Proning patients on NIV or HFNC

Disclaimer: I am a consultant for a company mentioned in this paper but I am not being compensated in any way, shape or form for this post.

People have asked if it is safe to prone patients who are in ARDS and use either non-invasive ventilation or high flow nasal cannula. In this paper, which is completely FREE for you to download looked at 20 patients who were in ARDS (causes listed on the paper). This was not a randomized trial. It was an observational cohort. They included patients with with moderate ARDS per the Berlin Criteria.

Important teaching point is the Berlin Criteria for ARDS (PaO2/FiO2)
Mild P/F 200-300
Moderate P/F ≤200
Severe: P/F ≤100

Also important to know that moderate ARDS has a mortality of 32% and severe ARDS has a 45% mortality.

55% of patients avoided intubation (it's a small study). But when you consider the fact that these patients with COVID generally stay on the vent for more than 10 days anecdotally, require significant sedation and perhaps paralytics, and eventually move on to be trached, it may be worth consideration. 3 of the 9 patients who were intubated moved on to needing ECMO.

The short answer without me giving away any bias for the aforementioned reasons is that it could be done. The data supporting it is in this article. No, it is not a magic bullet. Not everyone will dodge the endotracheal tube. But one could start asking their patients to do this even in their Emergency Department.

Also, I cannot comment on the concern of aerosolization of the virus by NIV or HFNC at this juncture. I honestly don't know the answer. What I do know is that we may run out of vents if we intubate everyone early. Always wear as much PPE as you can reasonably get your hands on.

Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24(1):28. Published 2020 Jan 30. doi:10.1186/s13054-020-2738-5

-EJ
Link to Abstract

Link to PDF

Link to Berlin Criteria

Non-Invasive Ventilation Algorithm

Not every patient reads the textbook, but you and I have to know where to start when managing our patients who have hypercapnic respiratory failure that we want to treat with non-invasive ventilation (or what you and I frequently call BiPAP). This algorithm is taken from the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guidelines that were published in 2017. Fortunately, they are free for you to download your own copy and put it up on your wall. 

This guideline recommends starting with an EPAP of 3. If I'm honest, everywhere I've been and the way I've been trained is to start at 5. Also, they recommend uptitrating the IPAP up to 20-30. In my practice, once I start kissing 20, I start thinking very seriously about intubating the patient. 

For those who are unfamiliar with the kilopascal units (as I certainly was), the equivalent PCO2 is 48.75mmHg. Note that you need to have acidosis and hypercapnia in COPD exacerbations to have any benefit from NIV. 

A hat tip to the authors. 

Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71 (Suppl 2):ii1–35.

-EJ






Link to Article with FULL FREE Algorithm

Ghosh D, Elliott MW. Acute non-invasive ventilation - getting it right on the acute medical take. Clin Med (Lond). 2019;19(3):237–242.



Link to the FREE FULL Guidelines

Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71 (Suppl 2):ii1–35.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

BiPAP should not be used in Immunocompromised patients

This was a post-hoc analysis of the FLORALI trial that I have reviewed before on this medium. In that study they compared patients who had hypoxemic respiratory failure by putting them on 1:1:1 on high flow nasal cannula (HFNC), standard oxygen therapy, and non-invasive ventilation (NIV aka BiPAP).

My interest was piqued in trying to find out what they defined as immunocompromised patients. They looked at patient with hematologic and solid malignancies, AIDS, drug induced, and steroid related. The etiology for the respiratory failure in these patients was mostly for pneumonia, whether opportunistic etiology or not.

To make it simple, they found that patients treated wit HFNC did better than patients who received NIV regarding rates of intubation as well as mortality.

Frat J-P, Ragot S, Girault C, et al. Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial. Lancet Respir Med 2016;4:646–52.

Link to Abstract

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Do Not Resuscitate/Do Not Intubate does NOT mean Do Not Do Anything.

Nasal high flow oxygen therapy in do-not-intubate patients with hypoxemic respiratory distress

This topic is very dear to me because I am a huuuuuuuge proponent for appropriate end of life care. I'm an Intensivist after all and people unfortunately die on my service. We all are going to have our day. My goal with the patients I take care of is to make their passing to the next life as comfortable as possible with as much love surrounding the individual as humanly possible. It irks me at times when clinicians write patients off just because they have a DNR/DNI order written. For the non-medical people around here that means do not resuscitate/do not intubate. Also, what are you doing around here? Those patients also need our best efforts as they are already cognizant of their impending mortality. That usually means their friends and family members are also aware and would rather be around when the inevitable to all of us occurs and they pass. In this article, the authors attempted to avoid utilizing non-invasive ventilation, or as most of us just call it, BiPAP, by placing patients on high flow nasal cannula. Small study, 50 patients. Can you imagine the difficulty in enrolling patients into a study like this? It must have been quite challenging. In short, although mortality in hospital was appropriately high, they found that they were able to avoid placing patients on BiPAP in 82% of patients. To me, this is particularly important because that means these patients were able to comfort eat, speak to their families, say their goodbyes, give them unobstructed hugs (due to the BiPAP mask), kisses, and smiles without a NIV mask in the way. The decreased RR as a clinician to me is significant because if there's one thing that makes me uncomfortable, it's a patient who is in frank respiratory distress sucking wind to survive. A respiratory rate decrease from 30.6 to 24.7 is something I'd take any day. This is something I do in my practice. I was very happy to run into their article and find some data to support what I anecdotally believed.

A hat tip to the authors.

-EJ

Peters S, Holets S, Gay P. Nasal high flow oxygen therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 ; 58(4): 597-600.

Link to abstract

Link to full FREE article

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Noninvasive positive pressure ventilation in respiratory failure: the guidelines

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure.
Want to know which patients to use BiPAP on? This guideline published in the American Thoracic Society journal in conjunction with the European Respiratory Society in 2017 provides some good answers for the most common questions we all encounter in our daily practice.
Should NIV be used in COPD exacerbation?
Should NIV be used in ARF due to a COPD exacerbation to prevent the development of respiratory acidosis?
Should NIV be used in established acute hypercapnic respiratory failure due to a COPD exacerbation?
Should NIV be used in ARF due to cardiogenic pulmonary oedema?
Should NIV be used in ARF due to acute asthma?
Should NIV be used for ARF in immunocompromised patients?
Should NIV be used in de novo ARF?
Should NIV be used in ARF in the post-operative setting?
Should NIV be used in patients with ARF receiving palliative care?
Should NIV be used in ARF due to chest trauma?
Should NIV be used to prevent respiratory failure post-extubation?
Should NIV be used in the treatment of respiratory failure that develops post-extubation?
Should NIV be used to facilitate weaning patients from invasive mechanical ventilation?
Fortunately, this article is free for you to download. The link is below.





Link to FREE article

Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50: 1602426

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Cardiogenic Pulmonary Edema: Does Non-Invasive Ventilation work for this?

Link to the Abstract

This happens every single day at every shop I’ve worked at. Patient comes in with a CHF exacerbation sucking wind. You feel you have a little bit of wiggle room and don’t have to intubate them, while at the same time they’re too sick for nasal cannula or high flow. What do you reach for? The “BiPAP” machine! Now, just for clarification, the nomenclature is all wonky for this machine and its settings which is a different post all in itself. BiPAP is when you have a difference between the IPAP and EPAP settings while CPAP is when the IPAP and EPAP settings are the same. Being a good clinician; #physician or #respiratorytherapist, what you need to do is spend some time at the bedside hanging out with your patient to make sure you find the sweet spot that’s comfortable for them. Sometimes it’s easy, sometimes it’s impossible and they need to be intubated. This meta-analysis shows that pts who get placed on the #CPAP setting do better than those placed on #BiPAP setting with decreased mortality. A 🎩 tip to the authors.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Helmet vs Face Mask NIV for ARDS

I originally posted this article on 6/21/19 while preparing my NIV/BiPAP lecture. During that process, I learned and shared on IG about using a helmet rather than a mask for NIV (non-invasive ventilation). Looking at the footage that has been coming out of Italy and other parts of the world, you can catch a glimpse of their pumps, ventilators, and in the case of this post, the fact that many institutions are using the helmets.

Why are these places using helmets instead of face masks and what does the data say?

The study I am referring to was published in JAMA in 2016 and they compared utilizing a face mask vs a helmet setup in patients with ARDS. The study was actually stopped early because the data was so good. They were trying to get to 206 patients but stopped at 83.

The authors found that patients who wore the helmet were intubated less frequently, 18.2% vs. 61.5%, had more ventilator free days, a shorter length of stay in the ICU, and lower both in-hospital mortality and 90 day mortality. Patients were also on NIV with the helmet for a shorter period of time utilizing less PEEP, less pressure support, and required a lower FiO2.

Could the helmet be a tool to help out to minimize the need for intubation and mechanical ventilation? Does anyone here have experience with the helmet setup? This study was created in Chicago, I'm sure there's has to be someone around here who was at that institution while this study was being performed.

-EJ

Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2016;315(22):2435–2441. doi:10.1001/jama.2016.6338

Link to Article

Link to FULL FREE PDF

Link to PDF (Backup)




Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

NIV in COPD

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004104.pub4/full

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004104.pub4/epdf/full

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure: A Review of the FLORALI Trial

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

I first shared this article in June of 2019 on Instagram when my account had a mere 2500 followers. Since then the amount of followers to my account have skyrocketed and I could not have done it without the help of each and every one of you who find value in what I do.
As an aside, many of you know I'm preparing a lecture on high-flow nasal cannula and non-invasive ventilation. This article is one of the landmark trials in the HFNC literature and it's worth revisiting in greater detail. After all, I wasn't taking articles apart in as much depth several months ago as I am now. The name by which this study is commonly referred to is the FLORALI trial, as in high FLow Oxygen therapy in Resuscitation of patients with Acute Lung Injury. Witty, huh? The authors had noted that there weren't any studies looking at non-invasive ventilation in patients who were in acute hypoxemic respiratory failure that were not hypercapnic. They went ahead to detail all the beneficial effects of HFNC which I have beat you all over the head with on this medium. They went ahead and designed a prospective, multicenter, randomized, controlled trial to see which worked best to avoid intubations and improve outcomes in patients who were in hypoxemic respiratory failure: NIV, HFNC, or standard oxygen therapy which I will herein refer to as SOT.
They chose to enroll patients who were sick, but not too sick. After all, you need to enroll patients and keep them safe at the same time. If you choose patients who are too sick, then clinicians aren't going to follow the study protocol. They had a strict protocol as well to intubate patients so that patients wouldn't be left lingering without being intubated. After all, there is clear data that if you wait too long to intubate, patients do poorly and there is increased mortality. They included patients who were hypoxemic with a PF ratio < 300, needing a flow of 10L, a PaCO2 < 45 (so no COPD exacerbation patients here) and no chronic respiratory failure. Asthmatics were also excluded, as well as cardiogenic pulmonary edema, use of vasopressors, and hemodynamic instability. They had other parameters but you can check out the article for yourself.
Patients were randomized at 1:1:1 for SOT (nonrebreather at flow of 10L), HFNC (50L of flow and FiO2 titrated), and NIV (pressure support titrated to obtain a tidal volume of 7-10cc/kg ideal body weight and a PEEP between 2-10cmH2O).
When you look at the characteristics of the patients enrolled, and they enrolled 310 of them, the vast majority had pneumonia with a predominance of community acquired followed by healthcare associated pneumonia.
The primary outcome was rates of intubation. There was no difference if you just look at the direct comparison p-value of 0.18. When you look at the patients who had a PF ratio less than 200, though, the patients with HFNC did MUCH better with p-value of 0.009. This is your indication, team! You have someone with pneumonia, don't put the on NIV when HFNC may work better!
Fewer patients died in the ICU if they were to receive HFNC versus the other two (p=0.047).
There was also improved 90 day survival in the HFNC group (p=0.02). This was enough info, and more in the article that you really should read for yourself, to convince many ED and ICU practitioners that HFNC is the way to go in this patient population. Check the article out for yourself!

- EJ





FREE FULL PDF with an account

Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.; FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–2196.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.