Non Invasive Ventilation (NIV) for Weaning/Extubation from Invasive Mechanical Ventilation (MV)

Transcription

1 Interest of Non Invasive Ventilation in the Difficult Weaning Lyon - March 26-28, 2015 Non Invasive Ventilation (NIV) for Weaning/Extubation from Invasive Mechanical Ventilation (MV) Ch. GIRAULT Medical Intensive Care Unit Charles Nicolle University Hospital GRHV. UPRES EA 3830-IRIB Institute for Biomedical Research and Innovation Rouen University, France.

2 Conflicts of Interest Philips-Respironics : Consulting/ Expert (honoraria) Scientific research (logistic support) Congress Fisher & Paykel : Scientific research (logistic support) Congress Air Liquide Medical Systems : Congress Christophe.Girault@chu-rouen.fr

3 NIV and Weaning/Extubation from VM Why? MV implications Concern(s) with weaning/ extubation Objectives Which strategy? Weaning/extubation technique Post-extubation period ARF post-extub. prevention ARF post-extub. treatment Which patients? Medical /Surgical patients

4 MV : Cost-Care Implications MV Complications (nosocomial pneumonia. reintubation ) Weaning Difficulties (COPD ) Mortality Cost of care (length of stay ) Pingleton SK. ARRD1988;137: Fagon JY et al.am J Med 1993; 94: Papazian L et al. AJRCCM 1996; 154:91-7. Rosen et al. Clin Chest Med 1988; 9 : Menzies et al. Chest 1989; 95: Epstein SK et al. AJRCCM 1998; 158:

5 MV : Diaphragmatic Implications Diaphragmatic dysfonction ( with MV duration) Diaphragmatic atrophy (Stimulation phrénique magnétique) Short-term MV Long-term MV Jaber S et al. AJRCCM 2011;183:

6 ARF Management (MV) and Weaning Process of weaning/extubation fromvm «Weaning covers the entire processus of liberating the patient from mechanical support and from the endotracheal tube» = «de-ventilation» + extubation Boles JM et al. 6 th ICC ERJ 2007;29: Suspicion Evaluation Admission Initial ARF management Readiness to be weaned (DST)? Weaning/ extubation Discharge A daily challenge as soon as the initial ARF management! Weaning Trial (SBT) Weaning Success / Failure ü De-ventilation Extubation ü Weaning Readiness to be weaned ü Easy / difficult / prolonged. even not possible weaning ü Weaning success/ failure (extub./ reventilation/ re-intubation)

7 Weaning/Extubation Issues - Definitions Weaning issues (Definitions) Ø Weaning success Extubation and absence of ventilatory support 48 (Succès du sevrage) h following the extubation Ø Weaning failure (Echec du sevrage) 1) Failed one or more SBT; 2) reintubation and/or resumption of ventilator support following successful extubation; or 3) death within 48 h following extubation.extub. Ø Weaning in progress (Sevrage en cours) Patients who are extubated but remain supported by NIV. Weaning issues (Classification) Ø Simple weaning Patients who proceed from initiation of weaning to (Sevrage simple ou facile) successful extubation on the first attempt without difficulty Boles JM et al. 6 th International Consensus Conference ERJ 2007;29: Ø Difficult weaning (Sevrage difficile) Ø Prolonged weaning (Sevrage prolongé) Patients who fail initial weaning and require up to three SBT or as long as 7 days from the first SBT to achieve successful weaning Patients who fail at least three weaning attempts or require >7 days of weaning after the first SBT

8 Weaning/Extubation - Some Concerns Ø Induly delayed MV duration and morbi-mortality Ø 50-65% of auto-extubations are non réintubated!! Betbese AJ et al. CCM 1998; Chevron V et al. CCM 1998;26: ; Epstein SK et al. AJRCCM 2000;161: Ø Delayed extubation pneumonia, length of stay, mortality, costs Coplin WM et al. AJRCCM 2000;161: Ø Too early MV morbi-mortality Ø Extubation failure (re-intubation) MV morbidity (pneumonia) Torres A. et al. AJRCCM 1995;152 : ; Epstein SK. et al. AJRCCM 1998; 158: Ø Extubation failure (re-intubation-delay) mortality Esteban A et al. AJRCCM 97; Epstein SK et al. Chest 97; Epstein SK. et al. AJRCCM 1998; Vallverdu I et al. AJRCCM 98; Esteban A et al. AJRCCM 99. Ø Weaning/extubation success/failure sometimes difficult to predict Ø Post-extubation respiratory work (WOB) ( upper airway resistances) Straus C. et al. AJRCCM 1998;157:23-30; Mehta S. et al. CCM 2000:28: A true «Challenge»!

9 Weaning/Extubation Difficulties-Epidemiology Prospective studies Patients (n) First SBT Success First SBT Failure Extubation Failure Weaning/ Extubation Weaning/ Extubation (reintubation) Failure Success Brochard (AJRCCM 1994) Esteban (NEJM 1995) Esteban (AJRCCM 1997) Vallverdu (AJRCCM 1998) Esteban (AJRCCM 1999) Farias * (ICM 2001) (76%) 109 (24%) 8 (3%) 117 (25.6%) (76%) 130 (24%) 58 (14%) 188 (34.4%) (82%) 87 (18%) 74 (19%) 161 (33.3%) (68%) 69 (32%) 23 (16%) 92 (42.4%) (86%) 73 (14%) 61 (13%) 134 (25.5%) (78%) 56 (22%) 28 (14%) 84 (32.7%) 339 (74.4%) 358 (65.6%) 323 (66.7%) 125 (57.6%) 392 (74.5%) 173 (67.3%) Total /2486 (79%) 524 / 2486 (21%) 252 / 1962 (13%) 776 / 2486 (31.2%) 1710 / 2486 (68.8%) * Pediatric ICU

10 Weaning/Extubation Difficulties-Epidemiology Weaning duration and underlying disease Overall = 41% / total duration of MV ---> 59% (COPD) 46% 59% 48% 19% 29% 44% 26% 35% 23% 41% 59 (21%) 20 (7.2%) 14 (5%) 10 (3.6%) 36 (13%) 45 (16%) 19 (7%) 39 (14%) 37 (13%) 279 (100%) Esteban A. et al. Chest 1994; 106 :

11 Weaning/Extubation Difficulties-Epidemiology Extubation failure (re-intubation) and Mortality 10 20% 26 50% Thille AW et al. AJRCCM 2013; 187:

12 Weaning/Extubation Difficulties-Epidemiology Weanig/Extubation results and Outcome (definition according to 2007 Consensus Conference) 30 50% 26 40% 6 30% ns ns ns ns 0 13% 9 19% 5 33% * * * * 0 13% 1 11% 13 42% (2009) (2011) (2011) (2011) * p < 0.05 only for prolonged vs simple or difficult weaning Thille AW et al. AJRCCM 2013; 187:

13 Weaning/Extubation Difficulties - Physiopathological Determinants Mechanisms of weaning/extubation success / failure (MVÒ SB) Ø Gas exchange disorders (hypoxemia) Ø Inadequation between capacity of respiratory muscles and the imposed ventilatory load +++ :. Increase in ventilatory demand (fever. ). Increase in elastic or resistive load. Dynamic pulmonary hyperinflation / Intrinsic PEEP Ø Inadequation in cardiovascular response by left ventricular (LV) dysfunction +++ :. Changes in LV preload or postload (ACPE). Myocardic ischemia Ø Vascular overload * Ø Central ventilatory drive / Consciousness disorders (sedation) / Encephalopathy * Ø Diaphragmatic paralysis/ dysfunction (neuromyopathy) * Ø Obstruction / increase in airway resistances (laryngeal œdema, inflammation )* Ø Tracheo-bronchial secretions / Inefficient cough / Swallowing disorders * Ø Anemia / metabolic / nutritional / endocrine Factors Ø Psychological factors (delirium, anxiety, depression) * : mechanisms more particularly involved in extubation failure XXI è Conf. de Cons. Réanim.2001;10: / Boles JM et al. 6 th ICC ERJ 2007;29:

14 Weaning/Extubation Difficulties - Physiopathological Determinants Inadequation capacity / ventilatory load SB VS (Deconnexion from the Ventilator) Breathing pattern (rapid shallow breathing) Success Failure Tobin MJ et al. ARRD 1986;134: (14 COPD) Inadequation in cardio-vascular response (LF dysfunction) 15 COPD patients who failed weaning LV failure (17 COPD) Work of breathing (Pes) Lemaire F et al. Anesthesiol. 1988;69: Jubran A et al. AJRCCM 1997;155:

15 Weaning/Extubation Difficulties - Risk factors Risk factors and high-risk populations for weaning/extubation failure Ø Age 65 years * Ø Pneumonia as the cause for intubation Ø APACHE II score > 12 (day of extubation) * Ø Chronic respiratory disorder (COPD) * Ø Cardiac failure * / Vascular overload Ø Central or peripheric neurologic disorder / Glasgow coma scale 10 Ø More than one co-morbidity (either than cardiac failure) * Ø More than one consecutive weaning trial (SBT) failure * Ø f/vt index 105 cycles/mn/l Ø PaCO 2 > 45 mmhg during or at the end of the SBT * Ø Inefficient cough * / Peak cough expiratory flow 35 l/min Ø Moderate or abundant tracheo-bronchial secretions Ø Post-extubation stridor * Ø Morbide obesity (BMI 35kg/m 2 ) * * : selection criteria in RCT assessing prophylactic post-extubation NIV. Thille et al.ccm 2011;39: Epstein et al. Chest 1997;112: Frutos-Vivar et al. Chest 2006;130: Vallverdu et al.ajrccm 1998;158: Namen et al.2001 AJRCCM 2001;163: Mokhlesi et al.respir Care 2007;52: Smina et al.chest 2003;124: Khamiees et al. Chest 2001;120: Chien et al. CCM 2008;36: Teixeira et al. CCM 2010;38: * El-Solh AA et al. ERJ 2006;28: * Nava S et al. CCM 2005;33: * Ferrer M et al. AJRCCM 2006;173: * Ferrer M et al. Lancet 2009;374: * Khilnani GC et al. Anaesth Intensive Care 2011;39:

16 Weaning/Extubation Difficulties Any strategy with the aim of reducing the duration of MV and/or to optimize the conditions or results of weaning/extubation appears to be relevant, and should be developed to improve patient prognosis (morbidity and mortality), particularly in those at high risk of weaning/extubation failure.

17 NIV and ARF - Clinical Use Ø Preventing ETMV Ø Alternative to ETMV (Palliative care) Ø Post-extubation period (Weaning / post-extub. ARF) Ø High-risk procedures Avoid Intubation Ø Acute Hypercapnic RF (COPD, OHS) Ø Acute CPE Ø Acute Hypoxemic RF (Pneumonia, ALI, ARDS) Ø Not to be intubated patients Ø Weaning / Post-extubation ARF Ø Post-operative patients Ø Technical procedures (Fiberoscopy, ETI. ) Speed Extubation / Avoid or Prevent Re-intubation

18 NIV and ARF - Indications Strong recommandations : Do it (G1+) Ø Acute exacerbations of COPD (NIV) Ø Acute CPE (CPAP=NIV) French Consensus Weak recommandations : Probably Do it (G2+) Ø Weaning from MV in COPD Ø Post-extubation ARF prevention Post-extubation NIV Weak recommandation : Probably Don t do it (G2-) Ø Post-extubation ARF treatment! Robert R. et al. Consensus SFAR, SPLF, SRLF 2006:13-20.

19 NIV and Post-extubation - Strategies Role of NIV in the post-extubation period Indication Weaning/extubation management Post-extubation ARF management Condition Weaning difficulties (one or more SBTfailure) Weaning (SBT) success Risk factors for extubation failure Weaning/extubation success Post-extubation ARF Objective Decreasing ETI duration Preventing post-extubation ARF Preventing post-extubation ARF Preventing re-intubation Post-extubation ARF treatment Avoiding re-intubation Strategy NIV as a weaning/extubation technique Preventive (prophylactic) post-extubation NIV Curative (rescue) post-extubation NIV

20 NIV and Post-extubation - Physiological rationale Ø Increase in respiratory workload from ETMV to SB Ø NIV exhibits similar physiological effects to ETMV : Ø Decrease in respiratory workload (Pdi, Pes, WOB, EMG) Ø Improvement in breathing pattern (Vt,RR) and alveolar ventilation Ø Improvement in gas exchanges and dyspnea Ø No deleterious effect on hemodynamics Ø Comfortable ventilation / SB preservation Brochard L et al. ARRD 1989; 139: Brochard L et al. NEJM 1990; 323: Carrey Z et al. Chest 1990; 97: Meduri G et al. Chest 1991; 100: Nava S et al. Chest 1993; 103: Girault C et al. Chest 1997; 111: Diaz A et al. AJRCCM 1997; 156: Lenique F et al. AJRCCM 1997; 155: Vitacca M et al. AJRCCM 2001;164:

21 NIV and Post-extubation - Physiological rationale 12 COPD patients * * * Vitacca M et al. AJRCCM 2001;164:

22 NIV and Post-extubation - Physiological rationale Potential post-operative disorders in pulmonary function Ø Central ventilatory drive depression Ø in airway resistances Ø in PEEPi / Dynamic hyperinflation Ø in thoraco-pulmonary compliance Ø in WOB Ø Upper airways collapse Ø Tracheo-bronchial collapse Ø Atelectasis / Pneumonia Ø Alveolar oedema Stock C et al. Chest 85; 87: Pinilla JC et al. CCM 90;18: Gust R et al. ICM 96; 22: Joris JL et al. Chest 97; 111: Aguilo R et al. Chest 97; 112: Matte P et al. Acta Anesth Scand 2000; 44: Pasquina P et al. Anesth Analg 2004; 99:

23 NIV and Post-extubation - Physiological rationale NIV and post-operative period - Potential benefit Ø Ø Ø in WOB in pulmonary volumes ( restrictive syndrome and atelectasis) Improvement in gas exchanges Greif R et al. NEJM 2000; 342: Stock C et al. Chest 85; 87: Pinilla JC et al. CCM 90;18: Gust R et al. ICM 96; 22: Joris JL et al. Chest 97; 111: Aguilo R et al. Chest 97; 112: Matte P et al. Acta Anesth Scand 2000; 44: Pasquina P et al. Anesth Analg 2004; 99:

24 NIV and Post-extubation - Clinical rationale Ø Increased risks of morbidity and mortality with (prolonged) ETMV (nosocomial pneumonia ) Ø Weaning/extubation concerns : Ø Incidence of weaning/extubation difficulties : 25-30%! Ø Weaning period duration 40% of the total ETMV duration Ø Risks related to re-intubation (morbidity and mortality) Ø No «universal» weaning/extubation criterion Ø Factors of extubation failure less well established (than weaning) and valuable Ø Difficulties to accurately predict weaning/extubation issue (clinician) Ø NIV efficacy and sucess in ARF (hypercapnic ARF, ACPE. ) : Ø to prevent ETMV, reduce complications, LOS, mortality Prevention of ICU nosocomial infections with NIV Ø Fagon JY et al. Am J Med 1993; 94: Papazian L et al. AJRCCM 1996; 154:91-7. Brochard L et al. AJRCCM 1994; 150: Esteban A et al. NEJM 1995; 332: Esteban A et al. AJRCCM 1994; 106; Epstein SK et al. AJRCCM 1998; 158: Keenan SP et al. CCM 1997; 25: Pang D et al. Chest 1998; 114: Antonelli G et al. JAMA 2000; 283: Girou E et al. JAMA 2000; 284:

25 McCurdy BR. Ontario Health Technology Assessment Series 2012;12: NIV and Post-extubation - Clinical rationale NIV and results in COPD exacerbations Overall rate of success according trials = 60 à 80% «Pooled results» : risk of ETI = 62% Overall rate of survival according trials = 30 à 70% «Pooled results» : risk of mortality = 47%

26 NIV and Post-extubation - Clinical rationale NIV and risk of nosocomial pneumonia Parameters Relative Risk CI 95% p (multivariate analysis) (RR) ICU stay (d) NIV-Intub. group Intub.-NIV group x Intub. group! x NIV-Intub. : NIV followed by intubation; Intub.-NIV : intubation followed by NIV. Guérin C. et al. ICM 1997; 23:

27 NIV and Post-extubation - Clinical rationale Clinical Titre du diagramme practice Mechanical Ventilation 604 patients for 2 years 143 NIV (24%) in 123 patients Hypoxemic ARF n= % Hypercapnic ARF n=59 41% Weaning/Post-extubation n= % Overall success rate 92/143 (64%) Hypoxemic ARF 26/42 (52%) Hypercapnic ARF 30/59 (51%) Weaning/Post-extubation 36/42 (86%) Overall in-hospital survival 110/124 (89%) Girault C et al. CCM 2003; 31:

28 Esteban A et al. AJRCCM 2013;188: NIV and Post-extubation - Clinical rationale 1 month 927 ICUs 40 countries International epidemiology use of NIV

29 NIV and Post-extubation - Clinical rationale Epidemiology In France Influence of ICU case-volume on the management and hospital outcomes of acute exacerbations of chronic obstructive pulmonary disease*. 86% Any ventilatory support 49% 18% 36 34% 64% 41 19% Cub-Rea data base 32 ICUs 12 years ( ) COPD-AE ICUs categorization (mean annual volume of admissions) Low < 25 pts/year Medium = pts/year High> 47 pts/year 12% ICU mortality 14% Dres M et al. CCM 2013;41:

30 NIV and Post-extubation - Clinical rationale Epidemiology In France Global use The 2011 ovni Study 61 ICU 2 months 2445 MV p < % 23% 31% 23% 25% of all NIV 12% of all intubations Demoule A et al. AJRCCM 2012; 185:A3107.

31 NIV and Post-extubation - Objectives Ø To counteract the different physiopathological factors involved in the weaning/extubation failure Ø To limit the risk of prolonged ETI and those of a potential reintubation Ø To help ICU physicians in difficulties in predicting results of the weaning/extubation process Ø To treat or prevent the occurrence of a post-extubation ARF (sometimes not foreseeable)

32 NIV and Post-extubation - Strategies Role of NIV in the post-extubation period Indication Weaning/extubation management Post-extubation ARF management Condition Weaning difficulties (one or more SBTfailure) Weaning (SBT) success Risk factors for extubation failure Weaning/extubation success Post-extubation ARF Objective Decreasing ETI duration Preventing post-extubation ARF Preventing post-extubation ARF Preventing re-intubation Post-extubation ARF treatment Avoiding re-intubation Strategy NIV as a weaning/extubation technique Preventive (prophylactic) post-extubation NIV Curative (rescue) post-extubation NIV

33 Uncontrolled studies NIV and Weaning/Extubation Patients n COPD Weaning Success Home Discharge Mortality Udwadia (1992) (91%) 18 (82%) 2 (9%) Laïer-Groeneveld (1992) (94%) 30 (86%) 2 (6%) Goodenberger (1992) (100%) 2 (100%) 0 Restrick (1993) (93%) 2 (14%) 1 (7%) Laïer-Groeneveld G et al. ARRD 1992; 145:A 518. Goodenberger DM et al. Chest 1992; Restrick LJ et al. Respir Med 1993; 87: Udwadia ZF et al. Thorax 1992; 47:

34 NIV and Weaning/Extubation (Early) Medical population (COPD) n =25 n =25 p = Outcome variables Noninvasive PSV group n = 25 Invasive PSV group n = 25 p Value Duration of MV (d) 10.2 ± ± ICU stay (d) 15.1 ± ± Nosocomial pneumonia 0 7 (28%) - 2-month Success 22 (88%) 17 (68%) month Mortality 2 (8%) 7 (28%) Nava S et al. Ann Intern Med 1998; 128:

35 NIV and Weaning/Extubation (Early) Medical population (mixed CRF) Outcome variables Invasive PSV group n = 16 NIV weaning group n = 17 p Value Total duration of ETMV (d) 7.69 ± ± Weaning success/failure rate 12 (75%)/ 4 13 (76.5%)/ 4 ns Total duration of MV related to 3.46 ± ± weaning* Complications 9 (56.3%) 6 (35.3%) ns ICU stay (d) ± ± 6.82 ns Hospital stay (d) ± ± ns In-hospital mortality 2 0 ns 3-mo survival 14 (87.5%) 17 (100%) ns * in success patients. Girault C et al. AJRCCM 1999;160:86-92.

36 NIV and Weaning/Extubation (failure 3 SBT) NIV weaning group n = 21 Medical population (mixed CRF) Conventional weaning group n = 22 NIV weaning group Multivariate analysis COPD = 44% Decreased ICU survival Adjusted Odds-ratio 95% CI p value Conventionnal weaning approach Decreased 90-days survival Conventionnal weaning approach Age > 70 yr PaCO 2 during SB > 45 mmhg Conventional weaning group Ferrer M et al. AJRCCM 2003; 168:70-76.

37 NIV and Weaning/Extubation (Early) Medical population (mixed CRF) RCT COPD = 36% COPD = 35% Outcome NIV (n=28) IMV (n=37) p value ICU stay 18.9 ± ± 10.9 p = 0.51 Hospital stay 9.6 ± ± 18.6 p = 0.19 ICU mortality 8 (28.6%) 8 (21.6%) p = 0.57 Ward mortality 1 (3.6%) 2 (5.4%) p = 1.00 Complications 8 (28.6%) 28 (75.7%) p < Pneumonia 1 (3.6%) 17 (45.9%) p < Tracheotomy 0 (0%) 7 (18.9%) p = 0.01 Trevisan CR et al. Crit Care 2008;12:R51.

38 NIV and Weaning/Extubation Meta-analysis Burns KE et al. BMJ 2009;338:b1574.

39 NIV and Weaning/Extubation «VeNISE Trial» Flowchart Medical population (mixed CRF) * For the main outcome criterion Girault C et al. AJRCCM 2011; 184:

40 NIV and Weaning/Extubation «VeNISE Trial» Parameters median [Q1- Q3] Main results Invasive weaning Group n = 69 Oxygen Group n = 70 NIV Group n = 69 p Weaning results, n (%) Failure (re-intubation 7 d.) 20 (30%) * 26 (37%) 22 (32%) # Failure (re-intub. or death 7 d.) 22 (32%) 26 (37%) 23 (33%) Failure (re-intub.,postextub. ARFor death) 36 (54%) * 50/70 (71%) 22 (32%) * < Post-extubation NIV (rescue) 31 (45%) 40 (57%) Success (no re-intubation nor death) 14 (45%) 23 (57.5%) Intubation duration (d) 1.5 [ ] VM duration related to weaning (d) 1.5 [ ] [ ] Complications (intub. or weaning), n (%) 35 (51%) 43 (61%) 36 (52%) ICU stay (d) 7.5 [ ] 7.5 [ ] 7.5 [ ] Hospital stay (d) 18.5 [9.5-28] 19.5 [ ] 17.5 [ ] ICU survival, n (%) 64 (93%) 61 (87%) 56 (81%) Hospital survival, n (%) 60 (87%) 61 (87%) 53 (77%) * n = 67 et # n = 68 respectively due to 2 and 1 death beforet re-intubation within 7 d by excluding re-intubation and post-extubation NIV durations. Girault C et al. AJRCCM 2011; 184:

41 NIV and Weaning/Extubation «VeNISE Trial» Main results Probability of re-intubation O 2 Group n = 70 NIV Group n =68 # Days from extubation * n = 67 due to 2 deaths before re-intubation within 7 d # n = 68 due to 1 death before re-intubation within 7 d p = (logrank) Invasive weaning Group n = 67 * Probability of re-intubation, Post-extubation ARF or death Invasive weaning Group n = 69 O 2 Group n = 70 NIV Group n =69 p < (logrank) Girault C et al. AJRCCM 2011; 184: Days from extubation

42 NIV and Weaning/Extubation - Meta-analysis and Reviews Hess DR. Resp Care 2012;57: Glossop AJ et al. BJA 2012;109: Zhu F et al. Chin Med J (Engl). 2013;126: Burns KE et al. Cochrane Database Syst Rev.2013;12 : CD Burns KE et al. CMAJ ;186:E

43 = risk ratio; = mean difference Burns KE et al. Cochrane Database Syst Rev 2013;12 : CD Burns KE et al. CMAJ 2014 ;186:E NIV and Weaning/Extubation - Meta-analysis Effect of NIV weaning on weaning failures Summary estimates of effect of NIV weaning in adults (16 RCTs) Effect of NIV weaning on mortality

44 NIV and Weaning/Extubation - Meta-analysis Burns KE et al. Cochrane Database Syst Rev 2013;12 : CD Burns KE et al. CMAJ 2014 ;186:E112-22

45 NIV and Weaning/Extubation Post-operative patients 15 non COPD post op. patients PSV > CPAP and SB (ABG, mechanics, energy expenditure) Post-traumatic patients 22 trauma Patients NIPSV success n = 13 (59%) NIPSV failure n = 9 (41%) ICU mortality n = 6 (27%) Kilger E et al. ICM 1999; 25: Gregoretti C et al. ICM 1998; 24:

46 Hypoxemic ARF RCT (20pts) First outcomes NIV and Weaning/Extubation Secondary outcomes Ø Feasibility and potential benefit (ETI duration) but use of sedation, up to 3 interfaces/patient (Helmet first) Vaschetto R. et al ICM 2012;38:

47 Keenan SP et al. CMAJ 2011;183: E195-E214. NIV and Weaning/Extubation - Recommandations Post-extubation period Weaning/extubation technique Preventive post-extubation ARF Curative post-extubation ARF

48 NIV and Post-extubation - Strategies Role of NIV in the post-extubation period Indication Weaning/extubation management Post-extubation ARF management Condition Weaning difficulties (one or more SBTfailure) Weaning (SBT) success Risk factors for extubation failure Weaning/extubation success Post-extubation ARF Objective Decreasing ETI duration Preventing post-extubation ARF Preventing post-extubation ARF Preventing re-intubation Post-extubation ARF treatment Avoiding re-intubation Strategy NIV as a weaning/extubation technique Preventive (prophylactic) post-extubation NIV Curative (rescue) post-extubation NIV Populations Selected medical CRF pts (COPD+++) Selected medical high-risk pts (hypercapnia) > Surgical pts Selected surgical pts > Medical pts

49 NIV and Weaning/Extubation - Conclusion Ø Alternative to conventional weaning strategies Ø Suppose weaning difficulties (early or persistent SBT failure) Ø «Active» strategy for weaning/extubation : Feasibility / Efficacy / Security Benefits :. ETI duration and its morbi-mortality. Weaning success (reintubation post-extub. ARF). without in morbi-mortality Do not delay potential re-intubation Ø Selected medical populations : SBT failure and CRF (COPD+++) Ø Secured environnement and experienced team with NIV

50 Thank you for your attention! Lyon March