Role of sedation for agitated patients undergoing noninvasive ventilation: clinical practice in a tertiary referral hospital

BMC Pulmonary Medicine

Kazuo Chin¹  Michiaki Mishima²  Atsushi Nakagawa³  Kyoko Otsuka³  Kazuma Nagata³  Kojiro Otsuka³  Ryo Tachikawa²  Keisuke Tomii³  Takeshi Matsumoto² 

[1] Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto 606-8507, Japan;Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, 54 kawahara-cho, shogoin, sakyo-ku, Kyoto 606-8507, Japan;Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan

关键词: Richmond Agitation Sedation Scale;    Agitation;    Noninvasive ventilation;    Intermittent sedation;    Continuous sedation;   

Others  :  1219062
DOI  :  10.1186/s12890-015-0072-5

 received in 2015-01-09, accepted in 2015-07-06,  发布年份 2015

【 摘 要 】

Background

Although sedation is often required for agitated patients undergoing noninvasive ventilation (NIV), reports on its practical use have been few. This study aimed to evaluate the efficacy and safety of sedation for agitated patients undergoing NIV in clinical practice in a single hospital.

Methods

We retrospectively reviewed sedated patients who received NIV due to acute respiratory failure from May 2007 to May 2012. Sedation level was controlled according to the Richmond Agitation Sedation Scale (RASS). Clinical background, sedatives, failure rate of sedation, and complications were evaluated by 1) sedative methods (intermittent only, switched to continuous, or initially continuous) and 2) code status (do-not-intubate [DNI] or non-DNI).

Results

Of 3506 patients who received NIV, 120 (3.4 %) consecutive patients were analyzed. Sedation was performed only intermittently in 72 (60 %) patients, was switched to continuously in 37 (31 %) and was applied only continuously in 11 (9 %). Underlying diseases in 48 % were acute respiratory distress syndrome/acute lung injury/severe pneumonia or acute exacerbation of interstitial pneumonia. In non-DNI patients (n = 39), no patient required intubation due to agitation with continuous sedation, and in DNI patients (n = 81), 96 % of patients could continue NIV treatment. PaCO ₂level changes (6.7 ± 15.1 mmHg vs. -2.0 ± 7.7 mmHg, P = 0.028) and mortality in DNI patients (81 % vs. 57 %, P = 0.020) were significantly greater in the continuous use group than in the intermittent use group.

Conclusions

According to RASS scores, sedation during NIV in proficient hospitals may be favorably used to potentially avoid NIV failure in agitated patients, even in those having diseases with poor evidence of the usefulness of NIV. However, with continuous use, we must be aware of an increased hypercapnic state and the possibility of increased mortality. Larger controlled studies are needed to better clarify the role of sedation in improving NIV outcomes in intolerant patients.

【 授权许可】

   
2015 Matsumoto et al.

【 图 表 】

Fig. 1.

Fig. 2.

【 参考文献 】

• [1]Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-Diaz G, Confalonieri M, Pelaia P, Principi T, Gregoretti C, Beltrame F, Pennisi MA, Arcangeli A, Proietti R, Passariello M, Meduri GU. 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):1718-1728.
• [2]Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L. Noninvasive versus conventional mechanical ventilation. An epidemiologic survey. Am J Respir Crit Care Med. 2001; 163(4):874-880.
• [3]Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009; 374(9685):250-259.
• [4]Liesching T, Kwok H, Hill NS. Acute applications of noninvasive positive pressure ventilation. Chest. 2003; 124(2):699-713.
• [5]Devlin JW, Nava S, Fong JJ, Bahhady I, Hill NS. Survey of sedation practices during noninvasive positive-pressure ventilation to treat acute respiratory failure. Crit Care Med. 2007; 35(10):2298-2302.
• [6]Akada S, Takeda S, Yoshida Y, Nakazato K, Mori M, Hongo T, Tanaka K, Sakamoto A. The efficacy of dexmedetomidine in patients with noninvasive ventilation: a preliminary study. Anesth Analg. 2008; 107(1):167-170.
• [7]Takasaki Y, Kido T, Semba K. Dexmedetomidine facilitates induction of noninvasive positive pressure ventilation for acute respiratory failure in patients with severe asthma. J Anesth. 2009; 23(1):147-150.
• [8]Huang Z, Chen YS, Yang ZL, Liu JY. Dexmedetomidine versus midazolam for the sedation of patients with non-invasive ventilation failure. Intern Med. 2012; 51(17):2299-2305.
• [9]Clouzeau B, Bui HN, Vargas F, Grenouillet-Delacre M, Guilhon E, Gruson D, Hilbert G. Target-controlled infusion of propofol for sedation in patients with non-invasive ventilation failure due to low tolerance: a preliminary study. Intensive Care Med. 2010; 36(10):1675-1680.
• [10]Rocco M, Conti G, Alessandri E, Morelli A, Spadetta G, Laderchi A, Di Santo C, Francavilla S, Pietropaoli P. Rescue treatment for noninvasive ventilation failure due to interface intolerance with remifentanil analgosedation: a pilot study. Intensive Care Med. 2010; 36(12):2060-2065.
• [11]Tomii K, Tachikawa R, Chin K, Murase K, Handa T, Mishima M, Ishihara K. Role of non-invasive ventilation in managing life-threatening acute exacerbation of interstitial pneumonia. Intern Med. 2010; 49(14):1341-1347.
• [12]Murase K, Tomii K, Chin K, Tsuboi T, Sakurai A, Tachikawa R, Harada Y, Takeshima Y, Hayashi M, Ishihara K. The use of non-invasive ventilation for life-threatening asthma attacks: Changes in the need for intubation. Respirology. 2010; 15(4):714-720.
• [13]Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166(10):1338-1344.
• [14]Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D’Empaire G, Alia I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004; 350(24):2452-2460.
• [15]Merlani PG, Pasquina P, Granier JM, Treggiari M, Rutschmann O, Ricou B. Factors associated with failure of noninvasive positive pressure ventilation in the emergency department. Acad Emerg Med. 2005; 12(12):1206-1215.
• [16]Levy M, Tanios MA, Nelson D, Short K, Senechia A, Vespia J, Hill NS. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004; 32(10):2002-2007.
• [17]Azoulay E, Kouatchet A, Jaber S, Lambert J, Meziani F, Schmidt M, Schnell D, Mortaza S, Conseil M, Tchenio X, Herbecq P, Andrivet P, Guerot E, Lafabrie A, Perbet S, Camous L, Janssen-Langenstein R, Collet F, Messika J, Legriel S, Fabre X, Guisset O, Touati S, Kilani S, Alves M, Mercat A, Similowski T, Papazian L, Meert AP, Chevret S et al.. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med. 2013; 39(2):292-301.
• [18]Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select "do-not-intubate" patients. Crit Care Med. 2005; 33(9):1976-1982.