Journal of Critical Care xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Noninvasive ventilation in acute respiratory distress syndrome: Primum non nocere☆ We read with interest the study by Chawla et al [1], wherein the authors describe the role of noninvasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS). The authors conclude that the presence of moderate to severe ARDS, shock, and a high Acute Physiology and Chronic Health Evaluation II score predicted NIV failure in patients with ARDS. However, the study has several major limitations. The authors do not provide any data on the trends of clinical and blood gas parameters after the initiation of NIV. No details have been provided on the inspiratory and expiratory positive airway pressure administered during NIV. Furthermore, the study included patients even with hypotension and severe hypoxemia. The current evidence does not support the use of NIV in patients with hemodynamic instability, multiorgan dysfunction, and severe hypoxemia (PaO2/FIO2 b 100), making them candidates for invasive mechanical ventilation from the outset [2]. Whether patients with renal failure had a high occurrence of NIV failure [3] is also not clear from the present study. In addition, there was an inordinate delay in intubation (mean duration of NIV before intubation, 6.3 days) in the current study, which could contribute to the high mortality rate. The criteria for intubation and NIV failure were not objective and could have led to significant differences in the management of patients. The authors have allowed the use of NIV despite high FIO2 requirement (SpO2 b 90% despite FIO2 of 1 being a trigger for intubation), which is clearly the reason for delay in intubation. Finally, we do not agree with the authors that NIV should be used in patients with severe ARDS. The chances of NIV failure and mortality are very high in this subgroup of patients, and a delay of even 1 hour may be associated with a high mortality [3]. Understandably, patients with severe ARDS require a relatively high positive endexpiration pressure that is not achieved through NIV. Moreover, NIV does not guarantee a low tidal volume, and a recent study suggests that higher tidal volume delivered with NIV is associated with adverse outcomes [4]. Thus, a trial of NIV should only be considered in patients with mild to moderate ARDS with no or minimal organ dysfunction
with careful monitoring in the intensive care unit. Failure to improve by 1 to 3 hours after NIV trial should promptly trigger elective intubation and invasive mechanical ventilation [3,5,6].
Inderpaul Singh Sehgal, MD, DM Sahajal Dhooria, MD, DM Ashutosh N. Aggarwal, MD, DM Dhruva Chaudhry, MD, DM Ritesh Agarwal, MD, DM Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Pulmonary and Critical Care Medicine, Postgraduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India E-mail: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2015.12.022 References [1] Chawla R, Mansuriya J, Modi N, Pandey A, Juneja D, Chawla A. Acute respiratory distress syndrome: predictors of noninvasive ventilation failure and intensive care unit mortality in clinical practice. J Crit Care 2016;31:26–30. [2] Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192–211. [3] Sehgal IS, Chaudhuri S, Dhooria S, Agarwal R, Chaudhry D. A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome. Indian J Crit Care Med 2015;19:593–9. [4] Carteaux G, Millan-Guilarte T, De Prost N, Razazi K, Abid S, Thille AW. Failure of noninvasive ventilation for de novo acute hypoxemic respiratory failure: role of tidal volume. Crit Care Med 2015 [in press]. [5] Agarwal R, Aggarwal AN, Gupta D. Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion meta-analysis. Respir Care 2010; 55:1653–60. [6] Agarwal R, Reddy C, Aggarwal AN, Gupta D, et al. Is there a role for noninvasive ventilation in acute respiratory distress syndrome? A meta-analysis. Respir Med 2006; 100:2235–8.
☆ Conflicts of interest: none; financial disclosures: none.
0883-9441/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Sehgal IS, et al, Noninvasive ventilation in acute respiratory distress syndrome: Primum non nocere, J Crit Care (2016), http://dx.doi.org/10.1016/j.jcrc.2015.12.022
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Noninvasive ventilation in acute respiratory distress syndrome: Primum non nocere☆ We read with interest the study by Chawla et al [1], wherein the authors describe the role of noninvasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS). The authors conclude that the presence of moderate to severe ARDS, shock, and a high Acute Physiology and Chronic Health Evaluation II score predicted NIV failure in patients with ARDS. However, the study has several major limitations. The authors do not provide any data on the trends of clinical and blood gas parameters after the initiation of NIV. No details have been provided on the inspiratory and expiratory positive airway pressure administered during NIV. Furthermore, the study included patients even with hypotension and severe hypoxemia. The current evidence does not support the use of NIV in patients with hemodynamic instability, multiorgan dysfunction, and severe hypoxemia (PaO2/FIO2 b 100), making them candidates for invasive mechanical ventilation from the outset [2]. Whether patients with renal failure had a high occurrence of NIV failure [3] is also not clear from the present study. In addition, there was an inordinate delay in intubation (mean duration of NIV before intubation, 6.3 days) in the current study, which could contribute to the high mortality rate. The criteria for intubation and NIV failure were not objective and could have led to significant differences in the management of patients. The authors have allowed the use of NIV despite high FIO2 requirement (SpO2 b 90% despite FIO2 of 1 being a trigger for intubation), which is clearly the reason for delay in intubation. Finally, we do not agree with the authors that NIV should be used in patients with severe ARDS. The chances of NIV failure and mortality are very high in this subgroup of patients, and a delay of even 1 hour may be associated with a high mortality [3]. Understandably, patients with severe ARDS require a relatively high positive endexpiration pressure that is not achieved through NIV. Moreover, NIV does not guarantee a low tidal volume, and a recent study suggests that higher tidal volume delivered with NIV is associated with adverse outcomes [4]. Thus, a trial of NIV should only be considered in patients with mild to moderate ARDS with no or minimal organ dysfunction
with careful monitoring in the intensive care unit. Failure to improve by 1 to 3 hours after NIV trial should promptly trigger elective intubation and invasive mechanical ventilation [3,5,6].
Inderpaul Singh Sehgal, MD, DM Sahajal Dhooria, MD, DM Ashutosh N. Aggarwal, MD, DM Dhruva Chaudhry, MD, DM Ritesh Agarwal, MD, DM Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India Department of Pulmonary and Critical Care Medicine, Postgraduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India E-mail: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2015.12.022 References [1] Chawla R, Mansuriya J, Modi N, Pandey A, Juneja D, Chawla A. Acute respiratory distress syndrome: predictors of noninvasive ventilation failure and intensive care unit mortality in clinical practice. J Crit Care 2016;31:26–30. [2] Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:192–211. [3] Sehgal IS, Chaudhuri S, Dhooria S, Agarwal R, Chaudhry D. A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome. Indian J Crit Care Med 2015;19:593–9. [4] Carteaux G, Millan-Guilarte T, De Prost N, Razazi K, Abid S, Thille AW. Failure of noninvasive ventilation for de novo acute hypoxemic respiratory failure: role of tidal volume. Crit Care Med 2015 [in press]. [5] Agarwal R, Aggarwal AN, Gupta D. Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion meta-analysis. Respir Care 2010; 55:1653–60. [6] Agarwal R, Reddy C, Aggarwal AN, Gupta D, et al. Is there a role for noninvasive ventilation in acute respiratory distress syndrome? A meta-analysis. Respir Med 2006; 100:2235–8.
☆ Conflicts of interest: none; financial disclosures: none.
0883-9441/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Sehgal IS, et al, Noninvasive ventilation in acute respiratory distress syndrome: Primum non nocere, J Crit Care (2016), http://dx.doi.org/10.1016/j.jcrc.2015.12.022
