Benefits of non-invasive ventilation in acute hypercapnic respiratory failure.pdf
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1、INVITED REVIEW SERIES:NON-INVASIVE VENTILATIONSERIES EDITORS: AMANDA PIPER AND CHUNG-MING CHUBenefits of non-invasive ventilation in acute hypercapnicrespiratory failureVITTORIACOMELLINI,1ANGELAMARIAGRAZIAPACILLI2AND STEFANONAVA1,21Respiratory and Critical Care Unit, University Hospital St Orsola-Ma
2、lpighi, Bologna, Italy;2Department of Specialistic,Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, ItalyABSTRACTNon-invasive ventilation (NIV) with bilevel positive air-way pressure is a non-invasive technique, which refersto the provision of ventil
3、atory support through thepatients upper airway using a mask or similar device.This technique is successful in correcting hypoventila-tion. It has become widely accepted as the standardtreatment for patients with hypercapnic respiratory fail-ure (HRF). Since the 1980s, NIV has been used in inten-sive
4、 care units and, after initial anecdotal reports andlarger series, a number of randomized trials have beenconducted. Data from these trials have shown that NIVis a valuable treatment for HRF. This review aims toexplore the principal areas in which NIV can be useful,focusingparticularlyonpatientswith
5、acuteHRF(AHRF). We will update the evidence base with the goalof supporting clinical practice. We provide a practicaldescription of the main indications for NIV in AHRFand identify the group of patients with hypercapnic fail-ure who will benefit most from the application of NIV.Key words:hypercapnia
6、, non-invasive ventilation, respiratoryacidosis, respiratory failure.INTRODUCTIONThe normal level of carbon dioxide (CO2) tension inthe arterial blood (PaCO2) results from the relationshipbetween the rate of CO2production and the portion ofCO2eliminated by the lung with alveolar ventilation.Acute hy
7、percapnic respiratory failure (AHRF) is morecommonly determined by a defect of this latter mecha-nism (respiratory pump failure), when the respiratorymuscles do not provide sufficient alveolar ventilation tomaintain a normal arterial PaCO2.1A rapid elevation ofPaCO2leads to a drop in arterial blood
8、pH as a conse-quence of the lowering of HCO3_/PaCO2ratio.AHRF is classically considered a main feature ofadvancedchronicobstructivepulmonarydisease(COPD), and the role of non-invasive ventilation (NIV)for its treatment is established.2However, an imbalancebetween the increased elastic and resistive
9、load andthe reduced capacity of the respiratory pump is not auniquefeatureofacuteexacerbationofCOPD(AECOPD). Many other diseases may lead to AHRF,and therefore NIV has been also used in a wide rangeof other conditions associated with acidosis and hyper-capnia, despite most of the studies having been
10、 con-ducted in patients with COPD (see Table 1).3This review aims to discuss what is known from thepresent literature and to summarize the main indica-tions of NIV in AHRF in a practical way.ACUTE EXACERBATION OF COPDNIV is considered the standard of care in the manage-ment of AHRF secondary to AECO
11、PD4both in patientswith and without previous chronic hypercapnia.Since the late 1980s, NIV has been used in intensivecare units (ICU) and emergency departments. In thefirstrandomized controlledtrial,Brochardet al.5showed NIV significantly reduced the need for endotra-cheal intubation (ETI) when comp
12、ared to standardmedical treatment among patients admitted to an ICUwith AECOPD. The frequency of complications was sig-nificantly lower in the NIV group and the mean hospi-tal stay significantly shorter. The in-hospital mortalityrate was also significantly reduced with NIV. A subse-quentstudyconfirm
13、edNIVwasassociatedwithreduced rates of ETI and mortality.6Conti et al.7compared NIV and invasive mechanicalventilation (IMV) in 49 patients with an AECOPD whofailed standard medical treatment. In these very sickpatients, NIV was proven to be non-inferior than ETIand IMV. Moreover, in those patients
14、who could bemanaged successfully with NIV, there was an advan-tage both in terms of reduction in ICU stay, readmis-sions to hospital in the following year and need for denovo long-term oxygen therapy.The application of NIV in general wards has beenalso widely investigated in a number of studies. In
15、theCorrespondence: Stefano Nava, Respiratory and Critical CareUnit, University Hospital St Orsola-Malpighi, Via G. Massarenti9, Bologna 40138, Italy. Email: Received 3 September 2018; invited to revise 19 September,19 and 28 October, and 15 November 2018; revised 9, 22 and30 October, and 18 November
16、 2018; accepted 9 December 2018. 2019 Asian Pacific Society of RespirologyRespirology (2019)doi: 10.1111/resp.13469largest one, it was confirmed that delivery of NIV ingeneral ward is feasible.8In this multicentre UK trialcomparing NIV with standard therapy, early institutionof NIV reduced treatment
17、 failure and halved hospitalmortality. From a post hoc subgroup analysis, dataemerged suggesting a worse outcome in patients withpH 7.30. Thus, sicker, more acidotic patients should bemonitored more closely in order to avoid delays inintubation.In a prospective pilot cohort study conducted byFiorino
18、 et al. in a non-highly protected environmentin a medical ward of a rural hospital,9NIV producedsimilar improvements in arterial blood gases not onlyin patients with mild, but also with severe forms ofrespiratory acidosis. The favourable results of this pro-spective study, and of another retrospecti
19、ve one10maybe related to the long-term experience of the staff withNIV and the improved technology of ventilators andinterfaces, compared with Plant et al.s study.8The benefits of NIV and its non-inferiority to stan-dard therapy have been confirmed in a large numberof other randomized controlled tri
20、al (RCT) in many dif-ferent settings, in different countries and healthcaresystems.11Several large surveys showed that the use of NIV hasbecome widespread in the treatment of AECOPD inEurope and in the United States.1214Nowadays, NIV can be delivered safely in any dedi-cated setting, ranging from em
21、ergency departments,medical units to high-dependency and ICU. Of note,however, NIV should be performed by adequatelytrained staff with the availability of appropriate moni-toring facilities because despite increasing experiencewith this technique, the rate of NIV failure remainshigh at 20% and 30% i
22、n patients with COPD admittedto ICU, especially in those patients with severe dys-pnoea.15,16A successful outcome is highly dependenton accurate patient selection and among patients withCOPD the severity of hypercapnia and/or acidosis afterinitiation of NIV is a major predictor of NIV failure.1719As
23、 remarked in recent ATS/ERS guidelines,4strongevidence supports the use of NIV in patients whodevelop AHRF (pH 7.35, PaCO2 45 mm Hg) due toAECOPD.Within this group, we can identify less severely illpatients with a pH of 7.257.35. For these patients, NIVcould be useful to prevent the progression of a
24、cidosisand the requirement of ETI and mechanical ventilation(MV). For the more severely ill patients, typically with apH 1000 patients were randomized toCPAP, NIV or standard oxygen therapy. This trial foundphysiological improvement in the CPAP and bilevelNIV groups compared with the standard group,
25、 but nodifference in intubation rate or mortality at 7 and30 days. Although a pH of 7.35 was one of the inclu-sion criteria, only 60 mm Hg) may require particular attention.Contou et al. demonstrated that among patients treatedfor severe CPE and having no identified underlyingCLD, severe hypercapnia
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