Hüseyin YILDIRIM, Muzaffer METİNTAŞ, İrfan UÇKUN, Güntülü AK

The efficacy of non-invasive positive pressure ventilation in ARDS: A controlled cohort study

Akut solunum sıkıntısı sendromu (ARDS)’nda noninvaziv pozitif basınçlı ventilasyon (NPPV)’un kullanımını inceleyen çalışmalar oldukça azdır. Bu kontrollü kohort çalışmasında amacımız; ARDS’de NPPV’nin etkinliğini belirlemektir. Solunum yoğun bakım ünitesinde iki yıl boyunca takip edilen 287 hasta çalışmaya dahil edildi. Yirmi iki hasta Avrupa-Amerika uzlaşı konferansı kriterlerine göre ARDS olarak kabul edildi ve çalışmaya dahil edildi. Hastalar sırayla “NPPV grubu” ve “standart tedavi grubu” olarak ikiye ayrıldı. Çalışma öncesi invaziv mekanik ventilasyon endikasyonları belirlendi. Her iki grupta da entübasyon endikasyonu olduğunda hastalar hemen entübe edildi. Standart tedavi grubunda acil entübasyon endikasyonu olmayan hastalara standart medikal destek tedavisi uygulandı. NPPV grubu ARDS hastalarında ise standart medikal tedaviye ek olarak NPPV uygulandı. Primer amacımız entübasyon sıklıkları, ikinci amacımız hastane mortalitesi idi. Hastaların 17 (%85)’si erkekti. Toplam 20 hastanın 18 (%90)’i primer ARDS idi. Ortalama yaş 45.2 ± 19.7 yıl, ortalama PaO2/FiO2 oranı 106.6. Standart tedavi grubunda sekiz hasta, NPPV grubunda ise üç hasta acil entübe edilerek invaziv mekanik ventilasyon uygulandı. NPPV grubundaki yedi hastaya yüz maskesi ile NPPV uygulandı. NPPV uygulanan hastaların 4 (%57)’ünde başarılı olundu, üçünde ise NPPV başarısızlığı nedeniyle entübasyon gerekti. Ortalama NPPV uygulama süresi 58.3 saatti. NPPV başarılı ve başarısız hastalar arasında “Acute Physiology Assessment and Chronic Health Evaluation (APACHE)” II skoru ve başlangıç PaO2/FiO2 değerleri açısından anlamlı bir fark yoktu. Yirmi dördüncü saatteki PaO2/FiO2 değerleri açısından fark istatistiksel olarak da anlamlı idi (sırasıyla 193 ve 93; p= 0.003). Sonuç olarak; ARDS’de NPPV uygulamasında ilk 24 saatte olumlu gelişme olmazsa gecikmeden invaziv mekanik ventilasyona başlanmalıdır.

ARDS’de noninvaziv pozitif basınçlı ventilasyonun etkinliği: Kontrollü kohort çalışması

Few studies have investigated non-invasive positive pressure ventilation (NPPV) in acute respiratory distress syndrome (ARDS). The aim of this controlled cohort study was to determine the efficacy of NPPV in ARDS. Two hundred and eighty- seven patients were monitored in the respiratory intensive care unit over two years. Twenty-two subjects met the American-European consensus criteria for ARDS and were included in the study. Patients were prospectively allocated into standard therapy group and NPPV group. Indications for invasive mechanical ventilation were determined before study commencement. Invasive ventilation was applied to those needing intubation. Those in the NPPV group showing no indications for urgent intubation received NPPV in addition to standard medical therapy. Subjects with indications for intubation were intubated. Primary outcome was intubation rate; secondary outcome was hospital mortality. Seventeen patients were males, 18 (90%) patients were treated for pulmonary ARDS. Mean age was 45.2 years; mean PaO2/FiO2 was 106.6. The need for intubation emerged for eight patients in the standard therapy group. Seven patients in the NPPV group received NPPV, and three patients in this group needed immediate intubation. NPPV was successful in 4 (57%) patients and the other three required intubation for high PEEP or NPPV intolerance. Mean duration of NPPV was 58.3 hours. There was no difference in Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II scores and initial PaO2/FiO2 values between successful and unsuccessful NPPV groups; but the difference between PaO2/FiO2 ratios at 24 hours between these groups was statistically significant (193.0 and 93.3, respectively; p= 0.003). While using NPPV in ARDS patients, if improvement is not seen in the first day, invasive mechanical ventilation should be implemented immediately.

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1. Liesching T, Kwok H, Hill NS. Acute applications of noninvasive positive pressure ventilation. Chest 2003; 124: 699-713.
2. International Consensus Conferences in Intensive Care Medicine: Noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001; 163: 283-91.
3. Mehta S, Hill NS. Noninvasive ventilation (state of the art). Am J Respir Crit Care Med 2001; 163: 540-77.
4. Martin TJ, Hovis JD, Costantino JP, et al. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Am J Respir Crit Care Med 2000; 161: 807-13.
5. Rocker GM, Mackenzie MG, Williams B, Logan PM. Noninvasive positive pressure ventilation. Successful outcome in patients with acute lung injury/ARDS. Chest 1999; 115: 173-7.
6. Xu SC, Huang YF, Wang XY, Jia M. Effect of noninvasive positive pressure ventilation on treatment of acute respiratory distress syndrome. Zhongguo Wei Zhong Bing Ji Jiu Yu Xue (Abstract) 2003; 15: 354-7.
7. Antonelli M, Conti G, Moro ML, et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: A multi-center study. Intensive Care Med 2001; 27: 1718-28.
8. Antonelli M, Conti G, Esquinas A, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007; 35: 18-25.
9. L’Her E, Deye N, Lellouche F, et al. Physiologic effects of noninvasive ventilation during acute lung injury. Am J Respir Crit Care Med 2005; 172: 1112-8.
10. Sameer Rana, Hussam Jenad, Peter C Gay, et al. Failure of non-invasive ventilation in patients with acute lung injury: Observational cohort study. Crit Care 2006; 10: 79.
11. Schuster DP, Iregui M, Blackmon M. Respiratory failure part II: The acute respiratory distress syndrome and pulmonary edema. In: Irwin RS, Rippe JM (eds). Intensive Care Medicine. 5th ed. Philadelphia: Livingstone Williams and Wilkins, 2003: 489-502.
12. ARDS Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The acute respiratory distress syndrome network. N Engl J Med 2000; 342: 1301-8.
13. Garpestad E, Hill NS. Noninvasive ventilation for acute lung injury: How often should we try, how often should we fail? Crit Care 2006; 10: 147.
14. Ferrer M, Esquinas A, Leon M, et al. Noninvasive ventilation in severe hypoxemic respiratory failure: A randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-44.
15. Delclaux CL, Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. JAMA 2000; 284: 2352-60.
16. Antonelli M, Conti G, Bufi M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: A randomized trial. JAMA 2000; 283: 235-41.
17. Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998; 339: 429-35.
18. Bernard GR, Artigas A, Brigham KL, et al. The AmericanEuropean Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818-24.
19. Hess DR. The evidence for noninvasive positive-pressure ventilation in the care of patients in acute respiratory failure: A systematic review of the literature. Respir Care 2004; 49: 810-29.
20. Meduri GU, Antonelli M, Conti G. Noninvasive positivepressure ventilation in acute respiratory failure not related to COPD. In: Hill N (ed). Ventilatory Management Strategies for Critical Care. New York: Marcel Dekker, 2001: 451-97.
21. Pierson DJ. Invasive mechanical ventilation. In: Albert RK, Spiro SG, Jett JR (eds). Clinical Respiratory Medicine. Philadelphia: Mosby Publishers, 2004: 189-209.
22. Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 2001; 344: 481-7.
23. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818-29.
24. Hudson LD. Protective ventilation for patients with acute respiratory distress syndrome. N Engl J Med 1998; 338: 385-7.
25. Montgomery AB, Stager MA, Carrico J, Hudson LD. Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1985; 132: 485-9.
26. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995; 338: 817-22.
27. Meduri GU, Turner RE, Abou-Shala N, et al. Noninvasive positive pressure ventilation via face mask: First line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996; 109: 179-93.
28. Vitacca M, Ambrosino N, Clini E, et al. Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. Am J Respir Crit Care Med 2001; 164: 638-42.
29. Garpestad E, Schumaker G, Hill NS. Noninvasive ventilation for acute respiratory distress syndrome: Breaking down the final frontier? Crit Care Med 2007; 35: 288-90.