Nasal Mask Ventilation in Acute Respiratory Failure* Experience In Elderly Patients Daniel Benhamou, M.D.; Christophe Girault, M.D.; Colette Faure, M.D.; Florence Portief; M.D.; and jean-Francois Muir; M.D., RC.C.E Nasal mask veDtiiatioD (NMV) bas beeD used successfully in chrooic restrictive respiratory failure aod more receDtly in acute exacerbations of chronic obstrnctive pulmonary disease (COPD). This study aimed to evaluate the possible role of NMV in acute respiratory failure (ARF) episodes when mechanical ventilation with endotracheal intubatioD is questionable. Thirty patients (age, 76:1:8.1 years) were treated by NMV during ARF episodes (COPD, 20; other chrooic respiratory failure [CRF], 5; chronic heart failure [CHF], 4). All patieDts were hypoxemic (P.O., 5.85 ± 1.62 lcPa) aod hypercapnic (PaCO., 8.63± 1.89 kPa) with respiratory acidosis (pH, 7.29 ± 0.08). In all cases, clinical or physiologic parameters indicated the Deed for mechanical ventilation, but endotracheal intubation was either not applied because of the age aod the physiologic conditioD of the patieDts (17 cases) or was postponed (13 cases). NMV was performed using a volume-cycled ventilator and a customized nasal mask. VeDtiiation was CODtinUOUS during the 8rst 12 hours aod the foUowing nights aod was then intermittent during the day. Twenty-one patients improved clinieally, within a few hours. Progressive correction of
arterial blood gases was observed: PaO. increased during the 8rst hour, but PaCO. decreased more sl~ Eighteen patients were able to be successfully weaned from NMV. Twelve patients failed to improve despite NMV: eight of them died and four required endotracheal intubation. There was DO difference in the success rate between patieots in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even· in very mpatients, when endotracheal ventilation is cootroversial or not immediately required. (Cheat 1992; 102:912-11)
ventilation constitutes the last theraM echanical peutic resort for acute respiratory failure (ARF)
The aim of this study was to assess the value of this method (1) as first-line treatment for 'severe ARF in order to avoid, whenever possible, ET\; whose indication may sometimes be questionable, especially in very elderly patients, and (2) as last resort treatment when ElV is contraindicated.
when oxygen therapy and medical treatment fail to improve the respiratory status of the patient. This invasive ventilation, classically administered by endotracheal intubation or by tracheotom~ is associated with significant mortality and morbidity. The poor prognostic elements include the presence of a severe underlying disease and the patient's age .1-3 Consequentl); any less invasive method able to avoid the use of endotracheal ventilation (E1V) would appear to be particularly useful in high-risk patients. Over recent years, the efficacy of nasal mask ventilation (NMV) has been demonstrated in the treatment ofchronic restrictive respiratory failure, 4,3 particularly in patients with neuromuscular diseases. &-8 Several authors, especially Leger et al,9 have demonstrated its very good tolerance and efficacy in this type ofpatient, even in the course ofacute decompensations. 10,11 More recently, this method has been successfully used in the treatment of ARF due to parenchymal disease. 12-17 *From the Service de Pneumologie, CHU de Rouen (H8pital de Boisguillaume), Rouen, France. Manuscript received December 9; revision accepted March 12. Reprint requuts: Dr. Benhamou, Seroice de Pneumologie~ CHU de
Bouen 7000 ~ France 812
=
=
CRF chronic respiratory failure; CRRF chronic restrictive respir=~ failure; ETV = endotracheal ventilation; NMV mask ventilation; SAPS simplified acute physiology score
=
=
MATERIAL AND METHODS
This study successively included patients admitted to the unit with ARF defined by the combination of severe dyspnea, profound hypoxia in room air or during nasal oxygen the~ severe hypercapnia with respiratory acidosis, and/or disturbances of consciousness. Endotracheal v~ntilation was discussed in every case taking into account the following elements: the patients age, his or her previous physiologic and pathologic condition, the family·s opinion, and the previous decisions of other medical teams (other units, emergency department). All patients requiring immediate E1V were excluded. Endotracheal intubation could be performed at any time in the event of insufficient improvement in response to NM~ except for cases in which E1V was contraindicated by the patienfs age or the family·s wishes and in whom NMV constituted the last resort. Each patient was ventilated by means of a volumetric respirator (Monnal D (CFPO] or Eole 1 A [Saime] using a preformed plastic nasal mask (Sefam) or a mask individually molded to the patienfs nose in Silicone paste mixed in a slow catalyzer (Sefam kit). The mask was prepared rapidly (about 15 min) and urgently from the onset of ventilation or was deferred by several hours (in which case ventilation was begun with a preformed mask). Ventilation was Nasal Mask ventilation in Acute Respiratory Failure (Benhamou et 81)
Table 1- CharacteriBticB and BaaeUrae Parameterl in Patients ira Whom Endotracheal Ventilation Was Contraindicated (Subgroup 1)* Patients!Age, yr/Sex lI80IF '1I17/F 3179/F 5189/F 6189/F 8I83IM 9I83IF
1O/83/F Il1831M 13179/M 15182/M l6I93IF 19/77/F 2OI91/M 2l181/M 22/81/F 28182/M Mean (1) 83 SD4.2
History
Cause ofARF
COPD COPD (asthma) Heart failure COPD (asthma) Unknown COPD COPD COPD COPD COPD Heart failure CRRF COPD Heart failure COPD
Bronch inf Bronchosp Bronch inf Bronchosp Unknown Acute PN Acute PN LVF Acute PN Bronch inf Acute PN Acute PN Acute PN Acute PN Acute PN
COPD COPD
Bronch inf Bronch inf
RIVmin 30
38 36
20
18 Pause 28 / 17 30 30
24 20 22 24 /
40 26.92 7.44
Consciousness Drowsiness Drowsiness Drowsiness Agitation Agitation Coma Drowsiness Coma Drowsiness Agitation Agitation Normal Drowsiness Drowsiness Normal4 Conflobnub Coma
SAPS
Pa02 ' (kPa)
PaC02 , (kPa)
pH
12 14 15 11 21 18 14 14 6 13 15 17 12 14 10
5.1 6.1 4.7 6 4.3 7.7 4.1 5.4 8.6 4.5 4.1 9.8 5.3 6 6.5
11.36 11.4 6.6 11.47 9.24 12.3 8.5 9.34 13.77 11.96 7.85 11.67 8.19 8.1 10.93
7.3 7.22 7.24 7.33 7.18 7.04 7.39 7.24 7.16 7.23 7.29 7.29 7.32 7.29 7.29
8 14 13.4 3.57
5.3 3.3 5.69 1.7
7.7 9.6 9.99 2.01
7.41 7.28 7.26 0.08
*bronch inf = bronchial infection; bronchosp = bronchospasm; PN = pneumonia; LVF = left ventricular failure; pulm emb = pulmonary embolism; thor traum = thoracic traumatism; SAPS = simplified acute physiology score; conf = confusion; obnub = obnubilation; CRRF = chronic restrictive respiratory failure; ARF = acute respiratory failure. performed in controlled mode and the settings were adapted to each patient based on results of the blood gases. In every case, the volumes were measured by spirometry (Haloscale standard Ferraris) and the Flo! was measured by an analyzer (Oxy 2100 CFPO or TPCl Positron). The blood gases were measured by means of an automatic apparatus (IL 1302 Delhomme). Ventilation was performed in a continuous monitoring unit continuously for the first 12 h and during the night, then intennittendy during the day according to a protocol adapted to each patient. The minimal monitoring consisted of clinical monitoring of vital parameters, tolerance and the patienfs ventilatory adaptation, blood gas measurements before ventilation, 1 h, 3 to 6 h, 12 h, and
24 h, after starting ventilation, then at least once a day on the following days. Statistical analysis was perfonned by means of a Xl test for the qualitative data and by Wilcoxon or Wilcoxon-Mann-Whitney tests for the quantitative data. RESULTS
Thirty patients were included in the study (Tables 1 and 2): 16 women and 14 men with a mean age of 76 years (range, 59 to 93 years). All patients suffered from severe respiratory distress (mean Pa0 2 ,
Table 2-CharacteriBtics and Baaeline Parameterl ira Patients in Whom Endotracheal Ventilation Was Deferred (Subgroup 2)*
Patients!Age, yr/Sex 4/731M 7/68/M 12/73/F 14/79/F 17/66/M
18166IF 23174/M 24I68IF
25I68IF 26159/M 27/62/M 29n5IF 3O/67/M Mean (2) 69.1 SD5.53
History
Cause ofARF
COPD(LTO) COPD COPD Heart failure COPD MixedCRF Mixed CRF COPD (bronchiectasis) CRRF COPD(LTO) MixedCRF COPD COPD
Bronch inf LVF Bronch inf Pulmemb Bronch inf Bronch inf LVF Thor traum LVF Bronch inf Acute PN Acute PN Bronch inf
RRlmin 40 14 28 22 / 32 18 32 36 30 / 20 22 26.72 8.11
Consciousness Drowsiness Drowsiness Drowsiness Drowsiness Agitation Nonnal Conflobnub Nonnal Normal Normal Conflobnub Conflobnub Drowsiness
SAPS 13 7 4 23 15 9 5 11 9 12 10 27
8
11.76 6.66
Pa02 (kPa)
PaC02 (kPa)
pH
3.6 6.9 8.3 9.9 8.3 6.6 6.1 6.6 4.6 8.2 7.5 4.2 7.8 6.81 1.82
8.36 8.41 11.32 10.22 7.8 8.39 8.76 6.73 7.8 6.94 9.28 7.38 8.44 8.44 1.27
7.31 7.29 7.23 7.34 7.35 7.33 7.4 7.38 7.36 7.3 7.28 7.39 7.28 7.32 0.05
*bronch inf = bronchial infection; bronchosp = bronchospasm; PN = pneumonia; LVF = left ventricular failure; pulm emh = pulmonary embolism; thor traum = thoracic traumatism; SAPS = simplified acute physiology score; conf = confusion; obnub = obnubilation; CRF = chronic respiratory failure; CRRF = chronic restrictive respiratory failure; ARF = acute respiratory failure; LTO = long-term oxygen therapy. CHEST I 102 I 3 I SEPTEMBER. 1992
913
Table 3-Compariaon of the Baaeline lbrametera of Subgt"OUfM 1 (~ in Whom Endotracheal ~ (ETV) Waa ContrtJindicated) tmd 2 (~ in Whom ETV
PaC02 (KPa)
E1V contraindicated E1V deferred p
SAps·
82.2 69.1
arterial blood gases was observed: PaO. increased during the 8rst hour, but PaCO. decreased more sl~ Eighteen patients were able to be successfully weaned from NMV. Twelve patients failed to improve despite NMV: eight of them died and four required endotracheal intubation. There was DO difference in the success rate between patieots in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even· in very mpatients, when endotracheal ventilation is cootroversial or not immediately required. (Cheat 1992; 102:912-11)
ventilation constitutes the last theraM echanical peutic resort for acute respiratory failure (ARF)
The aim of this study was to assess the value of this method (1) as first-line treatment for 'severe ARF in order to avoid, whenever possible, ET\; whose indication may sometimes be questionable, especially in very elderly patients, and (2) as last resort treatment when ElV is contraindicated.
when oxygen therapy and medical treatment fail to improve the respiratory status of the patient. This invasive ventilation, classically administered by endotracheal intubation or by tracheotom~ is associated with significant mortality and morbidity. The poor prognostic elements include the presence of a severe underlying disease and the patient's age .1-3 Consequentl); any less invasive method able to avoid the use of endotracheal ventilation (E1V) would appear to be particularly useful in high-risk patients. Over recent years, the efficacy of nasal mask ventilation (NMV) has been demonstrated in the treatment ofchronic restrictive respiratory failure, 4,3 particularly in patients with neuromuscular diseases. &-8 Several authors, especially Leger et al,9 have demonstrated its very good tolerance and efficacy in this type ofpatient, even in the course ofacute decompensations. 10,11 More recently, this method has been successfully used in the treatment of ARF due to parenchymal disease. 12-17 *From the Service de Pneumologie, CHU de Rouen (H8pital de Boisguillaume), Rouen, France. Manuscript received December 9; revision accepted March 12. Reprint requuts: Dr. Benhamou, Seroice de Pneumologie~ CHU de
Bouen 7000 ~ France 812
=
=
CRF chronic respiratory failure; CRRF chronic restrictive respir=~ failure; ETV = endotracheal ventilation; NMV mask ventilation; SAPS simplified acute physiology score
=
=
MATERIAL AND METHODS
This study successively included patients admitted to the unit with ARF defined by the combination of severe dyspnea, profound hypoxia in room air or during nasal oxygen the~ severe hypercapnia with respiratory acidosis, and/or disturbances of consciousness. Endotracheal v~ntilation was discussed in every case taking into account the following elements: the patients age, his or her previous physiologic and pathologic condition, the family·s opinion, and the previous decisions of other medical teams (other units, emergency department). All patients requiring immediate E1V were excluded. Endotracheal intubation could be performed at any time in the event of insufficient improvement in response to NM~ except for cases in which E1V was contraindicated by the patienfs age or the family·s wishes and in whom NMV constituted the last resort. Each patient was ventilated by means of a volumetric respirator (Monnal D (CFPO] or Eole 1 A [Saime] using a preformed plastic nasal mask (Sefam) or a mask individually molded to the patienfs nose in Silicone paste mixed in a slow catalyzer (Sefam kit). The mask was prepared rapidly (about 15 min) and urgently from the onset of ventilation or was deferred by several hours (in which case ventilation was begun with a preformed mask). Ventilation was Nasal Mask ventilation in Acute Respiratory Failure (Benhamou et 81)
Table 1- CharacteriBticB and BaaeUrae Parameterl in Patients ira Whom Endotracheal Ventilation Was Contraindicated (Subgroup 1)* Patients!Age, yr/Sex lI80IF '1I17/F 3179/F 5189/F 6189/F 8I83IM 9I83IF
1O/83/F Il1831M 13179/M 15182/M l6I93IF 19/77/F 2OI91/M 2l181/M 22/81/F 28182/M Mean (1) 83 SD4.2
History
Cause ofARF
COPD COPD (asthma) Heart failure COPD (asthma) Unknown COPD COPD COPD COPD COPD Heart failure CRRF COPD Heart failure COPD
Bronch inf Bronchosp Bronch inf Bronchosp Unknown Acute PN Acute PN LVF Acute PN Bronch inf Acute PN Acute PN Acute PN Acute PN Acute PN
COPD COPD
Bronch inf Bronch inf
RIVmin 30
38 36
20
18 Pause 28 / 17 30 30
24 20 22 24 /
40 26.92 7.44
Consciousness Drowsiness Drowsiness Drowsiness Agitation Agitation Coma Drowsiness Coma Drowsiness Agitation Agitation Normal Drowsiness Drowsiness Normal4 Conflobnub Coma
SAPS
Pa02 ' (kPa)
PaC02 , (kPa)
pH
12 14 15 11 21 18 14 14 6 13 15 17 12 14 10
5.1 6.1 4.7 6 4.3 7.7 4.1 5.4 8.6 4.5 4.1 9.8 5.3 6 6.5
11.36 11.4 6.6 11.47 9.24 12.3 8.5 9.34 13.77 11.96 7.85 11.67 8.19 8.1 10.93
7.3 7.22 7.24 7.33 7.18 7.04 7.39 7.24 7.16 7.23 7.29 7.29 7.32 7.29 7.29
8 14 13.4 3.57
5.3 3.3 5.69 1.7
7.7 9.6 9.99 2.01
7.41 7.28 7.26 0.08
*bronch inf = bronchial infection; bronchosp = bronchospasm; PN = pneumonia; LVF = left ventricular failure; pulm emb = pulmonary embolism; thor traum = thoracic traumatism; SAPS = simplified acute physiology score; conf = confusion; obnub = obnubilation; CRRF = chronic restrictive respiratory failure; ARF = acute respiratory failure. performed in controlled mode and the settings were adapted to each patient based on results of the blood gases. In every case, the volumes were measured by spirometry (Haloscale standard Ferraris) and the Flo! was measured by an analyzer (Oxy 2100 CFPO or TPCl Positron). The blood gases were measured by means of an automatic apparatus (IL 1302 Delhomme). Ventilation was performed in a continuous monitoring unit continuously for the first 12 h and during the night, then intennittendy during the day according to a protocol adapted to each patient. The minimal monitoring consisted of clinical monitoring of vital parameters, tolerance and the patienfs ventilatory adaptation, blood gas measurements before ventilation, 1 h, 3 to 6 h, 12 h, and
24 h, after starting ventilation, then at least once a day on the following days. Statistical analysis was perfonned by means of a Xl test for the qualitative data and by Wilcoxon or Wilcoxon-Mann-Whitney tests for the quantitative data. RESULTS
Thirty patients were included in the study (Tables 1 and 2): 16 women and 14 men with a mean age of 76 years (range, 59 to 93 years). All patients suffered from severe respiratory distress (mean Pa0 2 ,
Table 2-CharacteriBtics and Baaeline Parameterl ira Patients in Whom Endotracheal Ventilation Was Deferred (Subgroup 2)*
Patients!Age, yr/Sex 4/731M 7/68/M 12/73/F 14/79/F 17/66/M
18166IF 23174/M 24I68IF
25I68IF 26159/M 27/62/M 29n5IF 3O/67/M Mean (2) 69.1 SD5.53
History
Cause ofARF
COPD(LTO) COPD COPD Heart failure COPD MixedCRF Mixed CRF COPD (bronchiectasis) CRRF COPD(LTO) MixedCRF COPD COPD
Bronch inf LVF Bronch inf Pulmemb Bronch inf Bronch inf LVF Thor traum LVF Bronch inf Acute PN Acute PN Bronch inf
RRlmin 40 14 28 22 / 32 18 32 36 30 / 20 22 26.72 8.11
Consciousness Drowsiness Drowsiness Drowsiness Drowsiness Agitation Nonnal Conflobnub Nonnal Normal Normal Conflobnub Conflobnub Drowsiness
SAPS 13 7 4 23 15 9 5 11 9 12 10 27
8
11.76 6.66
Pa02 (kPa)
PaC02 (kPa)
pH
3.6 6.9 8.3 9.9 8.3 6.6 6.1 6.6 4.6 8.2 7.5 4.2 7.8 6.81 1.82
8.36 8.41 11.32 10.22 7.8 8.39 8.76 6.73 7.8 6.94 9.28 7.38 8.44 8.44 1.27
7.31 7.29 7.23 7.34 7.35 7.33 7.4 7.38 7.36 7.3 7.28 7.39 7.28 7.32 0.05
*bronch inf = bronchial infection; bronchosp = bronchospasm; PN = pneumonia; LVF = left ventricular failure; pulm emh = pulmonary embolism; thor traum = thoracic traumatism; SAPS = simplified acute physiology score; conf = confusion; obnub = obnubilation; CRF = chronic respiratory failure; CRRF = chronic restrictive respiratory failure; ARF = acute respiratory failure; LTO = long-term oxygen therapy. CHEST I 102 I 3 I SEPTEMBER. 1992
913
Table 3-Compariaon of the Baaeline lbrametera of Subgt"OUfM 1 (~ in Whom Endotracheal ~ (ETV) Waa ContrtJindicated) tmd 2 (~ in Whom ETV
PaC02 (KPa)
E1V contraindicated E1V deferred p
SAps·
82.2 69.1
