VENTILACION MECANICA NO

INVASIVA EN FALLA
RESPIRATORIA HIPOXEMICA
Rodrigo Múnera

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 Hypoxemic respiratory failure-
Definition
• PaO2/FiO2<200 (despite a maximum medical
therapy)
• Respiratory distress (respiratory rate >35/min)
– Use of accessory respiratory muscles
– Paradoxic respiration
• Diagnosis of an illness other than COPD
– Cardiac failure
– Pneumonia
– ARDS
– Trauma

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 Noninvasive mechanical ventilation in
hypoxemic respiratory failure
• Acute cardiogenic pulmonary edema
• Pneumonia
• Immunosupressive patients
• ARDS
• Postextubation period
• Postoperative period of lung resection
• Chest trauma

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 NIMV- definition of a candidate patient

• Cooperative patient which is able to protect

his/her airway

• Clinically stable

• Appropriate for mask application

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 Primary and secondary objectives of studies

• Decreased Mortality
– ICU mortality
– Hospital mortality
– Long-term mortality
• Symptom, Vital Findings, Arterial Blood Gases
– Prevention form intubation
– Dyspnea index
– Systemic blood pressure
– Respiratory rate
– Pulse rate
– PaO2
– PaCO2
– pH

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 Noninvasive Versus Conventional Mechanical Ventilation
An Epidemiologic Survey Am. J. Respir. Crit. Care Med., Volume 163, 2001, 874-880

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 NIMV - hypoxemic respiratory failure
• Intubation can be avoided in one
third of patients treated with
NIMV

• Mortality may be prevented in

one of 10 patients treated with
NIMV

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 Noninvasive mechanical ventilation in acute hypoxemic
respiratory failure -
ICU mortality

17% decrease
Mortality decrease in 2 studies.

Not changed in 6 of these studies

If COPD and acute cardiogenic

pulmonary edema patients
were excluded, mortality
decreased
by 16%

*SP Keenan, T Sinuff, DJ Cook, NS Hill. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic
respiratory failure? A systematic review. Crit Care Med 2004;32:2526-2523.
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 Noninvasive mechanical ventilation in acute hypoxemic respiratory
failure - endotracheal intubation

23% risk decrease

4 studies effective
4 studies ineffective

If COPD and cardiogenic edema

patients are excluded,
the risk is decreasing by 24%

SP Keenan, T Sinuff, DJ Cook, NS Hill. Does noninvasive positive pressure ventilation improve outcome
in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2004;32:2526-2523.
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NIMV in acute hypoxemic respiratory failure

• NIMV efficiency is increasing in hypoxemic

patients who have an additional
hypercapnia.

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NIMV and pneumonia

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 Pneumonia
• Intubation need decreases

• ICU stay shortens.

• Effect on mortality???

• ICU mortality decreases in hypercapnic

patients

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 NIMV- pneumonia

Confalonieri M, Potena A, Carbone G et al. Acute respiratory failure in patient with severe community-acquired pneumonia.
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A prospective randomized evaluation of non-invasive ventilation. Am J Respir Crit Care Med 1999;160:1585-1591
 NIMV- pneumonia

Confalonieri M, Potena A, Carbone G et al. Acute respiratory failure in patient with severe community-acquired pneumonia.
A prospective randomized evaluation of non-invasive ventilation. Am J Respir Crit Care Med 1999;160:1585-1591
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Acute respiratory failure in immunosupressive patients
requiring mechanical ventilation

Diagnosis Mortality
Hematological %70-80
malignancy

Bone marrow %80-95

transplantation

Patients with solid %70-90

tumors
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 NIMV-Immunosupressive patients
• immünosupression+ fever + lung infiltration
• 26 NIMV, 26 standard therapy
– Intubation need decreases (12 vs 20)(p=0.03)
– Serious complications decreases (13 vs 21)(p=0.02)
– ICU mortality decreases (10 vs 18) (p=0.03)
– Hospital mortality decreases (13 vs 21)

Hilbert G et al. Non-invasive ventilation in immunosupressed patients with pulmonary infiltrates,

fever and acute respiratory failure. N Eng J Med 2001;344:481-487.

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 NIMV-Immunosupressive patients

• 40 solid organ transplantation + acut hypoxemic

respiratory failure
– 20 NIMV, 20 standard therapy
– Rapid improvement of oxygenation (%60 vs %25,p=0.03)
– Decrease of intubation (%20 vs %70, p=0.002)
– Decrease of fatal complications (%20 vs %50, p=0.05)
– Decrease of ICU stay (5.5 day vs 9, p=0.05)
– Hospital mortality was not changed (%35 vs %55).

M Antonelli, G Conti, M Buli, MG Costa, A Lappa, M Rocco, A Gasparetto, GU Meduri. Noninvasive ventilation
for treatment of acute respiratory failure in patients undergoing solid organ transplantation. JAMA 2000;283:235-241.

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 NIMV- Immunosupressive patients

• Hemorrhagic and infectious complications

seen during IMV decrease with NIMV.
• Nasocomial pneumonia risk decreases as 4
fold.
• Intubation need decreases.
• ICU mortality decreases.
• Hospital mortality decreases ???

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 NIMV-ARDS
• It may improve hypoxemia (decrease in
shunt fraction)
• It may lower need for intubation.
• Patients should be hemodynamically stable.

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Acute hypoxemic respiratory failure after
lung resection and NIMV

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 Acute hypoxemic respiratory failure after
lung resection and NIMV

• Cause of respiratory failure

– Pulmonary edema
– Atelectasis
– Pneumonia
• P/F=127

Auriant I, Jallot A, Herve P, Cerrina J, F Le Roy Laduire, JL Fornier, B Lescot, F Parquin. Noninvasive ventilation
reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med 2001;164:1231-35.

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 Acute hypoxemic respiratory failure after
lung resection and NIMV

STANDARD TREATMENT NPPV

p
(n = 24 ) (n = 24 )

Invasive mechanical 12 (50%) 5 (20.8%) 0.035

ventilation
n (%)
Hospital mortality, n (%)  9 (37.5%) 3 (12.5%) 0.045
ICU stay (day) 14 ± 11.1 16.65 ± 23.6 0.52

Hospital stay (day) 22.8 ± 10.7 27.1 ± 19.5 0.61

120 day mortality, n (%)  9 (37.5%) 3 (12.5%) 0.045

Auriant I, Jallot A, Herve P, Cerrina J, F Le Roy Laduire, JL Fornier, B Lescot, F Parquin. Noninvasive ventilation
reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med 2001;164:1231-35.
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NIMV

Truwit, J. D. et al. N Engl J Med 2004;350:2512-2515

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 RESULT: NIMV in Acute Hypoxemic
Respiratory Failure
EFFECTIVE INNEFECTIVE

• Acute cardiogenic • Pneumonia

pulmonary edema • Postextubation respiratory
• Immunosupressive patients failure
• Acute hypoxemic • ARDS
respiratory failure after
lung resection

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