Non-Invasive Ventilation for Weaning

OVERVIEW

• Non-invasive ventilation can be used as adjunct for weaning patients from mechanical ventilation

USE

NIV can potentially be used in 3 ways:

• facilitation technique — to permit early extubation in patients who fail to meet standard extubation criteria
• rescue or curative technique — to avoid re-intubation in patients who fail extubation
• preventive or prophylactic technique — to preventing extubation failure in selected or non-selected patients

PATIENT SELECTION

Potential patients for NIV as part of ventilator discontinuation include:

• Facilitation — patients who have failed spontaneous breathing trials
• Rescue — patients who have started to develop respiratory failure post-extubation
• Prevention — patients who are at high risk of extubation failure (e.g. COPD and chronic hypercapnic respiratory failure — perhaps also OSA and pre-existing neuromuscular weakness)

RECOMMENDATIONS

• Routine use of NIV as part of ventilator discontinuation process in unselected patients not advised
• Facilitation — can use NIV for facilitation in COPD/ chronic hypercapnia patients
• Rescue — do NOT use NIV as rescue therapy, except perhaps in COPD/ chronic hypercapnia (these patients should probably already be on NIV!)
• Prevention — can use NIV for patients COPD/ chronic hypercapnia and those at high risk of extubation failure

EVIDENCE

Summary

• NIV should not be used for rescue therapy for post-extubation respiratory failure as it increases mortality, probably due to delaying necessary re-intubation (rescue approach) — Estaban et al, 2004 RCT (whereas smaller RCT by Keenan et al, 2002 found no difference)
• Mortality benefit if COPD/ hypercapnia patients extubated onto NIV following a failed SBT (facilitative approach) — Nava et al, 1995 RCT.
• Benefit for preventative use of NIV in patients at high risk of extubation failure (i.e. they were electively extubated on to NIV as part of a preventative approach) — Nava et al, 2005.
• Burns et al, 2012 systematic review found that NIV for weaning improved mortality and rates of VAP, based on 12 small studies with mostly COPD patients enrolled.
• Glossop et al, 2012 meta-analysis suggests that NIV used for weaning decreases ICU LOS and pneumonia rates.

Glossop et al, 2012

• meta-analysis of 16 RCTs
• assessed role of NIV in 3 areas:
  — weaning
  — reduction in reintubation rates post-extubation on ICU
  — reduction in RF after major surgery
• NIV used in weaning
  -> decreased ICU LOS (5.12 days)
  -> decreased incidence of pneumonia (OR 0.12, 95% CI 0.05-0.31)
  -> no evidence to suggest improved ICU survival
• Conclusion: NIV use may reduce ICU and hospital length of stay, pneumonia, reintubation rates and hospital survival.

Esteban et al, 2004

• MCRCT, 37 centers, 8 countries
• 221 patients who were electively extubated after at least 48 hours of mechanical ventilation and who had respiratory failure within the subsequent 48 hours (i.e. rescue therapy)
• NIV by face mask versus standard therapy
• trial was stopped early, after an interim analysis.
• no difference in rate of reintubation (48% vs 48%)
• higher mortality in NIV group (25% vs 14%; RR 1.78; 95% CI 1.03-3.20; P=0.048)
• longer median time from respiratory failure to reintubation in NIV group (12h vs. 2.5h, P=0.02)
• Conclusion: NIV should not be used for rescue therapy for post-extubation respiratory failure as it increases mortality, probably due to delaying necessary re-intubation.
• this followed smaller RCT by Keenan et al, 2002 that found no difference

Nava, 1998

• MCRCT of 3 ICUs
• only 50 patients
• Included intubated patients with COPD and acute hypercapnic respiratory failure that failed T-piece weaning trial 48 hours after intubation (mean PaCO2 94.2!)
• extubation and NIV vs PSV while intubated
• NIV was beneficial:
  — more successfuly weaned at 60 days (88 vs 68%)
  — shorter duration of MV (10.2 vs 16.6 days)
  — less mortality at 60 days (92% vs 72%, P = 0.009)
  — less pneumonia (0 vs 7 patients)
• Conclusion: NIV is useful for facilitative extubation of COPD/ hypercapnia patients.

References and Links

Review articles

• Epstein SK. Noninvasive ventilation to shorten the duration of mechanical ventilation. Respir Care. 2009 Feb;54(2):198-208; 208-11. PMID: 19173752. [Free Fulltext]
• Hess DR. The role of noninvasive ventilation in the ventilator discontinuation process. Respir Care. 2012 Oct;57(10):1619-25.. PMID: 23013899. [Free Fulltext]

Trials and Systematic Reviews

• Burns KE, Adhikari NK, Keenan SP, Meade MO. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD004127 PMID: 20687075.[Free Fulltext]
• Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, Epstein SK, Hill NS, Nava S, Soares MA, D’Empaire G, Alía I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 10;350(24):2452-60. PMID: 15190137. [Free Fulltext]
• Glossop AJ, Shephard N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth. 2012 Sep;109(3):305-14. doi: 10.1093/bja/aes270. Review. Erratum in: Br J Anaesth. 2013 Jan;110(1):164. Shepherd, N [corrected to Shephard, N]. PubMed PMID: 22879654.
• Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002 Jun 26;287(24):3238-44. PMID: 12076220. [Free fulltext]
• Nava S, Ambrosino N, Clini E, Prato M, Orlando G, Vitacca M, Brigada P, Fracchia C, Rubini F. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998 May 1;128(9):721-8. PMID: 9556465.
• Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005 Nov;33(11):2465-70. PMID: 16276167.