Inspiratory muscle workload due to dynamic intrinsic PEEP in stable COPD patients: effects of two different settings of non-invasive pressure-support ventilation

Background: In severe stable hypercapnic COPD patients the amount of pressure time product (PTP) spent to counterbalance their dynamic intrinsic positive end expiratory pressure (PEEPi,dyn) is high: no data are available on the best setting of non invasive pressure support ventilation (NPSV) to reduce the inspiratory muscle workload due to PEEPi,dyn. Methods: The objectives of this randomised controlled physiological study were: 1. To measure the inspiratory muscle workload due to PEEPi,dyn 2. To measure the effects on this parameter of two settings of NPSV in stable COPD patients with chronic hypercapnia admitted in a Pulmonary Division of two Rehabilitation Centers. Twenty- three stable COPD patients with chronic hypercapnia on domiciliary nocturnal NPSV for 30±20 months were submitted to an evaluation of breathing pattern, PEEPi,dyn, inspiratory muscle workload and its partitioning during both assisted and unassisted ventilation. Two settings of NPSV were randomly applied for 30 minutes each: i- “at patient’s comfort” (C): Inspiratory pressure support (IPS) was the maximal tolerated pressure able to reduce awake PaCO2 with the addition of a pre-set level of external PEEP (PEEPe); ii- “physiological setting” (PH): the level of IPS able to achieve a > 40% and < 90% decrease in transdiaphragmatic pressure in comparison to spontaneous breathing (SB). A PEEPe level able to reduce PEEPi,dyn by at least 50% was added. Results: During SB the tidal diaphragmatic pressuretime product (PTPdi/b) was 17.62±7.22 cmH2O*sec, the component due to PEEPi,dyn (PTPdiPEEPi,dyn) being 38 ± 17% (range: 16-65%). Compared to SB, PTPdiPEEPi,dyn was reduced significantly with both settings, the reduction being greater with PH compared to C. Conclusions: In conclusion in severe COPD patients with chronic hypercapnia the inspiratory muscle workload due to PEEPidyn is high and is reduced by NPSV at a greater extent when ventilator setting is tailored to patient’s mechanics.

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Weaning from mechanical ventilation in COPD patients: interest to measure, in post-extubation, the airway occlusion pressure (P0.1), in order to indicate non-invasive pressure support ventilation (NIPSV) to prevent relapse

Critical Care ◽

10.1186/cc57 ◽

1997 ◽

Vol 1 (Suppl 1) ◽

pp. P055

Author(s):

G Hilbert ◽

D Gruson ◽

E Parrens ◽

F Vargas ◽

JC Favier ◽

...

Keyword(s):

Mechanical Ventilation ◽

Pressure Support Ventilation ◽

Pressure Support ◽

Weaning From Mechanical Ventilation ◽

Occlusion Pressure ◽

Support Ventilation ◽

Airway Occlusion ◽

Non Invasive ◽

Copd Patients ◽

Airway Occlusion Pressure

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T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised controlled trial (TIP-EX)

BMJ Open ◽

10.1136/bmjopen-2020-042619 ◽

2020 ◽

Vol 10 (11) ◽

pp. e042619

Author(s):

Arnaud W Thille ◽

Rémi Coudroy ◽

Arnaud Gacouin ◽

Stephan Ehrmann ◽

Damien Contou ◽

...

Keyword(s):

High Risk ◽

Randomised Controlled Trial ◽

Pressure Support Ventilation ◽

Spontaneous Breathing ◽

Pressure Support ◽

Controlled Trial ◽

Invasive Mechanical Ventilation ◽

Support Ventilation ◽

Number Of Patients ◽

Randomised Controlled

IntroductionIn intensive care unit (ICU), the decision of extubation is a critical time because mortality is particularly high in case of reintubation. To reduce that risk, guidelines recommend to systematically perform a spontaneous breathing trial (SBT) before extubation in order to mimic the postextubation physiological conditions. SBT is usually performed with a T-piece disconnecting the patient from the ventilator or with low levels of pressure-support ventilation (PSV). However, work of breathing is lower during PSV than during T-piece. Consequently, while PSV trial may hasten extubation, it may also increase the risk of reintubation. We hypothesise that, compared with T-piece, SBT performed using PSV may hasten extubation without increasing the risk of reintubation.Methods and analysisThis study is an investigator-initiated, multicentre randomised controlled trial comparing T-piece vs PSV for SBTs in patients at high risk of reintubation in ICUs. Nine hundred patients will be randomised with a 1:1 ratio in two groups according to the type of SBT. The primary outcome is the number of ventilator-free days at day 28, defined as the number of days alive and without invasive mechanical ventilation between the initial SBT (day 1) and day 28. Secondary outcomes include the number of days between the initial SBT and the first extubation attempt, weaning difficulty, the number of patients extubated after the initial SBT and not reintubated within the following 72 hours, the number of patients extubated within the 7 days following the initial SBT, the number of patients reintubated within the 7 days following extubation, in-ICU length of stay and mortality in ICU, at day 28 and at day 90.Ethics and disseminationThe study has been approved by the central ethics committee ‘Ile de France V’ (2019-A02151-56) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04227639.

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Non-invasive ventilation

The ESC Textbook of Intensive and Acute Cardiovascular Care ◽

10.1093/med/9780198849346.003.0022 ◽

2021 ◽

pp. 267-283

Author(s):

Josep Masip ◽

Kenneth Planas ◽

Arantxa Mas

Keyword(s):

Pressure Support Ventilation ◽

Pressure Support ◽

Hospital Setting ◽

Positive Pressure ◽

Chronic Obstructive ◽

Invasive Ventilation ◽

Obstructive Pulmonary Disease ◽

Support Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, immunocompromised or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure, bilevel pressure support ventilation and more recently, high flow nasal cannula. Whereas non-invasive pressure support ventilation requires a ventilator, the other two techniques are simpler and can be easily used in non-equipped areas by less experienced teams, including the pre-hospital setting. The success of non-invasive ventilation is related to an adequate timing, proper selection of patients and interfaces, close monitoring as well as the achievement of a good adaptation to patients’ demand.

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Non-invasive ventilation

10.1093/med/9780199687039.003.0025_update_002 ◽

2017 ◽

Author(s):

Josep Masip ◽

Kenneth Planas ◽

Arantxa Mas

Keyword(s):

Continuous Positive Airway Pressure ◽

Pressure Support Ventilation ◽

Airway Pressure ◽

Pressure Support ◽

Positive Airway Pressure ◽

Fine Tuning ◽

Invasive Ventilation ◽

Support Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

During the last 25 years, the use of non-invasive ventilation has grown substantially. Non-invasive ventilation refers to the delivery of positive pressure to the lungs without endotracheal intubation and plays a significant role in the treatment of patients with acute respiratory failure and in the domiciliary management of some chronic respiratory and sleep disorders. In the intensive and acute care setting, the primary aim of non-invasive ventilation is to avoid intubation, and it is mainly used in patients with chronic obstructive pulmonary disease exacerbations, acute cardiogenic pulmonary oedema, or in the context of weaning, situations in which a reduction in mortality has been demonstrated. The principal techniques are continuous positive airway pressure and bilevel pressure support ventilation. Whereas non-invasive pressure support ventilation requires a ventilator, continuous positive airway pressure is a simpler technique that can be easily used in non-equipped areas such as the pre-hospital setting. The success of non-invasive ventilation is related to the adequate timing and selection of patients, as well as the appropriate use of interfaces, the synchrony of patient-ventilator, and the fine-tuning of the ventilator.

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