TURKISH THORACIC SOCIETY 9TH ANNUAL CONGRESS ANTALYA, TURKEY 21, APRIL, 2006

1. TURKISH THORACIC SOCIETY9TH ANNUAL CONGRESSANTALYA, TURKEY21, APRIL, 2006 WEANINGRole of Non-Invasive Mechanical Ventilation Peter C Gay MD Associate Professor Mayo Clinic College of Medicine Rochester, MN

2. Sean Caples, Peter Gay. Concise Review CCM 33: 2005

3. NPPV to ReduceReintubation & MV time • Issues/Rationale • After extubation • Routine • Respiratory distress after extubation • Prevention in selected high risk patients • Adjunct to weaning: Early extubation for prolonged weaning failure

4. What Can we Extrapolate from NPPV in Acute Respiratory Failure? • Need for assisted ventilation • Pathophysiology may be similar but not identical • Unique issues related to weaning, post-operative period, and extubation

5. Pathophysiology Increased WOB/RSB Respiratory muscle weakness Abnormal gas exchange Atelectasis Increased PEEPi Adverse CV effects NPPV Effect Decrease WOB/RSB Unload respiratory muscles Improve gas exchange, raise MV Decrease atelectasis Counterbalance PEEPi ?Reduce CV events Rationale for NPPV for Weaning

6. Routine Use of NPPV to Prevent Extubation Failure/ReintubationJiang et al, Respirology 4:161-165, 1999 • Prospective, RCT: 93 pts, Mean age 73 • (56 planned, 37 unplanned) • 47 BiPAP (face mask) vs 46 Oxygen pts • No Sig Difference for BiPAP vs O2 pts • Failed extubation: 13/47 (28%) BiPAP • 7/46 (15%) Oxygen • -BiPAP pts had more unplanned extubations

7. NPPV for Post-extubation Respiratory Distress: Randomized Controlled TrialKeenan SP, JAMA 287:3238-3244, 2002 • Objective- • Prevent reintubation in high-risk pts with established mixed cause respiratory distress during first 48 hrs after extubation. • Patients- • 2763 screened/880 eligible/358 consent • Total 81 cardiac or respiratory disease pts requiring MV for > 48 hours • Interventions- • Std medical therapy alone vs. NPPV

8. NPPV for Post-extubation Respiratory Distress: Randomized Controlled TrialKeenan SP, JAMA 287:3238-3244, 2002 • Results-No difference NPPV vs Std Care: • Rate of reintubation (72% vs 69%) • Hospital mortality (31% for both) • Duration of MV (8.4 vs 17.5 days; p=0.11) • Length of ICU (11.9 vs 10.8 days) • Hospital stay (32.2 vs 29.8 days) • Conclusions-NPPV no benefit in heterogeneous patients with respiratory distress <48 hours after planned extubation

9. NPPV for Post-extubation Respiratory DistressKeenan et al, JAMA 2002 • Excluded COPD pts after 1st yr • I/E= 10/5 cmH20 • Start up to 48 hrs • Selection bias

10. 37 ICUs, 8 countries, N = 993 MV>48h 228 dev resp distress within 48h of extubation Separate randomization for COPD Randomization (within 48h of extubation) if: Hypercapnia (PaCO2>45 or >20% from pre-extubation) Clinical signs of resp muscle fatigue or increased WOB Resp rate >25 (for 2 hours) Resp acidosis: pH < 7.30 with PaCO2 > 50 Hypoxemia: SpO2 < 90% or PaO2 < 80 on FiO2 > 0.50 NPPV with Early Signs of Extubation FailureEsteban et al, NEJM 2004; 350:2452

11. No diff in age, SAPS II, duration of vent (10 v 11d), initial cause for RF or pre-extubation variables NPPV with Early Signs of Extubation Failure % of pts * * Esteban et al, NEJM 2004; 350:2452

12. Esteban Trial CommentaryIs NPPV Making Some Pts Worse? • Very few COPD patients (13%) • Patients quite mild; RR 29, pH 7.39, PaCO2 46, PaO2 79 at time of randomization • Multicenter design; strength and weakness • 28 pts crossed over to NPPV in the control group, only 7 required intubation • If these are counted as “need for intubation”, failures in controls rise to 68% compared to 48% in NPPV

13. NPPV to Prevent Extubation Failure: Recommendations Routine (self-extubated)- No Overt, severe post-extubation failure; unstable cardiac or other medical problems- No In Selected High Risk Patients - Possibly If you use it: Don’t delay reintubation beyond 2 – 3 hours if the patient is not responding

14. NPPV DURING PERSISTENT WF- RCT of Early ExtubationFerrer, AJRCCM, 168 2003 • Results- NPPV vs Conventional pts had: • Shorter intubation (9.5 vs 20.1 days, p=0.003) • Less ICU stay (14.1 vs 25 , p=0.002) • Less Hospital stay (27.8 vs 40.8 days, p=0.026) • Lower needs of tracheotomy to withdraw ventilation (5% vs 59%, p<0.001) Trial was terminated after a planned interim analysis

15. NPPV DURING PERSISTENT WF- RCT of Early ExtubationFerrer, AJRCCM, 168 2003 • Comments • Well designed study • Most pts (75%) with COPD or CHF • 3) Unblinded- selection bias • 4) Huge number of pts trached • Results- NPPV vs Conventional pts had: • Less septic shock (10 vs 45%, p=0.045) • Less nosocomial pneumonia (24 vs 59%, p=0.042) • Decreased ICU mortality (10 vs 45%, p=0.045) and increased 90-days survival (p=0.044). • Conventional weaning an indep risk factor • Conclusions-Earlier extubation with NPPV has tremendous advantages in ?highly selected pts.

16. 1) For selected COPD/CHF pts? Yes 2) As a routine? No Caveats 1) Excellent candidate for NPPV 2) Unassisted breathing for >5 min 3) Able to breathe on same PSV settings 4) Not be difficult for re-intubation Can NPPV be used to expedite Weaning?

17. NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33: 2005 Multiple-center, randomized controlled study. >8 hrs/d in first 48 hrs

18. NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005

19. NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005

20. NPPV to Prevent Respiratory Failure after Extubation in High-Risk Patients.Nava S, CCM 33 2005 EDITORIAL- Girault, C MD NPPV for Post-extubation respiratory failure: Perhaps not to treat but at least to prevent! • Comments- • Preventive application of NPPV immediately after extubation is associated with clear benefit • Use of NPPV independently associated with a reduced risk of postextubation failure • Act of reintubation per se a strong predictor of mortality. • Recognize difference from recent negative studies to treat postextubation respiratory failure, • Very selected patients at high risk before developing postextubation respiratory distress.

21. NPPV for Post-extubation Respiratory Distress: Post-operative PatientsAuriant,AJRCCM 164: 2001 • Design- • Randomized 24 pts with ARF after Lung Resection • Dyspnea, RR>24/min, access musc use, P/F<200 • Results- NPPV pts vs. usual care had: • Less intubation= 50% vs. 21% (p= 0.035) • Hosp LOS= 23 vs. 27 days • Lower mortality= 38% vs. 13 % (p= 0.045) • Conclusions- NPPV is safe and effective in reducing intubation and improving survival

22. NPPV with Post-op Organ TransplantationAntonelli M, JAMA; 283: 235-241, 2000 • Randomized 40 solid organ transplant pts • NPPV pts had better gas exchange and: • Lower intubation rate (20% vs. 70%; p=0.002) • Less fatal complications (20% vs. 50%; p= 0.05) • Lower ICU mortality (20% vs. 50%; p= 0.05), but hospital mortality same • Consider NPPV use in these types of patient

23. NPPV to Avoid Re-intubation in Extubated Pts • After extubation? • Routine, prophylactic- No • Prevention high risk patients- Yes, but selectively • Post-operatively- Yes, but selectively

24. Conclusions • Issues/Rationale • After extubation • Routine • Respiratory distress after extubation • Prevention in selected high risk patients • Adjunct to weaning: Early extubation for prolonged weaning failure