EMERGENCY MEDICINE PRACTICE

A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E

Noninvasive Airway Management Techniques: How And When To Use Them

The old fellow is looking grim. Hes sweating profusely, and his lips are blue. Hes been here beforethree episodes of CHF in the past year. The nitro drip is running, but the blood pressure is marginal. He isnt responding to the furosemide. As you call for the airway cart, he suddenly becomes more alert. The old man grabs your arm and in a strained but unmistakable voice, gasps, Nono tube. ATIENTS in respiratory distress are among the most frustrating, frightening, and challenging patients seen by the emergency physician. They arrive with a state of severe anxiety, intense physical effort, and may wear out as the clinician attempts to get a history. Indeed, among the most common ED complaints are SOB (short of breath) and not getting enough airboth of which can stem from myriad causes, such as asthma, chronic obstructive pulmonary disease (COPD), and pulmonary edema. Noninvasive ventilation (NIV) is the technique of augmenting respirations without a tracheostomy or endotracheal intubation. The application of this technique to emergency and critical care patients received much attention during the 1980s and 1990s. It is the subject of numerous commentaries, review articles, editorials, physiologic investigations, case studies, and randomized, controlled clinical trials.1 But what is its role in the day-today practice of emergency medicine? What is the evidence? This issue of Emergency Medicine Practice explores this controversial and evolving topic. (It also complements two prior issues of Emergency Medicine Practice: Emergency Endotracheal Intubations: An Update On The Latest Techniques, published in May 2000, and Dyspnea: Fear, Loathing, And Physiology, published in August 1999.)

July 2001
Volume 3, Number 7
Author Charles Stewart, MD, FACEP Colorado Springs, CO. Peer Reviewers Michael S. Radeos, MD, MPH Clinical Assistant Professor of Emergency Medicine in Medicine, Weill Medical College of Cornell University, Lincoln Medical and Mental Health Center, Bronx, NY. David Della-Giustina, MD Program Director, MadiganUniversity of Washington Emergency Medicine Residency, Tacoma, WA. CME Objectives Upon completing this article, you should be able to: 1. discuss the advantages of both endotracheal intubation and noninvasive ventilation; 2. describe the techniques and indications for both CPAP and BiPAP; 3. summarize the current evidence relating to the use of noninvasive ventilation for COPD, pulmonary edema, asthma, and other conditions; and 4. list the contraindications and potential complications of noninvasive ventilation.

Date of original release: July 2, 2001. Date of most recent review: June 29, 2001. See Physician CME Information on back page.

Editor-in-Chief
Stephen A. Colucciello, MD, FACEP, Assistant Chair, Director of Clinical Services, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC; Associate Clinical Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Associate Editor
Andy Jagoda, MD, FACEP, Professor of Emergency Medicine; Director, International Studies Program, Mount Sinai School of Medicine, New York, NY.

Editorial Board
Judith C. Brillman, MD, Residency Director, Associate Professor, Department of Emergency

Medicine, The University of New Mexico Health Sciences Center School of Medicine, Albuquerque, NM. W. Richard Bukata, MD, Assistant Clinical Professor, Emergency Medicine, Los Angeles County/ USC Medical Center, Los Angeles, CA; Medical Director, Emergency Department, San Gabriel Valley Medical Center, San Gabriel, CA. Francis M. Fesmire, MD, FACEP, Director, Chest PainStroke Center, Erlanger Medical Center; Assistant Professor of Medicine, UT College of Medicine, Chattanooga, TN. Valerio Gai, MD, Professor and Chair, Department of Emergency Medicine, University of Turin, Italy. Michael J. Gerardi, MD, FACEP, Clinical Assistant Professor, Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Childrens Medical

Center, Atlantic Health System; Vice-Chairman, Department of Emergency Medicine, Morristown Memorial Hospital. Michael A. Gibbs, MD, FACEP, Residency Program Director; Medical Director, MedCenter Air, Department of Emergency Medicine, Carolinas Medical Center; Associate Professor of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC. Gregory L. Henry, MD, FACEP, CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI; Clinical Professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; President, American Physicians Assurance Society, Ltd., Bridgetown, Barbados, West Indies; Past President, ACEP. Jerome R. Hoffman, MA, MD, FACEP, Professor of Medicine/ Emergency Medicine, UCLA

School of Medicine; Attending Physician, UCLA Emergency Medicine Center; Co-Director, The Doctoring Program, UCLA School of Medicine, Los Angeles, CA. John A. Marx, MD, Chair and Chief, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC; Clinical Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC. Michael S. Radeos, MD, MPH, FACEP, Attending Physician in Emergency Medicine, Lincoln Hospital, Bronx, NY; Research Fellow in Emergency Medicine, Massachusetts General Hospital, Boston, MA; Research Fellow in Respiratory Epidemiology, Channing Lab, Boston, MA. Steven G. Rothrock, MD, FACEP, FAAP, Associate Professor of Emergency Medicine,

University of Florida; Orlando Regional Medical Center; Medical Director of Orange County Emergency Medical Service, Orlando, FL. Alfred Sacchetti, MD, FACEP, Research Director, Our Lady of Lourdes Medical Center, Camden, NJ; Assistant Clinical Professor of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA. Corey M. Slovis, MD, FACP, FACEP, Department of Emergency Medicine, Vanderbilt University Hospital, Nashville, TN. Mark Smith, MD, Chairman, Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Thomas E. Terndrup, MD, Professor and Chair, Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL.

History And Technology

Three modes of NIVcontinuous positive airway pressure support, bi-level airway pressure support (also called pressure support ventilation), and external negative pressure ventilation (the iron lung)are welldescribed in the literature. Current equipment uses the positive pressure technique, in which respirations are aided through the use of increased airway pressure. The use of positive airway pressure was first reported in the 1930s, when facemasks powered by vacuum cleaners were used to treat pulmonary edema.2 A few years later, World War II aviators used pressure masks to supply oxygen at high altitudes. These early technologies evolved into todays mechanical ventilators. The endotracheal tube came into routine use during the early 1960s. Advances in the late 1970s and early 1980s brought two methods of noninvasive positive pressure ventilation. Continuous positive airway pressure (CPAP) ventilation improved oxygen exchange in patients with hypoxemia and acute respiratory failure. Intermittent positive pressure ventilation (IPPV) was introduced as an inspiration-triggered, momentary boost of positive airway pressure. It was initially used to rest the respiratory muscles in patients with respiratory fatigue. Twenty years ago, intermittent positive pressure breathing (IPPB) was used in asthmatic patients to reduce the work of breathing, deposit aerosolized agents deep into the respiratory tree, and improve drainage. Most of these claims have since been repudiated, and IPPB is no

longer routine in the treatment of asthma. Bi-level positive airway pressure (BiPAP) devices also give positive airway pressure throughout the respiratory cycle. They use a higher inhalation pressure (IPAP) and a lower pressure during exhalation (EPAP).3 When the spontaneous mode of a BiPAP machine is used, it functions as a flow-triggered pressure support ventilator. (BiPAP is actually a trade name for a machine produced by Respironics.) In the past, external negative pressure ventilation (the iron lung) was used to manage acute and chronic respiratory failure. These negative pressure or tank ventilators of the 1950s were a form of NIV that did not require a spontaneously breathing patient. Modern literature is essentially devoid of articles on external negative pressure ventilation, and few hospitals have this equipment available.4

State Of The Literature

Multiple authors have studied NIV in patients in acute respiratory failure.5-12 Most compare NIV with intubation and use subsequent intubation as evidence of failure of NIV. While intubation is unavoidable in some patients, most studies show that NIV can prevent the need for mechanical ventilation in appropriately selected patients. Only one study concluded that NIV would delay intubation and subsequently result in increased mortality.13 Much of the literature on NIV suffers from the usual pitfalls, such as lack of randomization, lack of blinding, or differences between the groups. Some

Abbreviations Associated With Noninvasive Ventilation

AC: Assist control mode of respiration. The patient triggers ventilation when he or she inspires. (The ventilator should have a backup mode to ensure that a set number of breaths per minute are taken.) ACPE: Acute cardiogenic pulmonary edema. ARF: Acute respiratory failure. BiPAP: Bi-level positive airway pressure. BiPAP is pressure support ventilation with expiratory positive airway pressure. (Also, the trade name for the machine.) CHF: Congestive heart failure. CMV: Continuous mandatory ventilationthe most basic of ventilation assistance. There is no provision for patient-assisted breaths or spontaneous breaths. All paralyzed patients will be on CMV. CPAP: Continuous positive airway pressure. EPAP: Expiratory positive airway pressure. IMV: Intermittent mandatory ventilationthe ventilator allows patients to breathe independently of the ventilator, with a set minimum respiratory rate. IPAP: Inspiratory positive airway pressure. NIV: Noninvasive mechanical ventilation. PEEP: Positive end expiratory pressure. PEEP is provided by valves on the exhalation limb of the ventilator s circuit and is set by the therapist. PEFR: Peak expiratory flow rate. PSV: Pressure support ventilation. BiPAP is a subset of pressure support ventilation with EPAP applied. SIMV: Synchronized intermittent mandatory ventilation. The ventilator has both a set rate and assists with ventilatory efforts if the patient does not breathe spontaneously. Replaces IMV in most modern ventilators. Vt: Tidal volume.

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July 2001

studies are less than clear regarding inclusion and exclusion criteria. When evaluating studies of NIV vs. endotracheal intubation, one must be aware that any true comparison suffers from an unavoidable selection bias. In order to be randomized to NIV, the patient must be awake and cooperative. Once randomized to NIV, a patient who deteriorates must immediately be treated with endotracheal intubation. The best studies strictly define criteria for subsequent intubation prior to patient enrollment. The best evidence regarding the use of NIV in the acutely ill patient involves the treatment of COPD, and this fact is reflected in recent clinical guidelines. A joint panel from the American College of PhysiciansAmerican Society of Internal Medicine (ACPASIM) and the American College of Chest Physicians (ACCP) recently published a position paper on the management of acute exacerbations of COPD. 14 On the basis of five randomized, controlled trials and five observational studies, the authors concluded that noninvasive positive pressure ventilation [NPPV] is a beneficial support strategy that decreases risk for invasive mechanical ventilation and possibly improves survival in selected hospitalized patients with respiratory failure.

traditional gold standard for the management of acute respiratory failure of any etiology. A deviation from this standard must offer either fewer risks or greater benefits to the patient and should be based on strong evidence. The data show that in appropriately selected patients, NIV may improve survival, increase patient comfort, and decrease the cost of hospitalization.

Problems With Intubation

Despite the well-established position as the gold standard in respiratory failure, there are definite non-trivial risks associated with endotracheal intubation. Misplacement of the tube may have lethal consequences, including trauma to the airway, esophageal intubation, and aspiration. Other hazards during the intubation attempt include failure to intubate, hypoxia, bronchoconstriction, and increased intracranial pressure. A variety of infections result from intubation. Four to eight percent of patients will experience clinically significant aspiration during the act of intubation.19 Subsequent ventilator-associated pneumonias are frequent and may occur in 20%-25% of all patients intubated for more than 48 hours.20,21 Sinusitis is a delayed complication of nasal intubation.22 In addition to infectious complications, placing a patient on a ventilator may ultimately weaken the respiratory muscles.23 This is a significant factor during the weaning process in a patient with respiratory disease. Intubation is also uncomfortable. Agitation is so common that sedation must be routine. Finally, even if the patient is awake, he or she is unable to eat, drink, or speak with a tube through the vocal cords.

Physiology And Noninvasive Ventilation

Respiratory failure can result from either hypoxia or hypercapnia, both of which are amenable to NIV. NIV improves lung mechanics by recruiting atelectatic alveoli, improving pulmonary compliance, and reducing the work of breathing. Increasing mean airway pressure forces oxygen across the alveolar membrane in patients with underlying pulmonary disease.15 In addition, positive airway pressure reduces venous return to the heart. In most patients, this decrease in preload is inconsequential. In one study of 19 patients with COPD and acute ventilatory failure, the authors found no significant changes in pulmonary artery pressures and cardiac output by Doppler echocardiography in 15 patients; four patients (21%) showed a significant reduction (> 15%) of cardiac output during NIV.16 NIV, however, can cause a variety of negative physiologic effects. Some patients may strain against the ventilator and increase the work of breathing. Increased intrathoracic pressure can decrease venous return and thus cardiac output in those with marginal cardiac function.17 In some patients, the increased airway pressure may cause overdistension of the alveoli and produce barotrauma in acutely injured lungs.18

Advantages Of Noninvasive Ventilation

NIV may have significant advantages over endotracheal intubation. First, it is significantly less expensive than mechanical ventilation, and hospital stays may be shorter. Patients require less sedation, experience less muscle weakness, and have fewer complications, including infections.

Technique Of Noninvasive Mechanical Ventilation

Equipment
NIV may be provided by a machine designed specifically for this task, or by a traditional, full-capacity ventilator capable of the appropriate settings. The respiratory rate may either vary with patient demand or remain fixed at a set rate. Similar flexibility is available for the delivery mode that can give the patient either a desired volume or pressure. Both pressure- and volume-limited modes have been used successfully for NIV.

Management Of Respiratory Failure

IntubationThe Gold Standard
Endotracheal intubation and subsequent mechanical ventilation are lifesaving therapies in many cases of respiratory failure. Indeed, endotracheal intubation is the

Volume-Limited Ventilation
If volume-based NIV is used, the ventilator delivers a set flow to the patient for a timed interval. Unfortunately, if there is a leak at the patients mask or along the tubing,

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Emergency Medicine Practice

the patient will not receive the specified volume. Leaks in a mask secured with straps can develop quickly, especially in the restless patient. For this reason, some authorities recommend that volume-based NIV not be used for acutely ill patients (or, at least, it should be used with extreme caution).1 The actual data on this are mixed. A recent study showed that respiratory comfort (assessed by visual analog scale) was greater in patients who received pressure support ventilation compared to the volume mode.24 However, the work of breathing was diminished to a greater extent in the volume mode.

Continuous Positive Airway Pressure

CPAP delivers a static airway pressure maintained throughout both the inspiratory and expiratory cycle. CPAP is functionally equivalent to positive end expiratory pressure (PEEP) used in the intubated patient. To compensate for leaks, CPAP devices regulate airflow to maintain a set pressure. The amount of positive airway pressure can be adjusted to meet clinical needs. Generally, 5-10 cmH2O is the most common, and pressures above 15 cmH2O are rarely needed (or tolerated).25 (See also Table 1.)

Bi-level Positive Airway Pressure

BiPAP delivers continuous positive airway pressure coupled with inspiratory pressure support. The machine allows a different level of inspiratory and expiratory pressure support. Theory holds that positive expiratory pressure is functionally equivalent to CPAP, while the positive inspiratory pressure will further decrease the work of breathing. These two levels are clinically matched to patient demands. The BiPAP machine cycles between a targeted peak inspiratory pressure (inspiratory peak airway pressure [IPAP]) and a lower end expiratory pressure (expiratory peak airway pressure [EPAP]). The latter may also be called the peak end expiratory pressure. (The abbreviation may be confused with positive end expiratory pressure.) The ventilation achieved will vary with patient effort and with the compliance of the lungs. The BiPAP machine, however, can easily be programmed by the respiratory therapist to deliver CPAP instead of bi-

level pressure. Pressure support is an important concept. The level of pressure support in BiPAP is equivalent to the difference between the inspiratory and expiratory pressures (that is, IPAP minus EPAP equals pressure support). The cycle may be fixed in the machine as a function of time, or the machine may have an algorithm that terminates the cycle when inspiratory flow declines to a preset level. If the inspiratory phase is too prolonged, then the patient must actually work against the mechanical inspiration in order to exhale. This markedly increases the patient discomfort and, more importantly, the patients work of breathing. The ventilator must be properly adjusted so that the peak flow and the patients demand are synchronized. If the patient is both dyspneic and strong, then the ventilator must generate enough flow to meet the inspiratory pressure. If the ventilator cannot provide an adequate flow, then the patient will work harder by trying to suck air from the machine. Conversely, if the ventilator exceeds demand, then the patient will be uncomfortable, and gastric distention may result. Supplemental oxygen can be supplied through the tubing or may be added directly to the mask. Because the supplemental oxygen will be diluted by the high flow through the system, high concentrations of oxygen may be needed.

Proportional Assist Ventilation

Proportional assist ventilation is a new NIV technique in which the ventilator generates pressure in proportion to the patients effort. The applied pressure is designed to overcome the elastic and resistance loads in proportion to the patients volume and flow of breathing. This technique has been described in seven patients with an acute exacerbation of COPD.9 Although the initial report appears promising, more research is needed before any recommendation can be made.

Patient Selection
An alert and cooperative patient is critical for initiating NIV. (See also Table 2.) Patients who have CO2 narcosis

Table 1. Advantages And Disadvantages Of CPAP.

Advantages Improves pulmonary function Improves gas exchange Reduces inspiratory threshold pressure Reduces venous return to the heart Increases functional residual capacity May increase or decrease cardiac output depending on underlying pathology Disadvantages Reduces venous return to the left ventricle (this may also be an advantage) Potential for aspiration if patient vomits

Table 2. Indications For Noninvasive Ventilation.

NIV is considered highly effective in treatment of: Acute exacerbation of COPD Obstructive sleep apnea NIV may be effective for: Cardiogenic pulmonary edema without shock (CPAP, not BiPAP) Respiratory failure in patients with cystic fibrosis or neutropenia and fever Asthma Pneumonia Near-drowning The patient who is not a candidate for intubation

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from COPD may be an exception to this requirement. A significant number of these patients will improve mentation within 30 minutes during NIV, resulting in fewer intubations.26 NIV should be avoided in patients who cannot handle their secretions, who have life-threatening refractory hypoxemia (PaO2 < 60 mmHg on 100% inspired oxygen), or who are hypotensive.1,26 These patients are more appropriately managed with intubation and mechanical ventilation.

dead space, causes less claustrophobia, and minimizes aspiration if vomiting occurs.

Nasal Pads
A variant of the nasal mask is nasal pads or plugs. This device fits within the patients nostrils and delivers gas directly into the nose. The nasal pads decrease skin irritation across the bridge of the nose, at the expense of irritation within the nostrils.

Sedation Initiating Pressure Support

If NIV is to be successful, a management approach that emphasizes the earlier, the better may be helpful. One small study suggested that when NIV is available within minutes, some patients with severe new-onset respiratory distress may be spared intubation.27 Other studies confirm this finding.7 Keeping the CPAP or BiPAP machine in the ED permits such early intervention. Although NIV is generally well-tolerated, patients will often require coaching when starting therapy. The respiratory therapist should hold the mask to the patients face in the initial phase to allow the patient to become familiar with the mask and the high airflow. Providing reassurance and adequate explanations to the patient is critical. Patients should be instructed to call the nurse if they need to remove the mask to expectorate, if they develop abdominal distention, or if they become nauseated. During NIV, the patient rarely requires sedation; indeed, it interferes with patient cooperation. Extremely anxious patients are unsuitable candidates for NIV and may require endotracheal intubation and sedation. If necessary, moderately anxious patients may be given a small amount of morphine sulfate or a benzodiazepine. The clinician should carefully assess each patient to ensure that agitation is psychological and not due to worsening hypoxia, hypercarbia, hypovolemia, or hypotension.

Machine Settings
CPAP Settings
If CPAP is used, start with low pressures (5 cmH2O) and increase in increments of 2 cmH2O as tolerated by the patient. Respiratory goals may include an exhaled tidal volume greater than 7 mL/kg, a respiratory rate of less than 25, oxygen saturation greater than 90%, and perhaps most important, patient comfort.28

Mask Selection: Nasal Mask Or Facemask?

The choice in an ED is usually between a full facemask and a nasal mask. Both devices are effective, and the ED should have several types of masks available. A comfortable and properly fitted mask is important. Although a tight fit will decrease leakage from the mask, it may be too uncomfortable for the patient. Small degrees of air leakage are acceptable as long as the tidal volume is greater than 7 mL/kg.28 A proper fit may be quite difficult in edentulous patients and those with a beard or substantial mustache. Nasal pads may be more appropriate for these patients. In certain individuals, tincture of benzoin applied to the facial skin provides a better mask-face seal.

BiPAP Settings
With BiPAP, the IPAP setting may range from 4-24 cmH2O, while the EPAP setting may vary from 2-20 cmH2O. Typical initial settings for BiPAP are levels of 8-10 cmH2O IPAP and 2-4 cmH2O EPAP. These settings presume that the lower pressures will allow patient tolerance and training. When using BiPAP, remember that the inspiratory pressure must be maintained higher than the expiratory pressure at all times to ensure bi-level flow. Flow must be synchronized with patient respiratory efforts.

Pressure Support Ventilation Settings

Typical initial pressure support ventilation would be 8-10 cmH2O combined with PEEP of 2-4 cmH2O. (This is equivalent to BiPAP with IPAP at 8-10 cmH2O and EPAP at 2-4 cmH2O.)

Facemask
Although the evidence is not conclusive, some believe that facemasks are probably more effective than nasal masks in the acutely ill. Because most dyspneic patients are mouth breathers, masks that cover the mouth may result in less air leakage than nasal masks.28

Indications For Noninvasive Mechanical Ventilation

The most compelling symptom is the inability to breathe.

Nasal Mask
Most studies have used a nasal mask. However, if the mask covers the nostrils only, the airway is depressurized when the patient opens his or her mouth. Nonetheless, nasal masks offer many advantages. Eating, drinking, and talking are relatively easy. The nasal mask adds less

Prehospital Use Of NIV

There are few data on the prehospital use of NIV. In one non-randomized study, patients presumed to have congestive heart failure (CHF) were given BiPAP by the

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medics during transport and were compared to matched controls treated without NIV.29 In this trial, 97% of EMTs who used BiPAP thought it improved patients dyspnea; however, data analysis showed no statistical difference between groups in the length of subsequent hospital stay, intubation, or mortality. Likewise, a European study involving a mobile intensive care unit also showed that aggressive therapy of CHF in the prehospital arena improved symptoms during transport but had no effect on long-term mortality.30

patients with COPD had a lower 12-month mortality rate than matched historical controls who had been intubated (39% vs 50%).41

Pulmonary Edema
Most patients with pulmonary edema can be stabilized in the ED with conventional pharmacologic therapy and supplemental oxygen. However, a small number of patients will present with severe, persistent hypoxemia and respiratory failure that requires assisted ventilation. Multiple clinical trials and case studies conducted over the past 20 years support a role for NIV in the management of pulmonary edema.6,13,42-46 In one retrospective series of emergency patients presenting with acute CHF, use of NIV avoided endotracheal intubation in 91% of the patients in whom it was applied.47 To date, at least four randomized studies have compared CPAP with conventional intubation and pharmacologic therapy in the treatment of patients with pulmonary edema.15,48-50 In the first trial, 40 patients were randomized to a CPAP group or ambient pressure breathing.48 The CPAP group showed a more rapid improvement in oxygenation, a fall in PaCO2, and a better respiratory rate, heart rate, and blood pressure than the ambient pressure group. Six of the CPAP group required intubation compared to 12 in the ambient pressure group.48 In the second trial, 39 patients were randomized to a CPAP or ambient pressure.15 The CPAP group demonstrated similar improvement in monitored respiratory functions and vital signs. However, no patients in the CPAP group required intubation, whereas 35% of patients in the ambient pressure group needed intubation. In the third study, 100 ICU patients were randomized to ambient pressure or CPAP.49 Based on physiologic parameters, the CPAP group did better, demonstrating lower intrapulmonary shunt fraction and alveolar-arterial oxygen gradients as well as increased stroke volume and PaO2. There was also a statistically significant difference in the number of patients who required intubationeight patients in the CPAP group compared to 18 among the controls. The study size was not large enough to demonstrate a decrease in mortality. In the most recent study, 40 patients were randomly assigned conventional oxygen therapy or NIV through a facemask.50 Endotracheal intubation was required in one of 19 patients (5%) assigned NIV and in six of 18 (33%) assigned to ambient oxygen therapy. Patients receiving NIV improved more rapidly than those given simple oxygen. When the results of the first three studies were pooled in a meta-analysis, the CPAP group was shown to have 26% fewer intubations than the ambient pressure group.51 The patients with the most severe respiratory failure seemed to benefit most from NIV. CPAP may even be safe and effective in patients with pulmonary edema due to myocardial infarction. In a prospective, randomized study of 29 patients

Chronic Obstructive Pulmonary Disease

Acute respiratory failure in COPD is associated with significant expiratory obstruction, dynamic hyperinflation, and respiratory muscle fatigue. The end result is hypercapnia followed by respiratory acidosis. NIV can improve this situation.31 Standard medical therapy for COPD consists of inhaled -agonists, anticholinergic agents, systemic steroids, and antibiotics.32,33 When these agents fail, intubation and ventilation for 24-72 hours allow the respiratory muscles to rest with subsequent improvement in ventilation. Usually the decision to intubate is made within the first 24 hours of hospitalization, often during ED therapy.34 There have been at least four randomized, controlled trials comparing NIV to conventional therapy in patients with COPD.12,26,35,36 Most of the data show that NIV results in fewer intubations compared to standard therapy. The studies that compare NIV with standard medical therapy in COPD, both randomized and non-randomized, have examined a variety of endpoints. Two studies show that NIV decreased hospital stays, while a third was too small to show any difference in this parameter.26,35,37 These same studies showed a clear decrease in mortality of the patients treated with NIV. A fourth trial, by Barbe et al, did not demonstrate an advantage in NIV in patients with mild exacerbations of COPD; however, this trial was performed in a non-acute setting, and no patients required intubation.36 There have been several important meta-analyses regarding the use of NIV in COPD.38,39 They show that NIV is of value in treating acute exacerbations of COPD. Study patients have decreased hospital mortality, intubation rates, and length of stay. Furthermore, one economic evaluation noted a cost savings of $3244 for each patient treated with NIV vs. mechanical ventilation.40

Importance Of Early Intervention

In the COPD patient, NIV should be applied as soon as indicated to achieve maximum benefit. In one study, the success rate was 93% when NIV was used early in the course of hospital treatment, while the success rate was only 63% when standard medical therapy was used before NIV.7 Early initiation of NIV not only may help in the acute phase of treatment, but it also may improve longterm prognosis. In one study, the noninvasively treated

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without cardiogenic shock, nasal CPAP improved oxygenation and hemodynamics, as well as demonstrating a decreased mortality rate, compared to ambient oxygen.52

Potential Dangers Of BiPAP In Congestive Heart Failure And Pulmonary Edema

While theoretically beneficial, such clear and compelling evidence does not exist for BiPAP in the treatment of CHF. In several case studies, BiPAP was used for noninvasive respiratory support; intubation rates were comparable to those found in studies using CPAP (about 9% of selected patients).47 Some studies argue directly against the use of BiPAP in CHF. In one randomized clinical trial of BiPAP for

emergency patients with respiratory failure, where the most common diagnosis was pulmonary edema, BiPAP was associated with increased mortality.13 In this same study, there was no reduction in the rate of intubation. These investigators felt that NIV merely delayed intubation in some patients and caused a worse outcome. In another trial of 40 consecutive patients with pulmonary edema, all subjects received standard therapy consisting of oxygen, furosemide, and morphine sulfate.53 Subjects were then randomized to receive either highdose isosorbide-dinitrate vs. BiPAP and standard-dose nitrates. The study was prematurely terminated by the safety committee because of the significant deterioration observed in patients enrolled in the BiPAP arm.
Continued on page 10

Pearls And Pitfalls Of Noninvasive Ventilation

Why should I use NIV in a patient with acute respiratory failure? NIV avoids many of the risks associated with intubation. There is less likelihood of aspiration and fewer nosocomial infections such as pneumonia. Patients are more comfortable and do not require paralysis or sedation. Compared to intubation, NIV is substantially less expensive for both the patient and the hospital. What level evidence is available for NIV? This depends on the indication. For COPD, the evidence for NIV is considered Class II safe, supported, and considered effective for most patients. For the treatment of pulmonary edema, CPAP is not yet a standard of care; however, it is probably safe and effective (Class III ). Note that the current data would suggest that BiPAP is probably not safe in pulmonary edema, in view of the increased number of myocardial infarctions that occurred in one study. For asthma and pneumonia, the evidence is indet erminate. What are the disadvantages of NIV in a patient with acute respiratory failure? Noninvasive airway management takes longer to reverse hypoxia and hypercarbia than does intubation, and the patient requires frequent physician re-evaluation. What are the essential elements of success when NIV is used? The essential elements of success when NIV is used are proper patient selection; close monitoring of the patient by physician, nursing, and respiratory therapy staff; and careful attention to patient comfort. There is a steep learning curve for the patient with these devices, and titration should be in the hands of an experienced respiratory therapist. Of course, the underlying condition should be aggressively treated while the ventilator is working. What is the difference between CPAP, pressure support ventilation, and BiPAP? CPAP devices hold a constant positive airway pressure throughout the respiratory cycle. They may be full-service ventilators or devices specifically constructed for this purpose. BiPAP devices also give a positive airway pressure throughout the respiratory cycle, with a higher inhalation pressure (IPAP) and a lower pressure during exhalation (EPAP).3 (BiPAP is actually a trade name for the machine.) When does a patient need intubation rather than NIV? The decision to intubate should be made immediately if the patient suffers a loss of consciousness, worsening respiratory status, or hemodynamic instability. It may be made later if there is worsening blood gases or no improvement after a set period of time. When can the physician discontinue NIV in the ED? This requires a weaning process, and close observation of the patient is essential. Clinically, NIV can be discontinued when the patient s oxygenation can be maintained at 90% saturation or better with 4 L/min or less of supplemental oxygen, and when the respiratory rate is less than 24. At least one study resumed respiratory support if the respiratory rate increased to greater than 30 respirations per minute, the oxygen saturation fell below 90% despite 4 L/min of supplemental oxygen, or PaCO2 increased by 5 mmHg.42 v

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Emergency Medicine Practice

Clinical Pathway: Management Of Patients With Hypoxia And/Or Hypercapnia Unresponsive To Supplemental Oxygen Or Other Conventional Interventions
Significantly altered mental status? Profound hypoxia? Yes Apnea? Intubate (Class I-II) Inability to protect airway? Shock? Recent gastric, laryngeal, or esophageal surgery? No Yes Failure to improve despite oxygen, -agonists, anticholinergics, and steroids? Acute exacerbation of COPD?

Congestive heart failure? No

Yes Cystic fibrosis? Febrile neutropenia? No

Yes Pneumonia? Near-drowning? Failure to improve despite maximal conventional therapy? Asthma? No Yes Other causes of respiratory failure?

Yes Do Not Intubate patient?

The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright 2001 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited copying privileges for educational distribution within your facility or program. Commercial distribution to promote any product or service is strictly prohibited. Emergency Medicine Practice 8 July 2001

No

Yes

Go to Clinical Pathway: Noninvasive Ventilation (Class II)

Continue conventional therapy (Class II)

No

Yes

Failure to improve despite oxygen, nitrates, ACE inhibitors, and diuretics? Yes

Go to Clinical Pathway: Noninvasive Ventilation (Class III)

Go to Clinical Pathway: Noninvasive Ventilation (Class III)

Continue conventional therapy (Class II)

No

No

Go to Clinical Pathway: Noninvasive Ventilation (Class indeterminate)

Continue conventional therapy (Class indeterminate)

Go to Clinical Pathway: Noninvasive Ventilation if patient and/or family desire prolongation of life (Class indeterminate)

Clinical Pathway: Noninvasive Ventilation

Vomiting? Agitation? Yes Acute trauma? Cardiac arrhythmias? Cardiac ischemia or acute myocardial infarction? Consider intubation or further conventional therapy (Class III)

No

Explain procedure to patient Show them and apply the mask Ensure patient is on monitor and pulse oximeter Ensure adequate personnel to monitor patient

CPAP settings: Start with low pressures (5 cmH2O) and increase in increments of 2 cmH2O as tolerated by the patient. BiPAP* settings: Typical initial settings for BiPAP are levels of 8-10 cmH2O IPAP and 2-4 cmH2O EPAP. Titrate to effect. IPAP may range from 4-24 cmH2O while EPAP may vary from 2-20 cmH2O. *Note: Do not use BiPAP for treatment of CHFuse CPAP instead. (Class indeterminate)

Titrate settings to achieve the following goals: Patient comfort Oxygen saturation greater than 90% Respiratory rate less than 25 Exhaled tidal volume greater than 7 mL/kg (Class indeterminate)

Stop NIV and consider intubation or other interventions if: Respiratory arrest or progressive distress Increasing agitation, lethargy, or confusion Arterial pH below 7.30 that does not rapidly improve Persistent hypoxia Cardiac arrhythmias Hemodynamic instability Persistent vomiting or increased secretions (Class II)
The evidenc e for recommenda tions is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.

This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright 2001 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited copying privileges for educational distribution within your facility or program. Commercial distribution to promote any product or service is strictly prohibited. July 2001 9 Emergency Medicine Practice

Continued from page 7

Another small trial randomized BiPAP vs. CPAP in patients with acute pulmonary edema.42 Although BiPAP lowered the blood pressure, respiratory rates, and improved ventilation better than CPAP, this study was also terminated prematurely because patients treated with BiPAP had significantly more myocardial infarctions (71% vs 38%). The investigators argued that at least a few of the myocardial infarctions were present before the initiation of BiPAP, and surmised that higher intrathoracic pressures associated with BiPAP may have decreased myocardial perfusion. They recommended further studies using lower settings of BiPAP and more stringent exclusion of myocardial infarctions. Other reviewers suggested that inadequate supervision of the patients, inadequate randomization, and inadequate data collection during the study contributed to the additional mortality in the BiPAP arm.54 Although another recent study showed no significant complications in 20 patients with CHF who were treated with BiPAP,10 this study is too small to have substantial clinical significance. Because of these concerns regarding myocardial infarction, CPAP appears to be a better modality in pulmonary edema than BiPAP.

group (9% vs 64%; P = 0.02). However, this single study is probably not sufficient to change current practice. Validation through subsequent randomized, controlled trials remains to be seen.

Other Indications Near-Drowning

Patients who are not spontaneously breathing require intubation. In such patients, NIV is simply not an option. However, some near-drowning victims have spontaneous respirations and go on to develop non-cardiogenic pulmonary edema. While NIV is effective in these isolated cases,61 there are no large series that document its utility for this indication.

Cystic Fibrosis
NIV may be an alternative to intubation in the patient with cystic fibrosis who presents to the ED in respiratory failure. The one-year mortality rate in patients intubated for cystic fibrosis is 94%.62 While lung transplantation can improve survival, donors are in short supply. NIV may help bridge the time between the onset of respiratory failure and the availability of a lung transplant.57 One case series of eight patients bolsters this theory.62 The patient who fails NIV can be subsequently intubated if necessary.

Asthma
Status asthmaticus is defined as an exacerbation of asthma that is unresponsive to acute pharmacological therapy. (See also the February 2001 issue of Emergency Medicine Practice, Asthma: An Evidence-Based Management Update.) Patients with status asthmaticus have a significant increase in both inspiratory and expiratory obstruction that leads to respiratory fatigue and carbon dioxide retention. In recent years, the number of asthmatics who develop acute respiratory failure has risen significantly.55,56 Theoretically, the use of NIV would be expected to aid the asthmatic patient in a fashion similar to its wellstudied use in COPD. Researchers postulate that NIV should decrease airflow obstruction, re-expand atelectasis, reduce the work of breathing, and rest the diaphragm and inspiratory muscles. Unfortunately, the potential utility of NIV in asthmatics has not yet been substantiated by much evidence.57 A few case studies that have reported the use of NIV in patients with severe asthma suggest a decreased number of intubations.6,58,59 There are few randomized, controlled studies that evaluate only asthmatics. In one study, mild-tomoderate asthmatics were randomized to those given -agonists via IPPB vs. standard nebulization.60 The group that received the IPPB had greater improvement in their peak expiratory flow rate (PEFR) compared to controls. Two patients (18%) in the CPAP group and eight patients (73%) in the oxygen group required endotracheal intubation. Similarly, the mortality in the CPAP group was significantly lower than the oxygen

Obstructive Sleep Apnea

Noninvasive pressure support ventilation has long been used to provide respiratory support for patients with sleep apnea and obesity hypoventilation.63,64 A large body of literature documents its usefulness for this chronic condition. The sleep apnea patient who presents acutely with hypercapnia or hypoxia may also benefit from NIV.57 Intubation in these patients is often more difficult due to morbid obesity.

Do Not Intubate Patients

Patients with a variety of illnesses, including advanced age, poor physiologic condition, or terminal illness (such as cancer or terminal respiratory failure) may be unsuitable candidates for endotracheal intubation. NIV may give these patients time to complete life-closure tasks. Others may improve enough to be discharged from the hospital to hospice care.65

Neutropenic Patients With Respiratory Failure

Patients who have been treated with aggressive chemotherapy and immunosuppression for hematologic malignancies may develop respiratory infections and other respiratory complications. Such complications may include alveolar hemorrhage, graft-versus-host disease, idiopathic pneumonia syndrome, and drug or radiation toxicity.66 Unfortunately, in these neutropenic patients, endotracheal intubation is associated with in-hospital mortality rates in excess of 90%.67 In one small study of neutropenic patients with respiratory failure, CPAP reduced intubation by

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25%, and all responders to CPAP survived.66 Subsequent studies confirm the value of NIV in the immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure.68

Pneumonia
The literature regarding the utility of NIV in pneumonia is mixed. One prospective, randomized study compared standard treatment plus NIV delivered through a facemask to standard treatment alone in 56 patients with severe community-acquired pneumonia.69 In those patients with pneumonia and COPD, NIV reduced the need for endotracheal intubation and shortened ICU stays. Other studies also suggest that NIV may improve outcomes in some patients with community-acquired pneumonia.8,28,70,71 NIV has also been well-described in the treatment of respiratory failure due to Pneumocystis carinii.72 However, some data indicate that patients with pneumonia are the ones most likely to fail NIV.73 In one small study that included 16 patients with pneumonia as a primary cause of respiratory distress, NIV failed to prevent the need for intubation.11 Clearly, further research regarding the utility of CPAP or BiPAP in pneumonia is necessary.

Contraindications To Noninvasive Ventilation

NIV with positive pressure generally requires an alert, breathing patient. (Table 3 summarizes some contraindications to NIV.) The hypercapnic COPD patient with mild alterations of mental status may improve rapidly when NIV is started, but such a patient must be carefully monitored. If the patient is unable to cooperate with fitting or wearing a mask, then NIV is not appropri-

ate. Both apnea and coma are absolute contraindications to NIV. If the patient requires a definitive airway for prevention of aspiration or management of secretions, then intubation will be necessary. Significant facial trauma may make the mask seal that is necessary for NIV impossible. Because of concerns regarding tension pneumothorax, patients with a pneumothorax or significant chest trauma are not candidates for NIV (although the use of NIV to treat a patient with severe chest trauma has been described74). Hemodynamic instability is generally considered an absolute contraindication for NIV, while myocardial infarction and ventricular arrhythmias are relative contraindications. Patients with excessive secretions are poor candidates for NIV, particularly with a full facemask. Frequent expectoration interferes with positive pressure as the patient opens his or her mouth, even with a nasal mask. Although the possibility of barotrauma or disruption of a healing wound is small, it could be catastrophic in the postoperative patient. For this reason, the patient with recent tracheal, oropharyngeal, esophageal, or gastric surgery should not undergo NIV. While a recent tracheostomy or an open tracheal stoma is a contraindication, a remote, healed tracheostomy (with no open stoma) is not.

Complications Of NIV
There is a low rate of complications associated with NIV, and most are not dangerous.5 The most pressing, of course, is failure of the technique (as described in a subsequent section). (See also Table 4.)

Local Complications Table 3. Contraindications To Noninvasive Ventilation.

Absolute Apnea Shock Inability to protect the airway Significantly altered mental status Pneumothorax Recent gastric, laryngeal, or esophageal surgery Significant facial fractures (especially those involving cribriform plate) Inability to cooperate with fitting and wearing mask Rapid deterioration Inadequate staff to closely monitor patient for deterioration Relative Nausea and vomiting Agitation Cardiac arrhythmias Cardiac ischemia or acute myocardial infarction (an absolute contraindication in some studies) Significant chest trauma Facial skin necrosis occurs in about 10%-15% of NIV patients.35,40-42,69 A skin patch or non-adherent dressing may be applied over the bridge of the nose to prevent erosions.

Systemic Complications
While pneumonia is far less common in patients treated with NIV than with intubation, it can still occur.8 Barotrauma, however, is possible with any positive pressure ventilation technique. This is particularly true when patients with underlying pulmonary disease are subjected to high airway pressures. Nonetheless, reports of barotrauma (including pneumomediastinum and pneumothorax) occurring during NIV are

Table 4. Complications Of Noninvasive Ventilation.

Facial skin necrosis Pneumonia Gastric distention Barotrauma Failure of the technique

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extremely rare.75 Gastric distention is also uncommon with NIV (about 2%-5%). Gastric distention is decreased when the peak positive pressure is less than the resting upper esophageal sphincter pressure (33 12 mmHg).76 Nurses and therapists should examine patients frequently for signs of abdominal distention, as this may lead to vomiting and subsequent aspiration. If distention occurs, insert a nasogastric tube and apply suction.

have intubation equipment at hand and experienced practitioners readily available to intubate the failing patient. v

References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
1.* Hotchkiss JR, Marini JJ. Noninvasive ventilation: An emerging supportive technique for the emergency department Ann Emerg Med 1998;32:470-479. (Review; 53 references) 2. Poulton EP, Oxon DM. Left-sided heart failure with pulmonary oedema: Its treatment with the pulmonary plus pressure machine. Lancet 1936;231:981-983. (Anecdotal report; included for historical interest only) 3. Lim CM. Renaming BiPAP. Crit Care Med 2000;28:2180. (Letter to the editor) 4. Corrado A, Bruscoli G, Messori A, et al. Iron lung treatment of subjects with COPD in acute respiratory failure: evaluation of short- and long-term prognosis. Chest 1992;101:692-696. (Retrospective; 105 adult patients) 5.* Martin TJ, Hovis JD, Costantino JP, et al. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Am J Respir Crit Care Med 2000;161(3 Pt 1):807-813. (Prospective, comparative, randomized, controlled; 61 patients) 6. Pollack C Jr, Torres MT, Alexander L. Feasibility study of the use of bilevel airway pressure for respiratory support in the emergency department. Ann Emerg Med 1996;27:189192. (Convenience sample; 50 adult patients) 7. Celikel T, Sungur M, Ceyhan B, et al. Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest 1998;114:1636-1642. (Randomized, prospective; 30 adult patients) 8.* Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429-435. (Randomized; 64 adult patients) 9. Vitacca M, Clini E, Pagani M, et al. Physiologic effects of early administered mask proportional assist ventilation in patients with chronic obstructive pulmonary disease and acute respiratory failure. Crit Care Med 2000;28:1791-1797. (Prospective physiologic trial; 7 adult patients) 10. Poponick JM, Renston JP, Bennett RP, et al. Use of a ventilatory support system BiPAP for acute respiratory failure in the emergency department. Chest 1999;116:166171. (Case series; 58 adult patients) 11.* Wysocki M, Tric L, Wolff MA, et al. Noninvasive pressure support ventilation in patients with acute respiratory failure. A randomized comparison with conventional therapy. Chest 1995;107:761-768.

Failure Of The Technique

The most common complication of NIV is failure of the technique. Close monitoring of the respiratory rate, exhaled tidal volume, oxygen saturation, use of accessory muscles, dyspnea level, and blood gases clearly plays a role in successful therapy. When the patient is obviously not improving, then the clinician should strongly consider intubation. (See also Table 5.) The decision to intubate should be made immediately if the patient suffers a loss of consciousness, worsening respiratory status, or hemodynamic instability. The decision is less urgent if there is a gradual worsening of blood gases or no improvement after a set period of time.

Summary
NIV may be the preferred initial treatment of patients with hypercapnic acute respiratory failure in whom the clinical condition can be readily reversed, when airway control is not needed, and when the patient is hemodynamically stable. Postponing intubation appears to be the major complication, and in most patients this does not appear to have serious consequences. NIV is a complex and labor-intensive venture. It requires experienced nursing and respiratory staff who are able and willing to closely monitor the critical patient. For this reason, it may not be suitable for the overcrowded and understaffed ED. Success will entail a partnership with respiratory therapy to effectively utilize NIV, and using the equipment frequently may improve expertise. Keeping a machine in the ED can maximize early intervention. When starting this procedure, it is essential to

Table 5. Reasons To Abandon Noninvasive Ventilation.

Respiratory arrest Respiratory rate greater than 35 Progressive respiratory distress Loss of consciousness Arterial pH below 7.30 that does not rapidly improve Persistent hypoxia despite supplemental oxygenation Bradycardia or significant tachycardia Hemodynamic instability Increasing agitation, lethargy, or confusion Vomiting or increased secretions

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(Randomized; 41 adult patients) 12.* Kramer N, Meyer TJ, Meharg J, et al. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Resp Crit Care Med 1995;151:1799-1806. (Randomized; 31 adult patients) 13. Wood KA, Lewis L, Von Harz B, et al. The use of noninvasive positive pressure ventilation in the emergency department. Results of a randomized clinical trial. Chest 1998;113:1339-1346. (Randomized; 27 adult patients) 14.* Bach PB, Brown C, Gelfand SE, et al. American College of PhysiciansAmerican Society of Internal Medicine. American College of Chest Physicians. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med 2001;134(7):600-620. (Meta-analysis, guideline) 15.* Bersten AD, Holt AW, Vedig AE, et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 1991;325:1825-1830. (Randomized; 39 adult patients) 16. Confalonieri M, Gazzaniga P, Gandola L, et al. Haemodynamic response during initiation of non-invasive positive pressure ventilation in COPD patients with acute ventilatory failure. Respir Med 1998;92(2):331-337. (Regression analysis; 18 patients) 17. Fellahi JL, Valteir B, Beauchet A, et al. Does positive end-expiratory pressure ventilation improve left ventricular function? A comparative study by transesophageal echocardiography in cardiac and noncardiac patients. Chest 1998;114:556-562. (Prospective, comparative; 12 patients) 18. Vieira SR, Puybasset L, Lu Q, et al. A scanographic assessment of pulmonary morphology in acute lung injury. Significance of the lower inflection point detected on the lung pressure-volume curve. Am J Resp Crit Care Med 1999;159:1612-1623. (14 patients) 19. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. Anesthesiology 1996;82:367-376. (Prospective; 238 adult patients) 20. Bauer TT, Ferrer R, Angrill J, et al. Ventilator-associated pneumonia: incidence, risk factors, and microbiology. Semin Respir Infect 2000;15(4):272-279. (Review; 47 references) 21. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76. (Prospective; 150 adult patients) 22. Deutschman CS, Wilton P, Sinow J, et al. Paranasal sinusitis associated with nasotracheal intubation: a frequently unrecognized and treatable source of sepsis. Crit Care Med 1986;14(2):111-114. (Comparative; 27 patients) 23.* Orebaugh SL. Initiation of mechanical ventilation in the emergency department. Am J Emerg Med 1996;14:59-69. (Very useful review of principles of mechanical ventilation) 24.* Girault C, Richard JC, Chevron V, et al. Comparative physiologic effects of noninvasive assist: control and pressure support ventilation in acute hypercapnic respiratory failure. Chest 1997;111:1639-1648. (Randomized, controlled; 15 patients) 25. Kosowsky JM, Storrow AB, Carleton SC. Continuous and bilevel positive airway pressure in the treatment of acute cardiogenic pulmonary edema. Am J Emerg Med 2000;18:91. (Review) 26. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817-822. (Prospective, randomized; 85 patients)

27. Patrick W, Webster K, Ludwig L, et al. Noninvasive positive-pressure ventilation in acute respiratory distress without prior chronic respiratory failure. Am J Respir Crit Care Med 1996;153(3):1005-1011. (11 patients) 28.* Meduri GU, Turner RF, Abou-Shala N, et al. Noninvasive positive pressure ventilation via facemaskFirst-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996;109:179-193. (Prospective, uncontrolled; 158 adult patients) 29. Craven RA, Singletary N, Bosken L, et al. Use of bilevel positive airway pressure in out-of-hospital patients. Acad Emerg Med 2000;7(9):1065-1068. (Prospective; 71 patients) 30. Gardtman M, Waagstein L, Karlsson T, et al. Has an intensified treatment in the ambulance of patients with acute severe left heart failure improved the outcome? Eur J Emerg Med 2000;7(1):15-24. (158 patients) 31. Lien TC, Wang JA, Wu TC. Short term effects of nasal pressure support ventilation in acute exacerbation of hypercapnic COPD. Chin Med J 1996;57:335-342. (Prospective series; 10 adult patients) 32.* Sherk PA, Grossman RF. The chronic obstructive pulmonary disease exacerbation. Clin Chest Med 2000;21:705-721. (Very good review of pathophysiology and treatment of COPD exacerbations) 33.* Ferguson GT. Recommendations for the management of COPD. Chest 2000;117:23-28. (Review) 34.* Hoo GWS, Hakimian N, Santiago SM. Hypercapnic respiratory failure in COPD patients, response to therapy. Chest 2000;117:169-177. (Retrospective review; 138 adult patients) 35.* Bott J, Carroll MP, Conway JH, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet 1993;341:1555-1557. (Prospective, randomized, controlled; 60 patients) 36. Barbe F, Togores B, Rubi M, et al. Noninvasive ventilatory support does not facilitate recovery from acute respiratory failure in chronic obstructive pulmonary disease. Eur Respir J 1996;9:1240-1245. (Randomized, non-acute study; 24 patients) 37. Ahmed AH, Fenwick L, Angus RM, et al. Nasal ventilation versus Doxapram in the treatment of type II respiratory failure complicating chronic outflow obstruction. Thorax 1992;47:A858. (Randomized) 38. Keenan SP, Brake D. An evidence-based approach to noninvasive ventilation in acute respiratory failure. Crit Care Clin 1998;14:359-372. (Review, meta-analysis) 39. Keenan SP, Kernerman PD, Cook DJ, et al. The effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure. A meta-analysis. Crit Care Med 1997;25:1685-1692. (Review, meta-analysis) 40.* Keenan SP, Gregor J, Sibbald WJ, et al. Noninvasive positive pressure ventilation in the setting of severe, acute exacerbations of chronic obstructive pulmonary disease: More effective and less expensive. Crit Care Med 2000;28:2094-2102.(Meta-analysis and economic evaluation of treatment) 41. Confalonieri M, Parigi P, Sartabellati A, et al. Noninvasive mechanical ventilation improves the immediate and long-term outcome of COPD patients with acute respiratory failure. Eur Resp J 1996;9:422-430. (Case control; 48 adult patients) 42. Mehta S, Jay GD, Woolard RH, et al. Randomized, prospective trial of bilevel vs continuous positive airway pressure in acute pulmonary edema. Crit Care Med 1997;25:620-628. (Randomized; 30 patients) 43. Perel A, Williamson DC, Modell JH. Effectiveness of CPAP by mask for pulmonary edema associated with

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44.

45.

46.

47.

48.

49.*

50.

51.

52.

53.*

54. 55.

56.

57.*

58.

59.

60.

hypercarbia. Intensive Care Med 1982;9:17-19. (Case series report) Vaisanen IT, Rasanen J. Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema. Chest 1987;92:481-485. (Case series report) Lin M, Chiang HT. The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema. J Formosan Med Assoc 1991;90:736-743. (Case series report) Kelly AM, Georgakas C, Bau S, et al. Experience with the use of continuous positive airway pressure (CPAP) therapy in the emergency management of acute cardiogenic pulmonary oedema. Aust N Z J Med 1997;27:319-322. (Retrospective chart review; 75 patients) Sacchetti AD, Harris RH, Paston C, et al. Bi-level positive airway pressure support system use in acute congestive heart failure: Preliminary case series. Acad Emerg Med 1995;2:714. (Retrospective case series; 22 adult patients) Rasanen J, Heikkila J, Downs J, et al. Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema. Am J Cardiol 1985;55:296-300. (Randomized; 40 adult patients) Lin M, Yang YF, Chiang HT, et al. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow up. Chest 1995;107:1379-1386. (Randomized; 100 adult patients) Masip J, Betbese AJ, Paez J, et al. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. Lancet 2000;356(9248):2126-2132. (Randomized, controlled; 40 patients) Pang D, Keenan SP, Cook DJ, et al. The effect of positive pressure airway support on mortality and the need for intubation in acute cardiogenic pulmonary edema. Chest 1998;114:1185-1192. (Meta-analysis) Takeda S, Nejima J, Takano T, et al. Effect of nasal continuous positive airway pressure on pulmonary edema complicating acute myocardial infarction. Jpn Circ J 1998;62(8):553-558. (Randomized, controlled; 29 patients) Sharon A, Shpirer I, Kaluski E, et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol 2000;36(3):832837. (Randomized, controlled; 40 patients) Ntoumenopoulos G. Limitations to study on noninvasive ventilation. Chest 1999;115:303. (Letter to the editor) Centers for Disease Control and Prevention. Forecasted state-specific estimates of self-reported asthma prevalenceUnited States, 1998. MMWR Morb Mortal Wkly Rep 1998;47:1022-1025. (Retrospective) Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthmaUnited States, 1960-1995. MMWR Morb Mortal Wkly Rep 1998;47:1-28. (Retrospective) Meduri GU. Noninvasive positive pressure ventilation in patients with acute respiratory failure. Clin Chest Med 1996;17:513. (Review [this review is quite complete, although a bit dated in 2001]) Meduri GU, Abou-Shala N, Fox RC, et al. Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure. Chest 1991;100:445-454. (Case series) Meduri GU, Cook TR, Turner RE, et al. Noninvasive positive pressure ventilation in status asthmaticus. Chest 1996;110:767-774. (Case series; 17 adult patients) Pollack CV, Fleish KB, Dowsey K. Treatment of acute bronchospasm with beta-adrenergic agonist aerosols delivered by a nasal bilevel positive airway pressure circuit. Ann Emerg Med 1995;26:552-557. (Randomized;

100 patients) 61. Dottorini M, Eslami A, Baglioni S, et al. Nasal-continuous positive airway pressure in the treatment of near-drowning in freshwater. Chest 1996;110:1122-1124. (Case report; 2 patients) 62. Granton JT, Kesten S. The acute effects of nasal positive pressure ventilation in patients with advanced cystic fibrosis. Chest 1998;113:1013-1018. (Case report; 8 patients) 63. Strumpf DA, Carlisle CC, Millman RP, et al. An evaluation of the Respironics BPAP Bilevel CPAP Device of delivery of assisted ventilation. Respir Care 1990;35:415-422. 64. Sanders MH, Kern N. Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask. Chest 1990;98:317-324. 65. Muir JF, Cuvelier A, Verin E, et al. Noninvasive mechanical ventilation and acute respiratory failure: indications and limitations. Monaldi Arch Chest Dis 1997;52:56-59. (Review) 66.* Hilbert G, Gruson D, Vargas F, et al. Noninvasive continuous positive airway pressure in neutropenic patients with an acute respiratory failure requiring intensive care unit admission. Crit Care Med 2000;28:3185-3190. (Prospective, uncontrolled; 129 adult patients enrolled, 64 patients actually studied) 67. Rubenfeld GD, Crawford SW. Withdrawing life support from mechanically ventilated recipients of bone marrow transplants: A case for evidence based guidelines. Ann Intern Med 1996;125:625-633. (Retrospective, nested, casecontrol; 865 total patients, 56 selected patients, 106 selected controls) 68.* Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure [see comments]. N Engl J Med 2001;344(7):481-487. (Prospective, randomized, controlled; 52 patients) 69. Confalonieri M, Potena A, Carbone G, et al. Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation [see comments]. Am J Respir Crit Care Med 1999;160(5 Pt 1):1585-1591. (Prospective, randomized, controlled; 56 patients) 70. Brett A, Sinclair DG. Use of continuous positive airway pressure in the management of community acquired pneumonia. Thorax 1993;48(12):1280-1281. (Case report; 3 patients) 71. LHer E, Moriconi M, Texier F, et al. Non-invasive continuous positive airway pressure in acute hypoxaemic respiratory failureexperience of an emergency department. Eur J Emerg Med 1998;5(3):313-318. (Retrospective; 64 patients) 72.* Bedos JP, Dumoulin JL, Gachot B, et al. Pneumocystis carinii pneumonia requiring intensive care management: survival and prognostic study in 110 patients with human immunodeficiency virus [see comments]. Crit Care Med 1999;27(6):1109-1115. (Case series; 110 patients) 73. Ambrosino N, Foglio K, Rubini F, et al. Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax 1995;50:755-757. (Retrospective; 59 episodes, 47 patients) 74. Garfield MJ, Howard-Griffin RM. Non-invasive positive pressure ventilation for severe thoracic trauma. Br J Anaesth 2000;85(5):788-790. (Case report; 1 patient) 75. McEachern RC, Patel RG. Pneumopericardium associated with face-mask continuous positive airway pressure. Chest 1997;112:1441. (Case report) 76. Dodds WJ, Hogan WJ, Lyden SB, et al. Quantitation of pharyngeal motor function in normal human subjects. J Appl Physiol 1975;39:692-696. (Small scale adult measurement of esophageal sphincter pressure)

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Physician CME Questions

1. Noninvasive ventilation uses which of the following techniques? a. Constant positive airway pressure support b. Pressure support ventilation c. External negative pressure ventilation d. All of the above are techniques of noninvasive ventilation. Intubation of the trachea is considered a gold standard in the management of respiratory failure. Any technique that deviates from this standard must demonstrate: a. more risks. b. greater value to the hospital. c. evidence of therapeutic benefits provided. d. lower cost. Which of the following is most appropriate for the patient who will require long-term ventilator support? a. Traditional ventilation in the noninvasive role b. Dedicated noninvasive ventilator machine c. Volume-based NIV machine d. External negative pressure ventilator Which of the following presents the most significant threat in a patient who is currently being treated with noninvasive ventilation? a. Agitation or combativeness b. Diarrhea c. Minor nasal congestion d. A single episode of vomiting Techniques of positive pressure ventilation draw from which other discipline? a. Aviation b. Metallurgy c. Radiology d. Hoover vacuum cleaner manufacturing BiPAP: a. is a trade name for a specific pressure support ventilator. b. cycles between peak inspiratory pressure and peak end expiratory pressure. c. terminates inspiratory flow when the ventilator cycles from IPAP to EPAP. d. all of the above. What is the most likely serious complication of noninvasive ventilation? a. Facial skin necrosis b. Pulmonary barotrauma c. Gastric distention d. Failure of the technique

8.

CPAP appears to recruit lung mechanics by: a. recruiting normal alveoli. b. flattening pulmonary compliance. c. reducing the work of breathing. d. increasing patient agitation. Which of the following techniques of noninvasive ventilation is most appropriate for the patient who has a beard and mustache? a. Facemask b. Nasal pads c. Nasal mask d. NIV cannot be performed in a patient with facial hair

9.

2.

3.

10. Which of the following diseases is not appropriate to treat with noninvasive ventilation? a. Narcotic overdose with pulmonary edema b. Asthma c. COPD d. Pulmonary edema 11. Which of the following is a contraindication to noninvasive ventilation? a. Ruptured eardrum b. Remote history of tracheostomy with healed-over stoma c. Myocardial infarction d. Recent small bowel surgery 12. Which of the following is an advantage of noninvasive ventilation? a. The airway is better protected with noninvasive ventilation. b. The patients disease corrects more quickly. c. The patient is more comfortable. d. The patient needs very little monitoring. 13. Noninvasive ventilation should not routinely be considered as a therapeutic option for: a. an acute exacerbation of COPD. b. patients suffering from a narcotic overdose. c. respiratory failure in patients with cystic fibrosis. d. neutropenic patients with respiratory failure. 14. In which of the following scenarios should the emergency physician switch from noninvasive ventilation to intubation? a. If the patient develops bradycardia or significant tachycardia b. If the patient has a loss of consciousness c. If the patient becomes increasingly agitated, lethargic, or confused d. If any of the above occur

4.

5.

6.

7.

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15. In which of the following scenarios is NIV contraindicated? a. If the patient requires a secure airway b. If the patient has poor air movement with COPD c. If the patient has stable atrial fibrillation d. If the patient suffers from sleep apnea 16. Although intubation is a gold standard, it has certain inherent risks. Which of the following risks is lower for noninvasive ventilation than intubation? a. Physical risks relating to the insertion of the endotracheal tube b. Infection c. Avoidance of sedation and paralysis d. All of the above are lessened with noninvasive ventilation

Physician CME Information

This CME enduring material is sponsored by Mount Sinai School of Medicine and has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education. Credit may be obtained by reading each issue and completing the post-tests administered in December and June. Target Audienc e: This enduring material is designed for emergency medicine physicians. Needs A ssessmen t: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians. Date of O riginal R elease: This issue of Emergency Medicine Practice was published July 2, 2001. This activity is eligible for CME credit through July 2, 2004. The latest review of this material was June 29, 2001. Discussion of I nvestiga tional I nformation: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Disclosure of Off-Label Usage: This issue of Emergency Medicine Practice discusses no off-label use of any pharmaceutical product. Facult y Disclosur e: In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Stewart, Dr. Radeos, and Dr. Della-Giustina report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Accreditation: Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. Credit D esigna tion: Mount Sinai School of Medicine designates this educational activity for up to 4 hours of Category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit actually spent in the educational activity. Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category 1 credit (per annual subscription). Earning C redit: Physicians with current and valid licenses in the United States, who read all CME articles during each Emergency Medicine Practice six-month testing period, complete the CME Evaluation Form distributed with the December and June issues, and return it according to the published instructions are eligible for up to 4 hours of Category 1 credit toward the AMA Physicians Recognition Award (PRA) for each issue. You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates will be mailed to each participant scoring higher than 70% at the end of the calendar year.
Publisher : Robert Williford. Vice Presiden t/General Manager : Connie Austin. Executiv e Editor : Heidi Frost.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives an alpha-numerical score based on the following definitions.
Class I Always acceptable, safe Definitely useful Proven in both efficacy and effectiveness Level of Evidence: One or more large prospective studies are present (with rare exceptions) High-quality meta-analyses Study results consistently positive and compelling Class II Safe, acceptable Probably useful Level of Evidence: Generally higher levels of evidence Non-randomized or retrospective studies: historic, cohort, or case-control studies Less robust RCTs Results consistently positive Class III May be acceptable Possibly useful Considered optional or alternative treatments Level of Evidence: Generally lower or intermediate levels of evidence Case series, animal studies, consensus panels Occasionally positive results Indeterminate Continuing area of research No recommendations until further research Level of Evidence: Evidence not available Higher studies in progress Results inconsistent, contradictory Results not compelling

Significantly modified from: The Emergency Cardiovascular Care Committees of the American Heart Association and representatives from the resuscitation councils of ILCOR: How to Develop EvidenceBased Guidelines for Emergency Cardiac Care: Quality of Evidence and Classes of Recommendations; also: Anonymous. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part IX. Ensuring effectiveness of community-wide emergency cardiac care. JAMA 1992;268(16):2289-2295.

Direct all editorial or subscription-related questions to Pinnacle Publishing, Inc.: 1-800-788-1900 or 770-992-9401 Fax: 770-993-4323 Pinnacle Publishing, Inc. P.O. Box 769389 Roswell, GA 30076-8220 E-mail: emer gmed@pinpub .com Web Site: http://www .pinpub .com/emp
Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year) by Pinnacle Publishing, Inc., 1000 Holcomb Woods Parkway, Building 200, Suite 280, Roswell, GA 30076-2587. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a trademark of Pinnacle Publishing, Inc. Copyright 2001 Pinnacle Publishing, Inc. All rights reserved. No part of this publication may be reproduced in any format without written consent of Pinnacle Publishing, Inc. Subscription price: $249, U.S. funds. (Call for international shipping prices.)

Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.

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