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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 4  |  Page : 268-271

A study on noninvasive ventilation in Type-II respiratory failure in a tertiary care center


1 Department of Medicine, PESIMSR, Chittoor, Andhra Pradesh, India
2 Department of Anaesthesia and Intensivist, PESIMSR, Chittoor, Andhra Pradesh, India

Date of Submission05-Jan-2022
Date of Decision12-Jan-2022
Date of Acceptance25-Jan-2022
Date of Web Publication25-Oct-2022

Correspondence Address:
Dr. A Jaganath
Department of Anaesthesiology, PESIMSR, Kuppam, Chittoor - 517 425, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_4_22

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  Abstract 


Background: Type II respiratory failure is a common complication with considerable morbidity and mortality. Noninvasive ventilation (NIV) has been used preferentially with better results. The objective of this study was to assess the outcome and complications of NIV in type II respiratory failure patients. Methods: A clinical observational study of 67 consecutive adult patients with Type II respiratory failure who were assigned NIV, fulfilling inclusion and exclusion criteria were recruited in the study. NIV Bi level positive airway Pressure (Bi PAP) (spontaneous mode) was used in all patients with settings of 12/6 initially. Based on arterial blood gas values and clinical status, settings were adjusted and followed up as per British Thoracic Society guidelines (2016). In case of worsening of mental status, deterioration of potential of hydrogen (PH), increased partial pressure of carbon dioxide, and intolerance to NIV, patients were subjected to invasive ventilation within the first 4 h of NIV initiation. Results: Patients diagnosed with acute exacerbation of chronic obstructive pulmonary disease (–92.5%), and cases of obstructive sleep apnea (7.5%), showed significant improvement in NIV trial over 24 h in 91.7% and 100%, respectively, by the way of reduction of PCO2 levels and improvement in partial pressure of oxygen, oxygen saturation, which was statistically significant in 89.5% of patients. Clinical improvement noted by the decrease in heart rate, respiratory rate was also statistically significant with a P < 001. However, PH did not show significant changes in our study. Conclusions: A trial of NIV is a useful alternative to mechanical ventilation in many different situations with Type II respiratory failure. Advantages of cost-effectiveness, minimal utilization of intensive care unit resources, low morbidity and mortality rates with patient-friendly equipment features contribute to its preference over invasive ventilation.

Keywords: Acute exacerbation of chronic obstructive pulmonary disease, noninvasive ventilation, obstructive sleep apnea


How to cite this article:
Suresh R, Reddy S, Naidu Y R, Reddy Y J, Dhananjaya P E, Jaganath A. A study on noninvasive ventilation in Type-II respiratory failure in a tertiary care center. APIK J Int Med 2022;10:268-71

How to cite this URL:
Suresh R, Reddy S, Naidu Y R, Reddy Y J, Dhananjaya P E, Jaganath A. A study on noninvasive ventilation in Type-II respiratory failure in a tertiary care center. APIK J Int Med [serial online] 2022 [cited 2022 Dec 4];10:268-71. Available from: https://www.ajim.in/text.asp?2022/10/4/268/346647




  Background Top


Noninvasive ventilation (NIV) refers to ventilatory support through the patient's upper airway using a mask or similar device.[1] NIV has developed from home ventilation, predominantly used to treat hypoventilation in patients with neuromuscular disease or sleep apnea. NIV is administered in the intensive care unit (ICU). NIV decreases mortality in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with an arterial PH of <7.35, PCO2 >45 mmHg (uncompensated respiratory failure), as an adjunct to medical treatment. The advantage of using NIV includes avoidance of tracheal intubation and its associated morbidity and mortality.[2] On NIV, patients can eat, drink, cough, and expectorate, take medications by taking a break from treatment. NIV is one of the crucial developments in mechanical ventilation and critical care armamentarium.[3] NIV includes other forms of ventilator assistance that avoid airway invasion, such as negative pressure ventilation, but now mainly positive pressure ventilation is used. NIV has been shown to improve patient outcomes in certain forms of acute respiratory failure.[3] The selection guidelines for NIV use should be followed, and a comfortable, well-fitting interface should be used. NIV can be delivered using portable positive pressure bi-level ventilators or critical care ventilators. There is a strong evidence base for NIV use in the initial management of acute respiratory failure secondary to chronic obstructive pulmonary disease (COPD).[3] NIV prevents complications associated with invasive ventilation like airway problems, nosocomial pneumonia, and sinusitis.[4]

NIV can be used in other clinical situations and also at an early stage before tracheal intubation. Intermittent ventilator assistance is possible with NIV, allowing gradual weaning and regular eating, drinking, and communication. Breaks from ventilator support can be used for giving nebulized medications, physiotherapy, and expectoration.[5]

Keenan et al., over the past decade, popularity of NIPPV has increased in managing acute exacerbation of COPD. NIV decreases the rate of endotracheal intubation, length of hospital stay, and in-hospital mortality. The author concluded that in severe exacerbation of COPD, addition of NIV to standard therapy is beneficial.[6] In selected patients with acute exacerbation of COPD, NIV reduces the need for endotracheal intubation, the length of the hospital stay, and hospital mortality rate.[7] As per the 2011 guidelines for the management of critical care, NIV has assumed a prominent role in managing acute type II respiratory failure by avoiding endotracheal intubation.[4] Tomii et al. say that NIV is a valuable treatment for acute hypercapnic respiratory failure. It has several potential advantages, particularly avoiding tracheal intubation with its associated mortality and morbidity from problems such as pneumonia.[5]


  Methods Top


This observational study was conducted at the PES Institute of medical sciences and research, Kuppam, Andhra Pradesh, to assess the usefulness and outcome of NIV in Type II respiratory failure cases, over a period of 18 months (January 2019 to June 2020) which included adult patients over 18 years admitted to ICU managed by a team of intensivists and duty physicians as per British Thoracic society guidelines. Oxygen saturation (SPO2), heart rate, blood pressure, respiratory rate, and electrocardiogram were monitored. Arterial blood gas studies were carried out at 0, 1, 2, 4, and 24 h. Patients were evaluated for etiology, complications, and co-morbidities and chest radiography was done at bedside. All study patients were started on NIV BiPAP Spontaneous Timed (ST/Timed (T) or T) mode with basic settings of 12/6 inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). The same settings were continued in all patients for a period of 1 h. Those patients who failed the NIV trial, namely intolerance to NIV, increase in partial pressure of carbon dioxide (PCo2) levels and decreased conscious level, were put on mechanical ventilation at the end of the 1st h. During the 2nd h of ventilation, settings were changed to 14/7 IPAP/EPAP settings depending on PCO2 values. They were followed up until discharge from ICU and/or wards. Tight-fitting silicone-rubber made mask formed the interface between the patient and the mechanical ventilator. It was ensured to fit correctly over the bridge of the patient's nose and chin, preventing air leakage and to avoid the development of pressure sores over the bridge of the nose. The analysis and interpretation of this study, data were done by using STATA SPSS (version 20.0; SPSS Inc., Chicago IL, USA). 14.1. The results were compared with the descriptive and inferential statistics. A probability of <0.05 was considered significant.


  Results Top


Demographics

A total number of 67 patients were enrolled in the study, of which 4 were < 30 years (6%), 39 were in the range of 50–70 years (58.2%), 24 were >51 years (35.8%). The majority of the study subjects were above 50 years. Male preponderance was seen (M: F 8:3). There were 48 (58.2%) males and 19 females. Among the study subjects, 55 (82.1%) of the patients were from rural areas, and 12 (17.9%) were from urban and semi-urban areas. The majority belonged to 50–70 age group. Among 67 patients, smokers were 41 (60.15%), combined alcohol and smoking habits in 3 and alcohol consumption only was found in 1 case. The remaining 22 were habit free. The mean pack years for 41 male smokers were 29.26 and the females 22 included in our study were nonsmokers. Their second-hand smoking and biomass fumes exposure made them vulnerable to COPD and type II respiratory failure.

Etiology

There were 62 (92.5%) cases diagnosed with AECOPD and 5 (7.5%) cases were of obstructive sleep apnea (OSA). Co-morbidities such as hypertension in 21, diabetes only in 7, diabetes and hypertension in 7, and multiple conditions of hypertension, diabetes, and Ischemic Heart Disease were found in 4 cases.

Electro cardiogram and imaging findings among the patients

The majority of patients had sinus tachycardia (80.6%) and the remaining had right ventricular strain pattern (19.4%). The majority of patients (79.1%) had normal echocardiogram study; however, 13.4% had pulmonary hypertension with corpulmonale and ischemic heart disease with left ventricular dysfunction was found in 7.5%. Hyperinflation suggestive of AECOPD was found in X-ray chest of 60 cases. Normal study was seen in 3 patients.

Noninvasive ventilation outcome

NIV BiPAP of 12/6 settings achieved optimal/adequate blood gas parameters and clinical improvement in 75% of cases. The remaining patients required 14/7 settings. At the end of the 4th and 24th h, seven patients failed and 60 patients improved. The seven patients who failed NIV were treated with invasive ventilation. There was a significant improvement in NIV outcomes in COPD (91.7%), OSA (100%) (Chi-square value-39.9395, P < 0.427). The 24th-h value NIV outcomes were same as at the 4th h.


  Result Top


The potential of hydrogen (PH) values estimated over 24 h, at 0, 1, 2, 4, and 24 h for AECOPD cases ranged from 7.28 ± 0.08 to 7.31 ± 0.09, P < 0.193 is significant and in OSA patients, it was 7.24 ± 0.03-7.31 (P 0.6891), not significant (P < 0.05 being statistically significant) [Table 1].
Table 1: Change in potential of hydrogen values over 24 h

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Change in pressure of carbon dioxide values over time

There was a significant decrease in PCo2 levels, overtime on repeated measures. Analysis of variance (ANOVA) was done for the variables, and results are significant in AECOPD [Table 2].
Table 2: Change in partial pressure of carbon dioxide values over 24 h

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Change in partial pressure of oxygen values over time

There was a significant decrease in partial pressure of oxygen levels on repeated measures. ANOVA was done for the variables, and results are significant in AECOPD and OSA [Table 3].
Table 3: Change in oxygen saturation values over time

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Changes in respiratory rate over time

There was a significant decrease in respiratory rate levels overtime on repeated measures. ANOVA was done for the variables, and results are significant in AECOPD and OSA [Table 4].
Table 4: Change in respiratory rate values over time

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Change in heart rate over time

There was a significant decrease in heart rate overtime on repeated measures. ANOVA was done for the variables, and results are significant in AECOPD [Table 5].
Table 5: Change in heart rate values over time

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Change in oxygen saturation values over time

There was a significant increase in SPO2 levels, overtime on repeated measures. ANOVA was done for the variables, and results are significant in AECOPD and OSA [Table 3].

Morbidity and complications

Incidence of morbidity and complications on NIV over 24 h was assessed. Only minor complications were noted in our study. Three patients had complaints of nasal/mouth dryness, inability to tolerate mask for prolonged periods. However, no significant complications were noted on the NIV trial. Our study primarily focused on the first 24 h and long-duration trials may reveal other complications such as aerophagia, nausea, vomiting, and nasal bridge skin ulcerations. Nasal dryness was treated with a cold pass over or heated humidifier. Intolerance to NIV mask was treated with counseling and moral support. The frequency of breaks from NIV was increased to make the patient adapt to the face mask. Three patients with minor complications were managed successfully, of which two patients from AECOPD category had nasal dryness and dryness of mouth, and one patient of OSA category had mild abdominal distension due to aerophagia.

Comorbidities

Comorbidities were found in 39 patients which included hypertension (21), diabetes mellitus (7), diabetes and hypertension (7), hypertension and diabetes with Ischemic Heart disease (4).

Number of hours of noninvasive ventilation use

The average number of hours on NIV in the study group was 33.1 h (standard deviation [SD] 6.3) in AECOPD and 31.6 h (SD 5.7) in OSA cases.

Number of days of hospital stay

The number of days of hospital stay in the patients successfully treated with NIV was on an average 4.8 days (SD 5.7).

Treatment failure and complications of noninvasive ventilation

No major complications were encountered in the present study. Overall failure of NIV trial in the present study was 8.3%. In AECOPD group, 7 (10.4%) failed on NIV therapy due to intolerance to NIV, increased PCO2 levels, and decreased consciousness level and were switched over to invasive ventilation. Minor complications such as dryness of mouth and nose encountered in three patients. All five patients from the OSA category treated with NIV, improved, and there were no failures in this group. Only one patient encountered minor complications like aerophagia, and it was managed successfully by nasogastric tube insertion and suction.


  Discussion Top


Bhattacharyya et al. showed that NIV improved survival reduces the need for intubation and the rate of complications in COPD patients.[8] Garpestad et al. showed that NIV reduces the need for intubation, improves the vital signs, PH and gas exchange.[3] Nicolini et al. concluded that the use of NIV in obstructive sleep apnea promotes alveolar ventilation, unloads respiratory muscles, decreases the work of breathing, and controls obstructive hypopnea.[9],[10] The current study also reveals that NIV is effective and gratifying as found in the above studies. In type II respiratory failure, 67 (89.5%) patients due to AECOPD and OSA diagnosis showed improvement within 24 h of NIV-BiPAP trial as demonstrated by the improvement in clinical parameters and statistically significant with P values (<0.001). The recovery was 100% in cases of OSA. Failure was noted in 11.3% cases of acute exacerbation of COPD. Mortality in the present study is attributed to late admission, unwillingness for NIV and unaffordability of the cost of the treatment.

Mortality

Out of total 67 patients, seven patients failed to improve on NIV and were converted to invasive ventilation mode of therapy. Among these, five patients did not improve even with invasive ventilation and died. Overall mortality in the current study was five patients (7.4%), attributable to failed NIV and co-morbidities. Among AECOPD patients, one case had acute myocardial infarction with arrhythmias and died and the other one had sepsis with multiorgan failure leading to death.


  Conclusion Top


NIV of 33.1 h (SD 6.3) in AECOPD and 31.6 h in OSA is a useful alternative therapy to mechanical ventilation in cases of Type II respiratory failure with very few easily treatable minor complications. A 24 h “trial of NIV” is worthwhile with successful outcomes in COPD (91.7%) and OSA (100%), thus reducing the need for invasive ventilation and its attended complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Roberts CM, Brown JL, Reinhardt AK, Kaul S, Scales K, Mikelsons C, et al. Non-invasive ventilation in chronic obstructive pulmonary disease: Management of acute type 2 respiratory failure. Clin Med (Lond) 2008;8:517-21.  Back to cited text no. 1
    
2.
Pnadey R, Chokhani R, NB KC. Use of non invasive ventilation in patients with respiratory failure in Nepal. Kathmandu Univ Med J (KUMJ). 2011;9:256-9.  Back to cited text no. 2
    
3.
Garpestad E, Brennan J, Hill NS. Noninvasive ventilation for critical care. Chest 2007;132:711-20.  Back to cited text no. 3
    
4.
Rajesh Chawla. Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Guidelines for the Management of Critical Care, Govt. of India. 2011;2-11.  Back to cited text no. 4
    
5.
Tomii K, Seo R, Tachikawa R, Harada Y, Murase K, Kaji R, et al. Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU. Respir Med 2009;103:67-73.  Back to cited text no. 5
    
6.
Keenan SP, Sinuff T, Cook DJ, Hill NS. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med 2003;138:861-70.  Back to cited text no. 6
    
7.
Brochard L. Mechanical ventilation: Invasive versus non-invasive. Eur Respir J 2003;22:31s-7s.  Back to cited text no. 7
    
8.
Bhattacharyya D, Prasad B, Rajput AK. Recent advances in the role of non-invasive ventilation in acute respiratory failure. Med J Armed Forces India 2011;67:187-91.  Back to cited text no. 8
    
9.
Nicolini A, Banfi P, Barlascini C, Ferraioli G, Lax A, Grecchi B. Non-invasive ventilation in the treatment of sleep-related breathing disorders: Concise clinical review. J Med Person 2014;12:44-50.  Back to cited text no. 9
    
10.
Nicolini A, Banfi P, Grecchi B, Lax A, Walterspacher S, Barlascini C, et al. Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update. Rev Port Pneumol 2014;20:324-35.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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