HWN Suggests

Breathing Tubes Fail to Save Many Older Patients

Earlier this year, an ambulance brought a man in his 80s to the emergency room at Brigham and Women’s Hospital in Boston. He had metastatic lung cancer; his family had arranged for hospice care at home.

But when he grew less alert and began struggling to breathe, his son tearfully called 911. “As soon as I met them, his son said, ‘Put him on a breathing machine,’” recalled Dr. Kei Ouchi, an emergency physician and researcher at the hospital.

Hospice patients know that they’re close to death; they and their families have also been instructed that most distressing symptoms, like shortness of breath, can be eased at home.

But the son kept insisting, “Why can’t you…

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Featured

 Mastering the dark arts of BiPAP & HFNC

Skillful use of BiPAP and high-flow nasal cannula (HFNC) can avoid intubation and improve outcomes. However, there isn't comprehensive evidence about the nitty-gritty details of these techniques. In this post I will use my opinions to fill some gaps in the evidence. Noninvasive respiratory support remains more of an art than a science, perhaps a dark art at that.

 Noninvasive Ventilation and the critically ill

Although we have seen excellent results from the use of NIV in COPD, the use in acute asthma remains less convincing and controversial.

 Noninvasive ventilation in acute respiratory failure: which recipe for success?

Thanks to the accumulated body of scientific evidence, NPPV has become the first-choice ventilator technique in specific aetiologies underlying ARF, such as acidotic hypercapnic chronic obstructive pulmonary disease (COPD) exacerbation, cardiogenic pulmonary oedema, severe hypoxaemia in immunosuppression conditions and facilitation in transition from invasive mechanical ventilation (IMV) to spontaneous breathing in chronic hypercapnic patients.

Articles of Interest

Non-invasive ventilation in the ED: Whom, When, How?

As emergency physicians, we encounter patients suffering from either hypoxemic and/or hypercarbic respiratory problems on a daily basis. A stepwise approach to solving this problem seems logical from an emergency medicine perspective. Current literature supports the notion that NIV decreases endotracheal intubation rates and, mortality in select patient populations. The key to the success of NIV is patient cooperation and support for the care givers. In this narrative review, non-invasive ventilation (NIV) is discussed in terms of modes of delivery, interface and patient selection, as well as practical considerations.

CRACKCast E193 – Mechanical Ventilation and Noninvasive Ventilatory Support

This is an essential skill to master for the care of critically ill patients. This podcast will give you a solid approach to the basics of mechanical ventilation and and non-invasive ventilation...

EMCrit 19 – Non-Invasive Positive Pressure Ventilation (NIPPV)

Intubation is a critical procedure, there is no doubt about it. NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.

Modern Non-Invasive Mechanical Ventilation Turns 25

The history of non-invasive mechanical ventilation goes back more than 100 years, but it was not until 1987 when what we could call “modern” non-invasive mechanical ventilation was developed. The description of Delaubier and Rideau of a patient with Duchenne's disease who had been effectively ventilated through a nasal mask marked the start of a new era in the history of non-invasive mechanical ventilation. Over these last 25years, we have witnessed exponential growth in its use, field of activity and technological advances on an exciting fast-paced track. We believe that it is time to review the main milestones that have marked the development of non-invasive mechanical ventilation to date, while paying homage to this therapeutic method that has contributed so much to the advancement of respiratory medicine in the last 25years.

Non-Invasive Positive Pressure Ventilation in the ED

Noninvasive positive pressure ventilation (NIPPV) refers to the delivery of positive pressure ventilator support without the insertion of an endotracheal tube. This intervention works to improve lung volumes and decrease the work of breathing, making it a practical tool in the management of acute respiratory failure. Due to the multitude of indications, it is important for emergency physicians to understand both the ventilator settings of NIPPV devices and the types of respiratory failure they address.

Non-Invasive Ventilation (NIV)

In the modern era it implies the application of positive airway pressure, however some classifications include the application of a negative-pressure generator to the chest (‘iron lung’) as NIV

Non-invasive ventilation for people with respiratory failure due to exacerbation of chronic obstructive pulmonary disease (COPD)

Data from good quality randomised controlled trials show that NIV is beneficial as a first-line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD).

Noninvasive positive-pressure ventilation: Who and when

Best uses include acute hypercarbic respiratory failure in patients with chronic obstructive pulmonary disease (COPD), and acute cardiogenic pulmonary edema.

Noninvasive Ventilation For Patients In Acute Respiratory Distress: An Update

The ease of use of NIV makes it applicable to patients presenting in a variety of types of respiratory distress. In this review, the physiology of positive pressure ventilation is discussed, including indications, contraindications, and options for mask type and fit. Characteristics of patients who are most likely to benefit from NIV are reviewed, including those in respiratory distress from chronic obstructive pulmonary disease exacerbation and cardiogenic pulmonary edema. The literature for other respiratory pathologies where NIV may be used, such as in asthma exacerbation, pediatric patients, and community-acquired pneumonia, is also reviewed.

Positively Useful: A Brief ED Guide to NIPPV

When utilized optimally, NIPPV improves oxygenation, work of breathing, respiratory mechanics, and cardiac function. It should be considered for any dyspneic patient presenting to the ED assuming no contraindications exist. Among the most supported indications for NIPPV are ACPE and COPD.

Selling Ice Cream in the Desert

It's clear from both evidence and experience that NIV (aka NIPPV, CPAP, BiPAP) is very helpful for most acutely sick, dyspneic patients on a range of outcomes: symptom improvement, oxygenation, potential avoidable intubation, or preoxygenation for ETI.

The non-invasive mechanical ventilation: the experience of the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena

The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014,

The Role of the Emergency Department Clinician: Preventing Noninvasive Ventilation Intolerance

The usage of NIPPV in recent years has substantially increased as the benefits of this modality are being recognized, and delaying initiation can lead to failure. A survey of NIPPV use in academic EDs in the United States revealed that barriers of use were attributed to the insufficient physician or clinician familiarity, the shortage of trained clinicians, like respiratory therapists, and the lack of equipment availability