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Noninvasive mechanical ventilation in high-risk pulmonary infections: a clinical review

Antonio M. Esquinas, S. Egbert Pravinkumar, Raffaele Scala, Peter Gay, Arie Soroksky, Christophe Girault, Fang Han, David S. Hui, Peter J. Papadakos, Nicolino Ambrosino on behalf of the International NIV Network
European Respiratory Review 2014 23: 427-438; DOI: 10.1183/09059180.00009413
Antonio M. Esquinas
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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  • For correspondence: antmesquinas@gmail.com
S. Egbert Pravinkumar
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Raffaele Scala
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Peter Gay
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Arie Soroksky
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Christophe Girault
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Fang Han
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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David S. Hui
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Peter J. Papadakos
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Nicolino Ambrosino
1Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain. 2Dept of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. 3Pulmonary and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy. 4Dept of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA. 5General Intensive Care Unit, Assaf Harofeh Medical Center, Ramat Aviv, Israel. 6Dept of Medical Intensive Care, Charles Nicolle Rouen University Hospital, UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France. 7Dept of Pulmonary Medicine, The People’s Hospital, Beijing University, Beijing, China. 8Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China. 9Critical Care, University of Rochester, Rochester NY, USA. 10Pulmonary and Respiratory Intensive Care Unit, Cardio-Thoracic Dept, University Hospital Pisa, Pisa, Italy. 11For a full list of the International NIV Network collaborators see the Acknowledgements
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Tables

  • Table 1. Published data on noninvasive ventilation (NIV) during severe acute respiratory syndrome (SARS) infections
    First author [ref.]YearCountryStudy designInterfaceReceived NIVNIV failureTransmission among HCW#MortalityObservations
    Lin [11]2003ChinaRetrospective, single centreFace maskn=40 (51.9%)n=8 (10.3%)No9%70 (90.9%) patients were clinically cured
    Cheung [12]2004ChinaCase series, single centre (n=31)Face maskn=20n=14 (70%)No0%
    Fowler [13]2004CanadaRetrospective, single centreFace mask0n=38No50% after NIV failureAffected patients had primarily single organ respiratory failure
    Sung [14]2004ChinaProspective, single centre (n=37)Face maskn=15n=21 (15.2%)Non=15 (10.9%)Most patients had significant comorbidities
    Yam [8]2005ChinaRetrospective, single centreFace maskn=21n=8 (38%)Non=9 (35%)Early application of NIV as initial support for SARS-related ARF appeared to be associated with significantly reduced need for ETI and mortality
    • HCW: healthcare workers; ARF: acute respiratory failure; ETI: endotracheal intubation. #: instances of transmission of SARS among HCW.

  • Table 2. Published data on noninvasive ventilation (NIV) during pandemic influenza A H1N1
    First author [ref.]YearCountryStudy designInterfaceReceived NIVNIV failureTransmission among HCW#MortalityObservations
    Kaufman [21]2009AustraliaMulticentre, prospective cohort (n=3)Face mask0100%No
    Perez-Padilla [22]2009MexicoRetrospective, multicentre cohort (n=98)Face maskn=18 (IMV: n=12)Yesn=722 HCW were treated with oseltamivir
    None were hospitalised
    None of the secondary infections among HCW were severe
    Rello [23]2009SpainMulticentre cohort (n=32)Face maskn=8 (33%)75%Non=824 (75.0%) required IMV
    Djibre [28]2009FranceCase 1: pregnantFace mask10%No0Pregnancy population
    Kumar [24]2009CanadaProspective, observational, multicentre cohort (n=168)Face maskn=55 (33%)85%No136 (81.0%) patients received IMV
    DomÍnguez-Cherit [31]2009MexicoProspective, observational, multicentre cohort (n=58)Face mask00No0
    Miller [29]2009USAMonocentre, observational cohort (n=47)Face maskn=13 (3%)85%No17%Severe ARDS with MOF in the absence of bacterial infection was a common clinical presentation
    Li [26]2010ChinaRetrospective, monocentre cohort (n=75)Face maskn=33 (44%)n=10 (30%)No10%
    Koegelenberg [30]2010South AfricaMonocentre, observational cohort (n=19)Face maskn=6 (66%)66.6%Non=13 (68.4%)
    Winck [36]2010PortugalCase report (n=1)Face maskn=10No
    Esquinas [37]2010International NIV Network SurveyProspective, international, observational cohortFace maskNo
    Hajjar [38]2010BrazilMonocentre cancer patients, observational study cohort (n=8)Face maskn=8 (50%)n=5 (62.5%)No100%Cancer patients highlight the severity of the H1N1 pandemic in this vulnerable population and the urgent need to establish specific protocols of care and management strategies designed to face this healthcare challenge
    Louriz [40]2010MoroccoObservational, prospective, multicentre cohort (n=186)Face maskn=10n=10 (100%)30%
    Adigüzel [32]2010TurkeyObservational, monocentre cohort (n=19)Face maskNasal cannula: n=4 (21.1%)NoFirst study to include nasal cannula
    Nin [39]2011SpainMulticentre, observational, prospective cohort (n=96)Face maskn=43 (45%)77%No50% globalHigh mortality, primarily due to refractory hypoxia
    RÍos [25]2011ArgentinaFace maskn=49 (28%)94%No
    Liu [43]2011ChinaRetrospective, observational, monocentre cohort (n=62)Face maskn=23n=3Non=4 (6.5%)Hypoxaemia, MOF, and a requirement for IMV
    Timenetsky [46]2011BrazilProspective, observational, monocentre cohort (n=14)Face mask85.7%58.4%No2.1%
    Grasselli [45]2011ItalyProspective, observational, monocentre cohort (n=19)Face maskn=13n=11NoFrequent IMV
    Belenguer-Muncharaz [47]2011SpainRetrospective, observational, monocentre cohortFace mask and helmetn=100No0First study to use a helmet and a face mask
    Masclans [48]2012SpainProspective, observational, multicentre registry cohortFace maskn=177n=105 (59.32%)No0Best outcome in low APACHE II and SOFA, no vasopressor, lower chest radiograph quadrants and shorter ICU stay
    Zhang [33]2012ChinaRetrospective, observational, monocentre cohort (n=394, including 1 pregnant subject) IMV (n=186)Face maskn=83n=45 (24.32%)Non=24 (28.91%)Pregnancy population
    • HCW: healthcare workers; IMV: invasive mechanical ventilation; ARDS: acute respiratory distress syndrome; MOF: multi-organ failure; APACHE II: Acute Physiology and Chronic Health Evaluation II; SOFA: Sequential Organ Failure Assessment; ICU: intensive care unit. #: instances of transmission of influenza A H1N1 among HCW.

  • Table 3. Contribution to pandemic influenza A H1N1 case series (total n=23) based on country
    European countriesn=9
        Spainn=5
        Italyn=1
        Francen=1
        Portugaln=1
        Turkeyn=1
    Asian=3
    North American=1
    Australian=1
    Canadan=1
    Latin American=6
        Mexicon=2
        Braziln=2
        Chilean-Uruguayn=1
        Argentinan=1
    South African=1
    North Africa (Morocco)n=1
  • Table 4. Noninvasive ventilation (NIV) in acute exacerbations of pulmonary tuberculosis (TB) sequelae
    First author [ref.]YearCountryStudy designType of ARF-TBInterfaceNIV failureTransmission among HCW#MortalityObservationsHome MV after AEPTS
    Tsuboi [51]1996JapanProspective cohort (n=17)AEPTS in mixed groupsNasal mask0No0Yes
    Machida [53]1998JapanRetrospective survey (n=58)AEPTSNasal mask0No0Yes
    Prats Soro [60]1999SpainCase report (n=1)AEPTSNasal mask0No0Yes
    Schulz [54]1999GermanyProspective cohort (n=26)AEPTSNasal mask0No0Yes
    Agarwal [56]2005IndiaCases series cohort (n=3)ARDS and Mycobacterium tuberculosis AEPTSFace mask0No0No
    Utsugi [57]2006JapanCase report (n=1)ARF, miliary TB and AEPTSFace mask0No0No
    Aso [58]2010JapanProspective cohort (n=58)AEPTSFace mask13.8%No1.7%0No
    • ARF-TB: acute respiratory failure associated with TB pulmonary infection; HCW: healthcare workers; MV: mechanical ventilation; AEPTS: acute exacerbations of pulmonary TB sequelae; ARDS: acute respiratory distress syndrome. #: instances of transmission of Mycobacterium tuberculosis among HCW.

  • Table 5. Summary of recommendations for noninvasive ventilation (NIV) during severe acute respiratory syndrome (SARS), H1N1 and tuberculosis (TB) infections
    Specific NIV recommendations
        NIV in TB
            TB patients are contagious for a relatively long period of time after starting anti-TB treatment (at least 2 weeks)
            NIV needs a long period of time to improve the respiratory condition in severely ill TB patients
            NIV patients are exposed to a higher risk of pneumothorax and/or haemoptysis and the lowest pressures should be set
        NIV in SARS and H1N1
            Selection in early stages and mild forms of ARF, such as minimal pulmonary infiltrates and arterial oxygen tension/inspiratory oxygen fraction >250
            Exclude in shock or multi-organ failure
    HCW general recommendations for NIV#
        TB patients with contagious forms of the disease should be isolated in airborne infection isolation (AII) rooms
        Air cleaning technologies, such as HEPA filtration and UVGI, should be used
        HCW entering a room with an infectious TB patient should wear at least a N95 disposable respirator (preferably a FFP3 mask)
        Negative pressure rooms should be equipped with HEPA (where available) and have anterooms
        Use full protective clothing as per all aerosol generating procedures including a FFP3 mask when available (N95 masks are second choice), eye protection, a gown, gloves and an apron
        Strict personal protection equipment for HCW
        Minimise the number of individuals caring for the patient
        Strict monitoring of HCW for signs and symptoms of infection
    Equipment and setting recommendations for NIV#
        Viral/bacterial filter (99.9997 efficiency)
            These should be used between the mask/interface and the expiratory port, and at the outlet of the ventilator. In order to reduce the risk of contaminating the ventilator, a bacterial filter should be placed at the expiratory side of the breathing circuit or between the mask and the circuit. It is recommended to choose a model to filter particles 0.3 μm in size
        Ventilators
            Double hose tubing (inspiratory and expiratory limb) may be advantageous. Avoid high flow face mask CPAP (open exhalation port)
        Interface
            Helmet is preferred if applicable and available; if not, a non-vented face mask may be used
            For TB patients, select long-term nasal mask ventilation
            Apply and secure mask before turning on the ventilator
        Pressure setting
            Use the lowest possible pressures, e.g. EPAP 5 cmH2O and IPAP <10 cmH2O titrated to respiratory rate and arterial blood gas tensions.
            When applying the helmet, inspiratory pressures may be at least twice the pressures used with a standard face mask
            Turn off the ventilator before removing the mask
    • ARF: acute respiratory failure; HCW: healthcare workers; HEPA: high-efficiency particulate air; UVGI: ultraviolet germicidal irradiation; CPAP: continuous positive airway pressure; EPAP: expiratory positive airway pressure; IPAP: inspiratory positive airway pressure. #: these apply to SARS, H1N1 and TB.

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Noninvasive mechanical ventilation in high-risk pulmonary infections: a clinical review
Antonio M. Esquinas, S. Egbert Pravinkumar, Raffaele Scala, Peter Gay, Arie Soroksky, Christophe Girault, Fang Han, David S. Hui, Peter J. Papadakos, Nicolino Ambrosino
European Respiratory Review Dec 2014, 23 (134) 427-438; DOI: 10.1183/09059180.00009413

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Noninvasive mechanical ventilation in high-risk pulmonary infections: a clinical review
Antonio M. Esquinas, S. Egbert Pravinkumar, Raffaele Scala, Peter Gay, Arie Soroksky, Christophe Girault, Fang Han, David S. Hui, Peter J. Papadakos, Nicolino Ambrosino
European Respiratory Review Dec 2014, 23 (134) 427-438; DOI: 10.1183/09059180.00009413
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  • Article
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    • Effectiveness of NIV in pulmonary infections and pandemics
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