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Evaluation of the feasibility of average volume-assured pressure support ventilation in the treatment of acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease: A pilot study
YJCRC-52551; No of Pages 1 Journal of Critical Care xxx (2017) xxx
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Evaluation of the feasibility of average volume-assured pressure support ventilation in the treatment of acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease: A pilot study
We thank Briones and colleagues for their interest in our paper and for their comments. We agree with their valuable suggestions for this study. This study's data were obtained from the respiratory intensive care unit (ICU) of a chest diseases clinic. Data loss was not the case since the authors of this study were also in charge of the intensive care unit. As the study setting was a respiratory intensive care unit, our number of noninvasive mechanical ventilation (NIV) practices may have been greater than applied in general intensive care units. Therefore, our cases have reached a significant number. Acute hypercapnic respiratory failure (AHRF) due to COPD is the leading indication of NIV support at ICU [1]. First of all, we would like to indicate that our research was designed on the basis of realtime experiences. This means that, at our intensive care unit where the number of patients with COPD-induced acute hypercapnic respiratory failure was significantly greater than that of other patients, we experienced that NIV-applied patients were more effectively treated by the average volume assured pressure support (AVAPS) mode where target tidal volume was pre-determined. We fully agree with the view that pneumonia is a major factor affecting NIV success. It was a deliberate decision not to exclude patients with pneumonia when enrolling patients. We are well aware that comorbidities are so common in COPD [2]. We aimed to experience the efficacy of NIV under conditions known to influence its efficacy because it is known that the number of COPD patients with serious comorbidities is greater than that of patients with pure COPD [3]. Invasive ventilation requirements increase the mortality rate of these patients [4]. In one of our trials we conducted on different intensive care patient groups aged N 65 years with AHRF, the success rate of NIV was 52.6% in the pneumonia group and 80% in the COPD group [5]. This finding was attributed to a low PaO2/FiO2 ratio, low Glasgow coma score, and high APACHE II score in AHRF cases secondary to pneumonia [5]. NIV indication in patients with acute coronary syndrome should be very carefully determined [6]. These patients should also be closely monitored. During NIV, hemodynamic changes occur because of the change in intrathoracic pressure, reflecting the lower stroke volume. In the present study, NIV was not administered to patients with unstable cardiac
arrhythmias and hemodynamic instability, in whom NIV was contraindicated. When NIV is to be administered to COPD cases with stable coronary artery disease (CAD), tidal volume and maximum pressures should be adjusted by patient basis, and the AVAPS mode, a controlled and hybrid mode that is capable of protecting from high pressure and volume, may be appropriate. During our research tidal volume was adjusted in a patient-specific manner, between 8 and 10 mL/kg, in order to provide a protective ventilation against barotrauma-induced lung injury developed by higher pressures and volumes. We referred the results of one of your studies, published in 2013, where you compared AVAPS and BPAP-ST groups, very valuable in this regard [7]. We note from your study that although the initial target volume in infective COPD exacerbation cases was set to 10 to 12 mL/kg of IBW, i.e. to a slightly higher volume, until clinical stability was attained, rapid improvement occurred in arterial blood gases, which was parallel to our study and indicates that AVAPS mode is effective. References [1] Masa JF, Utrabo I, Gomez de Terreros J, Aburto M, Esteban C, et al. Noninvasive ventilation for severely acidotic patients in respiratory intermediate care units: precision medicine in intermediate care units. BMC Pulm Med 2016;16(1):97. [2] Rabe KF, Watz H. Chronic obstructive pulmonary disease. Lancet 2017;389(10082): 1931–40. [3] Vanfleteren LE, Spruit MA, Groenen M, Gaffron S, van Empel VP, Bruijnzeel PL, et al. Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013;187(7):728–35. [4] Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339(7):429–35. [5] Ciftci F, Ciledağ A, Erol S, Kaya A. Non-invasive ventilation for acute hypercapnic respiratory failure in older patients. Wien Klin Wochenschr 2017 Mar 10. http://dx. doi.org/10.1007/s00508-017-1182-2. [6] Ongel EA, Karakurt Z, Salturk C, Takir HB, Burunsuzoglu B, Kargin F, et al. How do COPD comorbidities affect ICU outcomes? Int J Chron Obstruct Pulmon Dis 2014;9: 1187–96. [7] Briones Claudett KH, Briones Claudett M, Chung Sang Wong M, Nuques Martinez A, Soto Espinoza R, Montalvo M, et al. Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy. BMC Pulm Med 2013;12 (13:12).
Fatma Ciftci Chest Disease, Ankara University, Cebeci, 06220 Ankara, Turkey E-mail address: [email protected] Available online xxxx
http://dx.doi.org/10.1016/j.jcrc.2017.06.003 0883-9441/© 2017 Published by Elsevier Inc.
Please cite this article as: Ciftci F, Evaluation of the feasibility of average volume-assured pressure support ventilation in the treatment of acute hypercapnic respiratory failure associated with chronic..., Journal of Critical Care (2017), http://dx.doi.org/10.1016/j.jcrc.2017.06.003
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Evaluation of the feasibility of average volume-assured pressure support ventilation in the treatment of acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease: A pilot study
We thank Briones and colleagues for their interest in our paper and for their comments. We agree with their valuable suggestions for this study. This study's data were obtained from the respiratory intensive care unit (ICU) of a chest diseases clinic. Data loss was not the case since the authors of this study were also in charge of the intensive care unit. As the study setting was a respiratory intensive care unit, our number of noninvasive mechanical ventilation (NIV) practices may have been greater than applied in general intensive care units. Therefore, our cases have reached a significant number. Acute hypercapnic respiratory failure (AHRF) due to COPD is the leading indication of NIV support at ICU [1]. First of all, we would like to indicate that our research was designed on the basis of realtime experiences. This means that, at our intensive care unit where the number of patients with COPD-induced acute hypercapnic respiratory failure was significantly greater than that of other patients, we experienced that NIV-applied patients were more effectively treated by the average volume assured pressure support (AVAPS) mode where target tidal volume was pre-determined. We fully agree with the view that pneumonia is a major factor affecting NIV success. It was a deliberate decision not to exclude patients with pneumonia when enrolling patients. We are well aware that comorbidities are so common in COPD [2]. We aimed to experience the efficacy of NIV under conditions known to influence its efficacy because it is known that the number of COPD patients with serious comorbidities is greater than that of patients with pure COPD [3]. Invasive ventilation requirements increase the mortality rate of these patients [4]. In one of our trials we conducted on different intensive care patient groups aged N 65 years with AHRF, the success rate of NIV was 52.6% in the pneumonia group and 80% in the COPD group [5]. This finding was attributed to a low PaO2/FiO2 ratio, low Glasgow coma score, and high APACHE II score in AHRF cases secondary to pneumonia [5]. NIV indication in patients with acute coronary syndrome should be very carefully determined [6]. These patients should also be closely monitored. During NIV, hemodynamic changes occur because of the change in intrathoracic pressure, reflecting the lower stroke volume. In the present study, NIV was not administered to patients with unstable cardiac
arrhythmias and hemodynamic instability, in whom NIV was contraindicated. When NIV is to be administered to COPD cases with stable coronary artery disease (CAD), tidal volume and maximum pressures should be adjusted by patient basis, and the AVAPS mode, a controlled and hybrid mode that is capable of protecting from high pressure and volume, may be appropriate. During our research tidal volume was adjusted in a patient-specific manner, between 8 and 10 mL/kg, in order to provide a protective ventilation against barotrauma-induced lung injury developed by higher pressures and volumes. We referred the results of one of your studies, published in 2013, where you compared AVAPS and BPAP-ST groups, very valuable in this regard [7]. We note from your study that although the initial target volume in infective COPD exacerbation cases was set to 10 to 12 mL/kg of IBW, i.e. to a slightly higher volume, until clinical stability was attained, rapid improvement occurred in arterial blood gases, which was parallel to our study and indicates that AVAPS mode is effective. References [1] Masa JF, Utrabo I, Gomez de Terreros J, Aburto M, Esteban C, et al. Noninvasive ventilation for severely acidotic patients in respiratory intermediate care units: precision medicine in intermediate care units. BMC Pulm Med 2016;16(1):97. [2] Rabe KF, Watz H. Chronic obstructive pulmonary disease. Lancet 2017;389(10082): 1931–40. [3] Vanfleteren LE, Spruit MA, Groenen M, Gaffron S, van Empel VP, Bruijnzeel PL, et al. Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013;187(7):728–35. [4] Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339(7):429–35. [5] Ciftci F, Ciledağ A, Erol S, Kaya A. Non-invasive ventilation for acute hypercapnic respiratory failure in older patients. Wien Klin Wochenschr 2017 Mar 10. http://dx. doi.org/10.1007/s00508-017-1182-2. [6] Ongel EA, Karakurt Z, Salturk C, Takir HB, Burunsuzoglu B, Kargin F, et al. How do COPD comorbidities affect ICU outcomes? Int J Chron Obstruct Pulmon Dis 2014;9: 1187–96. [7] Briones Claudett KH, Briones Claudett M, Chung Sang Wong M, Nuques Martinez A, Soto Espinoza R, Montalvo M, et al. Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy. BMC Pulm Med 2013;12 (13:12).
Fatma Ciftci Chest Disease, Ankara University, Cebeci, 06220 Ankara, Turkey E-mail address: [email protected] Available online xxxx
http://dx.doi.org/10.1016/j.jcrc.2017.06.003 0883-9441/© 2017 Published by Elsevier Inc.
Please cite this article as: Ciftci F, Evaluation of the feasibility of average volume-assured pressure support ventilation in the treatment of acute hypercapnic respiratory failure associated with chronic..., Journal of Critical Care (2017), http://dx.doi.org/10.1016/j.jcrc.2017.06.003