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Correspondence |

Noninvasive Ventilation as a Weaning Tool FREE TO VIEW

Salvador Díaz Lobato, PhD; Sagrario Mayoralas, PhD; for the Ventila Group
Author and Funding Information

Pneumological Department, Ramón y Cajal Hospital (Dr Lobato); and Hospital Moncloa (Dr Mayoralas).

Correspondence to: Salvador Díaz Lobato, PhD, Pneumological Dept, Ramón y Cajal Hospital, Carretera de Colmenar Viejo, Km 9,100, 28034 Madrid, Spain; e-mail: sdiazlobato@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1283-1284. doi:10.1378/chest.10-1445
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Published online

To the Editor:

We read with great interest the article recently published in CHEST by Ortiz et al (June 2010)1 about the use of synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control (A/C) ventilation as the primary mode of ventilatory support using the data of an international prospective cohort study of mechanical ventilation. The authors have analyzed the SIMV-PS and A/C modes as weaning modes. Although this is a statistical study, not a clinical study, the absence of any commentary about noninvasive ventilation (NIV) as a weaning mode is a point of attention that should be highlighted.

Several randomized controlled trials have reported the usefulness of NIV to facilitate weaning in patients who have failed at least one spontaneous breathing trial (SBT). In the study of Nava et al,2 68 patients with COPD with severe acute-on-chronic respiratory failure were included. The 50 patients who failed the T-piece SBT were randomized. Twenty-five patients were extubated to NIV delivered with an oronasal interface and an ICU ventilator in pressure-support mode, with a weaning protocol similar to that used in the invasive-ventilation group. The NIV patients had better outcomes, including shorter mechanical ventilation (10 vs 17 days) and ICU stay (15 vs 24 days). The NIV patients were more likely to succeed in weaning (88% vs 68%) and to be alive at 60 days (92% vs 72%). None of the NIV patients developed pneumonia, compared with 25% of those who remained intubated.

Ferrer et al3 applied a different design in randomizing 43 patients (77% with chronic lung disease) who had failed at least three SBTs. NIV was applied for at least 24 h, using a bilevel mode (inspiratory pressure 10-20 cm H2O, expiratory pressure 4-5 cm H2O) delivered via nasal or oronasal interface. Compared with invasive weaning, NIV weaning was associated with significant and substantial reductions in duration of invasive ventilation, duration of ICU and hospital stay, incidence of septic shock and pneumonia, and need for tracheostomy.

Burns et al4 have performed a metaanalysis of NIV weaning to facilitate liberation from mechanical ventilation. They have found that NIV was associated with lower mortality (risk ratio, 0.41), less ventilator-associated pneumonia (risk ratio, 0.28), and shorter mechanical ventilation (7.3 days), ICU stay (6.9 days), and hospital stay (7.3 days). NIV had no effect on the probability of weaning success. Recently, Burns et al5 updated their metaanalysis with new studies, totaling 227 patients with COPD with pneumonia, that randomized patients after they met criteria indicating control of pulmonary infection, rather than after failure to tolerate an SBT. In addition, some of these studies differed fundamentally from other studies in that the weaning mode was different in the two groups: NIV weaning was conducted with pressure support, whereas invasive weaning was performed with synchronized intermittent mandatory ventilation plus pressure support. With these caveats in mind, this metaanalysis of 12 studies and 530 patients, principally with COPD, showed that NIV weaning significantly reduced mortality (risk ratio, 0.55; 95% CI, 0.38-0.79), nosocomial pneumonia (risk ratio, 0.29; 95% CI, 0.19-0.45), ICU stay (weighted mean difference, 6.3 days), hospital stay (7.2 days), total duration of ventilation (5.6 days), and duration of invasive ventilation (7.8 days). NIV was associated with fewer tracheostomies.

Girault et al6 recently completed a randomized controlled trial with 208 patients in 17 centers in France. Patients were included if they had been intubated for at least 48 h with acute-on-chronic respiratory failure and had failed an SBT trial. Patients were randomized into three groups: continued intubation with conventional weaning on pressure support (n = 69), extubation to NIV (n = 69), or extubation to oxygen but without NIV (n = 70). There were no differences in weaning failure (predominately reintubation within 7 days of extubation), complications, ICU or hospital stay, or hospital survival. Interestingly, NIV was used effectively as salvage therapy in 14 (45%) of 31 patients weaned invasively and 23 (58%) of the 40 patients extubated to oxygen alone. In agreement with Epstein and Durbin,7 we believe that NIV is an effective tool for facilitating weaning in patients with acute-on-chronic respiratory failure, mainly patients with COPD.

Ortiz G, Frutos-Vivar F, Ferguson ND, et al; for the Ventila Group for the Ventila Group Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support: a comparative propensity score study. Chest. 2010;1376:1265-1277. [CrossRef] [PubMed]
 
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;1289:721-728. [PubMed]
 
Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;1681:70-76. [CrossRef] [PubMed]
 
Burns KE, Adhikari NK, Meade MO. A meta-analysis of noninvasive weaning to facilitate liberation from mechanical ventilation. Can J Anaesth. 2006;533:305-315. [CrossRef] [PubMed]
 
Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. [CrossRef] [PubMed]
 
Girault C, Chajara A, Dachraoui F, et al. VENISE: Non-invasive ventilation during mechanical ventilation weaning in chronic respiratory failure patients. A prospective randomised controlled and multicenter trial [in French]. Rev Mal Respir. 2003;206 Pt 1:940-945. [PubMed]
 
Epstein SK, Durbin CG Jr. Should a patient be extubated and placed on noninvasive ventilation after failing a spontaneous breathing trial? Respir Care. 2010;552:198-206. [PubMed]
 

Figures

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References

Ortiz G, Frutos-Vivar F, Ferguson ND, et al; for the Ventila Group for the Ventila Group Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support: a comparative propensity score study. Chest. 2010;1376:1265-1277. [CrossRef] [PubMed]
 
Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med. 1998;1289:721-728. [PubMed]
 
Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;1681:70-76. [CrossRef] [PubMed]
 
Burns KE, Adhikari NK, Meade MO. A meta-analysis of noninvasive weaning to facilitate liberation from mechanical ventilation. Can J Anaesth. 2006;533:305-315. [CrossRef] [PubMed]
 
Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. [CrossRef] [PubMed]
 
Girault C, Chajara A, Dachraoui F, et al. VENISE: Non-invasive ventilation during mechanical ventilation weaning in chronic respiratory failure patients. A prospective randomised controlled and multicenter trial [in French]. Rev Mal Respir. 2003;206 Pt 1:940-945. [PubMed]
 
Epstein SK, Durbin CG Jr. Should a patient be extubated and placed on noninvasive ventilation after failing a spontaneous breathing trial? Respir Care. 2010;552:198-206. [PubMed]
 
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