Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial

 

Valdecir C Galindo-Filho, Daniella C Branda˜o, Rita de Ca´ssia S Ferreira, Maria Jose´ C Menezes, Paulo Almeida-Filho, Veroˆnica F Parreira, Tayse N Silva, Maria da Glo´ria Rodrigues-Machado, Elizabeth Dean, and Arme`le Dornelas de Andrade

 

報告者：王貞慧

報告日期：102.10.23

 

BACKGROUND:

Despite the clinical improvements attributed to noninvasive ventilation (NIV) during asthma crises, and the well established effects of nebulization, there are few studies on the effects of these interventions together. We hypothesized that nebulization coupled to NIV should raise radio-aerosol pulmonary deposition in asthmatics. The aims of this study were to assess the effects of coupling b-agonist nebulization and NIV during asthma exacerbations on radio-aerosol pulmonary deposition, using scintigraphy and cardiopulmonary parameters, to correlate pulmonary function with radio-aerosol deposition index, radio-aerosol penetration index, and pulmonary clearance.

 

METHODS:

In this controlled trial, 21 adults with moderate to severe asthma attack were randomized to a control group (n = 11) or experimental group (NIV+ nebulizer group, n =10). All subjects inhaled bronchodilators for 9 minutes, and after particles were counted with a gamma camera to analyze regions of interest and pulmonary clearance at 0, 15, 30, 45, and 60 min.

 

RESULTS:

Breathing frequency (P =< .001) and minute ventilation (P = .01) were reduced, and tidal volume was increased (P =.01) in the NIV+ nebulizer group, compared with the control group. The NIV + nebulizer group had improvement from baseline values, compared to the control group in the following parameters: FEV1 46.7 ± 0.5% of predicted vs 29.8 ±8.9% of predicted, P =.02), FVC (41.2± 1.5% of predicted vs 23.2 ±7.1% of predicted, P=.02), peak expiratory flow (67.3 ±38.3% of predicted vs 26.9 ±12.1% of predicted, P= .01), and inspiratory capacity (54.9 ±28.8% of predicted vs 31.2 ±9.1% of predicted, P = .01). No differences were observed between groups regarding radio-aerosol deposition index or pulmonary clearance. Negative correlations were found between FEV1, forced expiratory flow during the middle half of the FVC maneuver (FEF25–75%), inspiratory capacity, and radio-aerosol penetration index.

 

CONCLUSIONS:

Coupling nebulization and NIV during asthma exacerbation did not improve radio-aerosol pulmonary deposition, but we observed clinical improvement of pulmonary function in these subjects.

(ClinicalTrials.gov registration NCT01012050)

Key words: noninvasive ventilation; asthma; nebulization; pulmonary scintigraphy; radio-aerosol; pulmonary function. [Respir Care 2013;58(2):241–249]

 

 

 
 

 

 

Medical Research Council dyspnea score

Simplified Acute Physiologic Score II

Score 0-162 points

Types of ICU outcome scoring systems

Specific

a. head injury Glasgow coma score

b. burns % + age ~ mortality

c. trauma injury severity score (ISS)

trauma score

d. IHD NYHA / AHA classification

e. pancreatitis Ranson’s scoring criteria

f. liver failure Child’s classification General

1. Anatomical – e.g. Injury Severity Score

• Useful for trauma audits and research

2. Therapeutic – e.g. Therapeutic Intervention Scoring System (TISS)

• Sum of weighted scores of therapeutic interventions

• Correlates well with outcome

• Wide applicability

3. Physiological – e.g. APACHE – Acute physiology and chronic health evaluation

• Designed for quality review rather than prognosis

Specific models

First generation: Second generation

APACHE I APACHE II

SAPS I

MPM I

Third generation Fourth generation

APACHE III APACHE IV

SAPS II SAPS III

MPM II MPM0 III

Knaux Index (according to APACH II)

 

Rescue Therapy  by Switching to Total Face Mask After Failure of  Face Mask-Delivered Noninvasive Ventilation  in Do-Not-Intubate Patients in Acute Respiratory Failure

作者：Malcolm Lemyze; Jihad Mallat; Olivier Nigeon; Stéphanie Barrailler; Florent Pepy; Gaëlle Gasan; Nicolas Vangrunderbeeck; Philippe Grosset; Laurent Tronchon; Didier Thevenin.
報告者：張桂禎
報告日期：102.10.16

Objective:
To evaluate the impact of switching to total face mask in cases where face mask-delivered noninvasive mechanical ventilation
has already failed in do-not-intubate patients in acute respiratory failure.
Design and Setting:
Prospective observational study in an ICU and a respiratory stepdown unit over a 12-month study period.

Intervention:
Switching to total face mask, which covers the entire face, when noninvasive mechanical ventilation using facial mask (oronasal mask) failed to reverse acute respiratory failure. Patients: Seventy-four patients with a do-not-intubate order and treated by noninvasive mechanical ventilation for acute respiratory failure.

Main Results:
Failure of face mask-delivered noninvasive mechanical ventilation was associated with a three-fold increase in in-hospital mortality (36% vs. 10.5%; p = 0.009). Nevertheless, 23 out of 36 patients (64%) in whom face mask-delivered noninvasive mechanical ventilation failed to reverse acute respiratory failure and, therefore, switched to total face mask survived hospital discharge. Reasons for switching from facial mask to total face mask included refractory hypercapnic acute respiratory failure (n = 24, 66.7%), painful skin breakdown or facial mask intolerance (n = 11, 30%), and refractory hypoxemia (n = 1, 2.7%). In the 24 patients switched from facial mask to total face mask because of refractory hypercapnia, encephalopathy score (3 [3–4] vs. 2 [2–3]; p < 0.0001), Paco2 (87 ± 25 mm Hg vs. 70 ± 17 mmHg; p < 0.0001), and pH (7.24 ± 0.1 vs. 7.32 ± 0.09; p < 0.0001) significantly improved after 2 hrs of total face mask-delivered noninvasive ventilation. Patients switched early to total face mask (in the first 12 hrs) developed less pressure sores (n = 5, 24% vs.n = 13, 87%; p = 0.0002), despite greater length of noninvasive mechanical ventilation within the first 48 hrs (44 hrs vs. 34 hrs;p = 0.05) and less protective dressings (n = 2, 9.5% vs. n =8, 53.3%; p = 0.007). The optimal cutoff value for face maskdelivered noninvasive mechanical ventilation duration in predicting facial pressure sores was 11 hrs (area under the receiver operating characteristic curve, 0.86 ± 0.04; 95% confidence interval 0.76–0.93; p < 0.0001; sensitivity, 84%; specificity, 71%).

Conclusion:
In patients in hypercapnic acute respiratory failure,for whom escalation to intubation is deemed inappropriate,switching to total face mask can be proposed as a last resort therapy when face mask-delivered noninvasive mechanical ventilation has already failed to reverse acute respiratory failure. This strategy is particularly adapted to provide prolonged periods of continuous noninvasive mechanical ventilation while preventing facial pressure sores. (Crit Care Med 2013; 41:481–488)

Key Words: acute respiratory failure; chronic obstructive pulmonary disease; do-not-intubate order; noninvasive ventilation; total face
mask