© Springer International Publishing Switzerland 2016
Antonio M. Esquinas (ed.)Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care10.1007/978-3-319-04259-6_1414. Noninvasive Ventilation Withdrawal Methodology After Hypercapnic Respiratory Failure
(1)
Division of Respiratory Medicine, Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong, China
Keywords
Noninvasive ventilationRespiratory failureWeaningAbbreviations
AHcRF
Acute hypercapnic respiratory failure
ARF
Acute respiratory failure
BTS
British Thoracic Society
COPD
Chronic obstructive pulmonary disease
NIV
Noninvasive ventilation
OSA
Obstructive sleep apnea
RCT
Randomized controlled trial
14.1 Introduction
Noninvasive ventilation (NIV) has been shown to be effective in treating acute respiratory failure (ARF) due to a variety of causes [1, 2], including chronic obstructive pulmonary disease (COPD) [3], neuromuscular diseases [4], and obesity-hypoventilation syndrome [5, 6]. NIV can augment ventilation and unloading of respiratory muscles, reduce atelectasis, and splint the upper airway in obstructive sleep apnea.
Despite the effectiveness of NIV as a treatment, there has been no study of the withdrawal method of NIV after recovery from ARF. The Royal College of Physicians (United Kingdom) and the British Thoracic Society (BTS) published 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 guideline 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 multicenter 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 extubation 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 discomfort, reduce cost, and facilitate early discharge. This chapter reviews the available evidence in relation to NIV withdrawal after resolution of ARF.
14.2 Analysis
14.2.1 Duration of NIV at Initiation
There is no comparative study on the duration of NIV at initiation. As patients suffering from ARF are at life-threatening risk, it seems reasonable to have long hours of NIV to improve their gas exchange at the beginning of treatment. The BTS guideline recommends the patient have NIV fir as long as they can tolerate at the beginning of treatment [7]. Many clinical trial protocols also encourage patients to use NIV for as long as they can tolerate [1, 2, 8].
14.2.2 Time to Consider NIV Withdrawal
The aim of NIV in AHcRF in COPD is to reduce PaCO2 by augmenting ventilation and unloading respiratory muscles. Physicians may consider NIV withdrawal after patients have achieved clinical stability with improvement in blood gases. The BTS recommends considering NIV withdrawal after 24 h of commencement, if NIV is successful, which is defined as pH ≥7.35, resolution of underlying cause or symptoms, and normalization of respiratory rate. Studies of NIV in COPD have similar criteria for NIV withdrawal [7]. Kramer et al. [2] attempted withdrawal when the respiratory rate was less than 24 breaths/min, heart rate less than 110 beats/min, pH ≥7.35 and adequate oxygenation with ≥90 % saturation with oxygen flow less than 3 L/min.
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