Early fiberoptic bronchoscopy during non-invasive ventilation in patients with decompensated chronic obstructive pulmonary disease due to community-acquired-pneumonia

Raffaele Scala, Mario Naldi, Uberto Maccari, Raffaele Scala, Mario Naldi, Uberto Maccari

Abstract

Introduction: Inefficient clearance of copious respiratory secretion is a cause of non-invasive positive pressure ventilation (NPPV) failure, especially in chronic respiratory patients with community-acquired-pneumonia (CAP) and impaired consciousness. We postulated that in such a clinical scenario, when intubation and conventional mechanical ventilation (CMV) are strongly recommended, the suction of secretions with fiberoptic bronchoscopy (FBO) may increase the chance of NPPV success. The objective of this pilot study was, firstly, to verify the safety and effectiveness of early FBO during NPPV and, secondly, to compare the hospital outcomes of this strategy versus a CMV-based strategy in patients with decompensated chronic obstructive pulmonary disease (COPD) due to CAP who are not appropriate candidates for NPPV because of inefficient mucous clearance and hypercapnic encephalopathy (HE).

Methods: This is a 12-month prospective matched case-control study performed in one respiratory semi-intensive care unit (RSICU) with expertise in NPPV and in one intensive care unit (ICU). Fifteen acutely decompensated COPD patients with copious secretion retention and HE due to CAP undergoing NPPV in RSICU, and 15 controls (matched for arterial blood gases, acute physiology and chronic health evaluation score III, Kelly-Matthay scale, pneumonia extension and severity) receiving CMV in the ICU were studied.

Results: Two hours of NPPV significantly improved arterial blood gases, Kelly and cough efficiency scores without FBO-related complications. NPPV avoided intubation in 12/15 patients (80%). Improvement in arterial blood gases was similar in the two groups, except for a greater PaO2/fraction of inspired oxygen ratio with CMV. The rates of overall and septic complications, and of tracheostomy were lower in the NPPV group (20%, 20%, and 0%) versus the CMV group (80%, 60%, and 40%; P < 0.05). Hospital mortality, duration of hospitalisation and duration of ventilation were similar in the two groups.

Conclusions: In patients with decompensated COPD due to CAP who are candidates for CMV because of HE and inability to clear copious secretions, NPPV with early therapeutic FBO performed by an experienced team is a feasible, safe and effective alternative strategy.

Figures

Figure 1
Figure 1
Fiberoptic bronchoscopy. (a) The fiberoptic bronchoscopy (FBO)-noninvasive positive pressure ventilation (NPPV) procedure. (b) The trans-nasally introduction of the bronchoscope. F = fiberoptic bronchoscope; H = heated humidifier; M = mask; T = T-adapter; V = ventilator.
Figure 2
Figure 2
(a) Changes of Kelly--Matthay and (b) cough efficiency score after two hours of noninvasive ventilation (NPPV). Values are expressed as mean (standard deviation). * P < 0.005 vs. baseline.
Figure 3
Figure 3
Trend of mean values of arterial blood gases. Values shown for before (pre-MV), after two hours (2 h-MV) and at the end of mechanical ventilation (end-MV) in the noninvasive positive pressure ventilation (NPPV) (Rectangles; pre-MV: n.15; 2 h-MV: n.15; end-MV: n.11) and the conventional mechanical ventilation (CMV) group (circles; pre-MV: n.15; 2 h-MV: n.15; end-MV: n.8). Dashed lines depicted the individuals values of pH, partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2), partial pressure of arterial carbon dioxide (PaCO2) of NPPV-treated patients. * P < 0.05 between the groups.

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