Estudio sobre VMNI precoz en agudización del EPOC

Hoy compartimos un estudio publicado en Medicine en Marzo 2017 sobre el uso precoz de VMNI en agudizaciones del EPOC.

Early use of noninvasive techniques for clearing respiratory secretions during noninvasive positive-pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease and hypercapnic encephalopathy: A prospective cohort study

Wang, Jinrong MD; Cui, Zhaobo MS; Liu, Shuhong MS; Gao, Xiuling MS; Gao, Pan BS; Shi, Yi MD; Guo, Shufen MS; Li, Peipei MS

Medicine: March 2017 - Volume 96 - Issue 12 - p e6371

Flexo ST30 ventilator

Puritan Bennett Ventilator

Abstract: 

Noninvasive positive-pressure ventilation (NPPV) might be superior to conventional mechanical ventilation (CMV) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPDs). Inefficient clearance of respiratory secretions provokes NPPV failure in patients with hypercapnic encephalopathy (HE). This study compared CMV and NPPV combined with a noninvasive strategy for clearing secretions in HE and AECOPD patients.

The present study is a prospective cohort study of AECOPD and HE patients enrolled between October 2013 and August 2015 in a critical care unit of a major university teaching hospital in China.

A total of 74 patients received NPPV and 90 patients received CMV. Inclusion criteria included the following: physician-diagnosed AECOPD, spontaneous airway clearance of excessive secretions, arterial blood gas analysis requiring intensive care, moderate-to-severe dyspnea, and a Kelly–Matthay scale score of 3 to 5. Exclusion criteria included the following: preexisting psychiatric/neurological disorders unrelated to HE, upper gastrointestinal bleeding, upper airway obstruction, acute coronary syndromes, preadmission tracheostomy or endotracheal intubation, and urgent endotracheal intubation for cardiovascular, psychomotor agitation, or severe hemodynamic conditions.

Intensive care unit participants were managed by NPPV. Participants received standard treatment consisting of controlled oxygen therapy during NPPV-free periods; antibiotics, intravenous doxofylline, corticosteroids (e.g., salbutamol and ambroxol), and subcutaneous low-molecular-weight heparin; and therapy for comorbidities if necessary. Nasogastric tubes were inserted only in participants who developed gastric distension. No pharmacological sedation was administered.

The primary and secondary outcome measures included comparative complication rates, durations of ventilation and hospitalization, number of invasive devices/patient, and in-hospital and 1-year mortality rates.

Arterial blood gases and sensorium levels improved significantly within 2 hours in the NPPV group with lower hospital mortality, fewer complications and invasive devices/patient, and superior weaning off mechanical ventilation. Mechanical ventilation duration, hospital stay, or 1-year mortality was similar between groups.

NPPV combined with a noninvasive strategy to clear secretions during the first 2 hours may offer advantages over CMV in treating AECOPD patients complicated by HE.

Este artículo tiene la limitación de que no sea randomizado

La NPPV fue desarrollada con ventilador Flexo ST30 en modo ST con Peep de 3 a 5 cmH2O, máscara oronasal y humidificador. Presión de soporte entre 8 y 10 ml/kg hasta un máximo de 25 cmh2O. La FR de respaldo entre 14 y 18 rpm. A esto se añadió la aspiración de secreciones.

La CMV se desarrolló con ventilador Puritan Bennett 840 en SIMV+PS con un vol tidal de 6-8 ml/kg, FR de respaldo 10-15 Peep 3-5 cmH2O, PS 8-14 cmH2O

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