Ventilation and Weaning
Invasive mechanical ventilation
Darioli R, Perret C. Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis 1984;129:385-7. Noteworthy for being the first description of permissive hypercapnea and low tidal volumes during mechanical ventilation of asthmatics with high airway pressures.
PMID: 6703497
Marini JJ, Pierson DJ, and Hudson LD. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy. Am Rev Resp Dis 1979;119:971-8. This study found FOB, for the sole purpose of atelectasis, followed by RT was no better than RT alone at 24-48 hours.
PMID: 453712
Miscellaneous - care of the intubated patient
Heiblum G, Chalumeau-Lemoine L, Joos V, et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre cluster-randomised, two-period crossover study. Lancet 2009;374:1687-93. This study examined the utility of routine daily chest radiographs in ventilated patients. 849 mechanically ventilated patients were randomized to a strategy of routine morning CXR or on-demand CXR as clinically indicated. The on-demand strategy significantly reduced the mean number of radiographs per day of ventilation from 1.09 to 0.75 (32% absolute reduction) with no change in length of ventilation, ICU stay, or mortality.
PMID: 19896184
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Ventilator Weaning
Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:1864-9. RCT found protocol of daily weaning parameters followed by trials of spontaneous breathing in appropriate patients and subsequent notification of physicians of successful trials reduced the duration of mechanical ventilation compared to usual care (daily weaning parameters only).
PMID: 8948561
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Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995; 332:345-50. Prospective, randomized study found once daily or multiple daily trials of spontaneous breathing (T-piece or CPAP <5 cm) resulted in more rapid successful extubation than gradual weaning of pressure support or IMV.
PMID: 7823995
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Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994; 150:896-903. Prospective, randomized study found weaning with pressure support mode superior to SIMV mode and T-piece trials.
PMID: 7921460
Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324:1445-50. Study in a VA population found the rapid shallow breathing index (RSBI = RR/Vtidal) was the single best predictor of weaning success (sensitivity 0.97, specificity 0.64).
PMID: 2023603
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Girard T, Kress J, Fuchs B, et al. Efficacy and safety of paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awake and Breathing Controlled trial): a randomised controlled trial. Lancet 2008;371:126-34. This RCT found the combination of daily sedation holiday and daily weaning trials resulted in reduced ventilator days and reduced mortality compared to daily weaning trials alone (HR 0.68, p = .01, NNT to save one life 7).
PMID: 18191684
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Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874-82. The first RCT to assess early mobilization of intubated adult patients during daily interruption of sedation. Ambitious intervention protocol allowed for progression from range of motion exercises to assisted transfers, ADLs, and ambulation as tolerated. Treatment group had statistically significant improvement in multiple outcomes including return to independent functional status (35% vs 59%), fewer days of delirium, shorter duration of mechanical ventilation, and lower incidence of ICU acquired paresis.
PMID: 19446324
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Francois B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postexutbation laryngeal oedema: a randomized double-blind trial. Lancet 2008;369:1083-89. The largest multicenter RCT of steroids for prevention of laryngeal edema. 698 adults intubated >36 hrs received methylprednisolone (20 mg IV) or placebo every 4 hours for 12 hours preceding extubation. Laryngeal edema was significantly reduced (22% vs 3%), as were overall reintubation rate (8% vs 4%) and reintubation due to laryngeal edema (54% vs 8%). Subsequent meta-analyses emphasize the benefit of multiple dose rather than single dose steroid administration.
PMID: 17398307
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***See also ARDS, Neurology Critical Care, Sedation and Analgesia, and Terragni PP et al. in “Prevention and Treatment” of Ventilator-associated Pneumonia
Noninvasive mechanical ventilation
COPD
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of COPD. N Engl J Med 1995; 333:817-22. Landmark prospective, randomized study found use of NIPPV in selected patients with COPD exacerbations resulted in fewer intubations, complications, days in hospital, and lower in-hospital mortality compared to standard treatment.
PMID: 7651472
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Nava S, Ambrosino N, Clini E, et al. Non-invasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. Ann Intern Med 1998;128:721-8. Oft-cited RCT included 50 patients intubated for a COPD exacerbation who failed a T-piece trial. Patients randomized to immediate extubation to NIPPV had decreased duration of mechanical ventilation and improved survival compared to the control group undergoing PS wean with twice daily spontaneous breathing trials.
PMID: 9556465
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Hypoxemic respiratory failure (all types)
Declaux C, L'Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with CPAP delivered by facemask. JAMA 2000;284:2352-60. Prospective, randomized, multicenter study compared oxygen to oxygen plus CPAP in this population (123 patients; 17% cardiac etiology, 83% ALI). Study found no difference in the need for intubation, length of hospital stay, or hospital mortality, and the CPAP group had an increased incidence of adverse events.
PMID: 11066186
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Antonelli M, Conti G, Rocco M, et al. A comparison on NIPPV and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998; 339:429-35. Randomized study compared NIPPV to immediate intubation and conventional ventilation in 64 patients with acute, non-hypercapnic, hypoxemic respiratory failure (19% cardiogenic and 25% ARDS). Use of NIPPV resulted in gas exchange and survival comparable to conventional ventilation but was associated with fewer serious complications and shorter ICU stays.
PMID: 9700176
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Ferrer M, Esquinas A, Leon M, et al. Non-invasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003;168:1140-4. Study of 105 non-hypercapnic patients found NIPPV decreased need for intubation and improved 90-day survival compared to oxygen therapy alone. Unlike some prior studies, subgroup analysis found the 34 patients with pneumonia had the greatest benefit while mask ventilation did not appear to reduce the need for intubation in patients with ARDS and cardiogenic edema.
PMID: 14500259
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Cardiogenic hypoxemic respiratory failure
Bersten AD, Holt AW, Vedig AE, et al. Treatment of severe cardiogenic pulmonary edema with CPAP delivered by facemask. N Engl J Med 1991;325:1825-30. Randomized study of 39 patients with hypercapnic cardiogenic respiratory failure found use of CPAP plus oxygen resulted in better gas exchange in the first 24 hours and less need for intubation than use of oxygen alone.
PMID: 1961221
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Masip J, Betbese AJ, Paez J, et al. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary edema: a randomized trial. Lancet 2000; 356:2126-32. Study of 37 patients (of whom 43% had hypercapnia) found pressure support by mask reduced the need for intubation (5% vs. 33%). There was no difference in duration of hospital stay or mortality.
PMID: 11191538
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Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008; 359:142-51. The C3PO study, performed in 26 emergency departments, randomized 1,156 patients to standard oxygen therapy, CPAP, or NIPPV. Neither form of noninvasive support reduced 7 or 30-day mortality, and patients receiving CPAP and NIPPV did not differ in need for intubation. The lack of benefit persisted after adjusting for severity of illness. These results differ from prior positive studies, possibly due to differences in study populations and design. Intubation rates and 30-day mortality were lower in the current study, and patients deteriorating with standard oxygen therapy were allowed rescue use of noninvasive support.
PMID: 18614781
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Following extubation
Ferrer M, Sellarés J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet 2009 ;374 :1082-8. In a randomized trial of over 100 patients with chronic lung disease who passed a spontaneous breathing trial but had hypercapnea, immediate post-extubation NIPPV led to a significant reduction in subsequent respiratory failure (15% vs 48% in the control group). Rescue NIPPV averted the need for re-intubation in 17 of 27 control patients with post-extubation respiratory failure. In contrast to the Esteban study below, NIPPV in post-extubation hypercapnic respiratory failure appears beneficial. Whether there is an advantage to immediate over prn NIPPV use in this population is unclear.
PMID: 19682735
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Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452-60. This trial of 221 patients with respiratory failure within 48 hours of being extubated after receiving at least 48 hours of mechanical ventilation randomized patients to noninvasive ventilation by face mask or standard medical therapy. Noninvasive ventilation did not reduce the need for re-intubation and the standard-therapy group had lower ICU mortality (14% vs. 25% in noninvasive group). These results suggest noninvasive positive-pressure ventilation should not be used in unselected patients failing extubation.
PMID: 15190137
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Primary neuromuscular disease
Perrin C, Unterborn JN, Ambrosio CD et al. Pulmonary complications of chronic neuromuscular diseases and their management. Muscle Nerve 2004;29:5-27 Concise review including use of non-invasive ventilation and general management of this subset of patients including sleep disordered breathing.
PMID: 14694494
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Bourke SC, Tomlinson M, Williams TL, et al. Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomised controlled trial. Lancet Neurol 2006; 5:140-7. This study of 41 patients found NIV improved survival by a median of 205 days (p < .01) in patients with normal or moderately impaired bulbar function. All patients had at least some degree of improved quality of life with NIV, but those with poor bulbar function did not have improved survival.
PMID: 16426990
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