Extubation to NIPPV

Non-invasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial.

Ornico SR, Lobo SM, Sanches HS, Deberaldini M, Tófoli LT, Vidal AM, Schettino GP, Amato MB, Carvalho CR, Barbas CS. Crit Care. 2013 Mar 4;17(2):R39. (full text available)

Background

There have been many studies demonstrating the benefits of extubation of patients with COPD on to non invasive ventilation (NIV). These studies lack a uniform method of assessment, with different protocols, different application methods and timings having been used. This study aims to demonstrate a reduced rate of reintubation in a wider population of patients, having been invasively ventilated for acute respiratory distress, when extubated onto NIV.

Study design

  • single centre (Sao Paolo, 24 bed ICU)
  • randomised, prospective, controlled, unblinded over 12 months comparing outcomes of extubating patients onto NIV against oxygen mask (OM)

Method

Population

  • 40 patients, 20 randomised to each group (NIV vs OM)
  • inclusion criteria: acute respiratory failure (PaO2/FiO2 ratio ≤ 300 orPaCO2 ≥ 50 mm Hg at intubation), invasive ventilation for >72 hours, weaning from invasive ventilation by using the ICU weaning protocol, no contraindications to NIV
  • excluded: <18yrs, pregnancy, and refusal to participate

Measured outcomes

  • APACHE II score
  • Gas exchange 15 minutes, 2 hours, and 24 hours after extubation
  • Reintubation rate after 48 hours
  • Duration of mechanical ventilation
  • ICU length of stay
  • Hospital mortality

Results

  • Rate of reintubation 5% NIV, 39% OM (P=0.016)
  • No difference in length of ICU stay
  • Hospital mortality: 0% NIV, 22% OM (P=0.041)- all of the patients who died required reintubation

Critique

  • Of 162 patients admitted to ICU needing mechanical ventilation, only 40 met inclusion criteria
  • 2 (ie 5%) patients withdrew (reasons not given)
  • No difference in ICU duration of stay- Unexpected, as reintubation rate was lower
  • small sample size powered to detect reintubation at 48h, not hospital mortality
  • unblinded due to equipment – could research staff have been blinded, could a sham mask have been used
  • nasal NIV – not in common use locally
  • local anecdote of why patients require reintubation – seldom due to respiratory variables alone

Conclusions

This was a well constructed paper with a robust study design. The use of NIV devices after extubation appears to improve outcomes and could be implemented in our ICU setting. A large multi-centre RCT would strengthen this argument.

 

Dr Prerna Mehrotra

CT2 AICU QMC

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1 comment so far

  1. danharvey on

    Thanks to Perna for this concise review. A study investigating predictors of success with NIPPV would be helpful I think, to back up what is always likely to be a clinical decision with a limited evidence base.


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