Asistencia ventilatoria no invasiva en el tratamiento inicial de la insuficiencia respiratoria aguda
Palabras clave:
RESPIRACIÓN ARTIFICIAL, INSUFICIENCIA RESPIRATORIA, ENFERMEDAD AGUDAResumen
Introducción: la ventilación mecánica invasiva connota riesgo de neumonía y daño traumático de vía aérea. La ventilación no invasiva (VNI) demostró beneficios en insuficiencia respiratoria aguda (IRA), en enfermedad pulmonar obstructiva crónica (EPOC) y en edema agudo pulmonar cardiogénico (EAP), pero disparidad en la insuficiencia respiratoria hipoxémica no EAP.
Objetivos: evaluar VNI en IRA hipoxémica e hipercápnica como tratamiento inicial. Respuesta, evolución, riesgo de fracaso y muerte.
Material y método: estudio de cohorte prospectivo que incluyó a adultos inmunocompetentes tratados con VNI. Período: enero de 2011 a julio de 2013. Fueron pacientes ingresados en UCI-CI polivalente de 16 camas con IRA hipercápnica: presión arterial de anhídrido carbónico (PaCO2) ≥45 mm Hg, y pH ≤7,35 y >7,25, o hipoxémica: presión arterial de oxígeno (PaO2) con máscara de oxígeno >80 y ≤150 mmHg. Se excluían si había: indicación de intubación inmediata, depresión sensorial, inestabilidad hemodinámica, broncoplejía.
Resultados: fueron 61 pacientes, 62 ± 14 años (edad media ± 1 desvío estándar). Apache II 15 ± 5,5. Hubo 36 pacientes con IRA hipoxémica, fracasaron 9 (25%) y fallecieron 7 (19%); con IRA hipercápnica fueron 25 pacientes, fracasaron 5 (20%) y fallecieron 4 (16%). Los que fracasaron tuvieron una internación más prolongada, p=0,01, mayor incidencia de infecciones respiratorias, p=0,009, y extrarrespiratorias, p=0,03. Los factores independientes de riesgo relacionados a fracaso y muerte (regresión logística) fueron:
. Fracaso: cada incremento unitario de la frecuencia respiratoria (FR) en primera hora de VNI, odds ratio (OR) 2,2 (IC 95% 1,4-3,5).
. Muerte: fracaso de la VNI, OR 19,5 (IC 95% 4,0-94,6).
Conclusiones: cada incremento de la FR en la primera hora de VNI duplica el riesgo de fracaso y este multiplica por 20 la probabilidad de muerte.
Citas
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(2) American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Société de Réanimation de Langue Française. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med 2001; 163(1):283-91.
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(11) Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367(9517):1155-63.
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(14) Conti G, Costa R. Noninvasive ventilation in patients with hypoxemic, nonhypercapnic acute respiratory failure. Clin Pulm Med 2011; 18(2):83-7.
(15) Lellouche F. Noninvasive ventilation in patients with hypoxemic acute respiratory failure. Curr Opin Crit Care 2007; 13(1):12-9.
(16) Rana S, Jenad H, Gay PC, Buck CF, Hubmayr RD, Gajic O. Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study. Crit Care 2006; 10(3):R79.
(17) Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168(12):1438-44.
(18) Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007; 35(1):18-25.
(19) Zhan Q, Sun B, Liang L, Yan X, Zhang L, Yang J, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit Care Med 2012; 40(2):455-60.
(20) Antonelli M, Pennisi MA, Montini L. Clinical review: noninvasive ventilation in the clinical setting—experience from the past 10 years. Crit Care 2005; 9(1):98-103.
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(23) Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive-pressure ventilation in acute respiratory failure outside clinical trials: experience at the Massachusetts General Hospital. Crit Care Med 2008; 36(2):441-7.
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(25) Meduri GU, Turner RE, Abou-Shala N, Wunderink R, Tolley E. Noninvasive positive pressure ventilation via face mask. First-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996; 109(1):179-93.
(26) Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350(24):2452-60.
(27) Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13(10):818-29.
(28) Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation. Respir Care 2004; 49(3):295-303.
(29) Wysocki M, Tric L, Wolff MA, Millet H, Herman B. Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy. Chest 1995; 107(3):761-8.
(30) Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, 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(7):429-35.
(31) Girault C, Briel A, Hellot MF, Tamion F, Woinet D, Leroy J, et al. Noninvasive mechanical ventilation in clinical practice: a 2-year experience in a medical intensive care unit. Crit Care Med 2003; 31(2):552-9.
(32) Ambrosino N, Foglio K, Rubini F, Clini E, Nava S, Vitacca M. Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax 1995; 50(7):755-7.
(33) Plant PK, Owen JL, Elliott MW. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001; 56(9):708-12.
(34) Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L; SRLF Collaborative Group on Mechanical Ventilation. Noninvasive versus conventional mechanical ventilation: an epidemiologic survey. Am J Respir Crit Care Med 2001; 163(4):874-80.
(2) American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Société de Réanimation de Langue Française. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med 2001; 163(1):283-91.
(3) Keenan SP, Sinuff T, Burns KE, Muscedere J, Kutsogiannis J, Mehta S, et al; Canadian Critical Care Trials Group/Canadian Critical Care Society Noninvasive Ventilation Guidelines Group. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ 2011; 183(3):E195-214.
(4) Martin TJ, Hovis JD, Costantino JP, Bierman MI, Donahoe MP, Rogers RM, et al. A randomized, prospective evaluation of noninvasive ventilation for acute respiratory failure. Am J Respir Crit Care Med 2000; 161(3 Pt 1):807-13.
(5) Brochard L. Mechanical ventilation: invasive versus noninvasive. Eur Respir J Suppl 2003; 47:31s-7s.
(6) Hill NS, Brennan J, Garpestad E, Nava S. Noninvasive ventilation in acute respiratory failure. Crit Care Med 2007; 35(10):2402-7.
(7) Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995; 333(13):817-22.
(8) Keenan SP, Gregor J, Sibbald WJ, Cook D, Gafni A. 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(6):2094-102.
(9) Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 2003; 326(7382):185.
(10) Girou E, Brun-Buisson C, Taillé S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA 2003; 290(22):2985-91.
(11) Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367(9517):1155-63.
(12) Winck JC, Azevedo LF, Costa-Pereira A, Antonelli M, Wyatt JC. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema: a systematic review and meta-analysis. Crit Care 2006; 10(2):R69.
(13) Delclaux C, L’Her E, Alberti C, Mancebo J, Abroug F, Conti G, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. JAMA 2000; 284(18):2352-60.
(14) Conti G, Costa R. Noninvasive ventilation in patients with hypoxemic, nonhypercapnic acute respiratory failure. Clin Pulm Med 2011; 18(2):83-7.
(15) Lellouche F. Noninvasive ventilation in patients with hypoxemic acute respiratory failure. Curr Opin Crit Care 2007; 13(1):12-9.
(16) Rana S, Jenad H, Gay PC, Buck CF, Hubmayr RD, Gajic O. Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study. Crit Care 2006; 10(3):R79.
(17) Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168(12):1438-44.
(18) Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007; 35(1):18-25.
(19) Zhan Q, Sun B, Liang L, Yan X, Zhang L, Yang J, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit Care Med 2012; 40(2):455-60.
(20) Antonelli M, Pennisi MA, Montini L. Clinical review: noninvasive ventilation in the clinical setting—experience from the past 10 years. Crit Care 2005; 9(1):98-103.
(21) Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2004; 32(12):2516-23.
(22) Demoule A, Girou E, Richard JC, Taille S, Brochard L. Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med 2006; 32(11):1756-65.
(23) Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive-pressure ventilation in acute respiratory failure outside clinical trials: experience at the Massachusetts General Hospital. Crit Care Med 2008; 36(2):441-7.
(24) Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-Diaz G, Confalonieri M, et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med 2001; 27(11):1718-28.
(25) Meduri GU, Turner RE, Abou-Shala N, Wunderink R, Tolley E. Noninvasive positive pressure ventilation via face mask. First-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996; 109(1):179-93.
(26) Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004; 350(24):2452-60.
(27) Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13(10):818-29.
(28) Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation. Respir Care 2004; 49(3):295-303.
(29) Wysocki M, Tric L, Wolff MA, Millet H, Herman B. Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy. Chest 1995; 107(3):761-8.
(30) Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, 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(7):429-35.
(31) Girault C, Briel A, Hellot MF, Tamion F, Woinet D, Leroy J, et al. Noninvasive mechanical ventilation in clinical practice: a 2-year experience in a medical intensive care unit. Crit Care Med 2003; 31(2):552-9.
(32) Ambrosino N, Foglio K, Rubini F, Clini E, Nava S, Vitacca M. Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax 1995; 50(7):755-7.
(33) Plant PK, Owen JL, Elliott MW. Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome. Thorax 2001; 56(9):708-12.
(34) Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L; SRLF Collaborative Group on Mechanical Ventilation. Noninvasive versus conventional mechanical ventilation: an epidemiologic survey. Am J Respir Crit Care Med 2001; 163(4):874-80.
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2014-09-30
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França AG, Formento CI, Olivera S, Ebeid Bocchi A. Asistencia ventilatoria no invasiva en el tratamiento inicial de la insuficiencia respiratoria aguda. Rev. Méd. Urug. [Internet]. 30 de septiembre de 2014 [citado 21 de noviembre de 2024];30(3):168-7. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/241
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