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

doi:10.1183/09059180.00009413

Tables

Table 1. Published data on noninvasive ventilation (NIV) during severe acute respiratory syndrome (SARS) infections

First author [ref.]	Year	Country	Study design	Interface	Received NIV	NIV failure	Transmission among HCW^#	Mortality	Observations
Lin [11]	2003	China	Retrospective, single centre	Face mask	n=40 (51.9%)	n=8 (10.3%)	No	9%	70 (90.9%) patients were clinically cured
Cheung [12]	2004	China	Case series, single centre (n=31)	Face mask	n=20	n=14 (70%)	No	0%
Fowler [13]	2004	Canada	Retrospective, single centre	Face mask	0	n=38	No	50% after NIV failure	Affected patients had primarily single organ respiratory failure
Sung [14]	2004	China	Prospective, single centre (n=37)	Face mask	n=15	n=21 (15.2%)	No	n=15 (10.9%)	Most patients had significant comorbidities
Yam [8]	2005	China	Retrospective, single centre	Face mask	n=21	n=8 (38%)	No	n=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.]	Year	Country	Study design	Interface	Received NIV	NIV failure	Transmission among HCW^#	Mortality	Observations
Kaufman [21]	2009	Australia	Multicentre, prospective cohort (n=3)	Face mask	0	100%	No
Perez-Padilla [22]	2009	Mexico	Retrospective, multicentre cohort (n=98)	Face mask	n=18 (IMV: n=12)		Yes	n=7	22 HCW were treated with oseltamivir None were hospitalised None of the secondary infections among HCW were severe
Rello [23]	2009	Spain	Multicentre cohort (n=32)	Face mask	n=8 (33%)	75%	No	n=8	24 (75.0%) required IMV
Djibre [28]	2009	France	Case 1: pregnant	Face mask	1	0%	No	0	Pregnancy population
Kumar [24]	2009	Canada	Prospective, observational, multicentre cohort (n=168)	Face mask	n=55 (33%)	85%	No		136 (81.0%) patients received IMV
DomÍnguez-Cherit [31]	2009	Mexico	Prospective, observational, multicentre cohort (n=58)	Face mask	0	0	No	0
Miller [29]	2009	USA	Monocentre, observational cohort (n=47)	Face mask	n=13 (3%)	85%	No	17%	Severe ARDS with MOF in the absence of bacterial infection was a common clinical presentation
Li [26]	2010	China	Retrospective, monocentre cohort (n=75)	Face mask	n=33 (44%)	n=10 (30%)	No	10%
Koegelenberg [30]	2010	South Africa	Monocentre, observational cohort (n=19)	Face mask	n=6 (66%)	66.6%	No	n=13 (68.4%)
Winck [36]	2010	Portugal	Case report (n=1)	Face mask	n=1	0	No
Esquinas [37]	2010	International NIV Network Survey	Prospective, international, observational cohort	Face mask			No
Hajjar [38]	2010	Brazil	Monocentre cancer patients, observational study cohort (n=8)	Face mask	n=8 (50%)	n=5 (62.5%)	No	100%	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]	2010	Morocco	Observational, prospective, multicentre cohort (n=186)	Face mask	n=10	n=10 (100%)		30%
Adigüzel [32]	2010	Turkey	Observational, monocentre cohort (n=19)	Face mask	Nasal cannula: n=4 (21.1%)		No		First study to include nasal cannula
Nin [39]	2011	Spain	Multicentre, observational, prospective cohort (n=96)	Face mask	n=43 (45%)	77%	No	50% global	High mortality, primarily due to refractory hypoxia
RÍos [25]	2011	Argentina		Face mask	n=49 (28%)	94%	No
Liu [43]	2011	China	Retrospective, observational, monocentre cohort (n=62)	Face mask	n=23	n=3	No	n=4 (6.5%)	Hypoxaemia, MOF, and a requirement for IMV
Timenetsky [46]	2011	Brazil	Prospective, observational, monocentre cohort (n=14)	Face mask	85.7%	58.4%	No	2.1%
Grasselli [45]	2011	Italy	Prospective, observational, monocentre cohort (n=19)	Face mask	n=13	n=11	No		Frequent IMV
Belenguer-Muncharaz [47]	2011	Spain	Retrospective, observational, monocentre cohort	Face mask and helmet	n=10	0	No	0	First study to use a helmet and a face mask
Masclans [48]	2012	Spain	Prospective, observational, multicentre registry cohort	Face mask	n=177	n=105 (59.32%)	No	0	Best outcome in low APACHE II and SOFA, no vasopressor, lower chest radiograph quadrants and shorter ICU stay
Zhang [33]	2012	China	Retrospective, observational, monocentre cohort (n=394, including 1 pregnant subject) IMV (n=186)	Face mask	n=83	n=45 (24.32%)	No	n=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 countries	n=9
Spain	n=5
Italy	n=1
France	n=1
Portugal	n=1
Turkey	n=1
Asia	n=3
North America	n=1
Australia	n=1
Canada	n=1
Latin America	n=6
Mexico	n=2
Brazil	n=2
Chilean-Uruguay	n=1
Argentina	n=1
South Africa	n=1
North Africa (Morocco)	n=1

Table 4. Noninvasive ventilation (NIV) in acute exacerbations of pulmonary tuberculosis (TB) sequelae

First author [ref.]	Year	Country	Study design	Type of ARF-TB	Interface	NIV failure	Transmission among HCW^#	Mortality	Observations	Home MV after AEPTS
Tsuboi [51]	1996	Japan	Prospective cohort (n=17)	AEPTS in mixed groups	Nasal mask	0	No	0		Yes
Machida [53]	1998	Japan	Retrospective survey (n=58)	AEPTS	Nasal mask	0	No	0		Yes
Prats Soro [60]	1999	Spain	Case report (n=1)	AEPTS	Nasal mask	0	No	0		Yes
Schulz [54]	1999	Germany	Prospective cohort (n=26)	AEPTS	Nasal mask	0	No	0		Yes
Agarwal [56]	2005	India	Cases series cohort (n=3)	ARDS and Mycobacterium tuberculosis AEPTS	Face mask	0	No	0		No
Utsugi [57]	2006	Japan	Case report (n=1)	ARF, miliary TB and AEPTS	Face mask	0	No	0		No
Aso [58]	2010	Japan	Prospective cohort (n=58)	AEPTS	Face mask	13.8%	No	1.7%	0	No

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.