Andrés Esteban
Modes of Mechanical Ventilation:
Is There Anyone Better?
Hospital Universitario de Getafe
1952:
Copenhagen polio epidemic
First month
31 patients with respiratory
paralysis
27 patients died (87%)
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8
Mortality July 1952  March 1953
Months
QUESTIONAIRE MAILED ………… 3982
QUESTIONAIRE RETURNED ……. 1272 (32%)
IMV IS USED AS
PRIMARY MODE OF VENT…….... 71.6 %
B. Ven...
Ventilatory Modes
CMV / ACV ………….... 55 %
IMV / SIMV ……………. 26 %
SIMV + PSV …………… 8 %
PSV ……………………. 8 %
PCV ……………………. 1 %
...
USA
CAN SPA ARG BRA CHI POR URU TOTAL
A / C 34 62 68 40 75 44 25 47
SIMV 6 7 9 4 5 -- 20 6
P S 18 11 10 10 5 34 2 15
SIMV ...
Canada
U.S.A.
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
México
Perú
Uruguay
Venezuela
England
France
Greece
Ireland
...
0
1000
2000
3000
4000
5000
1 4 7 10 13 16 19 22 25 28
0
10
20
30
40
50
60
70
80
90
100
Patients A/C PCV PS
SIMV SIMV+PS VN...
A. Esteban, A. Anzueto, F. Frutos, et al.
JAMA 2002;287:345-355
International study of 5183 patients
449 patients (8.6%) m...
USA
CANADA
AC
SIMV
SIMV-PSV
PSV
PCV
46 %
6 %
15 %
2 %
20 %
AC
SIMV
SIMV-PSV
PSV
PCV
52%
4 %
10 %
4 %
22 %
AC
SIMV
SIMV-PSV...
Esteban A et al.
Chest 2000; 117:1690-1696
ARDS
N = 79
PCV
vs.
CMV
Mortality
Hospital
Relative risk
0.65
(0.46 - 0.96)
Der...
79 patients with criteria of ARDS
Randomization
PCV (n = 42)
VCV (n =37)
Main outcome
Hospital Mortality
Esteban A, Alía I...
Ventilator Modes
Esteban et al Chest 2000; 117:1690
UNIVARIATE ANALYSIS
O R CI 95 %
AGE ≥ 65 a. 1’57 1’13 – 2’17
SAPS II ≥ 40 1’63 1’15 – 2’32
≥ 2 ORGAN FAILURE 2’31 1’38 – 3...
Odds ratio (CI 95 %) p
SAPS II, per point 1.03 (1.00 – 1.05) 0.03
Cardiovascular failure 4.00 (1.87 – 8.86) < 0.001
Hepati...
39
2 12 12 12 6 9 6
2
60
6 12 6 7 4
3
0
10
20
30
40
50
60
C MV S IMV S IMV-
PS V
PS V PC V PR VC B IPAP NIV Other
Overall ...
CMV, AMV, SIMV, HFV
PS, PRV, PCV, VCV
ACPRV, FLOW BY, CPAP
VENTILATORY MODE SIMV
START TO BE USED ............................. 1970
FIRST PUBLICATION
Intermittent mandatory ventila...
PRESSURE SUPPORT VENTILATION
START TO BE USED ................................. 1980
FIRST PUBLICATIONS
M.J. Banner, R.R. ...
Topics to solve…
 There is some mode of ventilation
superior or better than other?
 What is the optimal tidal volume?
 ...
Topics to solve…
 There is some mode of ventilation
superior or better than other?
 What is the optimal tidal volume?
 ...
New Modes
 Volume Assured Pressure Support
 Pressure Regulated Volume Control/ Volume Support
 Proportional Assist Vent...
N = 4968
22 %
Excluded patients because they were
ventilated with other modes that A/C or SIMV
N = 1681
N = 3287
N = 1969
...
Patients ventilated with SIMV - PS 367
Patients ventilated with A/C 1.228
PRIMARY OUTCOME was in hospital mortality
After ...
Factors Associated with Ventilation Using SIMV-PS:
Univariate and Multivariate Logistic-Regression Analysis
Univariate Ana...
Factors Associated with Ventilation Using SIMV-PS:
Univariate and Multivariate Logistic-Regression Analysis
Univariate Ana...
Cases
N = 234
Controls
N = 234
P
value
Days of mechanical ventilation,
median (interquartile range)
3 (2, 5) 3 (2,6) 0,61
...
 Preservation of spontaneous breathing
 It may have important effects on VILI (not proven)
 Better cardiac output and o...
Putensen,
AJRCCM 2001;164:43
APRV - What is The Evidence
 Six studies (740 patients) and 2 RCT
 Most of the studies are ...
4968 Patients
563 (11.3 %) patients
were ventilated at least
one day with
APRV/BIPAP
1228 (24.7 %)
were ventilated
with AC...
APRV - Discussion
 APRV/BIPAP were in a minority of patients (5.2 %).
 The major outcomes in a heterogeneous population ...
Outcomes
 There were no differences in the proportion of patients
that received sedatives (73% in the APRV/BIPAP vs. 79
%...
Outcomes
Cases
N = 263
Controls
N = 263
P value
Reintubation, n (%) 10/147 (6.5 %) 7/142 (5%) 0.50
Tracheostomy, n (%) 54 ...
• Non Invasive Mechanical Ventilation
A. Esteban, A. Anzueto, I. Alía et al
JAMA 2002;287:345-355
ARF INVASIVE VENTILATION.......... 31 % (p=0.01)
Mortality
COP...
Ram FS et al. (COPD and Mortality)
Cochrane Database Syst Rev. 2004;(3):CD004104.
Bott 1993 0.33 (0.10 – 1.11)
Servillo 19...
Keenan SP et al. (ARF and Mortality)
Crit Care Med 2004; 32:2516-2523
Confalonieri 1999
Antonelli 2000
Hilbert 2001
Aurian...
16,5
4
7
44
10
27
0
10
20
30
40
50
60
COPD ARF CHF
1998
2004
Use of non-invasive ventilation
(ICU Participant in both stud...
All – NIV Repeat ICUs
1998
n=256
2004
n=479
1998
n=61
2004
n=186
p
value
Arterial Blood Cases
Prior to NIV
• pH, mean (SD)...
All – NIV Repeat ICUs
1998
n=256
2004
n=479
1998
n=161
2004
n=186
p
value
Arterial Blood Cases
Prior to NIV
• pH, mean (SD...
N I V utilization
1998
N = 161
2004
N = 186
p value
Chronic obstructive
pulmonary disease
22 / 133(16.5%) 40 / 113 (35 %) ...
Invasive
ventilation
n=162
Successful
NIV
n=78
Failure NIV
n=27
p
Hours NIV
median (IQR)
48 (21, 98) 16 (6, 30) < 0.001
Da...
All – NIV Repeat ICUs
1998
n=256
2004
n=479
1998
n=161
2004
n=186
p
value
Need for intubation
(failure NIV)
32 % 40 % 31 %...
All – NIV Repeat ICUs
1998
n=256
2004
n=479
1998
n=161
2004
n=186
p
value
Need for intubation
(failure NIV)
32 % 40 % 31 %...
Conclusions
 The use of NIV in the ICU has doubled
from 1998 to 2004 for all causes of
acute respiratory failure.
 The s...
Mechanical ventilation is useful
to “buy” time….
Meanwhile:
 To avoid to injury the lung (barotrauma,
volutrauma, atelect...
Ventilatory Modes.
Ventilatory Modes.
Upcoming SlideShare
Loading in …5
×

Ventilatory Modes.

729 views

Published on

Presented by Dr.Andres Esteban at Pulmonary Medicine Update Course 2009 at Cairo, Egypt.
Pulmonary Medicine Update Course is organized by Scribe . www.scribeofegypt.org

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
729
On SlideShare
0
From Embeds
0
Number of Embeds
52
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Ventilatory Modes.

  1. 1. Andrés Esteban Modes of Mechanical Ventilation: Is There Anyone Better? Hospital Universitario de Getafe
  2. 2. 1952: Copenhagen polio epidemic First month 31 patients with respiratory paralysis 27 patients died (87%)
  3. 3. 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 Mortality July 1952  March 1953 Months
  4. 4. QUESTIONAIRE MAILED ………… 3982 QUESTIONAIRE RETURNED ……. 1272 (32%) IMV IS USED AS PRIMARY MODE OF VENT…….... 71.6 % B. Venus et al 1987 Crit Care Med 15:530
  5. 5. Ventilatory Modes CMV / ACV ………….... 55 % IMV / SIMV ……………. 26 % SIMV + PSV …………… 8 % PSV ……………………. 8 % PCV ……………………. 1 % A. Esteban, I. Alía et al. Chest 1994;106:1188
  6. 6. USA CAN SPA ARG BRA CHI POR URU TOTAL A / C 34 62 68 40 75 44 25 47 SIMV 6 7 9 4 5 -- 20 6 P S 18 11 10 10 5 34 2 15 SIMV / PS 34 13 7 31 17 13 52 25 OTHERS 7 6 6 15 2 9 -- 7 A. Esteban, A. Anzueto, I. Alía et al Am J Respir Crit Care Med 2000;161:1450 Modes of ventilation (%)
  7. 7. Canada U.S.A. Argentina Bolivia Brazil Chile Colombia Ecuador México Perú Uruguay Venezuela England France Greece Ireland Italy Portugal Spain Tunizia
  8. 8. 0 1000 2000 3000 4000 5000 1 4 7 10 13 16 19 22 25 28 0 10 20 30 40 50 60 70 80 90 100 Patients A/C PCV PS SIMV SIMV+PS VNI Others Numbersofpatientsmechanicallyventilated Days from the start of mechanical ventilation Percentageofpatientsventilatedwith eachventilatorymode A.Esteban, A. Anzueto, F. Frutos, I. Alía et al. JAMA 2002;287:345-355
  9. 9. A. Esteban, A. Anzueto, F. Frutos, et al. JAMA 2002;287:345-355 International study of 5183 patients 449 patients (8.6%) meet the ARDS criteria Mode of ventilation  Volume controlled: 69%  Pressure controlled: 24%
  10. 10. USA CANADA AC SIMV SIMV-PSV PSV PCV 46 % 6 % 15 % 2 % 20 % AC SIMV SIMV-PSV PSV PCV 52% 4 % 10 % 4 % 22 % AC SIMV SIMV-PSV PSV PCV 39 % 3 % 21 % 6 % 24 % LATIN AMERICA AC SIMV SIMV-PSV PSV PCV 85 % 3 % 6 % 2 % 2 % AC SIMV SIMV-PSV PSV PCV 74 % 5 % 9 % 2 % 7 % AC ----- SIMV-PSV ----- PCV 71 % 14 % 7% EUROPE AC SIMV SIMV-PSV PSV PCV 62 % 3 % 9 % 1 % 15 % AC SIMV SIMV-PSV PSV PCV 57 % 2 % 6 % 2 % 23 % AC ---- SIMV-PSV PSV PCV 57 % 5 % 4 % 23 % DAY 1 DAY 4 DAY 7 MODES OF VENTILATION
  11. 11. Esteban A et al. Chest 2000; 117:1690-1696 ARDS N = 79 PCV vs. CMV Mortality Hospital Relative risk 0.65 (0.46 - 0.96) Derdak S et al. Am J Respir Crit Care Med 2002; 166:801-808 ARDS N = 148 HFOV vs. PCV 30 day Survival Relative risk 1.14 (0.73 - 1.80)
  12. 12. 79 patients with criteria of ARDS Randomization PCV (n = 42) VCV (n =37) Main outcome Hospital Mortality Esteban A, Alía I, Gordo F, et al. Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS Chest 2000; 117:1690-1696
  13. 13. Ventilator Modes Esteban et al Chest 2000; 117:1690
  14. 14. UNIVARIATE ANALYSIS O R CI 95 % AGE ≥ 65 a. 1’57 1’13 – 2’17 SAPS II ≥ 40 1’63 1’15 – 2’32 ≥ 2 ORGAN FAILURE 2’31 1’38 – 3’85 RENAL FAILURE 1’76 0’98 – 3’17 COAGULOPATHY 1’36 0’99 – 3’86 V C V 1’53 1’08 – 2’17 A, Esteban, I. Alía, et al. Chest 2000;117:1690-1696
  15. 15. Odds ratio (CI 95 %) p SAPS II, per point 1.03 (1.00 – 1.05) 0.03 Cardiovascular failure 4.00 (1.87 – 8.86) < 0.001 Hepatic Failure 3.99 (1.35 – 11.81) 0.01 Variables associated to mortality Multivariate analysis
  16. 16. 39 2 12 12 12 6 9 6 2 60 6 12 6 7 4 3 0 10 20 30 40 50 60 C MV S IMV S IMV- PS V PS V PC V PR VC B IPAP NIV Other Overall population 1998 2004
  17. 17. CMV, AMV, SIMV, HFV PS, PRV, PCV, VCV ACPRV, FLOW BY, CPAP
  18. 18. VENTILATORY MODE SIMV START TO BE USED ............................. 1970 FIRST PUBLICATION Intermittent mandatory ventilation A new approach to weaning patients from mechanical ventilation J. B. Downs, EF Klem et al Chest 64:331.................................... 1973
  19. 19. PRESSURE SUPPORT VENTILATION START TO BE USED ................................. 1980 FIRST PUBLICATIONS M.J. Banner, R.R. Kirby Crit Care Med 13;997-998 ................... 1985 O. Prakash, S. Meij Chest 88;403-408 ................................. 1985
  20. 20. Topics to solve…  There is some mode of ventilation superior or better than other?  What is the optimal tidal volume?  What is the “best” PEEP?  How we can optimize patient–ventilator interaction?  When to think that the NIV has failed?  When it is necessary to use adjunctive therapies (eg. prone position) in the ARDS?
  21. 21. Topics to solve…  There is some mode of ventilation superior or better than other?  What is the optimal tidal volume?  What is the “best” PEEP?  How we can optimize patient–ventilator interaction?  When to think that the NIV has failed?  When it is necessary to use adjunctive therapies (eg. prone position) in the ARDS?
  22. 22. New Modes  Volume Assured Pressure Support  Pressure Regulated Volume Control/ Volume Support  Proportional Assist Ventilation  Automatic Tube Compensation  Adaptive Support Ventilation  Airway Pressure Release Ventilation/ Bi-level Pressure Ventilation
  23. 23. N = 4968 22 % Excluded patients because they were ventilated with other modes that A/C or SIMV N = 1681 N = 3287 N = 1969 37 % 21 % 42 % Patients ventilated only with SIMV-PSV N = 350 Patients initially ventilated with SIMV-PSV and switched to A/C N = 54 Patients ventilated only with A/C N = 1228 Patients initially ventilated with A/C and switched to SIMV-PSV N = 54 Crude (non-adjusted) Intensive Care Unit Mortality Excluded patients because they were ventilated with a combination of more than 2 modes including A/C and SIMV N = 1318
  24. 24. Patients ventilated with SIMV - PS 367 Patients ventilated with A/C 1.228 PRIMARY OUTCOME was in hospital mortality After adjustment for propensity score, the overall effect of SIMV - PS was not significant. Odds ratio 1.04;95% CI 0.77-1.42 p= .78 G. Ortiz, F. Frutos-vivar et al. Chest 2010 (in press)
  25. 25. Factors Associated with Ventilation Using SIMV-PS: Univariate and Multivariate Logistic-Regression Analysis Univariate Analysis Multivariate analysis Odds Ratio (95% CI) P value Odds Ratio (95% CI) P value Geographic area • Latin America • Europe • United States and Canada • Other (Saudi Arabia, Tunisia, Turkey) 1 1.76 (1.32 - 2,53) 4.25 (3.07 - 5.88) 8.13 (4.77 - 13.87) <.001 1 1.64 (1.12 - 2.40) 3.41 (2.40 - 4.83) 8.58 (4.77 - 15.44) <.001 Simplified acute physiology score II, per point 0.98 (0-97 - 0-99) <.001 0.99 (0-98 - 0.99) .02 Main reason for mechanical ventilation • COPD • Asthma • Coma • Acute respiratory failire Postopoerative Sepsis Pneumonia Congestive heart failure Trauma 0.59 (0.31 - 1.13) 0.20 (0.03 - 1.38) 0.48 (0.36 - 0.63) 2.46 (2.06 - 2.93) 0.69 (0.48 - 1.01) 0.66 (0.44 - 1.00) 0.62 (0.36 - 1.09) 2.51 (1.98 - 3.19) .09 .06 <.001 .001 .05 .04 .08 <.001 --- 0.12 (0.02 - 0.94) 0.56 ( 80.38 - 0.82) 2.58 (1.85 - 3.60) -- -- -- 3.59 (2.09 - 6.18) -- .04 .003 <.001 -- -- -- <.001
  26. 26. Factors Associated with Ventilation Using SIMV-PS: Univariate and Multivariate Logistic-Regression Analysis Univariate Analysis Multivariate analysis Odds Ratio (95% CI) P value Odds Ratio (95% CI) P value Complications during the mechanical ventilation • ARDS • Sepsis • Ventilator associated pneumonia • Cardiovascular failure • Respiratory failure • Hematologic failure 0.21 (0.07 - 0.63) 0.21 (0.09 - 0.49) 0.40 (0.18 - 0.86) 0.49 (0.38 - 0.65) 0.57 (0.45 - 0.72) 0.46 (0.26 - 0.81) .001 <.001 .009 <.001 <.001 .003 --- 0.28 (0.11 - 0.73) --- 0.66 (0.46 - 0.94) --- --- -- .009 -- .02 -- --
  27. 27. Cases N = 234 Controls N = 234 P value Days of mechanical ventilation, median (interquartile range) 3 (2, 5) 3 (2,6) 0,61 Days of weaning, median (interquartile range) 1 (1, 2) 1 (1,2) 0.28 Reintubation, n (%) 100/140 (7) 101/139 (7) 0.99 Tracheostomy, n (%) 46 (20) 25 (11) 0.007 Lengh of stay in the intensive care unit, median (interquartile range) 6 (3, 14) 6 (3, 12) 0.11 Mortality in the intensive care unit, n (%) 65 (28) 78 (33) 0.19 Lengh of stay in the hospital, median (interquartile range) 18 (11, 38) 17 (8, 31) 0.05 Mortality in the hospital, n (%) 81 (35) 90 (38) 0.50 Outcomes of patients included in the matched-case study
  28. 28.  Preservation of spontaneous breathing  It may have important effects on VILI (not proven)  Better cardiac output and oxygen delivery Improvements in gas exchange  Reduction in overall sedation requirements APRV - Advantages
  29. 29. Putensen, AJRCCM 2001;164:43 APRV - What is The Evidence  Six studies (740 patients) and 2 RCT  Most of the studies are small case series or cross-over studies with surrogates of outcome or physiologic endpoints such as oxygenation.  One RCT enrolled 30 trauma patients with ARDS, APRV with SB vs PC time cycled ventilation with sedation and paralysis for 72 hours. Weaning in both group was performed on APRV.
  30. 30. 4968 Patients 563 (11.3 %) patients were ventilated at least one day with APRV/BIPAP 1228 (24.7 %) were ventilated with AC all the time 234 patients were ventilated all the time with APRV/BIPAP 234 were ventilated with AC Study Patients Controls
  31. 31. APRV - Discussion  APRV/BIPAP were in a minority of patients (5.2 %).  The major outcomes in a heterogeneous population of mechanicaly ventilated patients were similar when they are ventilated with APRV/BIPAP or with AC.  The upper airway pressure was lower than peak airway pressure and the low pressure was higher than PEEP.  There was a lack of improvement in gas exchange (may be to different population).  The proportion of patients the received sedatives were similar between the group.
  32. 32. Outcomes  There were no differences in the proportion of patients that received sedatives (73% in the APRV/BIPAP vs. 79 % in the AC group, p=0.08) or neuromuscular blocking (11 % vs 9%; p=0.47)  We excluded the 29 patients who received a neuromuscular blocking agent irrespective of the number of doses and did not change the results of the outcome
  33. 33. Outcomes Cases N = 263 Controls N = 263 P value Reintubation, n (%) 10/147 (6.5 %) 7/142 (5%) 0.50 Tracheostomy, n (%) 54 (21 %) 29 (11 %) 0.003 Lenght of stay in the hospital, median (interquartile range) 19 (11, 38) 17 (8, 33) 0.06 Mortality in the hospital, n (%) 92 (35 %) 105 (40 %) 0.23
  34. 34. • Non Invasive Mechanical Ventilation
  35. 35. A. Esteban, A. Anzueto, I. Alía et al JAMA 2002;287:345-355 ARF INVASIVE VENTILATION.......... 31 % (p=0.01) Mortality COPD-NIV-SUCCESSFUL................... 9.5 % COPD-NIVINTUBATED...................... 27.3 % COPD INVASIVE VENTILATION....... 23.8 % (p=0.91) ARF-NIV-SUCCESSFUL...................... 16.8 % ARF-NIV-INTUBATED......................... 48.1 %
  36. 36. Ram FS et al. (COPD and Mortality) Cochrane Database Syst Rev. 2004;(3):CD004104. Bott 1993 0.33 (0.10 – 1.11) Servillo 1994 1.00 (0.08 – 11.93) Brochard 1995 0.33 (0.11 – 0.93) Celikel 1998 0.33 (0.01 – 7.56) Avdeev 1998 0.33 (0.10 – 1.11) Plant 2000 0.50 (0.26 – 0.95) Conti 2002 1.36 (0.48 – 3.86) Dikensoy 2002 0.50 (0.05 – 5.01) Khihari 2002 1.50 (0.28 – 8.04) POOLED RESULTS 0.52 (0.35 – 0.76) Relative Risk 1 5 10.1 .2 Favors NIV Favors Conventional
  37. 37. Keenan SP et al. (ARF and Mortality) Crit Care Med 2004; 32:2516-2523 Confalonieri 1999 Antonelli 2000 Hilbert 2001 Auriant 2001 Keenan 2002 POOLED RESULTS -1.0 -0.5 0 0.5 1.0 Absolute Risk Reduction Favors NIV Favors Control
  38. 38. 16,5 4 7 44 10 27 0 10 20 30 40 50 60 COPD ARF CHF 1998 2004 Use of non-invasive ventilation (ICU Participant in both studies)
  39. 39. All – NIV Repeat ICUs 1998 n=256 2004 n=479 1998 n=61 2004 n=186 p value Arterial Blood Cases Prior to NIV • pH, mean (SD) 7.31 (0.09) 7.32 (0.1) 7.31 (0.09) 7.32 (0.1) 0.73 • PaCO2, mean (SD) 56 (21) 52 (21) 58 (23) 53 (22) 0.23  PaO2/FiO2, mean (SD) 162 (73) 171 (94) 172 (33) 175 (90) 0.8 Day 1 after NIV • pH, mean (SD) 7.37 (0.08) 7.34 (0.09) 7.35 (0.09) 7.34 (0.1) 0.49 • PaCO2, mean (SD) 50 (18) 50 (19) 53 (21) 51 (21) 0.57  PaO2/FiO2, mean (SD) 200 (76) 191 (95) 194 (92) 211 (77) 0.20
  40. 40. All – NIV Repeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Arterial Blood Cases Prior to NIV • pH, mean (SD) 7.31 (0.09) 7.32 (0.1) 7.31 (0.09) 7.32 (0.1) 0.73 • PaCO2, mean (SD) 56 (21) 52 (21) 58 (23) 53 (22) 0.23  PaO2/FiO2, mean (SD) 162 (73) 171 (94) 172 (33) 175 (90) 0.8 Day 1 after NIV • pH, mean (SD) 7.37 (0.08) 7.34 (0.09) 7.35 (0.09) 7.34 (0.1) 0.49 • PaCO2, mean (SD) 50 (18) 50 (19) 53 (21) 51 (21) 0.57  PaO2/FiO2, mean (SD) 200 (76) 191 (95) 194 (92) 211 (77) 0.20
  41. 41. N I V utilization 1998 N = 161 2004 N = 186 p value Chronic obstructive pulmonary disease 22 / 133(16.5%) 40 / 113 (35 %) <0.001 Asthma 1 / 13 (8 %) 7 / 28 (25 %) 0.38 Congestive heart failure 10 / 152 (7 %) 18 / 105 (17 %) <0.001 Acute respiratory failure 21 / 373 (6 %) 44 / 446 (10 %) 0.03 ● Acute respiratory distress syndrome 4 / 67 (6 %) 8 / 65 (12 %) 0.19 ● Pneumonia 16 / 183 (9 %) 20 / 2006 (15 %) 0.08 ● Sepsis 1 / 123 (1 %) 6 / 175 (3 %) 0.25
  42. 42. Invasive ventilation n=162 Successful NIV n=78 Failure NIV n=27 p Hours NIV median (IQR) 48 (21, 98) 16 (6, 30) < 0.001 Days of MV median (IQR) 4 (2, 9) 3 (2, 5) 5 (3, 15)* 0.01 Tracheostomy, % 15% -- 11% 0.002 Length of stay ICU median (IQR) 9 (5, 15) 5 (3, 8) 11 (5, 21) <0.001 Length of stay hospital median (IQR) 15 (10, 27) 17 (9, 22) 20 (11, 32) 0.25 ICU Mortality, % 23% 9% 41% 0.001 Hospital Mortality, % 32% 17% 54% 0.001
  43. 43. All – NIV Repeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Need for intubation (failure NIV) 32 % 40 % 31 % 35 % 0.59 Mortality (failed NIV) 42 % 47 % 47 % 47 % 0.98 COPD 27 % 41 % 50 % 47 % 0.73 ARF 48 % 50 % 46 % 54 % 0.63 Mortality (successful NIV) 14 % 14 % 21 % 10 % 0.08 COPD 9 % 9 % 12.5 % 3 % 0.24 ARF 17 % 15 % 27 % 15 % 0.21
  44. 44. All – NIV Repeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Need for intubation (failure NIV) 32 % 40 % 31 % 35 % 0.59 Mortality (failed NIV) 42 % 47 % 47 % 47 % 0.98 COPD 27 % 41 % 50 % 47 % 0.73 ARF 48 % 50 % 46 % 54 % 0.63 Mortality (successful NIV) 14 % 14 % 21 % 10 % 0.08 COPD 9 % 9 % 12.5 % 3 % 0.24 ARF 17 % 15 % 27 % 15 % 0.21
  45. 45. Conclusions  The use of NIV in the ICU has doubled from 1998 to 2004 for all causes of acute respiratory failure.  The strong concordance of predicted and observed practice changes suggest that clinical trials have influenced usual care over time.
  46. 46. Mechanical ventilation is useful to “buy” time…. Meanwhile:  To avoid to injury the lung (barotrauma, volutrauma, atelectrauma..)  To avoid the organ dysfunction  To avoid the muscular atrophy  To avoid the nosocomial infections

×