Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations

Abstract

A bstract Aim This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.

Impact of non-invasive ventilation and non-medical caregiver presence on nursing workload – an observational study

“…13 A significant amount of NIV patients need sedation on order to improve mask and ventilation tolerance, otherwise, nurses will spend extra time at the patient's bedside in order to fix these problems constantly. 15 Although we measured an increased time for monitoring and assistance of the patients during NIV, the overall NAS in NIV patients is lower compared to IMV because several other factors are compensating. Looking at nursing workload as a whole, not just at this one component, different authors have stated that NIV is equally, 8,11 or sometimes less burdensome than IMV for the nursing staff.…”

Noninvasive positive pressure in acute exacerbations of chronic obstructive pulmonary disease

“…The authors concluded that before considering sedation, the clinician should attempt nonpharmacological strategies (e.g. reassurance, orientation, environmental measures), followed by ventilator/interface optimisation [66 ▪ ]. Dexmedetomidine is a frequent choice - given the pharmacological profile and preservation of airway protection and respiratory drive.…”

Analgo-sedation in Patients on Non-invasive Mechanical Ventilation: Need for Guideline Recommendation

“…There is good quality evidence that the use of analgosedation is associated with improved NIV tolerance and reduced risk of invasive mechanical ventilation. 4 , 5 While the use of sedation or analgesia alone is beneficial, their combined use is associated with increased NIV failure. 6 An ideal analgo-sedative drug should have a rapid onset and offset of action, minimal respiratory depression, wide therapeutic window, good reversibility, minimal impact on cognitive function, and should have predictive pharmacokinetics.…”