Rescue treatment for noninvasive ventilation failure due to interface intolerance with remifentanil analgosedation: a pilot study

Abstract

This clinical study suggests that a remifentanil-based sedation protocol can decrease the rate of failure in patients with intolerance to NPPV.

Is sedation safe and beneficial in patients receiving NIV? Yes

“…Taken together, the results of these studies are encouraging [7][8][9][10][11][12][13]. Overall, the use of sedation during NIV appears feasible and safe.…”

“…In addition to the present trial [5], several observational studies [7][8][9][10][11] and three randomized trials comparing midazolam and dexmedetomidine or placebo [12][13][14] have assessed the potential use of sedative and/or analgesic drugs to reduce discomfort and risk of NIV failure. The main characteristics and results of these studies are Table 1.…”

“…Whatever the drugs used, the goal was to achieve a level of sedation to a point where patients were awake, arousable, and comfortable. Pilot studies have suggested that continuous infusion of a single sedative agent may decrease patient discomfort, with no significant deleterious effects on respiratory drive, respiratory pattern or hemodynamics, and with improvement in gas exchanges [7][8][9][10][11].…”

“…Overall, the use of sedation during NIV appears feasible and safe. The ''curative'' use of sedation-analgesia, i.e., applied for treating discomfort leading to NIV intolerance, seems to be able to avoid intubation in 55-70 % of cases [8][9][10][11][12][13], while ensuring the desired level of awake sedation. By contrast, the ''preventive'' administration of sedation-analgesia, i.e., at initiation of NIV to prevent discomfort leading to intolerance, has so far not shown encouraging results [14].…”

NIV should be delivered in do-not-intubate patients in acute respiratory failure, but how?

“…Of course there is a serious ethical concern regarding the use of restraints to maintain NIV in agitated patients with treatment-limitation decisions. Some have successfully used a protocol of light sedation with short-acting drugs such as remifentanil to enhance patient comfort and pursue NIV [3,4]. Nevertheless, such ''intervention that deprives patients of their dignity and ability to recognize that family members are present'' may be considered unethical.…”