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9 Ing

9 Ing

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9 Ing
9 Ing

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Introduction
Non-invasive ventilation (NIV) is a form of sup-port for spontaneous patient ventilation or respi-ratory support that does not require invasive tech-niques of orotracheal intubation (OTI), or anyother device that creates an artificial way (laryn-geal mask, combitube etc.) to ventilate the pa-tient, but is done through an external device or interface (nasal or facial mask, helmet, etc.)
1
. Inthe past the only option for the treatment of acute respiratory failure (ARF) resistant to conven-tional treatment was OTI, which subjects the pa-tient to invasive mechanical ventilation, but thesetechniques are related with many serious compli-cations that may be life-threatening
2
.The fact that professionals attending pre-hospi-tal health emergencies can use this technique inselected patients with ARF is crucial for their sub-sequent evolution. The training of emergency de-partment (ED) doctors and nursing staff in themanagement of NIV patients, with early applica-tion of an effective technique, will undoubtedlyimprove their prognosis.For this review, the primary sources of refer-ence material were the Cochrane Central Register of Controlled Trials and Medline until March2008, using keywords such as non-invasive venti-lation, cardiogenic pulmonary edema, respiratoryinsufficiency, respiratory failure and Chronic Ob-structive Pulmonary Disease.
Emergencias
2009; 21: 189-202
189
REVIEW ARTICLE
Noninvasive ventilation (NIV) offers the emergency physician a way to provide initialsupport for the patient with acute respiratory failure. Application of NIV in emergencycare settings can have a decisive effect on clinical course. Clear advantages thatconclusively support the use of NIV over invasive mechanical ventilation include thepreservation of the cough reflex and the patient’s ability to talk and eat; furthermore,NIV avoids invasion of the airway, with all the associated complications that implies.Recent years have seen the publication of many studies whose results encourage theearly application of NIV in appropriately selected patients. Following the appearance of the consensus statements of the American Thoracic Society in 2001 and the BritishThoracic Society in 2002, in which various modes of NIV were included in thetherapeutic arsenal for managing either hypoxemic or hypercapnic acute respiratory failure, NIV use has spread in hospital emergency and ambulance services. Likewise, it isbeing used increasingly for home treatment of patients with chronic respiratory failure.In the immediate future, the challenge will be to train emergency department staff, toequip them with essential pathophysiologic concepts and the skills for managing acuterespiratory failure, while preserving the chain of care by creating consensus on protocolsto govern interdepartmental responsibilities. [Emergencias 2009;21:189-202]
Key words:
Mechanical ventilation. Acute respiratory failure. Emergency health services.
C
ORRESPONDENCE
:
Fernando Ayuso BaptistaESPES 061Córdoba, SpainE-mail: fayuso@co.espes.es
R
ECEIVED
:
21-4-2008
A
CCEPTED
:
10-7-2008
C
ONFLICTOFINTEREST
:
Ninguno
A
CKNOWLEDGEMENTS
:
The authors wish to thank the following EM work groups:“Grupo de Ventilación NoInvasiva en Urgencias yEmergencias” (José A. Minaya,Rafael Artacho, Valentín Cabriada, Antonio Esquinas, Fernando Ayuso), and the “Grupo deUrgencias de SEMERGEN”(especially Emilio I. García Criadoand Ignacio Cantero).
Management of acute respiratory failure withnoninvasive ventilation in the emergency department
F
ERNANDO
AYUSO BAPTISTA
1
,
G
ABRIEL
JIMÉNEZ MORAL
2
, F
RANCISCO
J
AVIER
FONSECA DEL POZO
3
1
EPES 061 Córdoba. Secretaría Científica y de Calidad de SEMES-Andalucía. Spain.
2
EPES 061 Córdoba.Spain.
3
Medicina Familiar y Comunitaria. Servicio de Cuidados Críticos y Urgencias. Hospital Valle de losPedroches. Pozoblanco, Córdoba. Spain. Secretaría de Urgencias de SEMERGEN. Spain.
Formaciónacreditada
 
History of NIV
Historically, non-invasive procedures began tobe used at the beginning of last century, such asthe iron tank or the negative pressure chamber perfected by Phillip Drinker and Louis Shaw, as from 1928 after the poliomyelitis epidemics, inwhat was called an iron lung (Figure 1). Dräger in1907 was the first to patent and use a time-cyclerespirator - the Pulmotor. Brunnel in 1912 applieda device that delivered a mixture of air and oxy-gen (O
2
) under pressure to the airway of patientswith ARF after thoracic surgery. In 1940 Barachdefined and applied the principles of NIV in pa-tients with cardiogenic pulmonary edema (CPE).In 1947 the principle of intermittent ventilationappeared with positive pressure in non-intubatedpatients, but it was not until 1971 that Gregoryapplied NIV and specifically continuous positivepressure to the airway, which he called Continu-ous Positive Airway Pressure (CPAP), used in childrespiratory distress
3
. In recent decades progress inNIV techniques has been significant, especially ap-plied in the field of exacerbated respiratory dis-ease
3
.
NIV objectives in the ED
The essential point to optimize ventilation withthis technique is the adequate selection of pa-tients with ARF, which excludes those cases notmeeting the inclusion criteria for the use of NIV.Used appropriately, NIV offers
1,4-7
:1. Decreased early respiratory work for the pa-tient, as well as optimizing the exchange of gases,which reduces the sensation of breathlessness andrespiratory fatigue. In the pre-hospital care set-ting, time with the patient is limited and thereforethe primary objective is to alleviate signs of hy-poxemia and respiratory fatigue and avoid OTI, if possible, in these initial stages, ensuring that thepatient tolerates the procedure.2. Decreased number of patients arriving at EDwith OTI and invasive mechanical ventilation or,once there, requiring it, thereby reducing thenumber of patients requiring admission to the in-tensive care unit (ICU), with complications, in-creased hospital stay and the expenses involved.
Advantages of NIV
NIV has numerous advantages over the use of conventional mechanical ventilation, in patientsmeeting the inclusion criteria, primarily because itallows spontaneous coughing, removal of secre-tions, reducing the need for sedation, and makesself feeding and social interaction possible
1,6-8
.It also prevents muscle atrophy typical of pa-tients undergoing prolonged mechanical ventila-tion, since deep sedation and muscle relaxants arenot administered. Furthermore, it diminishes thetypical complications of mechanical ventilation inpatients with OTI, is better tolerated and easier toprogressively remove
9
.
Selection of patient candidates for NIVin emergencies (Table 1)
Patients clearly benefiting from the use of NIV,especially when applied early, are those with po-tentially reversible conditions or those requiringrespiratory support on being weaned off pro-longed mechanical ventilation, as well as patientswhose baseline condition discourages aggressivemeasures like invasive mechanical ventilation, suchas those with very advanced chronic diseases
1,5-7,9-11
.Regarding the indications for NIV (Table 2)
1,5-7,11-14
at present, there is abundant scientific evi-dence that patients with ARF who meet the crite-ria for NIV evolve favourably faster with thisrespiratory therapy than patients administered tra-ditional oxygen therapy
10,14-17
.The results are beyond doubt in exacerbatedchronic obstructive pulmonary disease (COPD)and CPE, but there is some variability in the find-ings of studies on pneumonia, adult respiratorydistress syndrome (ARDS) and post-extubationrespiratory failure
18
.
F. Ayuso Baptista et al.
190
Emergencias
2009; 21: 189-202
Figure 1.
Hospital ward for poliomyelitis patients in the firstdecade of the twentieth century, replete with iron lung devices.By courtesy of the Archives of the University of Pennsylvania(USA).
 
 As a criterion for the initiation of NIV in emer-gencies, we can include all patients who presentwith ARF and failure to respond to traditional oxy-gen therapy associated with specific pharmaco-logical treatment, situations of uncontrolled dysp-nea as well as refractory hypoxemia withinsufficient PaO
2
/FiO
2
, progressive hypercapniawith acid pH and increased respiratory work
11,13
.The success of the technique depends on theappropriate selection of patients who meet thewell established criteria for indication of NIV andpresent no reason for exclusion.The training and experience of the physicianresponsible, as well as of the support team at-tending patient, are essential for the correct per- formance of NIV. The treatment should be initiat-ed as soon as possible, applying the mostappropriate interface and controlling the vitalconstants: familiarity with the equipment is alsomost important for correct implementation of thetechnique
10,11,13
.Patients with hypercapnic ARF, which is themost severe form of COPD exacerbation, arethose who show most favourable response to NIV therapies
18,19
. The results of the NIV associatedwith non-hypercapnic ARF appear to be less clear regarding decreased patient mortality, but aregood in terms of morbidity and evolution of thepicture
20,21
.Finally, a key element in the successful use of this technique is knowing the situations where itsuse is contraindicated
5-7,10-13,20,21
(Table 3), initially or during evolution after starting treatment.
Conditions for withdrawal of NIVin emergencies (Table 4)
The criteria for withdrawal of NIV are: clinicaldeterioration of the patient, the appearance of some other reason for counter-indication, and clin-ical improvement after controlling the causativeagent of ARF
1,6,7,11-14,22,23
. The patient should presenta respiratory frequency (Rf) of less than 24 breathsper minute, a heart rate (HR) of less than 100bpm; O
2
saturation above 92% with nasal specta-cles at 2 l/m; improvement of gasometric parame-ters, pH greater than 7.35, PaO
2
/FiO
2
above 200and progressively reduced need of pressure sup-port or inspiratory positive airway pressure (IPAP),exhaled tidal volume greater than 8 ml/kg in hy-poxemic patients or greater than 6 ml/kg in pa-tients with obstructive airways.It is recommended that, once NIV is deemedappropriate and is tolerated by the patient, itshould be maintained for at least 24 hours contin-uously, assuming the patient tolerates it and thereare no contra-indications, until gasometrical andclinical improvement is evident, while treatment isadministered to deal with the causal agent trig-gering the ARF (pneumonia, CPE, COPD exacer-bation, etc.). Withdrawal of NIV should be per- formed in a progressive manner, graduallyincreasing the periods of breathing with high-flowoxygen therapy and reducing those correspon-ding to the NIV therapy maintained, if necessary,during the night periods. When clinical and gaso-metric signs show improvement, one can changeto high-flow oxygen therapy with a Venturi mask,and tolerance to this approach monitored. Pro-gressive "weaning" off NIV depends on the pa-tient’s evolution and, when initiated, the patientshould be strictly monitored.Most authors agree that the clinical and gaso-metric response to the first hour of treatment
M
 ANAGEMENTOFACUTERESPIRATORYFAILUREWITHNONINVASIVEVENTILATIONINTHEEMERGENCYDEPARTMENT
Emergencias
2009; 21: 189-202
191
Table 1.
Patients who are candidates for NIV
11
1. Absence of contraindications for NIV application (see below).2. Presence of spontaneous breathing.3. Patient collaboration.4. Patient with sufficient level of consciousness to expectorate andcough.5. Patient with established ARF initially unresponsive to conventionaltreatment: tachypnoea with respiratory rate higher than 24breaths/minute, oxygen saturation below 90% after application of FiO
2
greater than 0.5, use of accessory muscles andthoracoabdominal asynchrony.6. If gasometric data are available, we should include patients with ARFwho, in addition to the above clinical signs, also presentPaCO
2
> 45 mmHg pH < 7.35 and PaO
2
/FiO
2
< 200.NIV: noninvasive mechanical ventilation, ARF: acute respiratory failure.
 
Table 2.
Indications for NIV
1,5-7,10-13
– Exacerbation of COPD.– Acute pulmonary edema.– Moderate asthma attack.– Weaning off conventional mechanical ventilation.– Pneumonia.– Acute bronchiolitis.– Postoperative phrenic paralysis.– Acute Interstitial lung disease.– Alveolar Hypoventilation secondary to CNS involvement (syndromeGuillain Barre syndrome, Arnold Chiari syndrome, Ondine syndrome,hydrocephalus, CNS tumors, myelomeningocele, syringomyelia,spinal muscular atrophy, poliomyelitis, amyotrophic lateral sclerosis,myasthenia gravis, muscular dystrophies, myopathies, acute spinalcord injury etc.).– Kyphoscoliosis.– Malformation of the thoracic cavity.– Obstructive sleep apnea syndrome (OSAS).– PIC syndrome.– Pulmonary fibrosis.– Post-surgery chest.– Palliative therapy in patients with indication for OTI.NIV: non-invasive mechanical ventilation, COPD: Chronic ObstructivePulmonary Disease; CNS: central nervous system. OTI: orotracheal in-tubation.

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