CPAP, NIV, high-flow:How to choose?

Laurent Brochard

Toronto

Conflicts of interest

• Our clinical research laboratory has received research grantsand/or equipment for clinical research projects from the following companies: – Covidien (PAV+)

– Dräger (SmartCare)

– General Electric (FRC)

– Philips (NIV-sleep)

– Fisher Paykel (High flow)

– Maquet (NAVA)

– Air Liquide (Helium)

Outcomes of Non-invasive Ventilation for Acute Exacerbations of COPD in the United States, 1998-2008

Chandra et al. AJRCCM 2012

7,511,267 admissions for acute exacerbations occurred from 1998-2008

NIV & COPD

2006

• Invasive MV: 7 /20 pts vs. 20

• Complications: 7 in 20 pts vs.

23 in 20

• Duration of MV 14 vs. 27 d

• LOH 5 vs. 22 d

• 1-year survival 55 vs. 50%

0

-20

-40

-60

-80

*

**

0

-20

-40

-60

-80

*

*

*WOB DPdi

NIV + helium-O2 = external + internal Assistance

Noninvasive Ventilation with Helium–Oxygen in Acute Exacerbations

of Chronic Obstructive Pulmonary Disease

VS-HeO2 NIV-HeO2NIV-AirO2 VS-HeO2 NIV-HeO2NIV-AirO2

Jaber,….Brochard. AJRCCM 2000; 161: 1191

% %

Respiratory rate /min.

pHSpO2

PaCO2 mmHg

Physiological effects during 1st 72 hours

p <0.0001 - all time points

p <0.0001 - all time points

mean ± 95% CI

mean ± 95% CImean ± 95% CI

mean ± SD

Jolliet P et al in revision

Encephalopathy score over first 72 hrs

mean ± 95% CI

Jolliet P et al in revision

Jolliet P et al in revision

N= 4400

CCM 2013

Thorax 2004

Lenique et al AJRCCM 1997, 155:500

9 patients

CPAP 10 cmH2OImprovement in compliance & resistance.

CPAP and CPO

(1%)

(10%)

« Early » application of CPAP (+7.5 cmH2O)» decreases endotracheal intubation and severe complications in patients with hypoxemia after elective major abdominal surgery

0

2

4

6

8

10

12

Pneumonia Sepsis Mortality

N o

f p

ati

en

ts (

%)

Control CPAP

* *

0.12

JAMA 2016

Demoule A et al ICM 2006

Mortality

PaO2/FiO2Respiratory mechanics

May preventor be useless

Insufficientor risky

May help

Dangerous

Needed

May help or worsen

NIV ETI

Time window

Time (hours/days)

Severity window

Brochard et al. Semin Resp Med. 2014

High

Gas Flow

Washout of nasopharyngeal dead space

The high gas flow decreases the

upper airway dead space like

trans-tracheal airway insufflation

Resp Care 2012

Acute Respiratory Failure

RR >25 c/min ; PaO2/FiO2 300, PaCO2 <45 mmHg

Consent

(patient, Family, emergency)

Delay between random. and Tt <3 h

stratification on cardiac disease

NIV / O2-HFH O2-HFH O2

( ≥8h/d, D0,D1,D2 min.) (24/24h, D0,D1,D2 min.) (24h/24)

Clinical Effect of the Association of Noninvasive Ventilation and High Flow Nasal Oxygen

Therapy

in Resuscitation of Patients With Acute Lung Injury (FLORALI Study)

JP Frat

Poitiers University Hospital

ClinicalTrials.gov Identifier:

NCT01320384

Cumulative incidence of Being Intubated in the Overall Population

0.2

0.4

0.6

0.8

0

0 4 8 12 16 20 24 28

Days After Enrollment

1.0C

um

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tive In

cid

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f B

ein

g In

tub

ate

d

High-Flow Oxygen group

Standard oxygen group

NIV group

Number at risk

High-Flow Oxygen group 106 68 67 67 65 65 65 65

Standard Oxygen group 94 52 50 49 49 49 48 48

NIV group 110 64 57 53 53 53 53 52

P=0.17 by log-rank test

0 4 8 12 16 20 24 28

0

0.2

0.4

0.6

0.8

1

Days After Enrollment

Cu

mu

lati

ve

In

cid

en

ce

of

Be

ing

In

tub

ate

d

High-Flow Oxygen group

Standard Oxygen group

NIV group

Cumulative Incidence of Being Intubated in the Patients With a PaO2:FiO2 ≤ 200 mm Hg

Number at risk

High-Flow Oxygen group 83 55 54 54 53 53 53 53

Standard Oxygen group 74 37 35 34 34 34 33 33

NIV group 81 41 34 32 32 32 32 32

P=0.009 by log-rank test

0

0.2

0.4

0.6

0.8

1.0

0 15 30 45 60 75 90

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lati

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P

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ab

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f S

urv

iva

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Days After Enrollment

Kaplan-Meier Plot of the Probability of Survival from Randomization to Day 90

P=0.015 by log-rank test

High-Flow Oxygen group

Standard oxygen group

NIV group

Number at risk

High-Flow Oxygen group 106 100 97 94 94 93 93

Standard Oxygen group 94 84 81 77 74 73 72

NIV group 110 93 86 80 79 78 77

Maggiore SM et al AJRCCM 2014

JAMA 2016

Hernandez et al. JAMA 2016

Coudroy et al. AOIC 2016

Impact of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: post hoc analysis of a randomized trial.

0 4 8 12 16 20 24 28

0.2

0.4

0.6

0.8

1.0

Pro

bab

ility

of

Intu

bat

ion

P=0•04 by log-rank

NIV

Standard oxygen

HFNC

Days since enrollment

Frat JP et al Lancet Resp Med 2016

0.2

0.4

0.6

0.8

1.0P

rob

abili

ty o

f su

rviv

al

0 15 30 45 60 75 90

Days since enrollment

P=0•03 by log-rank

NIV

Standard oxygen

HFNC

Frat JP et al Lancet Resp Med 2016

Nasal Cannula High Flow therapy

• Needs more rigorous clinical and physiological assessment to understand mechanisms and indications

CPAP, NIV, Nasal Cannula High Flow therapy

• NHFC Needs more rigorous clinical and physiological assessment to understand mechanisms and indications

• NIV (BIPAP) save lives in COPD

• NIV or CPAP improves distress in pulmonary edema amd may save lives

• NIV or CPAP reduce reintubation and infections after (abdominal) surgery