Patients with chronic respiratory disorders are at increased risk of respiratory failure (and subsequent death) when they have the internal tubing used to assist their breathing removed (extubation). An Article published Online First, and in an upcoming edition of The Lancet, concludes that those patients given early non-invasive ventilation after extubation have a lower risk of death and respiratory failure than those given normal oxygen therapy. The Article is written by Dr Miquel Ferrer, Hospital Clínic of Barcelona (Universitat de Barcelona), Spain, and colleagues.
In this randomised controlled study, the authors looked specifically at patients with chronic respiratory disorders who were hypercapnic (ie, had high levels of carbon dioxide in their blood) before extubation—since this population was seen as one that could benefit most from the intervention from previous studies. The authors enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia. Following extubation, patients received either non-invasive ventilation for 24 hours (54 patients) or conventional oxygen treatment (52). The primary endpoint was avoidance of respiratory failure within 72 h after extubation.
The researchers found that respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation (15% of patients) than in those allocated conventional oxygen therapy (48%). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was associated with an 83% decreased risk of respiratory failure after extubation—a reduction independent from other potential confounding factors. 90-day mortality was lower in patients assigned non-invasive ventilation (11%) than in those allocated conventional oxygen (31%).
The authors conclude: "Early non-invasive ventilation after extubation diminished risk of respiratory failure and lowered 90-day mortality in patients with hypercapnia during a spontaneous breathing trial. Routine implementation of this strategy for management of mechanically ventilated patients with chronic respiratory disorders is advisable."
In an accompanying Comment, Dr Peter Calverley, University Hospital Aintree, Liverpool, UK, says: "Hopefully, data such as these will change our perceptions of how and when aggressive treatment should be offered to the many patients with chronic obstructive pulmonary disease who still need this form of help."
For Dr Miquel Ferrer, Hospital Clínic of Barcelona (Universitat de Barcelona), Spain please contact Marc de Semir or Àlex Argemí, Corporate Communications, Hospital Clínic of Barcelona. T) +34932275700/ +34 627947528 E) MDESEMIR@clinic.ub.es / AARGEMI@clinic.ub.es
Dr Peter Calverley, University Hospital Aintree, Liverpool, UK T) +44 (0) 151 529 5886 E) pmacal@liverpool.ac.uk
For full Article and Comment see: http://press.thelancet.com/ventfinal.pdf
Journal
The Lancet