Preventive Use of Noninvasive Ventilation After Extubation: A Prospective, Multicenter Randomized Controlled Trial

Su, Chien-Ling; Chiang, Ling Ling; Yang, Shih Hsing; Lin, Hen‐I; Cheng, Kuo-Chen; Huang, Y.-C. T.; Wu, Chin Pyng

doi:10.4187/respcare.01141

Cited by 82 publications

(66 citation statements)

References 20 publications

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“…65,66 Another RCT 67 in patients with hypercapnia at the time of extubation prospectively confirmed the latter findings, but these results were not confirmed when NIV was applied to all patients after extubation, without selecting the patients at higher risk. 68 Two other earlier RCTs tested the hypothesis that NIV could avoid reintubation in patents already showing signs of acute respiratory distress within the first 48 hours after extubation, but found no reduction in reintubation rate, 69 and one 70 even found significantly higher ICU mortality in the NIV group, associated with longer delay in reintubation. Interestingly enough, a pilot study performed in patients extubated early after hypoxic respiratory failure showed that NIV was very useful as a bridge to unsupported breathing, reducing the frequency of post-extubation failure.…”

Section: Prevention Of Extubation Failurementioning

confidence: 98%

Behind a Mask: Tricks, Pitfalls, and Prejudices for Noninvasive Ventilation

Nava

2013

Respir Care

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It is difficult to exactly date the beginning of mechanical ventilation, but there are no doubts that noninvasive ventilation (NIV) was the first method of ventilatory support in clinical practice. The technique had a sudden increase in popularity, so that it is now considered, according to criteria of evidence-based medicine, the first-line treatment for an episode of acute respiratory failure in 4 pathologies (the Fabulous Four): COPD exacerbation, cardiogenic pulmonary edema, pulmonary infiltrates in immunocompromised patients, and in the weaning of extubated COPD patients. The so-called emerging applications are those for which the evidence has not achieved level A, mainly because the number or sample size of the published studies does not allow conclusive meta-analysis. These emerging applications are the post-surgical period, palliation of dyspnea, asthma attack, obesity hypoventilation syndrome, and to prevent extubation failure. Potentially "risky business" uses include for respiratory failure from pandemic diseases and ARDS, where probably the "secret" for success is early use. Healthcare is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly, if at all, so their clinical use remains limited and heterogeneous. The low rate of NIV use in some hospitals relates to lack of knowledge about or experience with NIV, insufficient confidence in the technique, lack of NIV equipment, and inadequate funding. But NIV use has been increasing around the world, thanks partly to improved technologies. The skill and confidence of clinicians in NIV have improved with time and experience, but NIV is and should remain a team effort, rather than the property of a single local "champion," because, overall, NIV is beautiful!

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Section: Prevention Of Extubation Failurementioning

confidence: 98%

Behind a Mask: Tricks, Pitfalls, and Prejudices for Noninvasive Ventilation

Nava

2013

Respir Care

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“…7 Investigators have also used NIV in asthma, pneumonia, neuromuscular disease, post-extubation, and hypoxemic and postoperative acute respiratory failure, with varying success. [8][9][10][11][12][13][14][15] The timing and location of initiation of NIV has been evaluated by investigators. Early commencement of NIV in appropriate patients is associated with better outcomes, because delay can adversely affect the patient and increase the need for invasive ventilation.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards

et al. 2013

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BACKGROUND: Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear. METHODS: We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality. RESULTS: Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ؎ 5.1 versus 14.4 ؎ 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P ‫؍‬ .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs 13.3%) or ICU mortality (3.7% vs 8%). CONCLUSIONS: In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

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“…This selection should include a high risk of post-extubation respiratory failure, a condition likely to respond to low level ventilatory support, and the minimization of factors that impair the effectiveness of NIV (inadequate airway clearance and mental status). The unselective approach of the Su et al study, 14 at least as far as the first 2 elements, seems not beneficial. The criteria for selection in the other studies, [11][12][13] although with few in common, were quite different from each other.…”

mentioning

confidence: 83%

“…ICU and hospital length of stay and mortality were no different, but an intriguing 90 day mortality advantage for the preventive NIV group was noted. SEE THE ORIGINAL STUDY ON PAGE 204 In this issue of RESPIRATORY CARE, Su et al 14 report a large prospective randomized trial performed in 3 ICUs in Taiwan, aiming to evaluate whether the preventive use of NIV after planned extubation would reduce re-intubation rate. Different from prior studies, this study did not select patients according to risk of post-extubation respiratory failure.…”

mentioning

confidence: 99%