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Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1116-1120

Noninvasive ventilation as a method of weaning from mechanical ventilation

1 Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Critical Care, Ministry of Health, Giza, Egypt

Date of Submission12-May-2017
Date of Acceptance31-Jul-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Mohammed A Rahman
El Shikh Ragheb Street, Qutour City, Gharbeya Governorate
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_334_17

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The aim of this study was to evaluate the adequacy of noninvasive ventilation (NIV) as a technique of weaning from mechanical ventilation.
Materials and methods
Medline databases (PubMed, Medscape, and ScienceDirect), all materials accessible on the Internet from the beginning date of every database to 2016. The initial investigation exhibited 43 articles, of which, nine met the incorporation criteria. The articles concentrated on the viability of NIV as a technique of liberation from mechanical ventilation. In light of heterogeneity in the gathered information, it had been impractical to perform meta-investigation. Noteworthy information had been gathered; accordingly an organized audit had been performed.
NIV observed to be successful in encouraging weaning in cases fit to be freed from mechanical ventilation, but failed an unrestrained breathing trial. Likewise, when utilized as a measure to avoid respiratory failure after removal of the endotracheal tube in high-hazard cases, it had benefits as far as mortality and reintubation rates that had not accomplished if NIV had been utilized as a treatment for postextubation respiratory failure.
We talk about the adequacy of NIV as a liberation strategy from mechanical ventilation, its utilization to encourage weaning, prohibit, or treat postextubation respiratory failure.

Keywords: acute respiratory failure, mechanical ventilation, noninvasive positive-pressure ventilation, postextubation respiratory failure, weaning

How to cite this article:
Ammar AS, El-Feky EM, Rahman MA. Noninvasive ventilation as a method of weaning from mechanical ventilation. Menoufia Med J 2018;31:1116-20

How to cite this URL:
Ammar AS, El-Feky EM, Rahman MA. Noninvasive ventilation as a method of weaning from mechanical ventilation. Menoufia Med J [serial online] 2018 [cited 2019 Sep 20];31:1116-20. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1116/252046

  Introduction Top

Noninvasive positive-pressure ventilation (NPPV) was defined as a ventilatory support delivered without establishing an endotracheal airway[1].

Noninvasive ventilation (NIV) had conveyed through an interface, normally a facial or a nasal mask, which links the case's airway to the ventilator tubing[2].

NIV in acute respiratory failure is considered as a lifesaving application that offers benefits over invasive positive-pressure ventilation. The most critical one is the evasion of intubation. Endotracheal intubation is correlated with adverse effects, for example, airway injury, increased danger of aspiration, nosocomial pneumonia, and patient inconvenience, requiring the utilization of narcotics. Such adverse effects could prompt a more extended health center stay, higher death rate, and expanded social insurance costs. NIV might help reverse the intense condition, when utilized in conjunction with ordinary medicinal therapy[3].

In chronic respiratory failure, NIV is a treatment that supports the patient as opposed to a lifesaving treatment. Most of the clinical conditions that need this level of help suffered from recurrent hypoventilation, night-time desaturation, respiratory muscle tiredness, and poor sleep quality. Night-time utilization of NIV (4–6 h) could have certain clinical advantages of various kinds as it gives sporadic rest to the respiratory muscles, bringing about less muscle tiredness, more effectiveness of capacity, diminishes the recurrence of sleep-interrupted breathing, prompting longer sleep, abolishes night-time hypoventilation, and lastly may abolish auto-positive end-expiratory pressure, which would lessen the work of breathing required to trigger a breath through NIV[4].

Noninvasive ventilation as a weaning technique

During weaning, in the periextubation period, NIV was utilized to shorten the period of invading weaning, prohibiting repetitive respiratory failure in hazardous cases, who had been extubated, saving cases with a failed endeavor at extubation. In the premier case, clinicians had extubated chosen cases who had been prepared for weaning, yet who had failed an unrestrained breathing trial, straightforwardly to NIV. The targets had to shorten the period of invading ventilation, restrict intubation-related entanglements, and limit failed endeavors at extubation. In the second case, clinicians prophylacticaly had applied NIV to cases at danger of reintubation, for example, in the emergency unit, or postoperative setting, with the objective of lessening extubation failure. At last, by applying NIV to safeguard cases who failed extubation, clinicians expect to maintain a strategic distance from reintubation, decreasing advanced introduction to invading ventilation and its complications[5].

  Materials and Methods Top

Search strategy

We checked on papers on NIV in weaning process from Medline databases (PubMed, Medscape, ScienceDirect), and furthermore from materials accessible on the web. We utilized NIV – weaning as seeking things in the title of the papers. The pursuit had performed in the electronic databases from the beginning date of every database to 2016.

Study selection

Every one of the reviews freely surveyed for consideration criteria. They had incorporated on the off-chance that they satisfied the accompanying criteria:

  1. Published in English language
  2. Published in analog-reviewed journals
  3. Focused on part of NIV in the weaning process
  4. If a review had several distributions on specific angles, we utilized the most recent production giving the most critical information.

Data extraction

Information from each qualified review had freely extracted in a copy, utilizing an information accumulation frame to catch data on study attributes, mediations, and quantitative outcomes detailed for every result of intrigue. Conclusion, remarks on each review were made.

As a result of heterogeneity in the gathered information, it was unrealistic to perform meta-examination. Critical information was gathered, then an organized survey was performed with the outcomes arranged.

Quality assessment

The nature of all reviews was surveyed. Essential elements had been incorporated, ponder outline, fulfillment of moral endorsement, proof of power estimation, determined qualification criteria, suitable controls, satisfactory data, and the indicated appraisal measures. It was expected that the confounding factors would be reported and controlled for, and appropriate data analysis was made in addition to an explanation of missing data.

Data synthesis

An organized deliberate audit was performed with the outcomes arranged [Table 1],[Table 2],[Table 3].
Table 1: Summary estimates of the effect of extubation to noninvasive ventilation, compared with weaning on conventional invasive ventilation

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Table 2: Trials that employed noninvasive positive-pressure ventilation in patients at high risk of postextubation respiratory failure

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Table 3: Trials that employed noninvasive positive-pressure ventilation in postextubation respiratory failure

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  Results Top

The chosen studies were nine; these reviews were considered qualified by satisfying the consideration criteria, surveying the part of NIV in the weaning process, anticipating, and treating postextubation respiratory failure.

Noninvasive ventilation to shorten the duration of invasive ventilation

Five concentrates enlisted a sum of 171 patients, most with chronic obstructive pulmonary disease (COPD). Patients received ventilation with a level of pressure support (19 ± 2 cmH2O) that was adjusted to achieve satisfactory blood gases and a respiratory rate of less than 25 breaths/min. The level of pressure support was decreased by 2 or 4 cmH2O per day in patients with good tolerance; patients were allowed to breathe spontaneously. At least two trials of spontaneous breathing of gradually increased duration were attempted each day. Weaning was considered successful if reintubation was not required within 72 h of suspension of ventilation. Contrasted, invading weaning, NIV had been altogether connected with decreased mortality, ventilator-associated pneumonia, ICU and hospital days, period of ventilation and period of invading ventilation [Table 1][6],[12].

Noninvasive ventilation to prevent extubation failure

Two studies had intended to evaluate whether early use of NIV promptly after extubation had been compelling in avoiding postextubation respiratory failure in hazardous cases. The cases were heterogenous in nature (cardiac failure, trauma, postoperative respiratory failure, COPD, asthma, pneumonia, and neurosurgery patients). In these two trials, the cases were extubated once they were physiologically fit to inhale unrestrained; they had randomized promptly after extubation (in the event that they had any high-chance qualities that inclined them to create postextubation respiratory failure) to get either ordinary medicinal treatment in addition to NPPV (in the treatment arm), or regular restorative treatment alone [Table 2]. Biphasic positive airway pressure mode was initiated. For patients who were hypercapnic, the inspiratory pressure was adjusted according to the patient's tolerance and with a positive end-expiratory pressure at 6 cmH2O. For the nonhypercapnic patients, the external positive end-expiratory pressure was initially set at 5 cmH2O and could be increased until oxygen saturation was constantly 92%, whereas the inspiratory pressure support was initially set at 10 cmH2O and then increased to the maximum tolerated. After the first 48 h, if the patient was clinically stable, NIV was withdrawn; otherwise it was ventilated. The two concentrates incorporated a sum of 259 cases, gave information on reintubation rate, ICU mortality, and hospital mortality. There was no significant difference in ICU and hospital length of stay and also days on mechanical ventilation[7],[8].

Noninvasive ventilation to rescue failed extubation

Two examinees surveyed the part of NIV in built-up postextubation respiratory failure in ICU; the patients were of heterogeneous population (cardiac, COPD, asthma, pneumonia, postoperative, and neuromuscular diseases). In these two trials, cases who created postextubation hypoxemic respiratory failure were randomized to get either ordinary therapeutic treatment in addition to NPPV (in the treatment arm), or traditional restorative treatment alone [Table 3]. Biphasic positive airway pressure mode was initiated with an expiratory positive airway pressure (EPAP) of 4 cmH2O and inspiratory positive airway pressure of 9 cmH2O, with EPAP increments of 2 cmH2O, while keeping inspiratory positive airway pressure at a fixed increment above EPAP to achieve an oxygen saturation of greater than 92%. These two trials incorporated a sum of 302 cases, gave information on reintubation rates, and ICU mortality. The duration of mechanical ventilation was shorter in the NPPV group, with no significant difference in ICU and hospital length of stay. The review by Keenan et al.[10] (yet not the one by Esteban et al.[11]) additionally gave information on hospital mortality.

  Discussion Top

The consequences of this survey proposed that NIV could be a viable system to permit prior extubation in chosen cases, with intense on-incessant respiratory failure (e.g., hypercapnic respiratory failure or COPD worsening). Epstein[13] prescribes the accompanying considerations:

  1. The criteria to start a spontaneous breathing trial (SBT) must be fulfilled
  2. The upper airway ought to be patent
  3. The case ought to have the capacity to clear secretions (with or without help)
  4. The case ought to be a decent contender for NIV; ready to endure the interface
  5. The case ought to had the capacity to inhale unrestrained long enough to permit mask, ventilator alterations
  6. Extubation to NIV had disheartened if the case would be actually hard to reintubate.

The utilization of NPPV taking after extubation, contrasted with standard treatment, diminishes the reintubation rate, and ICU mortality, yet no health center mortality, in cases who had 'at hazard' for postextubation respiratory failure; however not once they create respiratory failure. A few reasons might clarify these distinctions. To begin with, though the reviews by Keenan et al.[10], Esteban et al.[11] connected NPPV after cases had created respiratory failure, the last two ponders by Nava et al.[7], Ferrer et al.[8] connected NPPV instantly after extubation in high-chance cases. Since longer time from extubation to reintubation was related with the desired outcome[14], the postponement in reintubation is associated with more serious survival rates in cases who got NPPV for set up postextubation respiratory failure[10],[11]. Thus, the early use of NPPV appears to be essential to evade respiratory failure after extubation, subsequently reintubation. Second, a fundamentally higher extent of cases with ceaseless respiratory issue had incorporated into the 'at hazard' studies (145/383), whereas the postextubation respiratory disappointment trials enlisted just 10–11% of cases with perpetual pneumonic malady. In addition, it was seen that cases with hypercapnic respiratory failure had the best responders to NPPV[15].

  Conclusion Top

NIV could be utilized to permit earlier extubation in chosen cases who do not effectively fulfill an SBT. Its utilization in this setting ought to be limited to cases who had been intubated because of COPD exaggeration condition, or cases with neuromuscular disease. In cases who effectively fulfill an SBT, was at risk for extubation failure, and NIV could be utilized to prohibit extubation failure, cases ought to be great contender for NIV, ought to be extubated straightforwardly to NIV. NIV ought to be utilized mindfully in cases who effectively fulfill an SBT, however, create respiratory failure within 48 h postextubation. In this setting, NIV was shown just in cases with hypercapnic respiratory failure. Reintubation ought not to be postponed if NIV had not instantly been fruitful in turning around the postextubation respiratory failure.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Krishna B, Sampath S, Moran JL. The role of non-invasive positive pressure ventilation in post-extubation respiratory failure: an evaluation using meta-analytic techniques. Menoufia Med J 2013; 17:253–261.  Back to cited text no. 1
Pedersen MB. Noninvasive ventilation in the hospital setting; 2010:4.  Back to cited text no. 2
Brochard L, Isabey D, Piquet J. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med 1990; 323:1523–1530.  Back to cited text no. 3
Ellis ER, Bye PT, Bruderer JW. Treatment of respiratory failure during sleep in patients with neuromuscular disease: positive pressure ventilation through a nose mask, Am Rev Respir Dis 1987; 135:148–152.  Back to cited text no. 4
Ferreyra G, Fanelli V, Del Sorbo L, Ranieri VM. Are guidelines for non-invasive ventilation during weaning still valid? Minerva Anestesiol 2011; 77:921–926.  Back to cited text no. 5
Burns KEA, Adhikari NKJ, Keenan SP, Meade M. Use of noninvasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ 2009; 338:b1574.  Back to cited text no. 6
Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33:2465–2470.  Back to cited text no. 7
Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006; 173:164–170.  Back to cited text no. 8
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17:1–12.  Back to cited text no. 9
Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 2002; 287:3238–3244.  Back to cited text no. 10
Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350:2452–2460.  Back to cited text no. 11
Nava S, Ambrosino N, Clini E, Prato M, Orlando G, Vitacca M, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med 1998; 128:721–728.  Back to cited text no. 12
Epstein SK. Noninvasive ventilation to shorten the duration of mechanical ventilation. Respir Care 2009; 54:198–208. discussion 208–211.  Back to cited text no. 13
Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998; 158:489–493.  Back to cited text no. 14
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001; 163:540–557.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3]


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