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384 PART 4: Pulmonary Disorders

support plus PEEP), 166-168 and that this approach is not only safe but also
results in better tolerance of the procedure and reduces complication • Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in
immunosuppressed patients with pulmonary infiltrates, fever, and
rates and the subsequent need for ETI. 168,169 acute respiratory failure. N Engl J Med. 2001;344:481-487.
■ TRAUMA • Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventila-
Respiratory failure following trauma is not a classical indication for tion for acute exacerbations of chronic obstructive pulmonary
disease on general respiratory wards: a multicentre randomised
NIPPV. In one study addressing this issue, NIPPV compared to stan-
dard oxygen therapy, significantly averted intubation in patients with controlled trial. Lancet. 2000;355:1931-1935.
trauma-related hypoxemia and reduced hospital stay. Multivariate
170
analysis highlighted NIPPV as the only factor independently associated
with reduced intubation rate. Pneumothorax, pneumonia or sepsis rates
https://kat.cr/user/tahir99/
were not influenced by this intervention. Independent to these favorable REFERENCES
results, larger multicenter trials are required to better clarify the role of Complete references available online at www.mhprofessional.com/hall
NIPPV in this field.

CONCLUSION CHAPTER Airway Management
NIPPV has the ability to improve physiological parameters such as
respiratory rate, relieve dyspnea, reduce the invasiveness of patient 45 Michael F. O’Connor
management, and finally to bring important benefits in important David B. Glick
clinical outcomes like reducing ICU and hospital stay and decreasing
morbidity and mortality. These results are mostly well demonstrated
in patients with acute-on-chronic respiratory failure and acute CPE,
but they can also be obtained in other groups of selected populations: KEY POINTS
cooperative patients with acute hypoxemic ARF due to pneumonia and • The choice between noninvasive ventilation via mask versus ventila-
no other organ failures, immunocompromised patients, or patients with tion via translaryngeal tracheal intubation is an increasingly critical
treatment limitations. NIPPV may also be useful during the postextuba- branch point in the management of patients with respiratory failure.
tion process as a preventive tool in some patients, during the weaning
process or in periprocedure phases, like during fiberoptic bronchoscopy • Shock, a failed trial of extubation, inability to protect and maintain
or before ETI with positive results. one’s own airway, need for larger minute ventilations or larger
It is crucial to carefully analyze which patient will benefit by NIPPV use transpulmonary pressures, and transport of an unstable patient all
and think whether NIPPV can also be deleterious by postponing ETI. The remain indications for tracheal intubation.
first hours of NIPPV use are important to estimate this risk and an experi- • Assessment and adequate preparation of the patient prior to intu-
enced health professional is mandatory at the bedside during this period. bation are crucial to ensuring successful and safe intubation.
• Awake tracheal intubation with topical anesthesia remains the
preferred technique, although skilled operators can perform rapid
KEY REFERENCES sequence induction and intubation with a high degree of success.
• Antonelli M, Conti G, Bufi M, et al. Noninvasive ventilation for treat- General anesthesia and paralysis are associated with substantial
ment of acute respiratory failure in patients undergoing solid organ risks in critically ill, hemodynamically unstable patients.
transplantation: a randomized trial. JAMA. 2000;283:235-2341. • The appropriate timing of tracheostomy remains poorly defined.
• Antonelli M, Conti G, Rocco M, et al. A comparison of noninva- Improved endotracheal tubes allow for prolonged intubation with
sive positive-pressure ventilation and conventional mechanical a low risk of associated traumatic injury.
ventilation in patients with acute respiratory failure. N Engl J Med. • Percutaneous tracheostomy and conventional tracheostomy are
1998;339:429-435. increasingly performed at the bedside to minimize the hazards asso-
• Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechani- ciated with transporting a critically ill patient to an operating room.
cal ventilation in patients having declined tracheal intubation.
Intensive Care Med. 2013;39:292-301.
• Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation
for acute exacerbations of chronic obstructive pulmonary disease. Tracheal intubation remains one of the most common and important
N Engl J Med. 1995;333:817-822. procedures performed in the intensive care unit (ICU). When done
• Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive posi- well, tracheal intubation can be a lifesaving procedure. When done
tive-pressure ventilation for respiratory failure after extubation. N poorly, it may initiate a cascade of events that can lead directly or
Engl J Med. 2004;350:2452-2460. indirectly to trauma, severe complications, and death. The widespread
• Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after adoption of noninvasive ventilation in the management of patients with
type II acute-on-chronic respiratory failure (ACRF) and high-pressure
extubation in hypercapnic patients with chronic respiratory dis- pulmonary edema has created a population of patients who have failed
orders: randomised controlled trial. Lancet. 2009;374:1082-1088. moderate levels of ventilatory support and require emergent airway
• Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres management (see Chap. 44). It is imperative that those who manage
A. Early noninvasive ventilation averts extubation failure in the airways in these patients have a high degree of knowledge, skill,
patients at risk: a randomized trial. Am J Respir Crit Care Med. and comfort in managing patients with little physiologic reserve. In
2006;173:164-170. addition, it is imperative that ICU physicians have knowledge and
• Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. understanding of the indications for tracheal intubation, the assessment
Noninvasive ventilation in acute cardiogenic pulmonary edema. N of the patient for tracheal intubation, the devices and techniques avail-
Engl J Med. 2008;359:142-151. able for tracheal intubation, and the consequences and complications
of tracheal intubation. 1

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