 2011;113:32935.
2. Alghamdi AA, Singh SK, Hamilton BCS, et al. Early extubation after pediatric cardiac sur-
gery: systematic review, meta-analysis, and evidence-based recommendations. J Card Surg.
2010;25:58695.
3. Gupta P, Kuperstock JE, Hashmi S, et al. Efficacy and predictors of success of non invasive
ventilation for prevention of extubation in critically ill children with heart disease. Pediatr
Cardiol. 2013;34:96477.
4. Mittnacht AJC. Pro: early extubation following surgery for congenital heart disease.
J Cardiothorac Vasc Anesth. 2011;25:8746.
5. Mittnacht AJ, Hollinger I. Fast-tracking in pediatric cardiac surgery the current standing.
Ann Card Anaesth. 2010;13:92101.
6. Shi S, Zhao Z, Liu X, et al. Perioperative risks factors for prolonged mechanical ventilation
following cardiac surgery in neonates and young infants. Chest. 2008;134:76874.
7. DiNardo JA. Con: extubation in the operating room following pediatric cardiac surgery.
J Cardiothorac Vasc Anesth. 2011;25:8779.
8. Kovacikova L, Skrak P, Dobos D, et al. Noninvasive positive pressure ventilation in critically
ill children with cardiac disease. Pediatr Cardiol. 2014;35:67683.
9. Harkel AD, van der Vorst MM, Hazekamp MZ, et al. High mortality rate after extubation
failure after pediatric cardiac surgery. Pediatr Cardiol. 2005;26:75661.
50 Application of Noninvasive Ventilation in Preventing Extubation Failure 415
10. Gupta P, McDonald R, Gossett JM, et al. A single-center experience of extubation failure in
infants undergoing the Norwood operation. Ann Thorac Surg. 2012;94:12628.
11. Foster CB, Spaeder MC, McCarter RJ, et al. The use of near-infrared spectroscopy during an
extubation readiness trial as a predictor of extubation outcome. Pediatr Crit Care Med.
2013;14:58792.
12. Dohna-Schwake C, Stehling F, Tschiedel E, et al. Non-invasive ventilation on a pediatric
intensive care unit: feasibility, efficacy and predictors of success. Pediatr Pulmonol.
2011;46:111420.
13. Zhang C, Tan L, Shi S, et al. Noninvasive ventilation via bilevel positive airway pressure sup-
port in pediatric patients after cardiac surgery. World J Pediatr. 2006;4:297302.
14. Rimensberger P, Heulitt MJ, Meliones J, et al. Mechanical ventilation in the pediatric cardiac
intensive care unit: the essentials. World J Pediatr Congenital Heart Surg. 2011;2:60919.
15. Mayordomo-Colunga J, Pons M, Lpez Y, et al. Predicting non-invasive ventilation failure in
children from the SpO2/FiO2 (SF) ratio. Intensive Care Med. 2013;39:1095103.
Noninvasive Ventilation After
Extubation in Pediatric Patients: 51
Determinants of Response
and Key Topics
Abbreviations
51.1 Introduction
Despite being frequently used in many pediatric intensive care units (PICUs) for
some years, published data regarding noninvasive ventilation (NIV) use after extu-
bation in children are scarce. Many studies have analyzed NIV episodes in patients
with no previous invasive ventilation together with other episodes in children who
received NIV after extubation [1, 2]. Moreover, some authors used continuous posi-
tive airway pressure (CPAP) or two levels of pressure (bi-level positive airway pres-
sure, or BLPAP) indistinctly [3, 4]. Because of this, no A or B recommendations can
be provided for this technique.
Most authors agree that NIV episodes with no previous invasive ventilation should
be considered different from postextubation ones. Conditions after extubation place
patients in a completely different situation than that occurring when a child has not
been previously ventilated [4].
Postextubation NIV can be used in three ways: (1) as an adjunct in weaning
patients from conventional mechanical ventilation by early extubation directly to
NIV, (2) as a preventive application for NIV in high-risk patients who are extubated
at the time they fulfill standard extubation criteria, or (3) as a curative or rescue
application of NIV to patients who develop acute respiratory failure (ARF) after
being extubated according to standard criteria. The first two indications have been
suggested by some pediatric studies to be the so-called postextubation elective NIV
(e-NIV) group, which includes high-risk children treated with NIV immediately
after the endotracheal tube is removed. Those patients who develop ARF within
hours after extubation and receive NIV to try to avoid reintubation are considered
the so-called rescue NIV (r-NIV) group [4, 5].
These two groups should be analyzed separately, according to several adult stud-
ies [6] and to some pediatric reports [4]. However, there are few studies about
postextubation NIV in children. As has been previously mentioned, some studies
analyzed NIV episodes with or without previous invasive ventilation [1, 2]. In the
case of analyzing postextubation NIV, these studies frequently do not consider
r-NIV and e-NIV separately [3].
Some studies have underlined the usefulness of NIV after some surgeries. Most
of them focus on cardiac surgery, and others describe its utility after liver transplan-
tation or scoliosis surgery [1, 712]. Postoperative NIV is especially useful in pedi-
atric patients, who develop atelectasis quite frequently because of a lack of collateral
pathways for ventilation and low conductance of the central airways.
Children receiving NIV after cardiac surgery are a group of patients that deserve
special consideration. Early extubation is desirable and is associated with a better
outcome, and thus e-NIV is increasingly being used in these cases to shorten the
length of invasive ventilation. As such, NIV is frequently used to prevent
51 Noninvasive Ventilation After Extubation in Pediatric Patients 419
extubation failure. A study by Gupta et al. [7] suggested that NIV can be success-
fully applied for critically ill children with heart disease to avoid reintubation.
These benefits have been related to NIV improvement of existing or preexisting
lung disease, diaphragmatic paralysis, and airway edema (stenting of the airway).
These authors also included a sample of children with cardiac disease who received
r-NIV. They found an intubation rate similar to that in patients in whom e-NIV was
used. However, this study was retrospective and there were no clear criteria to initi-
ate NIV [7].
It should be highlighted that a randomized controlled trial in infants following
cardiac surgery showed no advantage in using elective CPAP versus rescue CPAP in
all patients after cardiac surgery [8]. Thus, further studies are needed to clarify
which patients would benefit from the use of e-NIV.
A main limitation of NIV in pediatrics is related to the lack of specific inter-
faces and ventilators featuring adequately sensitive triggers. This limits its use,
mainly in smaller and younger patients, and, importantly, it may affect the effi-
cacy of this technique, especially when BLPAP is applied [1, 4]. Fortunately,
some new interfaces are appearing, such as full-face masks for infants, which may
have an impact on the usefulness and spread of post-extubation NIV in children
(and other types of NIV). Furthermore, neurally adjusted ventilatory assist
(NAVA) has been suggested to help solve some synchrony issues, because leakage
would not be a problem and neural trigger should be superior to flow or pressure
inspiratory triggers.
An important point affecting NIV outcome in pediatric patients is the need for
physiotherapy to improve secretion drainage, especially in the younger patients and
also in children with neuromuscular diseases. Indeed, some studies focusing on
spinal surgery in this type of patient include the use of a mechanical cough-assisted
technique in addition to NIV [10]. It has been suggested that this postoperative
management may be useful in diminishing the occurrence of atelectasis and pneu-
monia in these patients in whom bronchial secretions accumulate rapidly after sur-
gery due to the inability to clear them effectively.
51.3 Discussion
The different studies on NIV use after extubation in children cannot be adequately
compared regarding success rates and causes of NIV failure because of the different
inclusion criteria. Thus, further studies with clearly defined inclusion criteria are
needed to draw definitive conclusions about post-extubation NIV in children.
However, given that this technique seems to be useful for such patients, as sug-
gested by many observational studies and some physiological ones, a prospective
randomized controlled trial would be difficult to realize because of ethical consid-
erations. Indeed, Stucki et al. [13] showed in a pilot study that NIV in infants devel-
oping ARF after extubation were able to unload respiratory muscles by means of a
turbine flow generator with no deleterious effects.
420 J. Mayordomo-Colunga et al.
We will discuss the available data in literature to date below. It should be noted
that all the studies have a very small number of episodes requiring reintubation.
Thus, these results should be interpreted with caution.
As suggested in many adult and pediatric NIV studies with no previous mechani-
cal ventilation, oxygen requirement seems to be related to NIV success or failure.
One pediatric study has described the usefulness of the transcutaneous oxygen
51 Noninvasive Ventilation After Extubation in Pediatric Patients 421
References
1. Essouri S, Chevret L, Durand P, et al. Noninvasive positive pressure ventilation: five years of
experience in a pediatric intensive care unit. Pediatr Crit Care Med. 2006;7:32934.
2. Lum LC, Abdel-Latif ME, de Bruyne JA, et al. Noninvasive ventilation in a tertiary pediatric
intensive care unit in a middle-income country. Pediatr Crit Care Med. 2011;12:e713.
3. James CS, Hallewell CP, James DP, et al. Predicting the success of non-invasive ventilation in
preventing intubation and re-intubation in the paediatric intensive care unit. Intensive Care
Med. 2011;37:19942001.
4. Mayordomo-Colunga J, Medina A, Rey C, et al. Non invasive ventilation after extubation in
paediatric patients: a preliminary study. BMC Pediatr. 2010;10:29.
5. Pons-Odena M. Anlisis de la efectividad de la ventilacin no invasiva en el paciente peditrico
con insuficiencia respiratoria aguda. MS thesis, University of Barcelona, Department of
Obstetrics and Gynecology. Pediatrics, Radiology and Medicine Physic, Anatomy, Spain;
2013. http://hdl.handle.net/10803/126115. Web. 21 Apr 2014.
6. Lin C, Yu H, Fan H, Li Z. The efficacy of noninvasive ventilation in managing postextubation
respiratory failure: a meta-analysis. Heart Lung. 2014;43:99104.
7. Gupta P, Kuperstock JE, Hashmi S, et al. Efficacy and predictors of success of noninvasive
ventilation for prevention of extubation failure in critically Ill children with heart disease.
Pediatr Cardiol. 2013;34:96477.
8. Wakeman R. A randomised trial of elective continuous positive airway pressure (CPAP) versus
rescue CPAP after extubation in infants following cardiac surgery. Available at: www.
controlled-trials.com/isrctn/pf/00171143. Accessed 10 June 2014.
9. Cai-Yun Z, Lin-Hua T, Shan-Shan S, et al. Noninvasive ventilation via bilevel positive airway
pressure support in pediatric patients after cardiac surgery. World J Pediatr. 2006;2:
297302.
10. Kovacikova L, Skrak P, Dobos D, et al. Noninvasive positive pressure ventilation in critically
Ill children with cardiac disease. Pediatr Cardiol. 2014;35:67683.
422 J. Mayordomo-Colunga et al.
11. Khirani S, Bersanini C, Aubertin G, et al. Non-invasive positive pressure ventilation to facili-
tate the post-operative respiratory outcome of spine surgery in neuromuscular children. Eur
Spine J. 2014;23 Suppl 4:S40611.
12. Murase K, Chihara Y, Takahashi K, et al. Use of noninvasive ventilation for pediatric patients
after liver transplantation: decrease in the need for reintubation. Liver Transpl. 2012;18:
121725.
13. Stucki P, Perez MH, Scalfaro P, et al. Feasibility of non-invasive pressure support ventilation
in infants with respiratory failure after extubation: a pilot study. Intensive Care Med.
2009;35:16237.
14. Gonzlez Snchez M. Saturacin transcutnea/fraccin inspirada de oxgeno es til para pre-
decir el fracaso de la ventilacin no invasiva? MS thesis, Departamento de Medicina, Facultad
de Medicina, Universidad de Oviedo, Spain; 2014.
15. Mayordomo-Colunga J, Pons M, Lpez Y, et al. Predicting non-invasive ventilation failure in
children from the SpO2/FiO2 (SF) ratio. Intensive Care Med. 2013;39:1095103.
High-Flow Nasal Cannula Oxygen
in Acute Respiratory Post-extubation 52
Failure in Pediatric Patients:
Key Practical Topics and Clinical
Implications
Abbreviations
52.1 Introduction
52.2 Concept
In high-flow oxygen (HFO) therapy, a flow of oxygen, which may or may not be
mixed with air, is delivered through a nasal cannula. This gas is humidified (>99 %
relative humidity) and heated (to body temperature). The heating and humidifica-
tion in the vapor phase allow comfortable delivery at higher flows [1, 2]. Figure 52.1
shows the mechanism through which the high flow obtains better concentrations of
oxygen compared with low-flow systems. High flow is considered to be between
When When
inspiratory peak flow > delivered flow : inspiratory peak flow < delivered flow :
Flow
(l/min) Flow
21% (l/min)
(ambiant air)
Delivered flow
Delivered flow
Delivered concentration
Delivered concentration
Delivered gas
dilution with
ambiant air
Fig. 52.1 Mechanism by which HFO therapy obtains better oxygen concentrations in relation to
low-flow systems
52 High-Flow Nasal Cannula Oxygen in Acute Respiratory Post-extubation Failure 425
2 and 8 l/min in neonates, 5 and 20 l/min in children, and 6 and 40 l/min in adults.
The HFO therapy concept was first used in neonatal intensive care units as an alter-
native to nasal continuous positive airway pressure (CPAP) in premature neonates.
There are few disadvantages because this system has good tolerance. In some cases,
abdominal distension may be observed due to flatulence. Condensation may occur
in the nasal cannula at low flows. There has been described air leak syndrome
(pneumothorax, pneumomediastinum) [4]. In prolonged situations, nasal trauma
may occur, and another disadvantage is the high level of noise correlated with the
flow (Table 52.1).
There are several commercial systems for administering HFO (Fig. 52.2):
Precision Flow (Vapotherm, Exeter, UK), the first system approved for use in
patients by the US Food and Drug Administration in 2004
Optiflow system (Fisher & Paykel, Auckland, New Zealand)
Comfort-flo (Teleflex Medical, Durham, NC, USA).
The HFO system can be used to incorporate medicinal gases (e.g., heliox 70/30,
NO) and drugs in aerosol form can also be administered. In vitro studies show that
with this method high dosis of drug are requiered, otherwise we can use heliox as a
vehicle to achive the appropiate levels. Until new studies emerge, the administration
of these drugs using this device is not recommended.
52.6 Indications
For clinical practice, HFO seems feasible in mild to moderate forms of respi-
ratory distress and hypoxemia, transcutaneous oxygen saturation (SpO2) <90 %,
despite standard flow oxygen. It is useful in hypoxemic, nonhypercapnic patients
who require fraction of inspired oxygen (FiO2) >0.3 using a face mask (type I
respiratory failure). It is not considered useful in type II respiratory failure
because it does not reduce PaCO2 levels and is not indicated in CO2 retainers
because it reduces the respiratory stimulus triggered by hypoxia that is produced
in hypoventilation.
Most pediatric studies published refer to infants with bronchiolitis, proving its
safety and efficacy, however, its efficacy has not been demonstrated in asthma or
pneumonia. The beneficial clinical effects of HFO (increase in SpO2, reduction in
O2, respiratory rate (RR) and heart rate (HR) needs, and improvement in breathing
difficulty symptoms) should be observed during the first 6090 min from initiation;
otherwise, more aggressive ventilation support should be considered.
Schibler et al. [6], who used HFO over a period of 5 years, determined that the
general need for intubation was reduced from 37 to 7 % in infants with bronchiol-
itis. This was not detected in children with other pathologies. They also showed that
infants using HFO who had a reduction of more than 20 % in RR and HR compared
with the initial rates did not require increased respiratory support.
If no improvement is observed after 90 min of support with HFO, it is essential
to evaluate the need to intensify respiratory assistance.
FiO2 is set to achieve target saturation >92 % then gradually increased until the
desired effect is obtained. Some patients improve with low flows and others need to
reach the maximum established limits.
Unfortunately, currently, there is no evidence to suggest that any particular
approach to weaning HFNC is either more effective or efficient. Once the respira-
tory rate has been normalized and the oxygenation improved, weaning can com-
mence. It usually starts by decreasing the oxygen concentration to FiO2 40 %, then
the flow is reduced 510 l/min every 12 h until it reaches the initial level. It is not
uncommon to use high flow without oxygen trying to keep the pressure of alveolar
distension. At this point, an oxygen mask or nasal cannula is used and the response
is evaluated. Some centers use other approaches to weaning, such as gradually
reducing FiO2 to 0.21 (room air) while maintaining appropriate oxygen saturations.
HFNC therapy is discontinued when the child remains well saturated in air.
In cases in which hypoxemia of the patient does not improve with HFO and he
or she is unable to tolerate continuous CPAP, CPAP used alternately with HFO can
be used.
A study by Milesi et al. [7] on infants under the age of 6 months with bronchiol-
itis in which the esophageal and pharyngeal pressure was measured showed that
positive pharyngeal pressures were obtained with flows higher than 6 l/min during
inspiration as well as expiration. When using flows of 2 l per kg of weight, the aver-
age pharyngeal pressure reached was higher than 4 cm of H2O. The 21 patients
studied by Milesi were 1.5 months old (95 % CI 0.752.19, range 0.56) and
weighed 4.3 kg (95 % CI 3.64.9, range 2.67.3). To prevent leaks, pacifiers and a
cannula with a diameter at least half that of the nostril was used. It was considered
that the basic fundamental of improving WOB in these children was reached at this
positive pressure.
In the neonatal population, weaning from invasive ventilation is one of the main
indications for HFO. Nasal CPAP is known to be superior to no positive-pressure
support and is the current standard of care for noninvasive respiratory support of
very preterm infants. The use of HFNC is an alternative means of providing nonin-
vasive respiratory support to very preterm infants.
Manley et al. [8], in a multicenter, randomized, noninferiority trial, studied 303
very preterm infants receiving treatment with either HFNC (56 l per minute) or
nasal CPAP (7 cm of water) after extubation. The primary outcome was treatment
failure within 7 days. They showed that the use of HFNC was noninferior to the use
of nasal CPAP, with treatment failure occurring in 52 of 152 infants (34.2 %) in the
nasal cannula group and in 39 of 151 infants (25.8 %) in the CPAP group (risk dif-
ference, 8.4 % points; 95 % CI, 1.9 to 18.7). Almost half the infants in whom
treatment with HFNC failed were successfully treated with CPAP without reintuba-
tion. The efficacy of HFNC was similar to that of CPAP as respiratory support for
very preterm infants after extubation
430 F.J. Pilar and Y.M.L. Fernandez
Collins et al. [9] studied whether post-extubation respiratory support via heated,
humidified, HFNC resulted in a greater proportion of infants younger than 32 weeks
gestation being successfully extubated after a period of endotracheal positive pres-
sure ventilation compared with conventional nasal continuous positive airway pres-
sure (NCPAP). The authors did not find differences in the rates of extubation failure
between infants randomized to HFNC or NCPAP in the first 7 days after extubation.
HFNC was associated with significantly less nasal trauma compared with NCPAP.
In the Cochrane review on HFO for respiratory support in premature infants,
Wilkinson et al. [10] concluded that here is insufficient evidence to determine the
safety and efficacy of HFO in infants.
No definitive data support that HFO is superior to CPAP in neonatal respiratory
distress.
In infants younger than 18 months, Testa et al. [11], in a randomized controlled
trial with 89 patients, compared HFO to conventional oxygen therapy in extubation
48-h after cardiac surgery. HFNC was not useful in decreasing PaCO2 in postcardiac
surgery infants. Conversely, the use of HFNC in pediatric cardiac surgical patients
can be considered safe and a better option than O2 therapy to improve oxygenation
and to decrease the need for noninvasive post-extubation respiratory support.
In the adult population, a few studies have suggested the advantages of using
HFO for this indication. Parke et al. [12] showed that in adult patients with cardiac
conditions, the use of post-extubation HFNC was not associated with an increase in
postoperative oxygenation compared with the usual therapy, although it may have
been associated with a reduced requirement for escalation of therapy and slightly
lower PaCO2. They concluded that, in the absence of any demonstrable benefit, it
would be hard to justify the routine use of HFNC after extubation in patients under-
going a normal postoperative trajectory after cardiac surgery.
Tiruvoipati et al. [13] compared high-flow face mask (HFFM) with high-flow
nasal prongs (HFNP) in extubated patients. Their study reveals that HFNP are com-
parable with HFFM in terms of providing adequate gas exchange. HFNPs were
tolerated better than HFFM, and there was a trend toward better patient comfort
with the use of HFNPs that did not reach statistical significance. However, the study
does not address other important issues such as the requirement of reintubation,
noninvasive ventilation, duration of intensive care unit (ICU) and hospital stay, and
survival. This study is the first to evaluate the short-term physiologic benefits of
HFNC compared with non-rebreathing mask in these subjects.
Rittayamai et al. [14], in a randomized crossover study of 17 mechanically ven-
tilated patients after extubation, found that the use of HFO via nasal cannula reduced
dyspnea and resulted in a lower breathing frequency and heart rate compared with
oxygen via non-rebreathing mask.
Finally, Maggiore et al. [15], in a randomized, controlled open-label trial with
105 patients with a PaO2/FiO2 ratio 300 immediately before extubation, compared
the effects of the Venturi mask and nasal high-flow therapy. The latter resulted in
better oxygenation for the same set FiO2 after extubation, better comfort, fewer
desaturations, and a lower reintubation rate.
52 High-Flow Nasal Cannula Oxygen in Acute Respiratory Post-extubation Failure 431
Conclusions
HFO is an interesting method for respiratory support, despite the lack of estab-
lished benefits in the medical literature. Until this happens, it should be consid-
ered a method of respiratory support that is easy to use, well tolerated, and with
few side effects, such as local trauma, but with potential risks (unpredictable
pressure in airways, pneumothorax, etc.).
Based on some reports, HFO may be effectively and safely applied to a
broader spectrum of patient ages and diagnoses. Based on our experience with
this method, we believe that HFO can be included as a therapy in respiratory
care. When initiating support with oxygen using nasal prongs or a mask, the next
step, depending on the patients situation, would be HFO before using other
options such as CPAP, NIV, mechanical conventional ventilation, and high-fre-
quency oscillatory ventilation.
For the moment, application of HFO in weaning is based only on clinical
judgment and initiated with great caution.
References
1. Pilar J, Lopez Y, Morteruel E. High flow oxygen therapy and continuous positive airway pres-
sure. In: Medina A, editor. Non-invasive ventilation in pediatrics. 2014. p. 5360.
2. Lee JH, Rehder KJ, Williford L, Cheifetz IM, Turner DA. Use of high flow nasal cannula in
critically ill infants, children, and adults: a critical review of the literature. 3rd edition ERGON
Barcelona 2014. Intensive Care Med. 2013;39:24757.
3. Dysart K, Miller TL, Wolfson MR, et al. Research in high flow therapy: mechanism of action.
Respir Med. 2009;103:14005.
4. Hegde S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula therapy:
a report of 3 cases. Pediatrics. 2013;131:e16.
432 F.J. Pilar and Y.M.L. Fernandez
5. Mayfield S, Jauncey-Cooke J, Hough JL, et al. High flow nasal cannula therapy for respiratory
support in children. Cochrane Database Syst Rev. 2014;3, CD009850.
6. Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduc-
tion of high flow nasal prong oxygen delivery. Intensive Care Med. 2011;37:84752.
7. Milesi C, Baleine J, Matecki S, et al. Is treatment with a high flow nasal cannula effective in
acute viral bronchiolitis? A physiologic study. Intensive Care Med. 2013;39:108894.
8. Manley BJ, Owen LS, Doyle LW, et al. High-flow nasal cannulae in very preterm infants after
extubation. N Engl J Med. 2013;369:142533.
9. Collins CL, Holberton J, Barfield C, et al. A randomized controlled trial to compare heated
humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextu-
bation in premature infants. J Pediatr. 2013;162:94954.
10. Wilkinson D, Andersen C, ODonnell C, et al. High flow nasal cannula for respiratory support
in preterm infants. Cochrane Database Syst Rev. 2011;5, CD006405.
11. Testa G, Iodice F, Ricci Z, et al. Comparative evaluation of high-flow nasal cannula and con-
ventional oxygen therapy in paediatric cardiac surgical patients: a randomized controlled trial.
Interact Cardiovasc Thorac Surg. 2014;19:45661.
12. Parke R, McGuinness S, Dixon R, et al. Open-label, phase II study of routine high-flow nasal
oxygen therapy in cardiac surgical patients. Br J Anaesth. 2013;111:92531.
13. Tiruvoipati R, Lewis D, Haji K, et al. High-flow nasal oxygen vs high-flow face mask: a ran-
domized crossover trial in extubated patients. J Crit Care. 2010;25:4638.
14. Rittayamai N, Tscheikuna J, Rujiwit P. High-flow nasal cannula versus conventional oxygen
therapy after endotracheal extubation: a randomized crossover physiologic study. Respir Care.
2014;59:48590.
15. Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen
therapy after extubation effects on oxygenation, comfort, and clinical outcome. Am J Respir
Crit Care Med. 2014;190:2828.
Noninvasive Positive Pressure
Ventilation by Means of a Nasal Mask 53
May Avoid Recannulation After
Decannulation in Pediatric Patients: Key
Practical Aspects and Implications
53.1 Introduction
responsible for severe upper-airway obstruction, which may persist despite medical
and surgical treatment. A large (including 249 children) prospective national survey
performed in Spain showed that the main indications for a tracheostomy were pro-
longed ventilation (63 %), acquired subglottic stenosis (14 %), congenital or
acquired craniofacial anomalies (10 %), and congenital airway anomalies (9.6 %)
[1]. The most frequent underlying disorders were neurological (51 %) and respira-
tory diseases (39 %).
However, tracheostomy is associated with significant morbidity and discomfort
and may impair normal development, particularly language development. The fre-
quency of complications directly related to the tracheostomy is high, reaching
almost 5080 % in most series. Infections, endotracheal granulation, tracheal hem-
orrhage, cannula obstruction by mucus plugs, accidental displacement or removal,
pneumothorax, subcutaneous emphysema, or trachea-innominate artery fistula are
rare but life-threatening complications. In addition to medical complications, family
and social problems such as social life and family disruption are common in patients
with a tracheostomy. Although tracheostomized children may be safely discharged
home after careful family education and training, home treatment may be difficult
or even unfeasible for some families.
Thus, whenever possible, a decannulation should be proposed. But decannula-
tion failure is common, and decannulation rates have been shown to be quite low in
some series, ranging between 17 and 24 % [1, 2]. Apart from the medical conse-
quences, the psychological consequence of decannulation failure on the child and
the family are important to consider. Indeed, restlessness, anxiety, and depression
were observed more frequently by nursing staff in children who failed decannula-
tion compared with those who were successfully decannulated.
Noninvasive ventilation (NIV), which consists of the delivery of positive airway
pressure by means of a noninvasive interface, is an effective procedure for the treat-
ment of upper-airway obstruction and alveolar hypoventilation due to lung diseases
such as cystic fibrosis, bronchopulmonary dysplasia, and bronchiolitis obliterans.
There is thus a rationale to use NIV as a tool to improve the rate of successful decan-
nulation in children.
patient safety and decannulation success in adult patients [3]. However, pediatric
patients cannot be compared with adult patients because of different underlying
diseases and a smaller diameter of the trachea in relation to the cannula, which may
preclude capping. NIV and, in particular, continuous positive airway pressure
(CPAP) in the case of isolated upper-airway obstruction, may constitute extremely
valuable tools to increase the success of decannulation in borderline situations of
respiratory compromise.
Before a decannulation, the patient should fulfill the following conditions [4]
(Fig. 53.1):
The patient should be in a stable condition for at least 1 month. This delay
depends on the childs age and also on the season (with a greater risk of respira-
tory infection precluding a decannulation during the winter season).
A flexible laryngoscopy should document a patent airway with at least one
mobile vocal cord.
Any granulation tissue should be excised prior to decannulation.
YES NO
Overnight sleep study with a cuffless or deflated cuffed (small) cannula No decannulation
Normal nocturnal gas exchange + normal breathing
YES NO
NO
Decannulation with
Decannulation without noninvasive continuous
noninvasive continuous positive airway pressure
positive airway pressure Normal nocturnal gas exchange +
normal breathing
YES
Long term follow up with repeated clinical, endoscopy and sleep evaluations
choice of an adequate interface is even more important for the acceptance and toler-
ance of CPAP [5]. Because of their excellent tolerance, nasal cannula or prongs are
used as a first-line interface but they are only available for children over the age of
68 years [5]. Nasal masks, or facial masks in case of mouth leaks, are proposed as
second-line choice interfaces. The availability of industrial nasal masks for infants
will help to expand the use of CPAP in this setting. Unintentional leaks through the
tracheal stoma, which may compromise the efficacy and tolerance of NIV, can be
managed by occluding the tracheal stoma with a sticking plaster. A surgical closure
of the tracheal stoma should be discussed in case of persistent leaks through the
tracheal stoma.
Discharge at home with CPAP is allowed when the following criteria are ful-
filled: (1) ability to sleep at least 5 h with CPAP, (2) absence of nocturnal hypoxemia
or hypercapnia while on CPAP without supplemental oxygen, and (3) parents and
family adequately educated to CPAP.
In our experience, CPAP has been shown to be an effective tool for the decan-
nulation of children who could not tolerate overnight sleep with a cuffless or deflated
cuffed cannula and also to avoid recannulation in case of upper-airway obstruction
recurrence after a successful immediate decannulation [6].
Conclusion
Tracheotomy remains an effective treatment for severe upper-airway obstruc-
tion, but this procedure is associated with a significant morbidity and mortality.
CPAP, by maintaining upper-airway patency by means of a noninvasive inter-
face, may increase the rate of success of decannulation and reduce the need for
recannulation. Close collaboration between ear, nose, and throat (ENT) sur-
geons and pediatric pulmonologists with an expertise in NIV is highly
recommended.
References
1. Prez-Ruiz E, Caro P, Prez-Fras J, et al. Paediatric patients with a tracheostomy: a multicen-
tre epidemiological study. Eur Respir J. 2012;40:15027.
2. Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int.
2011;53:2026.
3. Pandian V, Miller CR, Schiavi AJ, et al. Utilization of a standardized tracheostomy capping and
decannulation protocol to improve patient safety. Laryngoscope. 2014;124(8):1794800.
4. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care.
Otolaryngol Head Neck Surg. 2013;148:620.
5. Ramirez A, Delord V, Khirani S, et al. Interfaces for long term noninvasive positive pressure
ventilation in children. Intensive Care Med. 2012;38:65562.
6. Fauroux B, Leboulanger N, Roger G, et al. Noninvasive positive-pressure ventilation avoids
recannulation and facilitates early weaning from tracheotomy in children. Pediatr Crit Care
Med. 2010;11:317.
Home Mechanical Ventilation
in Ventilator-Dependent Children: 54
Criteria, Outcome, and Health
Organization
Noninvasive Ventilation in Ventilator-Dependent
Children with Neuromuscular Disease
Abbreviations
54.1 Introduction
Respiratory failure is the most common cause of morbidity and mortality in patients
with slowly or rapidly progressive NMD. There are a wide variety of NMDs that
can compromise respiratory functions, as summarized in Table 54.1. Depending on
clinical onset of ARF, NMDs can be also classified as: (1) slowly progressive NMD
with acute exacerbations of chronic respiratory failure, and (2) rapidly progressive
54 Home Mechanical Ventilation in Ventilator-Dependent Children 441
NMD with acute episodes of respiratory failure. Spinal muscular atrophy (SMA)
and inherited myopathies (e.g., Duchenne muscular dystrophy) are the most fre-
quent slowly progressive NMDs in children.
When these patients develop chronic respiratory failure, long-term MV is the
main therapeutic intervention to support their respiratory muscle function, increas-
ing life expectancy and health-related quality of life. However, these patients are at
high risk of developing acute exacerbations of respiratory failure. The potential
causes of respiratory failure in patients with NMD include upper respiratory tract
442 A. Agarwal and P. Gupta
Diurnal Sleep
Ventilation Atelectasis Pneumonia Disordered
failure Breathing
increasing the risk of developing atelectasis and pneumonia [9]. Thus, hypoventila-
tion, upper-airway obstruction, aspiration lung disease, secretion retention and
lower airway infection, and the mechanical effects of progressive scoliosis are seen
as a consequence of neuro muscular weakness (NMW). Bulbar muscle weakness
(facial, oropharyngeal, and laryngeal muscles) can affect the ability to speak, swal-
low, and clear airway secretions, resulting in an increased likelihood of aspiration
(Fig. 54.1)
Respiratory table infections are the most frequent cause of acute exacerbation of
chronic neuromuscular respiratory failure. During these events, the respiratory load
increases and the strength of the inspiratory muscles further worsens, resulting in
impaired alveolar ventilation. Moreover, weakness of expiratory and bulbar muscles
causes ineffective coughing and airway mucus accumulation, further increasing the
work of breathing and leading to respiratory distress.
in sick children with NMD [11, 12]. Baseline peak cough expiratory flow rate mea-
surements above 160 l/min, however, do not guarantee adequate airway clearance,
because respiratory muscle function can deteriorate during respiratory infections.
Therefore, a peak cough expiratory flow rate of 270 has been used to identify
patients who would benefit from an assisted cough technique. The common goal of
all of these interventions, used alone or in combination, is to increase the velocity of
expiratory flow during a cough maneuver. Peak cough flow was the single most
important factor in determining whether the artificial airway (endotracheal or tra-
cheostomy tube) could be removed in a group of 37 adults with NMD who required
assistance with secretion removal [13].
NPPV and assisted coughing techniques have become standard therapy for the treat-
ment of acute-on-chronic neuromuscular respiratory failure in the critical care set-
ting as an alternative to invasive MV, both in the outpatient patient and in the
intensive care unit (ICU). If it fails or is contraindicated (e.g., due to severe bulbar
impairment), patients can be intubated as a short-term measure. MV should be con-
sidered in patients with acute exacerbation who have at least one of the following
issues: (1) dyspnea, as referred by the patient; (2) lethargy; or (3) acute respiratory
acidosis (i.e., arterial pH <7.35 with PaCO2 >45 mmHg [14]).
In children with neuromuscular weakness, NIV can be used to reduce the fre-
quency of recurrent chest infections and improve growth of chest wall and/or in the
perioperative period during intercurrent surgery (e.g., correction of scoliosis). NIV
may work by (1) improving ventilator mechanics; (2) resting fatigued respiratory
muscles, thereby improving strength and endurance; and (3) enhancing ventilatory
sensitivity to CO2. In addition, improvement in sleep stage distribution may increase
chemosensitivity and enhance sleep quality [12].
There are two main types of ventilators: pressure-targeted and volume-targeted.
Pressure-targeted ventilation is the most widely used in the noninvasive setting and
delivers bi-level positive airway pressure (BiPAP) at operator-set expiratory and
inspiratory pressures. The major advantage of pressure-targeted ventilation is that
flow will increase until the preset pressure is reached and, as such, it adjusts well for
unintentional leaks around the mask. Continuous positive airway pressure (CPAP)
is continuous pressure delivered to the lower airways through the pharynx by differ-
ent types of airway interfaces. It helps to unload respiratory muscles and enhance
minute ventilation by relieving upper-airway obstruction. BiPAP provides respira-
tory support at two levels. The inspiratory positive airway pressure and CPAP or
end-expiratory pressures and back-up rate can be set up by the operator. Volume-
targeted ventilation is most often used for invasive ventilationeither via an endo-
tracheal tube or a tracheostomy tubein situations where it is important to be able
to set the desired minute ventilation.
54 Home Mechanical Ventilation in Ventilator-Dependent Children 445
Interfaces connect the patients airway to the ventilator tubing. Six types of inter-
faces are commercially available that can be used to apply positive pressure to the
upper airway during an episode of ARF: full-face (or oronasal) mask, total face
mask, nasal mask, mouthpieces, nasal pillows or plugs, and a helmet. For acute
applications, most clinicians use face masks that span from chin to nasal bridge.
These tend to be used when there are problems with nasal masks, either because of
a large mouth leak or pressure effects from the nasal mask. All nasal and full-face
masks are held in place by some form of headgear [10].
With short-term use (up to several days), the most likely complications associ-
ated with NIV are skin breakdown and eye irritation from mask leak. Prevention of
skin breakdown requires careful attention to mask fitting, avoidance of overtight-
ened straps, and use of gel pads on at-risk contact points, particularly the bridge of
the nose and the forehead. Full-face masks covering the nose and mouth can be
associated with aerophagia and uncomfortable abdominal distension. They also
carry a risk of asphyxia if the child vomits into the mask and it is not promptly
removed. Long-term use of nasal or face masks in children whose faces are still
growing is associated with underdevelopment of the maxilla, leading to mid-face
flattening and malocclusion of the teeth.
In acute care settings appropriate to handle a child with an endotracheal tube,
NIV is monitored with an electronic cardiorespiratory monitor, pulse oximeter, and
airway-disconnect alarm. Transcutaneous CO2 monitoring is extremely valuable in
children at risk of type II respiratory failure. Monitoring of mask interface pressures
is also helpful, especially in the presence of a large leak around the interface wherein
the mask pressure may be substantially lower than the set pressures on the ventila-
tor. In children using NIV during the day and at night, humidification is helpful in
preventing drying of secretions and may improve tolerability.
The best predictive factors for the NPPV failure in ARF appear to be the level of
FiO2 and PaCO2 on admission or within the first few hours after starting NPPV. NPPV
failure is defined as the inability to reduce dyspnea or lethargy, decrease the respira-
tory rate, or improve blood gas exchange (i.e., arterial pH <7.30 or below the value
on admission, or failure to maintain a PaO2 >65 mmHg with a FiO2 >0.6) within the
first 612 h of application, despite optimal ventilation. NPPV treatment is not advised
for pediatric-age patients with significant respiratory distress complicated by cardio-
vascular instability, complete nasopharyngeal obstruction, hemoptysis, obstruction
of the proximal airway with a foreign object, or advanced stages of acute respiratory
distress syndrome. In children with neuromuscular weakness, bulbar dysfunction
and difficulty clearing airway secretions were associated with NIV failure.
Tracheostomy could be considered in patients with severe bulbar dysfunction
resulting in frequent aspiration and if acute exacerbation has led to a period of invasive
ventilation and repeated extubation attempts have failed despite optimal management.
If NIV has failed to correct hypoxemia or hypercapnia or when a child requires venti-
lation for more than 16 h in each 24-h period, a tracheostomy may provide a more
satisfactory interface between the child and the ventilator than a mask [10].
446 A. Agarwal and P. Gupta
In children, two noncontrolled trials assessed the efficacy of NPPV in these settings.
The application of NPPV as a means of facilitating ventilation weaning and as
curative treatment for post-extubation respiratory failure was associated with suc-
cess rates of 8186 and 5075 %, respectively [15, 16]. Another prospective cohort
study evaluating only NMD patients treated with a noninvasive approach (NPPV
and mechanical insufflation-exsufflation) showed a low mortality rate (8.3 %) and a
short hospital stay (12.05 7.04 days) [17]. A meta-analysis by Burns et al. [18]
found that, compared with invasive weaning, NIV was (12.05 7.04) days associ-
ated with lower mortality (relative risk 0.41), less ventilator-associated pneumonia
(relative risk 0.28), shorter MV (by 7.33 days), shorter ICU stay (by 6.88 days), and
shorter hospital stay (by 7.33 days). There was no effect on the probability of wean-
ing success.
NIV in Duchenne muscular dystrophy has markedly changed the natural history
of the disorder. From a median age at death of 1820 years, patients using NIV
now live to their late twenties and around a third may live into their thirties or for-
ties [19, 20]. NIV may be used to palliate symptoms and facilitate discharge home
in some children with a very poor prognosis. The study by chatwin et al. [21] high-
lights the role of NIV to palliate symptoms of respiratory distress in children with
Type 1 SMA. NIV was used to allow transfer from hospital to home so could the
child could spend the last months with their family.
Conclusion
NIV is a useful alternative therapy to MV in many different situations where
patients may be experiencing ARF. Children with restrictive disorders compli-
cated by pneumonia or atelectasis accompanied by a reduction in functional
residual capacity are especially likely to benefit from NPPV therapy.
Noncontrolled trials have shown NPPV was well tolerated with rare major com-
plications and was associated with improved gas exchange, decreased work of
breathing, and decreased need for endotracheal intubation. Both critical care
ventilators and portable ventilators have been used for NPPV. The combination
of inspiratory muscle assistance with NIV and expiratory muscle assistance with
cough insufflation-exsufflation is effective and well tolerated during acute respi-
ratory exacerbations by patients with neuromuscular weakness. In cases of sick
patients who fail to respond to NIV or deteriorate on NIV, intubation and MV
should not be delayed.
References
1. Teague WG. Non-invasive positive pressure ventilation: current status in paediatric patients.
Paediatr Respir Rev. 2005;6(1):5260.
2. Padman R, Lawless ST, Kettrick RG. Noninvasive ventilation via bilevel positive airway pres-
sure support in pediatric practice. Crit Care Med. 1998;26(1):16973.
54 Home Mechanical Ventilation in Ventilator-Dependent Children 447
3. Fortenberry JD, Del Toro J, Jefferson LS, Evey L, Haase D. Management of pediatric acute
hypoxemic respiratory insufficiency with bilevel positive pressure (BiPAP) nasal mask ventila-
tion. Chest. 1995;108(4):105964.
4. Hertzog JH, Siegel LB, Hauser GJ, Dalton HJ. Noninvasive positive-pressure ventilation
facilitates tracheal extubation after laryngotracheal reconstruction in children. Chest.
1999;116(1):2603.
5. Friedman O, Chidekel A, Lawless ST, Cook SP. Postoperative bi-level positive airway pressure
ventilation after tonsillectomy and adenoidectomy in childrena preliminary report. Int J
Pediatr Otorhinolaryngol. 1999;51(3):17780.
6. Serra A, Polese G, Braggion C, Rossi A. Non-invasive proportional assist and pressure sup-
port ventilation in patients with cystic fibrosis and chronic respiratory failure. Thorax.
2002;57(1):504.
7. Najaf-Zadeh A, Leclerc F. Noninvasive positive pressure ventilation for acute respiratory fail-
ure in children: a concise review. Ann Intensive Care. 2011;1:15.
8. Graham RJ, Fleegler EW, Robinson WM. Chronic ventilator need in the community: a 2005
pediatric census of Massachusetts. Pediatrics. 2007;119(6):e12807.
9. Racca F, Del Sorbo L, Mongini T, et al. Respiratory management of acute respiratory failure
in neuromuscular diseases. Minerva Anestesiol. 2010;76:51e62.
10. Hull J, Aniapravan R, Chan E, Chatwin M, Forton J, et al. Thoracic society guideline for respira-
tory management of children with neuromuscular weakness. Thorax. 2012;67(1):2012201964.
11. Chatwin M, Ross E, Hart N, Nickol AH, Polkey MI, Simonds AK. Cough augmentation with
mechanical insufflation/exsufflation in patients with neuromuscular weakness. Eur Respir J.
2003;21(3):5028.
12. Panitch HB. Respiratory issues in the management of children with neuromuscular disease.
Respir Care. 2006;51(8):88593.
13. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with
ventilatory failure: a different approach to weaning. Chest. 1996;110(6):156671.
14. Vianello A, Bevilacqua M, Arcaro G, Gallan F, et al. Non-invasive ventilatory approach to
treatment of acute respiratory failure in neuromuscular disorders. A comparison with endotra-
cheal intubation. Intensive Care Med. 2000;26:38490.
15. Lum LC, Abdel-Latif ME, de Bruyne JA, Nathan AM, et al. Noninvasive ventilation in a ter-
tiary pediatric intensive care unit in a middle-income country. Pediatr Crit Care Med.
2011;12:e713.
16. Mayordomo-Colunga J, Medina A, Rey C, Concha A, Menendez S, et al. Non invasive ventila-
tion after extubation in paediatric patients: a preliminary study. BMC Pediatr. 2010;10:29.
17. Servera E, Sancho J, Zafra MJ, Catal A, Vergara P, Marn J. Alternatives to endotracheal
intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil.
2005;84:8517.
18. Burns KE, Adhikari NK, Meade MO. A meta-analysis of noninvasive weaning to facilitate
liberation from mechanical ventilation. Can J Anaesth. 2006;53(3):30515.
19. Eagle M, Baudouin SV, Chandler C, et al. Survival in Duchenne muscular dystrophy: improve-
ments in life expectancy since 1967 and the impact of home nocturnal ventilation. Neuromuscul
Disord. 2002;12:9269.
20. Simonds AK, Muntoni F, Heather S, et al. Impact of nasal ventilation on survival in hypercap-
nic Duchenne muscular dystrophy. Thorax. 1998;53:94952.
21. Chatwin M, Bush A, Simonds AK. Outcome of goal-directed non-invasive ventilation and
mechanical insufflation/exsufflation in spinal muscular atrophy type I. Arch Dis Child.
2011;96:42632.
Part VIII
Non Invasive Mechanical Ventilation
and Weaning. Outcome
Noninvasive Ventilation and Weaning
Outcome 55
Karen E.A. Burns and Neill K.J. Adhikari
Abbreviations
CI Confidence interval
COPD Chronic obstructive pulmonary disease
CPAP Continuous positive airway pressure
FEV1 Forced expiratory volume in 1 s
GRADE Grading of Recommendations Assessment Development and Evaluation
I2 Measure of heterogeneity
ICU Intensive care unit
MD Mean difference
NIV Noninvasive ventilation
PS Pressure support
RR Relative risk
55.1 Introduction
Avoidance of
Role of intubation in Weaning Prevention
noninvasive Treatment of
COPD, CPE, strategy of respiratory
ventilation recurrent
other (COPD vs. failure (high respiratory failure
indications non-COPD) risk vs. all
patients)
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 rec-
ommendations 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 evi-
dence, 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 respira-
tory 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 rou-
tinely used in patients who do not have COPD (GRADE 2C recommendation)
and made no recommendation for patients with COPD because of a lack of evi-
dence. 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
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 4 trials, of which 2 trials evaluated patients at risk for post-
extubation failure and 2 examined patients with established post-extubation respira-
tory 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) 0.250.84)
and ICU mortality (RR 0.26, 95 % CI 0.100.66) but not hospital mortality (RR
0.71, 95 % CI 0.421.20). Conversely, in 302 patients with post-extubation respira-
tory failure, NIV had no effect (RR for reintubation 1.03, 95 % CI 0.841.25; RR
for ICU mortality 1.14, 95 % CI 0.433.00). The authors concluded that NIV
454 K.E.A. Burns and N.K.J. Adhikari
In 2012, Glossop et al. [13] summarized RCTs (limited to English) that compared
NIV to standard care in patients weaning from invasive mechanical ventilation (5
trials), extubated in the ICU (6 trials), or extubated immediately after major surgery
(5 trials) (Table 55.1). Among trials of patients extubated in the ICU, 4 enrolled
patients at risk of respiratory failure and 2 enrolled patients who had developed
55 Noninvasive Ventilation and Weaning Outcome 455
respiratory failure (the same trials identified previously [10, 11]). Similarly, among
the surgical trials, 2 enrolled patients with postoperative hypoxemia and 3 studied
NIV to prevent respiratory failure. Amidst moderate to high heterogeneity, the
authors found that NIV reduced ICU stay when used for weaning (MD 5.12 days,
95 % CI 7.91 to 2.32) and after surgery (MD 0.04 days, 95 % CI 0.05 to
0.03), with similar results for length of hospital stay (MD 6.45 days, 95 % CI
12.41 to 0.48 for weaning; MD 1.03 days, 95 % CI 1.13 to 0.93 after sur-
gery). The length of stay meta-analyses in postoperative patients were dominated by
one trial. NIV did not have similar effects in the ICU post-extubation group. NIV
also reduced pneumonia in the weaning (OR 0.12, 95 % CI 0.050.31) and post-
surgery (OR 0.27, 95 % CI 0.090.77) groups and the risk of reintubation in the
post-surgery group (OR 0.24, 95 % CI 0.120.50). Notwithstanding these findings,
meta-analyses found that NIV increased hospital mortality in the weaning group
(OR 1.82, 95 % CI 1.02, 3.23), had no effect in the post-ICU extubation group (OR
0.81, 95 % CI 0.51, 1.28), and decreased hospital mortality in the postoperative
group (OR 0.22, 95 % CI 0.065, 0.74).
458 K.E.A. Burns and N.K.J. Adhikari
55.3 Discussion
In the absence of a single large, well-designed RCT of NIV in the weaning and
peri-extubation period for a well-defined patient population, pooled data from
meta-analyses provide the highest level of evidence of its effects on clinical out-
comes. As with any form of empirical evidence, meta-analyses have limitations.
First, they implicitly assume that trials are more similar than different with respect
to populations, interventions, and outcome definitions; however, results from large
trials may disagree with meta-analyses in 1023 % of comparisons [15]. Second,
55 Noninvasive Ventilation and Weaning Outcome 459
although differences among trial results that are felt to have sufficient clinical simi-
larity to justify pooling can be handled statistically, limitations of the standard
methods used have recently been highlighted [16]. Third, statistical power is
related to the number of patients and outcome events, and even statistically signifi-
cant results based on few events can be fragile [17]. Therefore, in the specific case
of NIV for prevention and treatment of post-extubation respiratory failure, the
strength of inferences is limited by relatively few events and clinical and statistical
heterogeneity of trials. While the meta-analysis of noninvasive weaning includes
more trials than other indications, the number of events remains lower than optimal
for clinically important outcomes of mortality and ventilator-associated pneumo-
nia [18]. Despite the emerging evidence base for NIV in weaning from mechanical
ventilation, no single large clinical trial, stratified for the presence of COPD, has
been conducted.
Accordingly, additional large definitive trials are needed to evaluate noninvasive
weaning from mechanical ventilation, especially in non-COPD patients, and prophy-
lactic NIV for patients at high risk of post-extubation respiratory failure in the critical
care and postoperative settings. Finally, we note that no new trials of NIV to treat
post-extubation respiratory failure in the ICU have been published since 2006, when
a prominent trial cited in all the meta-analyses was stopped early for harm [19].
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Index
D M
Decannulation, 61, 118, 120, 122125, Malnutrition, 7, 9, 17, 6466, 70, 149,
313319, 331337, 341349, 357, 259, 354
383385, 433437 Mechanical insufflation-exsufflation (MI-E),
Diaphragm, 69, 12, 13, 17, 29, 31, 34, 45, 58, 6061, 263, 316, 332, 335, 337,
46, 48, 58, 64, 97, 151, 173, 180, 181, 347, 348, 368, 446
186, 202, 208, 214, 228, 234236, Mechanically assisted coughing,
287289, 323, 349, 355, 409412, 247, 250, 290
414, 419, 440, 441 Mechanical ventilation (MV), 313, 1521,
Difficult weaning, 7381, 8588, 117125, 3741, 4348, 5155, 64, 7381,
147158, 322, 353357, 361368 8588, 9193, 95105, 112, 117125,
Dysphagia, 68, 69, 174, 259264, 345 129136, 147159, 165170, 180, 183,
191195, 198200, 208, 213218,
221223, 233239, 262, 265, 297302,
E 305, 313, 321, 333, 342, 353, 361368,
Extubation, 6, 22, 32, 5155, 5761, 85, 373, 383, 394, 402, 418, 428, 439446
9193, 95105, 112, 118, 132, Mechanical ventilator weaning, 46
139145, 147, 159, 165, 181, 183, 192,
197205, 209, 222, 237, 241244, 250,
259265, 275, 281284, 294, 305308, N
316, 322, 331337, 355, 395, 401405, Nasal high flow oxygen therapy, 140
407414, 417421, 423431, 452 Neurally adjusted ventilatory assist (NAVA),
Extubation failure, 5155, 57, 9193, 95, 123, 29, 31, 32, 419
150, 154, 165, 185, 192, 197205, 254, Neuromuscular, 4, 17, 46, 52, 61, 120, 150,
262, 284, 318, 395, 401405, 407414, 180, 221, 247255, 259, 276, 316, 323,
419, 423431 331337, 361368, 374, 388, 439446
Neuromuscular disease (NMD), 6, 19, 52, 54,
61, 111, 120, 121, 150, 153, 157, 200,
G 222, 247255, 299, 318, 323, 324, 327,
General surgery, 174 334, 337, 343, 361, 362, 380, 388, 419,
421, 439446
Noninvasive positive pressure ventilation
H (NIPPV), 150, 159162, 173, 202,
High flow nasal cannula, 139145, 202, 404, 253, 395, 403
423431 Noninvasive ventilation (NIV), 17, 2934, 37,
Home care, 252, 361368, 380, 386 54, 57, 74, 91, 96, 111114, 122, 132,
140, 147, 160, 165170, 181, 183187,
193, 197205, 225231, 233, 242,
I 259264, 281284, 300301, 383,
Inspiratory muscle training, 45 393398, 401405, 407414, 430,
Intensive care, 4, 16, 21, 26, 38, 44, 57, 64, 74, 434, 439446
86, 91, 95, 117, 132, 142, 148, 181, Noninvasive weaning, 160, 440, 458, 459
183, 192, 199, 209, 213, 228, 233, 241, Nutritional status, 103, 122, 409, 443
249, 265, 281, 305, 313, 321, 342, 344, Nutritional support, 19, 65, 381
361, 373, 383, 402, 418, 423, 444
Intrapulmonary percussive ventilation, 5859,
290, 443 O
Obesity, 6, 92, 111, 120, 121, 123, 152, 180,
222, 233235, 241244
L Oxygen, 9, 58, 85, 92, 100, 112, 118, 130,
Long term acute care hospital (LTAC), 140, 149, 161, 166, 173, 180, 184, 192,
18, 44, 380 200, 209, 214, 221, 226, 235, 241, 251,
Long term care hospital, 313, 355 262, 267, 283, 289, 298, 306, 315, 324,
Lung transplantation, 198, 201, 213218 342, 409, 413, 414, 423, 428, 434
Index 465
P R
Patient-ventilator interaction, 29, 30, 33, 87 Rehabilitation, 18, 19, 46, 48, 65, 68, 192,
Peak cough expiratory flow, 5153, 55, 203, 214, 260, 261, 263, 264, 314, 323,
254, 444 326, 356, 357, 363365, 368, 375, 376,
Pediatrics, 254, 408411, 417421, 423431, 380, 383
433437, 440, 445, 446 Reintubation, 25, 54, 55, 57, 61, 74, 86, 88, 92, 93,
Physical therapy, 4648, 61, 254 9599, 118, 123, 125, 132, 143, 147, 148,
Pneumonia, 17, 32, 39, 80, 86, 87, 95, 103, 150, 151, 154, 158, 165, 166, 168170,
119, 129136, 143, 148, 151, 153, 176, 179, 181, 183187, 192195, 209,
154, 157, 160162, 165, 166, 168, 215218, 221, 226230, 233, 239, 241,
169, 174, 175, 179181, 183, 186, 242, 254, 261263, 269, 275279,
192195, 201, 207, 208, 214, 217, 281284, 305308, 321, 325, 326, 328,
221, 222, 226, 227, 229, 235237, 335, 374, 395, 402404, 408, 410, 411,
239, 249253, 261, 262, 276, 281283, 413, 418421, 429431, 452458
288290, 307, 308, 332, 333, 335, Respiratory
337, 342, 346, 349, 363, 410, 411, failure, 16, 19, 29, 30, 32, 33, 37, 54,
414, 419, 428, 436, 440, 442, 443, 5761, 66, 86, 88, 92, 95105,
446, 452, 455459 111114, 119, 120, 122, 123, 125,
Positive pressure ventilation, 7, 9, 10, 148, 139145, 147, 150158, 165, 166, 168,
150, 186, 348, 430, 440 169, 174176, 180, 181, 183187,
Post-extubation, 6, 32, 33, 54, 61, 86, 91100, 191195, 199204, 207210, 214,
102, 104, 105, 118120, 123, 150, 216218, 221, 222, 228230, 234,
153155, 157, 176, 185187, 192, 193, 236239, 241, 242, 247249, 251253,
195, 216, 255, 259263, 265, 278, 282, 255, 259264, 275279, 282, 283, 289,
283, 394, 401405, 411, 419, 421, 290, 294, 314, 333, 337, 352, 363, 374,
423431, 446, 453457, 459, 460 383, 402, 410413, 417, 418, 420,
Post-extubation failure, 61, 86, 9193, 97, 439441, 443
150, 154, 185, 192195, 401405, function, 4, 40, 65, 66, 144, 175, 198, 199,
423431 201, 209, 214, 222, 223, 226, 228,
Post-operative, 25, 88, 9698, 100, 105, 143, 233237, 239, 247249, 294, 362, 410,
175177, 179181, 183187, 191, 192, 440, 441
194, 198, 199, 202, 204, 205, 209, 210, insufficiency, 64, 66, 68, 117119, 214,
213215 253, 289, 294, 363, 440
Post-operative pulmonary complications, 97, muscles, 57, 9, 11, 17, 44, 51, 54, 111,
175, 179, 186, 192, 221, 222, 225, 229, 112, 148, 180, 181, 201, 236, 239,
230, 289, 324, 342, 347 242, 247249, 287, 301, 324, 327,
Pre-oxygenation, 143 363, 419, 444
Prevention, 38, 99, 117, 120, 123, 124, Restrictive lung disease, 64
129136, 141, 151, 154155, 181, 186,
192, 193, 216, 229, 237, 269, 278, 288,
307, 403, 425, 445, 454, 455, 459 S
Procedures and techniques-therapeutic, 217 Saturation, 11, 87, 88, 100, 103, 112, 140,
Prolonged mechanical ventilation, 313, 142, 144, 145, 149, 192, 199, 214, 222,
1520, 4348, 5155, 69, 7381, 96, 229, 251, 253, 255, 276, 293, 294,
117125, 129136, 207210, 213218, 324328, 335, 345, 348, 410, 413, 421,
263271, 314, 316, 319, 342, 349, 373, 428431
374, 408, 409, 414, 452 SCI. See Spinal cord injury (SCI)
Prolonged weaning, 13, 1520, 7981, 85, 86, Scoliosis, 123, 222, 223, 248, 322,
147158, 166, 268, 314, 354357, 418, 443, 444
373381, 383388 Sedation, 17, 18, 21, 34, 3741, 46, 87, 117,
Pulmonary, 5, 6, 8, 10, 16, 17, 59, 61, 64, 97, 120, 121, 131, 136, 137, 145, 152, 157,
98, 122, 130, 143, 149151, 166, 167, 169, 183, 192, 193, 199, 265, 266,
174176, 179, 181, 183, 186, 191, 269271, 277, 279, 282, 305, 323, 324,
193, 195 345, 354, 356, 377, 413, 436
466 Index