Noninvasive Positive-Pressure Ventilation vs Conventional Oxygen Supplementation in Hypoxemic Patients Undergoing Diagnostic Bronchoscopy

doi:10.1378/chest.121.4.1149

Chest

Volume 121, Issue 4, April 2002, Pages 1149-1154

https://doi.org/10.1378/chest.121.4.1149 Get rights and content

Objective

We have reported previously on the use of noninvasive positive-pressure ventilation (NPPV) to assist spontaneous breathing in high-risk hypoxemic patients (ie, Pao₂/fraction of inspired oxygen [Fio₂] ratio, ≤ 100) who are undergoing diagnostic fiberoptic bronchoscopy (FOB). The efficacy of this intervention in patients with less severe forms of hypoxemia (ie, Pao₂/Fio₂ ratio, < 200) is unknown.

Patients and methods

Twenty-six patients with Pao₂/Fio₂ ratios ≤ 200 who required bronchoscopic BAL for suspected nosocomial pneumonia were entered into the study. Thirteen patients were randomized during FOB to receive NPPV, and 13 patients were randomized to receive conventional oxygen supplementation by Venturi mask. The primary end points were changes in the Pao₂/Fio₂ ratio during FOB and within 60 min of terminating the procedure.

Results and outcome

At study entry, the two groups were similar in terms of age, simplified acute physiologic score II values, and cardiorespiratory parameters. During FOB, the mean (± SD) Pao₂/Fio₂ ratio increased by 82% in the NPPV group (261 ± 100 vs 139 ± 38; p < 0.001) and decreased by 10% in the conventional oxygen supplementation group (155 ± 24 to 139 ± 38; p = 0.23). Sixty minutes after undergoing FOB, the NPPV group had a higher mean Pao₂/Fio₂ ratio (176 ± 62 vs 140 ± 38; p = 0.09), a lower mean heart rate (91 ± 18 vs 108 ± 15 beats/min; p = 0.02), and no reduction in mean arterial pressure in comparison to a 15% decrease from the baseline in the control group. One patient in the NPPV group and two patients in the control group required nonemergent intubation. Major bacterial isolates included Staphylococcus aureus (7 of 30 isolates; 23%) and Pseudomonas aeruginosa (12 of 30 isolates; 40%).

Conclusion

In patients with severe hypoxemia, NPPV is superior to conventional oxygen supplementation in preventing gas-exchange deterioration during FOB with better hemodynamic tolerance.

Section snippets

Materials and Methods

Between May 1998 and January 1999, all consecutive patients with acute hypoxemic respiratory failure and suspected nosocomial pneumonia who were admitted to a 14-bed general ICU at La Sapienza University Hospital (Rome, Italy) were screened for enrollment into the randomized study. An ad hoc ethics committee approved the protocol, and all patients gave informed consent. Computer-generated random assignments were put into sealed envelopes. The criteria for hypoxemic respiratory failure included

Results

Over a period of 9 months, 365 patients were admitted to the ICU. Of the 81 patients who met the study entry criteria, 30 were already intubated, 10 had a tracheostomy, 6 had mental status alterations or hemodynamic instability, and 9 refused to participate. Thus, 26 patients (16 men and 10 women) were enrolled into the study. Thirteen patients were assigned to each group. At study entry, the baseline characteristics of the two groups were similar, including severity of disease as calculated by

Discussion

In this randomized study, we found that, in patients with severe hypoxemia (ie, Pao₂/Fio₂ ratio, < 200), NPPV that was delivered through a full-face mask was superior to oxygen supplementation alone in improving gas exchange during and after diagnostic bronchoscopy. The procedure was well-tolerated and was not associated with complications. Following bronchoscopy, patients who were randomized to NPPV had less of a reduction in MAP and a lower heart rate. The rates for intubation within 10 h of

ACKNOWLEDGMENT

We wish to acknowledge the expert review of the manuscript by Dr. David Armbruster and Mrs. Gail Spake. Also, we thank participating investigators Maurizio Bufi (collected data), Mariano Alberto Pennisi (collected data), Riccardo Maviglia (provided and cared for study patients), and Paolo Pietropaoli (critically revised the study proposal).

References (21)

M Antonelli et al.
Bronchoalveolar lavage in pulmonary function in mechanically ventilated patients
J Chastre et al.
Procedures for the diagnosis of pneumonia in ICU patients
Intensive Care Med
(1992)
GU Meduri et al.
Protected bronchoalveolar lavage: a new bronchoscopic technique to retrieve uncontaminated distal airway secretions
Am Rev Respir Dis
(1991)
C Luna et al.
Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia
Chest
(1997)
SJ Levine et al.
Bronchoscopy and related techniques
RA Goldstein et al.
Clinical role of bronchoalveolar lavage in adults with pulmonary disease
Am Rev Respir Dis
(1990)
GU Meduri
Noninvasive ventilation
M Antonelli et al.
A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure
N Engl J Med
(1998)
M Confalonieri et al.
Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation
Am J Respir Crit Care Med
(1999)
M Antonelli et al.
Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial
JAMA
(2000)

There are more references available in the full text version of this article.

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Chest

Clinical InvestigationsVENTILATORSNoninvasive Positive-Pressure Ventilation vs Conventional Oxygen Supplementation in Hypoxemic Patients Undergoing Diagnostic Bronchoscopy

Objective

Patients and methods

Results and outcome

Conclusion

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENT

Bronchoalveolar lavage in pulmonary function in mechanically ventilated patients

Procedures for the diagnosis of pneumonia in ICU patients

Intensive Care Med

Protected bronchoalveolar lavage: a new bronchoscopic technique to retrieve uncontaminated distal airway secretions

Am Rev Respir Dis

Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia

Chest

Bronchoscopy and related techniques

Clinical role of bronchoalveolar lavage in adults with pulmonary disease

Am Rev Respir Dis

Noninvasive ventilation

A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure

N Engl J Med

Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation

Am J Respir Crit Care Med

Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial

JAMA

Clinical Investigations
VENTILATORS
Noninvasive Positive-Pressure Ventilation vs Conventional Oxygen Supplementation in Hypoxemic Patients Undergoing Diagnostic Bronchoscopy