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(BQ) Part 1 book Noninvasive mechanical ventilation and difficult weaning in critical care has contents: Weaning from mechanical ventilation determinants of prolonged mechanical ventlation and weaning, non invasive mechanical ventilation in weaning from mechanical ventilation general considerations,... and other contents.
Antonio M Esquinas Editor Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Key Topics and Practical Approaches 123 Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Antonio M Esquinas Editor Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Key Topics and Practical Approaches Editor Antonio M Esquinas Hospital Morales Meseguer Intensive Care Unit Murcia Spain ISBN 978-3-319-04258-9 ISBN 978-3-319-04259-6 DOI 10.1007/978-3-319-04259-6 (eBook) Library of Congress Control Number: 2015960386 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) To wife Rosario, my daughters and Rosana Alba, inspiration and meaning To the memory of my father Preface Ideally all strategies directed toward decreasing the duration of invasive mechanical ventilation (IMV) and reducing or avoiding its complications are useful in patients receiving IMV for different medical or surgical reasons In the past decade advancement in protocols focusing on weaning from mechanical ventilation and new ventilation modes such as neutrally adjusted ventilatory assist (NAVA) and airway pressure release ventilation (APRV) has been developed along with improving the patient-ventilator interaction, advance monitoring, and strategies for early diagnosis and prevention of ventilator-associated pneumonia However, there still remain a significant proportion of those who are dependent on IMV and develop difficulty in weaning from it even after their underlying acute respiratory failure (ARF) and other organ failure have resolved This population represents weaning failure and ventilator dependence More and more advanced surgical procedures and medical management in the elderly population and those with multiple comorbidities also lead to failure to wean from IMV and impact healthcare delivery both due to persistent long-term illness and increasing cost of care Currently, noninvasive mechanical ventilation (NIV) is considered one of the alternatives to endotracheal intubation in selected patients who develop ARF of diverse etiology Its establishment as a suitable, effective, and rational alternative is based not only for its strong and positive action on the respiratory muscles and gas exchange but also due to its positive influence on short- and long-term outcome in critically patients This influence is significant particularly in patients with exacerbation of COPD and acute cardiac pulmonary edema and who are immunodepressed In the past decade there has been significant development in NIV equipment and interfaces and in the understanding of the patient-NIV interaction This has led to physicians considering NIV as an alternate to endotracheal intubation and IMV, in the management of not only ARF but also failure to wean from IMV and extubation failure The latter is defined as a condition where the patient is unable to sustain respiratory status postextubation from IMV Is NIV a recognized alternative to IMV in these conditions? Will this strategy change patient outcomes and IMV-related complications? Will NIV influence healthcare delivery by improving quality of care and reduce cost of care? In this book, sections and chapters are structured in response to these questions based on evidence, clinical practice, and expert recommendations vii viii Preface The recognized chapters that we have contemplated on NIV have been divided into clinical conditions such as persistent weaning failure from prolonged mechanical ventilation, extubation post acute respiratory failure, and unplanned extubation and its use as alternative to short- and long-term IMV including those with tracheotomy The use of NIV in these clinical conditions will look at the diverse medical and surgical (thoracic, cardiac, abdominal, lung transplants) population Additionally, determinants of NIV response, comorbidities, equipments and interfaces, ventilatory modes, patient-ventilator interaction, and clinical monitoring will also be covered in this book We consider that this book represents a valuable tool for a practical approach by the rational use of NIV in prolonged mechanical ventilation, difficult weaning, and postextubation failure Murcia, Spain Antonio M Esquinas, MD, PhD, FCCP Contents Part I Weaning From Mechanical Ventilation Determinants of Prolonged Mechanical Ventlation and Weaning Physiologic Determinants of Prolonged Mechanical Ventilation and Unweanable Patients Dimitrios Lagonidis and Isaac Chouris Prolonged Weaning from Mechanical Ventilation: Pathophysiology and Weaning Strategies, Key Major Recommendations Vasilios Papaioannou and Ioannis Pneumatikos Automated Weaning Modes F Wallet, S Ledochowski, C Bernet, N Mottard, A Friggeri, and V Piriou Neurally Adjusted Ventilatory Assist in Noninvasive Ventilation B Repusseau and H Rozé Recommendations of Sedation and Anesthetic Considerations During Weaning from Mechanical Ventilation Ari Balofsky and Peter J Papadakos Weaning Protocols in Prolonged Mechanical Ventilation: What Have We Learned? Anna Magidova, Farhad Mazdisnian, and Catherine S Sassoon Evaluation of Cough During Weaning from Mechanical Ventilation: Influence in Postextubation Failure Pascal Beuret 15 21 29 37 43 51 ix 196 L.S De Santo et al References Ng CS, Wan S, Yim AP, et al Pulmonary dysfunction after cardiac surgery Chest 2002;121:1269–77 Asimakopoulos G, Smith PL, Ratnatunga CP, et al Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass Ann Thorac Surg 1999;68:1107–15 Stephens RS, Shah AS, Whitman GJ Lung injury and acute respiratory distress syndrome after cardiac surgery Ann Thorac Surg 2013;95:1122–9 Wynne R, Botti M Postoperative pulmonary dysfunction in adults after cardiac surgery with cardiopulmonary bypass: clinical significance and implications for practice Am J Crit Care 2004;13:384–93 García-Delgado M, Navarrete-Sánchez I, Colmenero M Preventing and managing perioperative pulmonary complications following cardiac surgery Curr Opin Anaesthesiol 2014;27:146–52 Vohra HA, Goldsmith IR, Rosin MD, et al The predictors and outcome of recidivism in cardiac ICUs Eur J Cardiothorac Surg 2005;27:508–11 Agarwal R Non invasive ventilation in postextubation ventilator failure In: Esquinas A, editor Noninvasive mechanical ventilation: theory, equipment, and clinical applications Berlin/ Heidelberg: Springer; 2010 p 305–16 Hein OV, Birnbaum J, Wernecke KD, et al Three-year survival after four major post-cardiac operative complications Crit Care Med 2006;34:2729–37 Rady MY, Ryan T Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery Crit Care Med 1999;27:340–7 10 Carron M, Freo U, BaHammam AS, et al Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials Br J Anaesth 2013;110:896–914 11 Glossop AJ, Shephard N, Bryden DC, et al Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis Br J Anaesth 2012;109:305–14 12 Guarracino F, Cabrini L, Ferro B, et al Noninvasive ventilation practice in cardiac surgery patients: insights from a European survey J Cardiothorac Vasc Anesth 2013;27:e63–5 13 Guarracino F, Ambrosino N Non invasive ventilation in cardio-surgical patients Minerva Anestesiol 2011;77:734–41 14 Cabrini L, Plumari VP, Nobile L, et al Non-invasive ventilation in cardiac surgery: a concise review Heart Lung Vessel 2013;5:137–41 15 Olper L, Corbetta D, Cabrini L, et al Effects of non-invasive ventilation on reintubation rate: a systematic review and meta-analysis of randomised studies of patients undergoing cardiothoracic surgery Crit Care Resusc 2013;15:220–7 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery (Excluding Lung Cancer) 25 Dimitrios Paliouras, Thomas Rallis, and Nikolaos Barbetakis Abbreviations AHRF ARDS ARF BPAP CPAP EPAP ETI HFNC ICU IPAP NCPAP NIPPV NIV NPPV PEEP VAP VT Acute hypoxemic respiratory failure Acute respiratory distress syndrome Acute respiratory failure Bi-level positive airway pressure Continuous positive airway pressure Expiratory positive airway pressures Endotracheal intubation High-flow nasal cannula Intensive care unit Inspiratory positive airway pressures Continuous-flow nasal CPAP Noninvasive intermittent positive pressure ventilation Noninvasive mechanical ventilation Noninvasive positive pressure ventilation Positive end-expiratory pressure Ventilation-associated pneumonia Tidal volume D Paliouras, PhD (*) • T Rallis, MD • N Barbetakis, PhD Thoracic Surgery Department, Anti-Cancer Hospital “Theageneio”, Thessaloniki, Greece e-mail: demtros@yahoo.gr; thrallis@gmail.com; nibarbet@yahoo.gr © Springer International Publishing Switzerland 2016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-04259-6_25 197 198 25.1 D Paliouras et al Introduction Thoracic surgery operations play a significant part and are a wide-range “weapon” in the confrontation and treatment of serious lung and heart conditions, lung cancer, or severe traumatic injuries involving the anatomy and integrity of the chest cavity and the underlying vital organs and tissues, such as the trachea and esophagus In the past two decades, thoracic surgery has also evolved as an accurate diagnostic aid in the histological identification of tumors or other granulomatous, autoimmune, and inflectional diseases involving the organs of the thorax Depending on the access in the thoracic cavity, great progress has been achieved against serious diagnostic issues that previously prevented or delayed the desired therapeutic evolution of the patient Today, pleural biopsy, chest wall biopsy, and pleural effusion drainage are performed in everyday practice with a high percentage of success [1] The evolution of thoracic surgery has led to the performance of operative procedures such as a radical video-assisted thoracic surgery, thymectomy, minimally invasive excisions of mediastinal tumors, and even lung transplantation On the other hand, the demands against the management of the manifestation of an acute or chronic cardiac disease, a situation that usually demands urgent attention, have required such procedures as percutaneous transluminal coronary angioplasty and coronary artery bypass grafting to be established as routine These operations can be performed through long chest incisions, such as thoracotomy or sternotomy, or through one to three small chest incisions with the additional use of a camera (thoracoscope), a minimally invasive procedure called video-assisted thoracic surgery The level of difficulty, the usual presence of high-risk patients, and the need to maintain constant focus and emphasis on every detail require optimum pre-, intra-, and postoperative cooperation between the surgeon and anesthesiologist A patient who is undergoing this kind of an operation can be expected to present a wide spectrum of medical history and additional chronic diseases, which may or may not receive the proper treatment This is a challenge that thoracic surgeons and anesthesiologists must always confront with great responsibility and a degree of vigilance, especially in terms of an emergency incident or during the admission of the patient to an emergency department Additional brief examination procedures, such as a spirometry, can indicate the degree of an individual’s respiratory functionality when the time potentiality is given A detailed and careful documentation of their medical record is a good start for the thoracic surgeon to anticipate and overcome possible undesirable complications along the way 25.2 Discussion 25.2.1 Indications for Noninvasive Mechanical Ventilation One of the most important issues that requires continuous observation and proper management is the satisfaction of the patient’s respiratory needs The regulation of postoperative analgesia is an additional variable that must be managed efficiently It is 25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 199 well-recognized that, as long as postoperative pain is correctly regulated, the patient’s respiration is carried out without relative complications (e.g., pulmonary atelectasis) We must not forget that every case has a unique medical history, with greater respiratory and recovery needs according to its complexity and seriousness [2] Postoperative respiratory needs notably depend on the type of the operation procedure and the type of excision of the pulmonary parenchyma Lung excisions include single or multiple wedge resections, segmentectomy, lobectomy or bilobectomy, and radical pneumonectomy The wide variety of thoracic procedures includes lung, pleural, mediastinal, or lymph node biopsies A necessary preoperative control via spirometry provides an indicative image of pulmonary functionality Emergency cases, such as pulmonary empyema, a tension pneumothorax, or a traumatic hemothorax are, of course, excluded, as their intraoperative process depends on the degree of damage According to the latest guidelines, the following spirometry measures indicate the maximum degree of excision that a patient can bear postoperatively without presenting a permanent respiratory disorder If the FEV1 measurement is above 2.00, the patient is capable of receiving a radical pneumonectomy; if it is above 1.80, a lobectomy can be performed; and readings below 1.60 allow only the performance of a lung biopsy Lower readings, for example, below 1.00, show a poor performance status, which makes an eventual procedure impossible The aggravation of the patient’s respiratory functionality is clinically manifested via sudden desaturation, the inability for independent respiration with the analog effect over the patient’s respiratory index, blood gas, disturbance of pO2, pCO2, PaO2/FiO2, and so on A novel indication for noninvasive mechanical ventilation (NIV) is its use during other invasive procedures, such as bronchoscopy, particularly in patients with a high risk of endotracheal intubation (e.g., immune-compromised patients) The use of NIV during bronchoscopy should be considered as an alternative to avoid the complications related to intubation and mechanical ventilation in patients with severe conditions, particularly in those with chronic obstructive pulmonary disease with a tendency to develop hypercapnia Other indications include transesophageal echocardiography, interventional cardiology, and pulmonology NIV may reduce the need for deep sedation or general anesthesia, preventing the respiratory depression that results from it Esophageal surgery may not be an absolute contraindication for NIV or noninvasive positive pressure ventilation (NPPV), although it is considered an effective treatment option in many cases because it can minimize trauma to these patients [3] A common and serious complication sometimes evolves as a result of the development of a pulmonary infection during the postoperative period in the intensive care unit (ICU), which may clinically result in acute respiratory failure (ARF) ARF may also be triggered by acute heart failure or pulmonary fibrosis This serious clinical disorder may require immediate endotracheal intubation (ETI) and mechanical ventilation for its management [4] Acute respiratory distress syndrome (ARDS) is another serious clinical complex and is characterized by alveolar capillary injury arising from various extra- and 200 D Paliouras et al intrapulmonary contributing factors This severe stage of acute lung injury is clinically presented as increased respiratory rate and respiratory distress, progressive hypoxemia, and diffuse infiltrations on chest X-ray [5] Chronic obstructive pulmonary disease (COPD) has been a major health problem for many years, and its manifestation is the result of many and variable factors and may lead to ARF An early diagnosis (especially in female patients), along with the recognition of the disease with the latest guidelines and approaches in mind, may ensure the optimum preoperative preparation for these kinds of chronic patients [6, 7] 25.2.2 Noninvasive Mechanical Ventilation The progressive inability of the patient to oxygenate, ventilate, or protect the airway, leading to weaning/postextubation failure, is a direct indication for applying NIV as a first choice of response The response to NIV varies from patient to patient and with the operative procedure the patient has undergone A mechanical breath can be classified according to three factors: (i) The “trigger”: This refers to the mechanism that initiates respiration Time is considered to be the traditional trigger, where the mechanical breath is delivered at a specific set rate and regular time intervals, making it possible to deliver it at any time during the patient's spontaneous respiratory cycle (ii) Pressure ventilation or volume limited: Pressure ventilation delivers each breath until a certain amount of peak inspiratory pressure is reached, no matter how much tidal volume (VT) corresponds to that pressure VT can vary from mechanical breath to mechanical breath On the contrary, volume-limited (also called volume-controlled) ventilation delivers a set VT of air with each mechanical breath, without the need to reach specific pressure to get that breath in As the lung compliance changes during the procedure, the pressure varies from mechanical breath to mechanical breath Nonetheless, the delivered volume of gas always remains the same (iii) The “cycle”: This is the mechanism responsible for breath termination Each cycle is regulated by different means, to be completed after a set time or inhale:exhale ratio When a certain pressure or volume is reached, or the inspiratory flow decreases to a small percentage, the process is considered complete By definition, the term NIV includes any means of ventilatory support that does not require tracheal intubation of the patient Although the use of NIV was introduced during the 20th century (severe polio epidemics in the 1950s are recorded as the first example of NIV application), the development of “modern NIV” has been registered after the late 1980s, with the application of positive or negative pressure NIV via a nasal mask The aim was the treatment of respiratory failure in patients with advanced neuromuscular disease, respiratory restrictive conditions, or even sleep apnea NIV is currently considered the gold standard as a first-line treatment against serious and life-threatening respiratory complications, especially those that accompany thoracic surgery In recent decades, the indications for NIV have expanded in both acute and chronic care NIV has decreased the need for intubation and mortality, effects that 25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 201 have been consistently observed in ICUs and respiratory wards Noninvasive ventilator assistance is usually delivered using masks or nasal prongs The flow of gas extends to both the respiratory and gastrointestinal tracts NIV is often chosen as a means to avoid intubation during ARF to reduce the risk of other complications, such as ventilation-associated pneumonia (VAP), especially in immune-suppressed patients The goal is to reestablish the functionality of the poorly ventilated alveoli, achieve the unloading of the respiratory muscles, attain a favorable hemodynamic preexisting level, and restore the normal respiratory function The efficacy of NIV treatment depends strictly on the etiology of the established ARF, whether or not a potentially reversible trigger (e.g., pneumonia/acute heart failure) or an acute exacerbation of (e.g., pulmonary fibrosis) takes place It is generally accepted that improvement in gas exchange during the performance of NIV treatment depends on the etiology of the ARF displayed The heterogeneity of the possible etiologies of ARF demonstrates the importance of patient selection and management with NIV For instance, it has been demonstrated that the application of noninvasive continuous positive airway pressure (CPAP) reduces the risk of needing to perform in patients with severe hypoxemic ARF due to pneumonia, compared with O2 therapy It improves oxygenation in patients with pneumonia In other cases, noninvasive CPAP has been successfully introduced during ARF caused by pneumonia in patients who underwent lung transplantation for idiopathic pulmonary fibrosis NPPV can be an effective technique to improve gas exchange in order to avoid endotracheal intubation in selected patients with ARF due to ARDS Nevertheless, the need for ETI via endotracheal intubation or tracheostomy is quite often necessary According to recent studies, trials and the latest guidelines, it has been registered that the success rate of the applied NPPV was measured about 50 %, and evidently it has been suggested that NPPV can be safely be applied in specific cases under close supervision It has also been concluded that the early use of NIV for mildly and moderately COPD patients, after a thoracic surgery procedure and their return to the general ward, results in a rapid improvement of their physiological variables The need for invasive mechanical ventilation, as well as in-hospital mortality, has been significantly reduced with the application of NIV, and it has also been demonstrated to be cost-effective After continuing trials, the clinical usefulness of NIV has been widely accepted for treating acute hypercapnic respiratory failure or obstructive atelectasis due to COPD in patients who underwent a thoracic operative procedure [8] 25.2.3 Equipment Respiratory support is achieved through the application of NIV, without the need for a tube in the tracheal lumen The delivery of the necessary amount of mechanically assisted breaths is performed without an artificial airway NIV may be performed via negative or positive pressure The expiration is passive until the alveolar pressure reaches atmospheric level The main goal is to improve the existing 202 D Paliouras et al ventilation-perfusion mismatch that has emerged, decreasing the airway resistance at the same time The equipment that is most commonly used in everyday practice includes facemasks, nasal masks, and short binasal prongs NIV is accomplished via the following means: high-flow nasal cannula of intermediate-size (HFNC), CPAP, continuous-flow nasal CPAP (NCPAP), variable-flow NCPAP, noninvasive intermittent positive pressure ventilation (NIPPV), bi-level positive airway pressure (BPAP), and a RAM nasal cannula for newborns (Neotech, Valencia, CA, USA) 25.2.3.1 High-Flow Nasal Cannula The HFNC systems (Fischer and Paykel, Auckland, NZ) manage to deliver gas flows that meet or may even exceed a patient's inspiratory flow demands With highhumidity high-flow nasal cannulas, the constant gas flow (2–8 l/min) is delivered through a narrow-diameter interface, with a high-velocity jet of gas into the nares The satisfaction of the respiratory needs is carried out through three different mechanisms: (1) the gas is heated and humidified; (2) the adverse effects of drying on the airway mucosa are eliminated; and (3) it is important to prevent any potential thermal losses The flow increases dead space washout and decreases inspiratory resistance Positive end-expiratory pressure (PEEP) is generated, which is limited and dependent on the prong diameter, the gas flow, even whether the patient’s mouth is open (Locke 1993; Frey 2001; Sreenan 2001) “High gas flow” is defined as up to 60 l/min in adults The difficulty of monitoring the positive pressure that HFNC delivers to the patient is its most important limitation 25.2.3.2 Continuous Positive Airway Pressure (CPAP) A CPAP system provides increased pulmonary pressure, mainly during the expiratory phase, in patients who breathe spontaneously and must also initiate all breaths This form of ventilatory support has been shown to reduce intubation rates and relieve symptoms of postoperative respiratory failure The delivery of constant airway pressure improves the patient’s respiratory effort by (i) increasing functional residual capacity, (ii) reducing airway resistance, (iii) decreasing the work of breathing, and (iv) improving diaphragmatic function and synchrony movement of the chest and abdomen CPAP is delivered through a ventilator or other CPAP systems that utilize a flow generator, oxygen blender, and humidifier The most common CPAP system, used widely in the ICU or general ward, is the Boussignac CPAP System (Vygon, Ecouen, France) The Boussignac valve takes gas from a single source and splits it to create four high-flow jets, which converge in the chamber, creating turbulence It is the turbulence that creates a virtual valve, providing resistance for the patient to breathe against Increased gas flow causes increased turbulence and thus creates a higher pressure Unlike most CPAP devices, this system requires no valves or moving parts There are two main types of CPAP based on gas flow: continuous flow or variable flow: • Continuous-flow nasal CPAP (NCPAP): Continuous flow is delivered by a ventilator or a CPAP machine The PEEP valve controls the flow delivery of 25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 203 independent pressure and there are no pressure oscillations A specific flow sensor is responsible for increasing the dead space, resistance, and work of breathing Pressure monitoring is located within the ventilator, distant from the patient, thus making the system less responsive Bubble CPAP is the simplest method of CPAP deliver Here, a CPAP generator generates a constant flow into the inspiratory line and the gas is then delivered into the patient At expiration, the exhaled breath goes through the expiratory limb, which is immediately immersed under water • Variable-flow NCPAP: Variable-flow NCPAP generates CPAP at the airway proximal to the nares via a dual-injector The injector is responsible for causing gas deceleration and maintaining constant pressure As the patient requires more inspiratory flow, according to his or her respiratory needs, the injector jets entrain additional flow During the expiratory effort, the air stream passes the wall of the airways, and a turbulent gas flow causes an attachment of the stream to the wall During the entire respiratory cycle, a residual gas pressure is provided by the constant gas flow This condition enables stable gas delivery at a desired pressure This “fluid-flip” mechanism leads to a fraction of the continuous-flow CPAP, against which the patient has to exhale 25.2.3.3 Noninvasive Intermittent Positive Pressure Ventilation (NIPPV) NIPPV is achieved through applied positive pressure cycles that are delivered on top of NCPAP Mechanical breaths are usually ventilator-generated, and the patient interfaces are similar to NCPAP, excluding the variable-flow interfaces NIPPV augments ventilation, increases mean airway pressure, decreases anatomic dead space, and stimulates respiratory drive through intermitted cycling 25.2.3.4 Bi-level Positive Airway Pressure (BPAP) BPAP (Respironics, Inc., Murrysville, PA, USA) is used during NIPPV It delivers inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) Finally, the VT delivered is determined by the difference between IPAP and EPAP The obvious advantage of NIV is the avoidance of the serious complications associated with ETI, such as hypoxemia, possible pneumothorax, local edema, pulmonary infection, and VAP or even ventilator-associated lung injury Additionally, due to the noninvasive nature of this method of mechanical ventilation, its application or interruption can be performed with the simultaneous collaboration of the patient, who maintains the ability to speak, feed, and cough, resulting in greater comfort and future rehabilitation [9] 25.2.4 Location and Application An important consideration is the optimal location at which NIV should be delivered Because of the clinical stage of the operated patients requiring NIV, the 204 D Paliouras et al progression of eventual gas exchange abnormalities, and the overall clinical conditions, the first few hours after the initial acute manifestation may determine their clinical outcomes NIV therapy of such patients requires a thorough knowledge of both respiratory physiology (including respiratory mechanics and gas exchange abnormalities) and existing ventilatory devices (e.g., interfaces, valves, etc.) A minimum monitoring level is necessary for its use In addition to traditional prognostic variables, inadequate use of NIV resulting from a lack of personnel training is detected in many cases of patients presenting with NIV The most common problems include (i) a lack of operating knowledge by the staff; (ii) improperly fitted equipment (e.g., a mask with excessive leaks); and (iii) the inability of the personnel to control oxygen therapy or manage the ventilator alarms Thus, the improper use of NIV in non-designated areas, combined with the absence of well-trained medical and nursing staff, may result in increased patient mortality The presence of a welltrained team, careful patient selection, continuous cooperation between thoracic surgeons and anesthesiologists, and optimal choice of the impact NIV outcomes [9] The question on where NIV should be applied during the patient’s postoperative period, after their hospitalization, is currently related to the available resources of each hospital and the knowledge and experience of the specialized staff ICU care is complex and expensive, and it is not needed “as a rule” for all the patients requiring NIV In this regard, specific intermediate locations (between the ICU and the respiratory ward) have been implemented for the application of NIV in postoperative patients These are called semi-critical, intermediate, or high-dependency units, and they have emerged especially in industrialized countries as an alternative to ICUs Their specific goal is to provide noninvasive respiratory support without the complex environment and the costs of an ICU The efficacy and cost effectiveness of such units give them the ability to provide an ideal location for ventilator support (equipped with adequate resources and staff) and a more comfortable environment for patients [10] 25.2.5 Prediction NIV is currently considered the gold standard for managing respiratory failure after a thoracic operative procedure Significant and continuous efforts have been made to identify the main predictors of successful NIV The British Thoracic Society defines treatment failure via the following guidelines: (i) deterioration in the patient’s clinical condition, (ii) lack of improvement or deterioration in arterial blood gas parameters, (iii) development of new symptoms or complications that require ETI or ICU admission, or (iv) a decrease in the level of consciousness If an effective NIV treatment is performed, patients should experience improvement within a few hours after the initiation of the ventilation NIV treatment failures can be divided into early (within 1–48 h of NIV use, with or without an initial success) and late (48 h after initiation of NIV, following an initial successful response) The latest international guidelines always recommend a second complete evaluation of the patient after a few hours of NIV use When there is no clinical improvement, the prognosis is uncertain In the presence of NIV 25 Noninvasive Ventilation in Postextubation Failure in Thoracic Surgery 205 failure, a decision concerning intubation should always be made Thus, the severity of the underlying disease and the operative procedure that has taken place must always be of first concern Conclusion The purpose of NIV is to achieve of a successful clinical reaction to a patient’s postoperative respiratory complications, improvement of gas exchange and the work of breathing, and, ultimately, avoid the need for ETI NIV can be used as a first-line treatment response because of its many advantages Overall results have shown a statistically significant decrease in the rate of ETI, mortality, and fatal complications along with reduced ICU and hospital length of stay We must not forget, however, that it is a complementary ventilation technique and cannot replace ETI in all instances Although it is efficacious, the implementation of NIV remains suboptimal, and the availability of trained staff and sufficient resources to guarantee its proper application must be ensured, especially for patients who have undergone a major thoracic operation NIV should be applied with close monitoring, and ETI should be promptly available in possible cases of failure An optimal team-training experience, careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes in critically ill patients References Jaber S, De Jong A, Castagnoli A, et al Non-invasive ventilation after surgery Ann Fr Anesth Reanim 2014;33:487–91 Beaussier M, Genty T, Lescot T, et al Influence of pain on postoperative ventilator disturbances Management and expected benefits Ann Fr Anesth Reanim 2014;33:484–6 Kai-Yan Y, Zhao L, Chen Z, et al Noninvasive positive pressure ventilation for the treatment of acute respiratory distress syndrome following esophagectomy for esophageal cancer: a clinical comparative study J Thorac Dis 2013;5(6):777–82 doi:10.3978/j.issn.2072-1439.2013.09.09 Aliberti S, Messinesi G, Gamberini S, et al Non-invasive mechanical ventilation in patients with diffuse interstitial lung diseases BMC Pulm Med 2014;14:194 http://www.biomedcentral.com/1471-2466/14/194 Claesson J, Freundlich M, Gunnarsson I, et al Scandinavian clinical practice guideline on mechanical ventilation in adults with the acute respiratory distress syndrome Acta Anaesthesiol Scand 2015;59:286–97 Lopez-Campos JL, Jara-Palomares L, Muñoz X, et al Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations Ann Thorac Med 2015;10(2):87–93 Lorut C, Lefebvre A, Planquette B, et al Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial Intensive Care Med 2014;40(2):220–7 Diaz Lobato S, Mayoralas AS Modern non-invasive mechanical ventilation turns 25 Arch Bronconeumol 2013;49:475–9 AlYami MA, AlAhmari MD, Alotaibi H, et al Evaluation of efficacy of non-invasive ventilation in non-COPD and non-trauma patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis Ann Thorac Med 2015;10(1):16–24 10 Lin F, Pan L, Huang B, Ruan L, et al Pressure-controlled versus volume controlled ventilation during one-lung ventilation in elderly patients with poor pulmonary function Ann Thorac Med 2014;9(4):203–8 Predictors of Prolonged Mechanical Ventilation in Lung Cancer: Use of Noninvasive Ventilation 26 E Antypa and N Barbetakis 26.1 Introduction Although dyspnea is a well-known symptom of tumors involving the lung or pleura, shortness of breath is commonly present in patients with terminal cancer who not have lung or pleura involvement Dyspnea in cancer patients may be caused by the tumor itself, treatment of the tumor, medical complications of the debilitated state, or underlying lung or cardiac disease 26.2 Analysis Considering that lung cancer is the leading cause of cancer death in both men and women and that as many as 65 % of these patients experience dyspnea, the contribution of lung cancer to dyspnea in patients with terminal cancer is substantial It is estimated that 30 % of patients with malignant disease will develop pulmonary metastasis at some time during the clinical course of their disease Mechanisms for acute respiratory failure in patients with bronchogenic carcinoma include the following: Replacement of lung tissue to the extent that a restrictive ventilator defect is produced Pneumonia, atelectasis, or whole-lung collapse occurring behind an occluded primary or segmental bronchus E Antypa, MD, PhD Intensive Care Unit, Gennimatas General Hospital, Thessaloniki, Greece N Barbetakis, MD, PhD (*) Thoracic Surgery Department, Theagenio Cancer Hospital, Thessaloniki, Greece e-mail: nibarbet@yahoo.gr © Springer International Publishing Switzerland 2016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-04259-6_26 207 208 E Antypa and N Barbetakis Entrapment of the phrenic nerve by tumor-filled mediastinal nodes and resulting diaphragmatic paralysis Lymphatic spread or interstitial edema, reducing lung compliance Acute respiratory failure in cancer patients with pulmonary or pleural involvement may be related to treatment of the carcinoma, for example, postradiation pneumonitis, postradiation lung fibrosis, or postpneumonectomy The main respiratory modifications after thoracic surgery mostly lead to atelectasis, hypoxemia, acute respiratory failure, pneumonia, or bronchopulmonary fistula Alternatively, acute respiratory failure in terminally ill cancer patients, including patients with lung cancer, may be related to chronic obstructive pulmonary disease caused by cigarette smoking Furthermore, acute respiratory failure in terminally ill cancer patients may be a manifestation of the debility of terminal cancer Reported causes include anemia, pulmonary embolism, and congestive heart failure Moreover, acute respiratory failure in these patients most likely represents the debility of terminal cancer, which includes general muscle weakness and medical complications These patients may be intubated for a long time Prolonged mechanical ventilation (MV) may be caused by Inadequate respiratory drive due to nutritional deficiencies, sedatives [1], central nervous system abnormality, or sleep deprivation Inability of the lungs to carry out gas exchange effectively Inspiratory respiratory muscle fatigue/weakness [2] Psychological dependency The most common cause is inspiratory respiratory muscle fatigue [3, 4], which is almost always multifactorial in etiology Possible causes of inspiratory respiratory muscle fatigue are Nutritional and metabolic deficiencies resulting from hypokalemia, hypomagnesemia, hypocalcemia, hypophosphatemia, or hypothyroidism [5] Corticosteroids Chronic renal failure Systemic diseases with decreased protein synthesis and increased degradation and/or decreased glycogen stores Hypoxemia and hypercapnia Increased work of breathing due to disease, ventilator, or airway humidification devices Failure of the cardiovascular system Neuromuscular dysfunction/disease caused by drugs or critical illness polyneuropathy-myopathy [6] A combination of the above causes [7] The predictors of prolonged MV are based on the clinical judgment of the physicians, for example, 26 Predictors of Prolonged Mechanical Ventilation in Lung Cancer 209 The patient who is unable to initiate spontaneous inspiratory efforts Inadequate oxygenation (Pao2/Fio2 < 200) The patient who is hemodynamically unstable The rapid shallow breathing index as reflected by the respiratory frequency (f) to tidal volume (Vt) ratio is the most accurate predictor of failure in weaning patients from MV [8] 26.3 Discussion Prolonged MV may be a consequence of persistent weaning failure and is associated with an increased morbidity and mortality Because patients with unsuccessful weaning are likely to develop a rapid and shallow breathing pattern, the ability of noninvasive mechanical ventilation (NIV) to improve hypoxemia and hypercapnia by correcting such an abnormal breathing pattern might explain the benefits of NIV in these patients The aims of NIV [9] are (1) to partially compensate for the affected respiratory function by reducing the work of breathing, (2) to improve alveolar recruitment with better gas exchange (oxygenation and ventilation), and (3) to reduce left ventricular afterload, increasing cardiac output and improving hemodynamics NIV is effective in shortening the period of invasive ventilation in patients with persistent weaning failure and, as a consequence, decreasing the incidence of nosocomially acquired infections, mortality, and other parameters such as length of intensive care unit (ICU) and hospital stay The physician should also consider the use of NIV to facilitate weaning after early extubation or for patients who develop hypoxic respiratory failure after more prolonged intubation [10] A select group of patients with a higher risk of failing an extubation trial may be good candidates to use NIV as a preventive measure for reintubation NIV could also be considered as a prophylactic and therapeutic tool to improve gas exchange in postoperative patients [11] The evidence is also strong for patients developing respiratory distress after surgery for lung resection [12] Short-term NIV with a ventilator support system improves the efficiency of the lung as a gas exchanger without noticeable nondesired side effects in patients submitted to lung resectional surgery In a randomized trial of postoperative lung resection patients [12], NIMV was shown to be safe and effective in reducing reintubation and improving survival Prophylactic postoperative NIV did not reduce the rate of acute respiratory events in COPD patients [13] undergoing lung resection surgery and did not influence other postoperative complication rates, mortality rates, or duration of ICU and hospital stay NIV has been successfully used after thoracic surgery However, NIV fails in about 20 % of patients [14] NIV failure is associated with higher mortality, but is merely a marker of progression of a more severe disease This may at least indicate the need for caution in some patients The selection of the appropriate patients who 210 E Antypa and N Barbetakis may benefit from postoperative preventive NIV is a key issue Interestingly, increased use of fiber-optic bronchoscopies during noninvasive ventilation use was identified as a risk factor for failure The following variables were associated with NIV failure following lung resection [14]: tachypnea, high Sequential Organ Failure Assessment score, number of bronchoscopies performed, and number of hours spent on NIV Key Major Recommendations A general protocol would urge that patients appropriate for NIMV be • Dyspneic due to hypoxic, hypercapnic, or mixed respiratory failure • Displaying physical signs of respiratory muscle weakness (accessory muscle use or paradoxical thoracoabdominal movement) • Tachypneic (respiratory rate 25 or higher) • Hemodynamically stable • Able to protect the airway and without excessive secretion control problems • Able to tolerate or submit to NIV use and adaptable to fitting with a wellsealed interface Patients who are hypercapnic [11] tend to have better results than those who are only hypoxemic Patients with severe acidosis (pH 7.22 or higher) and higher degrees of hypercapnia (PaCO2 near 100 mmHg), however, have worse prognosis The faster the onset of treatment, the better the outcome is Furthermore, the faster the gas exchange and respiratory rate improves [11], the better the outcome is In the postoperative period, it is sometimes difficult to separate preventive from curative application of NIV [15] Further studies are needed to better identify patients who may benefit from NIV after thoracic surgery [15] and the optimal NIV protocol delivered References Arroliga A, Frutos Vivar F, Hall J, et al Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation Chest 2005;128:496 Vassilakopoulos T, Petrof BJ Ventilator induced diaphragmatic dysfunction Am J Respir Crit Care Med 2004;169:336 Laghi F, Tobin MJ Disorders of the respiratory muscles Am J Respir Crit Care Med 2003;168:10 Laghi F, Cattapan SE, Jubran A, et al Is weaning failure caused by low-frequency fatigue of the diaphragm Am J Respir Crit Care Med 2003;167:120 Datta D, Scalise P Hypothyroidism and failure to wean in patients receiving prolonged mechanical ventilation at a regional weaning center Chest 2004;126:1307 Bolton CF Neuromuscular manifestations of clinical illness Muscle Nerve 2005;32:140 26 Predictors of Prolonged Mechanical Ventilation in Lung Cancer 211 Polkey MI, Moxham J Clinical aspects of respiratory muscle dysfunction in the critically ill Chest 2001;119:926 Yang KL, Tobin MJ A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation N Engl J Med 1991;324:1445–50 Cered M, et al Noninvasive respiratory support in the perioperative period Curr Opin Anaesthesiol 2013;26:134–40 10 Ferrer M, Esquinas A, Aranbica F, et al Non invasive ventilation during persistent weaning failure a randomized controlled trial Am J Respir Crit Care Med 2003;168(1):70–6 11 Chiumello D, Chevallard G, Gregoretetti C Non-invasive ventilation in postoperative patients: a systematic review Intensive Care Med 2011;37(6):918–29 12 Auriant I, Jallot A, Herve P, et al Non invasive ventilation reduces mortality in acute respiratory failure following lung resection Am J Respir Crit Care Med 2001;164:1231 13 Lorut C, Lefevre A, Planquette B, et al Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial Intensive Care Med 2014;40(2):220–7 14 Riviere S, Monconduit J, Zarka V, et al Failure of noninvasive ventilation after lung surgery: a comprehensive analysis of incidence and possible risk factors Eur J Cardiothorac Surg 2011;39(5):769–76 15 Jaber S, Antonelli M Preventive or curative postoperative noninvasive ventilation after thoracic surgery: still a grey zone? Intensive Care Med 2014;40:280–3 .. .Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Antonio M Esquinas Editor Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care Key Topics and. .. Publishing Switzerland 2 016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10 .10 07/978-3- 319 -04259-6_2 15 16 ... Springer International Publishing Switzerland 2 016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10 .10 07/978-3- 319 -04259-6_1