Acute Respiratory Failure in Patients with Severe Community-acquired Pneumonia

Abstract

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.

Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting

“…In one trial, patients with COPD were included, and results for patients who did and did not have this condition were reported separately. 38 In the subgroup of patients who did not have COPD (n = 33), the addition of noninvasive positivepressure ventilation did not reduce endotracheal intubation (6/16 v. 8/17 in control group) or hospital mortality (6/16 v. 4/17). In the other trial, which involved patients with acute hypoxemic respiratory failure but no underlying COPD, there was benefit (reduced endotracheal intubation and ICU mortality) for the subgroup of patients (n = 34) with severe communityacquired pneumonia.…”

“…We also report recommendations on technical strategies to optimize the use of noninvasive ventilation (e.g., interfaces, mode). See Table 2 38 whereas almost all other trials involving patients with exacerbation of COPD excluded patients with pneumonia. In that trial, 38 use of noninvasive positive-pressure ventilation was associated with a reduction in endotracheal intubation (0/12 in intervention arm v. 5/12 in control arm, p = 0.005).…”

Noninvasive ventilation in children: a review

“…Embora comprovada primeiramente em doenças como exacerbações agudas de doença pulmonar obstrutiva crôni-ca [42][43][44][45] , edema pulmonar cardiogênico agudo 46-48 e insuficiência respiratória pós-operatória 49,50 , o uso da VNI na insuficiência respiratória aguda também foi descrita em pacientes imunodeprimidos 51,52 , com pneumonia 53 , com interrupção ou falha na extubação 54 Ventilação não-invasiva em crianças -Loh LE et al…”

“…Estudos com adultos não mostraram um argumento convincente a favor da VNI nos quadros de pneumonia adquirida na comunidade 53 . Os estudos pediátricos existentes podem ser mais promissores.…”

The art and science of non-invasive ventilation

“…More recent studies have confirmed high failure rates in patients with pneumonia and severe ARF (27,(30)(31)(32). The only prospective randomised clinical trial (RCT) in the literature that compared conventional treatment with or without NIV demonstrated that patients who had received NIV together with conventional treatment had lower rate of tracheal intubation and a shorter stay in the intermediate care unit than those who received conventional treatment only, although the length of hospital stay and hospital mortality were similar between both groups (33). This study also showed in a subset analysis that the significant benefits of NIV occurred in patients with COPD and hypercapnic respiratory failure only; this subset of patients had also a lower mortality after two months.…”