Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations

Analgosedation practice during noninvasive respiratory supports: Results from an Italian survey

PURPOSE

There are currently no established guidelines pertaining the application of analgosedation strategies for patients undergoing Noninvasive Respiratory Supports (NRSs) for acute respiratory failure treatment. The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) conducted a nation-wide survey to describe the current clinical practice in the management of analgosedation during NRSs.

METHODS

This is a nationwide online survey, involving Italian anesthesiologist-intensivists, developed by experts affiliated with SIAARTI. Invitations to participate were distributed via emails and social networks. Data were collected over a period of three months (March 16 to May 10, 2024).

RESULTS

Two hundred and seventy-seven full responses were collected. Most respondents were attending physician (83 %), with <10 years of ICU experience (56 %) and work in ICU medical department (75 %). In terms of optimizing the NRS success, 80 % of respondents used a pharmacological strategy and 50 % of respondents did not use a non-pharmacological strategy. Dexmedetomidine was the most commonly administered drug (82 %), followed by morphine and remifentanil. Additionally, 33 % of respondents reported using a combination of dexmedetomidine and remifentanil as part of their pharmacological strategy during NRSs. Concerning the motivations for analgosedation use during NRSs, over 80 % of respondents aimed to improve patient-ventilator interaction, more than 60 % focused on reducing patient anxiety and dyspnea, 59 % sought for having a lower respiratory rate, and only 40 % prioritized pain reduction.

CONCLUSION

Sedation is frequently used in patients with acute respiratory failure undergoing NRSs. Current analgesic practices are becoming more standardized, with analgosedation strategies increasingly tailored to individual patient characteristics.

Risk factors and outcomes of pediatric non-invasive respiratory support failure in Latin America

Background

Noninvasive respiratory support (NRS) is standard in pediatric intensive care units (PICUs) for respiratory diseases, but its failure can lead to complications requiring invasive mechanical ventilation (IMV). This study aimed to identify risk factors for NRS failure in children with acute respiratory failure (ARF) in PICUs, and compare complications and outcomes between IMV-only and NRS failure patients.

Methods

We conducted a cohort study using data from the LARed Network prospective registry (April 2017-November 2022), in children under 18 years admitted to PICUs for ARF. Cases were divided into subgroups: those managed with IMV only, those who experienced NRS failure requiring IMV, those who received NRS successfully, and those who did not require NRS or IMV. Exclusions included patients with home respiratory support prior to admission, patients without PICU discharge at the cutoff date of the analysis and those with incomplete data. Multivariate mixed models analyzed NRS failure risk factors, and complications between the IMV-only and NRS failure groups, using centers as a random effect.

Results

A total of 7374 children met the inclusion criteria, with 6208 in the NRS group and 1166 in the IMV-only group. The NRS success rate was 85.3 %. Risk factors for NRS failure included age (median of 4.6 months, interquartile range of 2.1-14.2 months), history of prematurity (adjusted odds ratio [aOR]=1.53, 95 % confidence interval [CI]: 1.20 to 1.95) or malnutrition (aOR=1.85, 95 % CI: 1.18 to 2.91), suspected bacterial infection (aOR=5.12, 95 % CI: 4.05to 6.49), FiO2 >30 % (aOR=1.52, 95 % CI: 1.18 to 1.97), severe hypoxemia with SpO2/FiO2 ≤150 (aOR=1.85, 95 % CI: 1.48 to 2.30), tachypnea (aOR=1.42, 95 % CI: 1.18 to 1.72), tachycardia (aOR=1.77, 95 % CI: 1.47 to 2.12), and lung consolidations (aOR=1.45, 95 % CI: 1.14 to 1.85) or interstitial infiltrates (aOR=1.29, 95 % CI: 1.05 to 1.58) on chest X-ray. There were no significant differences in morbidity, mortality, duration of IMV, or PICU length of stay between patients who received IMV only and those who experienced NRS failure. However, patients who experienced NRS failure were more likely to develop withdrawal symptoms related to sedative or opioid discontinuation and/or delirium (aOR=2.57, 95 % CI: 1.85 to 2.57).

Conclusion

This study identified key risk factors for predicting NRS failure in children with acute ARF in PICUs, including younger age, prematurity, malnutrition, suspected bacterial infection, FiO2 >30 %, severe hypoxemia (SpO2/FiO2 ≤150), tachypnea, tachycardia, and radiological findings such as lung consolidation and interstitial infiltrates. Compared to patients managed with IMV from the start, those who experienced NRS failure were more likely to develop withdrawal symptoms and/or delirium, although clinical outcomes such as mortality, IMV duration, and PICU length of stay were similar in both groups.

High-velocity nasal insufflation versus noninvasive positive pressure ventilation for moderate acute exacerbation of chronic obstructive pulmonary disease in the emergency department: A randomized clinical trial

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) involve dyspnea, cough, and chest discomfort; frequent exacerbations are associated with increased mortality and reduced quality of life. Noninvasive positive pressure ventilation (NiPPV) is commonly used to help relieve symptoms but is limited due to patient intolerance. We aimed to determine whether high-velocity nasal insufflation (HVNI) is noninferior to NiPPV in relieving dyspnea within 4 h in ED patients with acute hypercapnic respiratory failure.

METHODS

This randomized control trial was conducted in seven EDs in the United States. Symptomatic patients with suspected COPD, partial pressure of carbon dioxide (pCO2) ≥ 60 mm Hg, and venous pH 7.0-7.35 were randomized to receive HVNI (n = 36) or NiPPV (n = 32). The primary outcome was dyspnea severity 4 h after the initiation of study intervention, as measured by the Borg score. Secondary outcomes included vital signs, oxygen saturation, venous pCO2, venous pH, patient discomfort level, and need for endotracheal intubation.

RESULTS

Sixty-eight patients were randomized between November 5, 2020, and May 10, 2023 (mean age 65.6 years; 47% women). The initial pCO2 was 77.7 ± 13.6 mm Hg versus 76.5 ± 13.6 mm Hg and the initial venous pH was 7.27 ± 0.063 versus 7.27 ± 0.043 in the HVNI and NiPPV groups, respectively. Dyspnea was similar in the HVNI and NiPPV groups at baseline (dyspnea scale score 5.4 ± 2.93 and 5.6 ± 2.41) and HVNI was noninferior to NiPPV at the following time points: 30 min (3.97 ± 2.82 and 4.54 ± 1.65, p = 0.006), 60 min (3.09 ± 2.70 and 4.07 ± 1.77, p < 0.001), and 4 h (3.17 ± 2.59 and 3.34 ± 2.04, p = 0.03). At 4 h, there was no difference between the groups in the pCO2 mm Hg (68.76 and 67.29, p = 0.63). Patients reported better overall comfort levels in the HVNI group at 30 min, 60 min, and 4 h (p = 0.003).

CONCLUSIONS

In participants with symptomatic COPD, HVNI was noninferior to NiPPV in relieving dyspnea 4 h after therapy initiation. HVNI may be a reasonable treatment option for some patients experiencing moderate acute exacerbations of COPD in the ED.

Evaluation of Effectiveness and Safety of Dexmedetomidine in non-Mechanically Ventilated COVID-19 Critically ill Patients: A Multicentre Cohort Study

Background: Dexmedetomidine (DEX) is a highly favored sedative agent in critically ill patients owing to its anxiolytic and analgesic properties, lower risk of delirium, and minimal respiratory depression. Additionally, DEX exhibits anti-inflammatory properties, which have prompted its use in managing COVID-19 patients to mitigate cytokine storm and multi-organ dysfunction. Thus, this study aims to evaluate the safety and effectiveness of DEX use in critically ill patients with COVID-19. Method: This multicenter, retrospective cohort study included adult patients with confirmed COVID-19 who were admitted to the ICUs and did not require invasive mechanical ventilation (MV). Patients were categorized into two groups based on receiving DEX use within 72 h of ICU admission. The primary outcome was respiratory failure requiring invasive MV; other outcomes were considered secondary. Results: A total of 155 patients were included in the study after propensity matching. DEX did not reduce respiratory failure requiring invasive MV (HR 0.66; 95% CI (0.28, 1.53), P = .33). However, the time for invasive MV was statistically significantly shorter in the DEX group compared with the control group (beta coefficient (95%CI): - 1.05 (-2.03, -0.07), P = .03). In contrast, ICU and hospital Length of stay (LOS) were not statistically significant compared to the control group (beta coefficient 0.04 (95% CI -0.29, 0.38), P = .80, and beta coefficient - 0.03 (95% CI -0.33, 0.26), P = .81, respectively). In addition, the 30-day and in-hospital mortality rates were similar between the two groups (HR 1.1; 95% CI 0.97, 1.20, P = .14, and HR 1.01; 95% CI 0.95, 1.06, P = .90, respectively). Conclusion: Dexmedetomidine did not appear to lower the risk of respiratory failure necessitating invasive mechanical ventilation in critically ill patients. However, the mean time for invasive mechanical ventilation was shorter in the DEX group. Future interventional studies are required to confirm our findings.

Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing

Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.

Combining O2 High Flow Nasal or Non-Invasive Ventilation with Cooperative Sedation to Avoid Intubation in Early Diffuse Severe Respiratory Distress Syndrome, Especially in Immunocompromised or COVID Patients?

This overview addresses the pathophysiology of the acute respiratory distress syndrome (ARDS; conventional vs. COVID), the use of oxygen high flow (HFN) vs. noninvasive ventilation (NIV; conventional vs. helmet) and a multi-modal approach to avoid endotracheal intubation ("intubation"): low normal temperature, cooperative sedation, normalized systemic and microcirculation, anti-inflammation, reduced lung water, upright position, lowered intra-abdominal pressure. Increased ventilatory muscle activity ("respiratory drive") is observed in early ARDS, at variance with ventilatory fatigue observed in decompensated chronic obstructive pulmonary disease (COPD). This increased drive leads to impending then overt ventilatory failure. Therefore, muscle relaxation presents little rationale and should be replaced by lowering the excessive respiratory drive, increased work of breathing, continued or increased labored breathing, self-induced lung injury (SILI), i.e. preserving spontaneous breathing. As CMV is a lifesaver in the setting of failure but does not heal the lung, side-effects of intubation, controlled mechanical ventilation (CMV), paralysis and deep sedation are to be avoided. Additionally, critical care resources shortage requires practice changes. Therefore, NIV should be routine when addressing immune-compromised patients. The SARS-CoV2 pandemics extended this approach to most patients, which are immune-compromised: elderly, obese, diabetic, etc. The early COVID is a pulmonary vascular endothelial inflammatory disease requiring lower positive-end-expiratory pressure than the typical pulmonary alveolar epithelial inflammatory diffuse ARDS. This leads one to reassess a) the technique of NIV b) the sedation regimen facilitating continuous and extended NIV to avoid intubation. Autonomic, circulatory, respiratory, ventilatory physiology is hierarchized under HFN/NIV and cooperative sedation (dexmedetomidine, clonidine). A prospective randomized pilot trial, then a larger trial are required to ascertain our working hypotheses.

Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BACKGROUND

Discomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS.

METHODS

The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus.

RESULTS

The use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting.

CONCLUSIONS

The use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Remifentanil vs. dexmedetomidine for cardiac surgery patients with noninvasive ventilation intolerance: a multicenter randomized controlled trial

BACKGROUND

The optimal sedative regime for noninvasive ventilation (NIV) intolerance remains uncertain. The present study aimed to assess the efficacy and safety of remifentanil (REM) compared to dexmedetomidine (DEX) in cardiac surgery patients with moderate-to-severe intolerance to NIV.

METHODS

In this multicenter, prospective, single-blind, randomized controlled study, adult cardiac surgery patients with moderate-to-severe intolerance to NIV were enrolled and randomly assigned to be treated with either REM or DEX for sedation. The status of NIV intolerance was evaluated using a four-point NIV intolerance score at different timepoints within a 72-h period. The primary outcome was the mitigation rate of NIV intolerance following sedation.

RESULTS

A total of 179 patients were enrolled, with 89 assigned to the REM group and 90 to the DEX group. Baseline characteristics were comparable between the two groups, including NIV intolerance score [3, interquartile range (IQR) 3-3 vs. 3, IQR 3-4, p = 0.180]. The chi-squared test showed that mitigation rate, defined as the proportion of patients who were relieved from their initial intolerance status, was not significant at most timepoints, except for the 15-min timepoint (42% vs. 20%, p = 0.002). However, after considering the time factor, generalized estimating equations showed that the difference was statistically significant, and REM outperformed DEX (odds ratio = 3.31, 95% confidence interval: 1.35-8.12, p = 0.009). Adverse effects, which were not reported in the REM group, were encountered by nine patients in the DEX group, with three instances of bradycardia and six cases of severe hypotension. Secondary outcomes, including NIV failure (5.6% vs. 7.8%, p = 0.564), tracheostomy (1.12% vs. 0%, p = 0.313), ICU LOS (7.7 days, IQR 5.8-12 days vs. 7.0 days, IQR 5-10.6 days, p = 0.219), and in-hospital mortality (1.12% vs. 2.22%, p = 0.567), demonstrated comparability between the two groups.

CONCLUSIONS

In summary, our study demonstrated no significant difference between REM and DEX in the percentage of patients who achieved mitigation among cardiac surgery patients with moderate-to-severe NIV intolerance. However, after considering the time factor, REM was significantly superior to DEX. Trial registration ClinicalTrials.gov (NCT04734418), registered on January 22, 2021. URL of the trial registry record: https://register.

CLINICALTRIALS

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Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease

The management of patients with life-threatening respiratory disease in the ICU and at home has become increasingly of interest over the past decades. Growing knowledge supports the use of NRS, aimed at improving patient comfort and improving quality of life. However, its role during palliative care is not well defined, and evidence of support remains limited. The aim of this narrative review is to examine the recent evidence relating to the use of non-invasive respiratory support at the end of life, in order to clarify who benefits and when. The literature research was conducted on PubMed, using MeSH words. A review of the relevant literature showed that non-invasive respiratory support techniques for patients with life-limiting respiratory disease vary (from high-flow oxygen therapy to conventional oxygen therapy, from CPAP to NPPV) and each has precise indications. To date, from the hospital to the home setting, the monitoring and application of these respiratory support techniques have varied widely. In conclusion, the choice of respiratory support in this category of patients should be based on the technique that will optimize the comfort of the patient and improve the quality of their life. On the other hand, regarding monitoring, both telemedicine and ultrasound diagnostics help to satisfy the patient's wish to spend the last period of his life in the home environment, to avoid inappropriately aggressive diagnostic interventions, and to reduce the high costs of hospitalized procedures in this category of patients.

Applying Noninvasive Ventilation in Treatment of Acute Exacerbation of COPD Using Evidence-Based Interprofessional Clinical Practice

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Identifying patients appropriate for NIV, and subsequently providing close monitoring to determine an improvement in clinical condition involves a team consisting of physician, nurse, and respiratory therapist in institutions that successfully implement NIV. We describe to our knowledge the first known evidence-based algorithm speaking to initiation, titration, monitoring, and weaning of NIV in treatment of acute exacerbation of COPD that incorporates the necessary interprofessional collaboration among physicians, nurses, and respiratory therapists caring for these patients.

Analgo-sedation in Patients on Non-invasive Mechanical Ventilation: Need for Guideline Recommendation

Shrinath V, Marwah V, Jyothis MC. Analgo-sedation in Patients on Non-invasive Mechanical Ventilation: Need for Guideline Recommendation. Indian J Crit Care Med 2024;28(3):309-310.

Noninvasive positive pressure in acute exacerbations of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Noninvasive positive pressure ventilation (NIV) is standard of care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We review the most current evidence and highlight areas of uncertainty and ongoing research. We highlight key concepts for the clinician caring for patients with AECOPD which require NIV.

RECENT FINDINGS

Implementation of NIV in AECOPD is not uniform in spite of the evidence and guidelines. Initiation of NIV should be done early and following protocols. Low-intensity NIV remains the standard of care, although research and guidelines are evaluating higher intensity NIV. Scores to predict NIV failure continue to be refined to allow early identification and interventions. Several areas of uncertainty remain, among them are interventions to improve tolerance, length of support and titration and nutritional support during NIV.

SUMMARY

The use of NIV in AECOPD is the standard of care as it has demonstrated benefits in several patient-centered outcomes. Current developments and research is related to the implementation and adjustment of NIV.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction

COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients.

Methods

Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain.

Results

424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713).

Conclusions

Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome.

Dexmedetomidine as Conduit for Non-Invasive Ventilation (NIV) Compliance in COVID-19 and Chronic Obstructive Pulmonary Disease (COPD) Patients in Intensive Care Unit (ICU) Setting: Case Series

Non-compliance to the non-invasive ventilation (NIV) mask in a distressed hypoxemic patient is not an unusual finding, especially in desaturated coronavirus disease (COVID-19) or chronic obstructive pulmonary disease (COPD) patients with respiratory distress who require ventilatory support to improve oxygenation. Failure to achieve success with the non-invasive ventilatory support with the tight-fitting mask led to emergent endotracheal intubation. This was in view to avert consequences such as severe hypoxemia and subsequent cardiac arrest.  Sedation is an important component of ICU management for noninvasive mechanical ventilation to improve NIV compliance/tolerance. Including the various sedatives used, such as fentanyl, propofol, or midazolam, the most suitable agent to be used as a primary/sole sedative still remains unclear. Dexmedetomidine providing analgosedation without significant respiratory depression facilitates better tolerance of NIV mask application. This case series is a retrospective analysis of patients in whom dexmedetomidine bolus followed by infusion was observed to facilitate compliance to NIV with the tight-fitting mask. Herein, a case summary of six patients with acute respiratory distress who were dyspnoic, agitated have severe hypoxemia were put on NIV with dexmedetomidine infusion is being reported. They were extremely uncooperative as their RASS score (Richmond Agitation-Sedation score) was + 1 to +3, not allowing the application of the NIV mask. Due to their poor compliance with to use of the NIV mask, proper ventilation could not be achieved. Dexmedetomidine infusion (0.3 to 0.4 mcg/kg/hr) was used after a bolus dose (0.2-0.3 mcg/kg). The RASS Score of our patients was +2 or +3 before this intervention which became -1 or -2 after including dexmedetomidine in the treatment protocol. The low dose dexmedetomidine bolus and infusion thereafter showed to improve the patient's acceptance of the device. Oxygen therapy with this was shown to improve patient oxygenation by allowing the acceptance of the tight-fitting NIV face mask. In conclusion, this case series serves as evidence of the use of dexmedetomidine as an effective therapy to calm the agitated desaturated patient, thereby facilitating non-invasive ventilation in COVID-19 and COPD patients and promoting better oxygenation. This may, in turn, avoid endotracheal intubation for invasive ventilation and the associated complications.