Page 97 - JSOM Summer 2022

from NPPV. 16–18 In a meta-analysis of 17 randomized trials of When Not to Use NPPV
patients diagnosed with AECOPD, there was a 50% reduction
in mortality as comparted to patients with standalone respi- Contraindications include:
ratory treatment. 16–18 Additionally, those patients showed a • Decreased level of consciousness (Glasgow Coma Scale
decreased rate of intubation, ventilator induced injuries, and (GCS) score < 10)
multiorgan failure. 16–18 • Cardiac arrest or dysrhythmias
• Acute coronary syndrome
Patients in acute cardiogenic pulmonary edema (ACPE) • Hemodynamic instability (systolic blood pressure < 90mmHg)
are likely to improve with NPPV as a result of preload re- • Open thoracic wound
duction, alveolar recruitment, and decreased left ventricular • Apnea
afterload. 19–26 In a 2013 meta-analysis of 32 studies (2,916 pa- • Upper airway obstruction
tients), it was reported that NPPV significantly reduced hos- • Upper gastrointestinal bleeding
pital mortality and respiratory failure (dyspnea, hypercapnia, • Facial trauma
26
acidosis, etc.). NPPV also reduced the need for intubation • Vomiting
and or frequency of intubations in lengthy hospital admissions • Pregnancy
in the same cohort. 26,27 • Patient refusal
• Patient ability to cooperate
• Excessive secretions
NPPV in Trauma Patients
• Inability to protect own airway
The respiratory management of trauma patients is complex • Facial burns
and tied tightly to multiple physiologic factors including in- • Abnormal anatomy
trinsic pulmonary function, respiratory mechanics, airway
integrity, and hemodynamic status. It is the responsibility of
the clinician to determine the best method of protecting and Summary
managing the patient’s airway appropriately. In general, there NPPV is a form of positive pressure ventilation that supports
is little evidence showing the efficacy of NPPV in the initial patients with ARF. Using NPPV on patients that will likely
management of the trauma patient. 28–29 Often complex pol- benefit has shown to lessen mortality, the need for intubation,
ytrauma patients are intubated for airway protection and ventilator management, and later stage organ failure. While
during surgical procedures, which would be a contraindica- the use of NPPV in the initial management of trauma patients
tion for the use of NPPV. Current Prehospital Trauma Life lacks evidence, these patients postintubation or in respiratory
Support and Advanced Trauma Life Support guidelines sug- failure may benefit.
gest early invasive airway intervention for those patients who
are in respiratory failure or have significant thoracic trauma. Disclosures
28
NPPV may be considered for the management of patients that None.
are postsurgical and at risk for development of nosocomial
pneumonia during prolonged hospital stays. The goal for
29
these trauma patients should be alveolar recruitment, oxygen- Disclaimer
Our opinions or assertions contained herein are the private
ation, and avoidance of ventilator-induced lung injury (VILI) views of the authors and are not to be construed as official
or worsening of existing injuries.
or as reflecting the views of the Department of Defense or its
Services.
Patients Who Will Not Benefit From NPPV
Patients suffering from hypoxemic, nonhypercapnic respi- Funding
ratory failure are less likely to benefit from NPPV and will None.
respond better to individualized approaches to reversing the
30
hypoxemia. The use of high-flow oxygen delivered via nasal References
cannula (HFNC) is typically a better option in these patients. 1. Rose L, Gerdtz MF. Review of noninvasive ventilation in the emer-
30
The targeted approach to correcting the hypoxemia is often gency department: clinical considerations and management priori-
ties. J Clin Nurs. 2009;18(23):3216–3224.
the primary cause to later acute respiratory failure, which re- 2. Rose L. Management of critically ill patients receiving noninvasive
quires aggressive NPPV and/or intubation. 30 and invasive mechanical ventilation in the emergency department.
Open Access Emerg Med. 2012;4:5–15.
All patients requiring PPV in either invasive or noninvasive pro- 3. Szucs-Farkas Z, Kaelin I, Flach PM, et al. Detection of chest trauma
cesses should be monitored for VILI. VILI can occur because with whole-body low-dose linear slit digital radiography: a multi-
of ventilation at high lung volumes, leading to alveolar rupture reader study. AJR Am J Roentgenol. 2010;194(5):W388–W395.
(bleb), air leaks, and gross barotrauma (e.g., pneumothorax, 4. Boldrini R, Fasano L, Nava S. Noninvasive mechanical ventilation.
Curr Opin Crit Care. 2012;18(1):48–53.
pneumomediastinum, and subcutaneous emphysema). The 5. Antonelli M, Conti G, Moro ML, et al. Predictors of failure of
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concern for barotrauma is secondary to lung overdistention, noninvasive positive pressure ventilation in patients with acute hy-
not high airway pressures, which may be measured utilizing poxemic respiratory failure: a multi-center study. Intensive Care
plateau pressures (most obtainable in the patient with an ad- Med. 2001;27(11):1718–1728.
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to high airway pressures, especially in settings of low PEEP. chest trauma: systematic review and meta-analysis. Intensive Care
Med. 2013;39(7):1171–1180.
The management and prevention of VILI are well noted in the 7. Hernandez G, Fernandez R, Lopez-Reina P, et al. Noninvasive ven-
ARDSNET protocols, seeking a lung protective strategy in all tilation reduces intubation in chest trauma-related hypoxemia: a
patients receiving positive pressure ventilation. 31 randomized clinical trial. Chest. 2010;137(1):74–80.

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