NIV in acute hypoxaemic respiratory failure after solid organ transplant

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NIV in acute hypoxaemic respiratory failure after solid organ transplant - less VAP?

The use of NIV in patients with acute respiratory failure following solid organ transplant reduces the need for intubation and ITU mortality, but with only a trend to reducing VAP.

Level of Evidence: 1⁺

Citation/s:
Massimo Antonelli, Giogio Conti et al: Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation. JAMA 2000; 283:235-241

Lead author's name and fax: Massimo Antonelli, max.antonelli@flashnet.it

Three-part Clinical Question: In patients with respiratory failure after solid organ transplant, does the use of noninvasive ventilation reduce the incidence of ventilator associated pneumonia?

Search Terms: NIV, VAP, ICU

The Study: Non-blinded randomised controlled trial with intention-to-treat.

The Study Patients: Adult ITU patients with acute hypoxaemic respiratory failure after solid organ transplant, admitted to 1 ITU over 22 months. Eligible patients: acute respiratory distress with RR>35, PaO₂/FiO₂ < 200mmHg on oxygen and active contraction of accessory muscles or paradoxical abdominal motion. Exclusion criteria included: emergency intubation for CPR, respiratory arrest, severe haemodynamic instability, decreased conscious level, respiratory failure caused by neurological disease or status asthmaticus, more than 2 new organ failures, tracheostomy, facial deformities, recent oral, oesophageal or gastric surgery.

Control group (N = 20; 20 analysed): Standardised medical management. Oxygen via venturi to achieve O₂ sats>90%.

Experimental group (N = 20; 20 analysed): Standardised medical management. Full face mask NIV with PS adjusted to achieve TV of 8-10ml/kg, RR<25, the cessation of accessory muscle use and patient comfort. PEEP was adjusted in 2-3 cm increments to a max of 10 until FiO2 ≤0.6. NIV management was standardised.

The Evidence:

Outcome	Time to Outcome	CER	EER	RRR	ARR	NNT
VAP		0.200	0.100	50%	0.100	NS
VAP	95% Confidence Intervals:			∞	∞	∞
Intubation		0.700	0.200	71%	0.500	2
Intubation	95% Confidence Intervals:			33% to 100%	0.233 to 0.767	1 to 4
ICU Mortality		0.500	0.2	60%	0.300	3
ICU Mortality	95% Confidence Intervals:			4% to 100%	0.019 to 0.581	2 to 52

Comments:
Do the methods allow accurate testing of the hypothesis? The study size was chosen to detect a difference in intubation based on previous experience in this patient group. The sample size may have been too small to detect a difference in VAP.
Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes
Are the conclusions valid in light of the results? Yes.
Did results get omitted and why? No
Did they suggest areas for further research? No
Did they make any recommendations based on the results and where they appropriate? Yes, they did - they recommended that in this patient group, NIV be considered if it can be delivered safely which would be appropriate.
Is the study relevant to my clinical practice? Yes. The patients in the NIV group who developed VAP developed VAP after intubation. Overall, VAP developed in 1/3 of patients after intubation with 100% mortality.
What level of evidence does this study represent? Level 1⁺
What grade of recommendation can I make on this result alone? B
What grade of recommendation can I make when this study is considered along with other available evidence? N/A – lack of similar studies.
Should I change my current practice because of these results? Yes
Shoul I audit my current practice because of these results? Yes – management of similar patients with NIV.

Appraised by: B Miles, Stobhill Hospital, Glasgow; 20 May 2004

Email: barbara.miles.stob@northglasgow.scot.nhs.uk

Kill or Update By: June 2007

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