Ventilação não invasiva com pressão positiva intermitente - experiência de 7 anos

Introduction: Nasal intermittent positive pressure ventilation (NIPPV) is a non invasive ventilation method that combines the benefits of nasal continuous positive airway pressure (NCPAP) and the cycles of positive pressure. Objectives: Description of the NIPPV experience in a neonatal intensive care unit. Methods: A descriptive study of newborns ventilated with NIPPV, from January 2002 to December 2008. Were considered two groups: the first group had mechanical ventilation before NIPPV, and in the second group the initial method was non-invasive ventilation. These 2 groups were subdivided: Group 1: sub-group A, NIPPV immediately after weaning and sub- group B, NIPPV after mechanical ventilation followed by NCPAP. The group 2 was sub-divided in sub-group C, NIPPV after NCPAP, and sub-group D, NIPPV as the initial mode of ventilation. Results: In group 1 we analysed 79 cycles of ventilation with 89% of success and in group 2 55 cycles, with 69% of success. Newborns in group 1 had a median weight of 925g and gestational age of 27 weeks and the group 2 had 1350g and 30 weeks, respectively. Conclusions: NIPPV was used mainly after conventional ventilation in lighter and immature babies, without relevant complications

Successful Extracorporeal Life Support for Life-threatening Hypercapnia with Bronchiolitis Obliterans after Allogeneic Hematopoietic Stem Cell Transplantation

Bronchiolitis obliterans (BO) is a disease with a poor prognosis, and a key factor that limits long-term survival after allogeneic hematopoietic stem cell transplantation (HSCT). We here report a case of a 31-year woman with acute lymphatic leukemia, which was treated by chemotherapy and HSCT, and consequently developed BO 2 years after HSCT. A non-tuberculous mycobacterial infection occurred and showed gradual exacerbation. She started taking anti-mycobacterial drugs, but lost appetite, felt tired and finally lost consciousness one month after beginning medication. Arterial blood gas revealed marked hypercapnia. Using extracorporeal life support (ECLS), the carbon dioxide concentration was reduced and her consciousness recovered. To our knowledge, this is the first case in which ECLS was successfully used for hypercapnia in a patient with BO

Domiciliary nasal respiratory support : first experiences in Malta

Nasal respiratory support is a non-invasive alternative to conventional assisted ventilation with endotracheal intubation, or the more cumbersome negative pressure ventilators. The two main types of this relatively new therapy are nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP) respiratory support, which are mostly used in chronic hypoventilatory states and obstructive sleep apnoea (OSA) respectively. We have introduced these two types of respiratory support to five patients suffering from neuromuscular disorders and twenty-four patients with OSA with marked improvement in the quality of life of all patients concerned. Our experiences with these patients should hopefully lead to further development in the diagnostic and therapeutic facilities in this field in Malta.peer-reviewe

Is NIPPV Superior to CPAP in Maintaining Targeted Oxygen Saturation Ranges in Preterm Infants on Moderate Non-Invasive Respiratory Support?

Background: Non-invasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP) are non-invasive respiratory supports commonly used in preterm infants. There is conflicting data on the superiority between these two modes of non-invasive respiratory support. The objective of this study was to determine if oxygen saturation is more within the target range on NIPPV compared to CPAP using the data from histograms. Methods: Retrospective analysis of premature neonates (\u3c 1500 grams, gestational age \u3c 30 weeks) admitted to the NICU for which oxygen saturation histogram data was available one day before and after the transition between NIPPV and CPAP. FiO2 at the time of data collection was greater than 21 percent. This histogram data, the percentage of time spent in certain SpO2 ranges, was compared before and after the de-escalation from NIPPV to CPAP or escalation from CPAP to NIPPV. FiO2 was additionally compared between the two modes of respiratory support. Results: A total of 26 infants were included. The median gestational age was 25.5 weeks and the median weight of the infants was 792 grams. Among the 26 infants, there were 34 episodes of transition between NIPPV and CPAP, 19 switches from NIPPV to CPAP, and 15 from CPAP to NIPPV. The percentage of time that oxygen saturation was within the target range (89-94 %) was not statistically significant between the two modes of respiratory support (CPAP 39.9% vs. NIPPV 43.9%, p=0.09) (Table 1). The percentage of time that oxygen saturation was between 86-88% was higher on NIPPV and the percentage of time that oxygen saturation was \u3e94% was higher on CPAP. There was a trend towards lower FiO2 on NIPPV compared to CPAP. When switched from NIPPV to CPAP, there was a higher percentage of time spent above the target range ( \u3e94%) while on CPAP (56% vs 49%, p=0.001), and below the target range (86-88%) while on NIPPV (5.0% vs 1.4%, p=0.02) (Table 3). When switched from CPAP to NIPPV, there was no difference in oxygen saturation ranges (Table 2). Conclusion: Target oxygen saturation ranges on histogram data were similar in premature infants when supported on CPAP and NIPPV. However, oxygen saturation below the target range was more frequent on NIPPV compared to CPAP. NIPPV is not superior to CPAP in maintaining oxygen saturation within the target range in premature infants on moderate non-invasive respiratory support. The potential risk of low oxygen saturation range while supported on NIPPV in preterm infants requires further research.https://jdc.jefferson.edu/pulmcritcareposters/1003/thumbnail.jp

Early Pulmonary Interstitial Emphysema in Preterm Neonates-Respiratory Management and Case Report in Nonventilated Very Low Birth Weight Twins

Early pulmonary interstitial emphysema in extreme preterm neonates is closely linked with respiratory distress syndrome and exposure to mechanical ventilation. In severe cases, maintaining adequate gas exchange aiming to avoid further lung damage and other neonatal morbidities associated with systemic/pulmonary hypoperfusion, prolonged hypoxia, and respiratory acidosis can be challenging and requires in-depth knowledge into the pathophysiology of the disease. Herein, we report on very low birth weight twins who developed early pulmonary interstitial emphysema during noninvasive respiratory support. We further review the current evidence from the literature, specifically addressing on possible preventive measures and the respiratory management options of this acute pulmonary disease in high-risk neonates

Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study

INTRODUCTION: The role of non-invasive positive pressure ventilation (NIPPV) in the treatment of acute lung injury (ALI) is controversial. We sought to assess the outcome of ALI that was initially treated with NIPPV and to identify specific risk factors for NIPPV failure. METHODS: In this observational cohort study at the two intensive care units of a tertiary center, we identified consecutive patients with ALI who were initially treated with NIPPV. Data on demographics, APACHE III scores, degree of hypoxemia, ALI risk factors and NIPPV respiratory parameters were recorded. Univariate and multivariate regression analyses were performed to identify risk factors for NIPPV failure. RESULTS: Of 79 consecutive patients who met the inclusion criteria, 23 were excluded because of a do not resuscitate order and two did not give research authorization. Of the remaining 54 patients, 38 (70.3%) failed NIPPV, among them all 19 patients with shock. In a stepwise logistic regression restricted to patients without shock, metabolic acidosis (odds ratio 1.27, 95% confidence interval (CI) 1.03 to 0.07 per unit of base deficit) and severe hypoxemia (odds ratio 1.03, 95%CI 1.01 to 1.05 per unit decrease in ratio of arterial partial pressure of O(2 )and inspired O(2 )concentration – PaO(2)/FiO(2)) predicted NIPPV failure. In patients who failed NIPPV, the observed mortality was higher than APACHE predicted mortality (68% versus 39%, p < 0.01). CONCLUSION: NIPPV should be tried very cautiously or not at all in patients with ALI who have shock, metabolic acidosis or profound hypoxemia

The cost-effectiveness of early noninvasive ventilation for ALS patients

BACKGROUND: Optimal timing of noninvasive positive pressure ventilation (NIPPV) initiation in patients with amyotrophic lateral sclerosis (ALS) is unknown, but NIPPV appears to benefit ALS patients who are symptomatic from pulmonary insufficiency. This has prompted research proposals of earlier NIPPV initiation in the ALS disease course in an attempt to further improve ALS patient quality of life and perhaps survival. We therefore used a cost-utility analysis to determine a priori what magnitude of health-related quality of life (HRQL) improvement early NIPPV initiation would need to achieve to be cost-effective in a future clinical trial. METHODS: Using a Markov decision analytic model we calculated the benefit in health-state utility that NIPPV initiated at ALS diagnosis must achieve to be cost-effective. The primary outcome was the percent utility gained through NIPPV in relation to two common willingness-to-pay thresholds: $50,000 and$100,000 per quality-adjusted life year (QALY). RESULTS: Our results indicate that if NIPPV begun at the time of diagnosis improves ALS patient HRQL as little as 13.5%, it would be a cost-effective treatment. Tolerance of NIPPV (assuming a 20% improvement in HRQL) would only need to exceed 18% in our model for treatment to remain cost-effective using a conservative willingness-to-pay threshold of $50,000 per QALY. CONCLUSION: If early use of NIPPV in ALS patients is shown to improve HRQL in future studies, it is likely to be a cost-effective treatment. Clinical trials of NIPPV begun at the time of ALS diagnosis are therefore warranted from a cost-effectiveness standpoint

Nasal intermittent positive pressure ventilation and bronchopulmonary dysplasia among very preterm infants never intubated during the first neonatal admission: a multicenter cohort study

[Abstract] Introduction: While non-invasive positive-pressure ventilation (NIPPV) is increasingly used as a mode of respiratory support for preterm infants, it remains unclear whether this technique translates into improved respiratory outcomes. We assessed the association between NIPPV use and bronchopulmonary dysplasia (BPD)-free survival in never intubated very preterm infants. Methods: This multicenter cohort study analyzed data from the Spanish Neonatal Network SEN1500 corresponding to preterm infants born at <32 weeks gestational age and <1,500 g and not intubated during first admission. The exposure of interest was use of NIPPV at any time and the main study outcome was survival without moderate-to-severe BPD. Analyses were performed both by patients and by units. Primary and secondary outcomes were compared using multilevel logistic-regression models. The standardized observed-to-expected (O/E) ratio was calculated to classify units by NIPPV utilization and outcome rates were compared among groups. Results: Of the 6,735 infants included, 1,776 (26.4%) received NIPPV during admission and 6,441 (95.6%) survived without moderate-to-severe BPD. After adjusting for confounding variables, NIPPV was not associated with survival without moderate-to-severe BPD (OR 0.84; 95%CI 0.62–1.14). A higher incidence of moderate-to-severe BPD-free survival was observed in high- vs. very low-utilization units, but no consistent association was observed between O/E ratio and either primary or secondary outcomes. Conclusion: NIPPV use did not appear to decisively influence the incidence of survival without moderate-to-severe BPD in patients managed exclusively with non-invasive ventilation

Management of Mechanical Ventilation in Decompensated Heart Failure.

Mechanical ventilation (MV) is a life-saving intervention for respiratory failure, including decompensated congestive heart failure. MV can reduce ventricular preload and afterload, decrease extra-vascular lung water, and decrease the work of breathing in heart failure. The advantages of positive pressure ventilation must be balanced with potential harm from MV: volutrauma, hyperoxia-induced injury, and difficulty assessing readiness for liberation. In this review, we will focus on cardiac, pulmonary, and broader effects of MV on patients with decompensated HF, focusing on practical considerations for management and supporting evidence

Mechanisms of active laryngeal closure during non-invasive intermittent positive pressure ventilation in non-sedated lambs

The present study stems from our recent demonstration (Moreau-Bussiere F, Samson N, St-Hilaire M, Reix P, Lafond JR, Nsegbe E, Praud JP. J Appl Physiol 102: 2149-2157, 2007) that a progressive increase in nasal intermittent positive pressure ventilation (nIPPV) leads to active glottal closure in nonsedated, newborn lambs. The aim of the study was to determine whether the mechanisms involved in this glottal narrowing during nIPPV originate from upper airway receptors and/or from bronchopulmonary receptors. Two groups of newborn lambs were chronically instrumented for polysomnographic recording: the first group of five lambs underwent a two-step bilateral thoracic vagotomy using video-assisted thoracoscopic surgery (bilateral vagotomy group), while the second group, composed of six lambs, underwent chronic laryngotracheal separation (isolated upper airway group). A few days later, polysomnographic recordings were performed to assess glottal muscle electromyography during step increases in nIPPV (volume control mode). Results show that active glottal narrowing does not develop when nIPPV is applied on the upper airways only, and that this narrowing is prevented by bilateral vagotomy when nIPPV is applied on intact airways. In conclusion, active glottal narrowing in response to increasing nIPPV originates from bronchopulmonary receptors