Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. [Time for extubation and sequential noninvasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation]. Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: An Indian experience Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. Noninvasive Mechanical Ventilation in the Weaning of Patients with Respiratory Failure Due to Chronic Obstructive Pulmonary Disease Ventilator-associated pneumonia: Incidence, risk factors, outcome, and microbiology. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey The influence of controlled mandatory ventilation (CMV), intermittent mandatory ventilation (IMV) and biphasic intermittent positive airway pressure (BIPAP) on duration of intubation and consumption of analgesics and sedatives. A prospective analysis in 596 patients following adult cardiac surgery. [Application of sequential noninvasive following invasive mechanical ventilation in COPD patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window]. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial.
OBJECTIVE To compare a practice of protocol -directed sedation during mechanical ventilation implemented by nurses with traditional non- protocol -directed sedation administration . DESIGN R and omized , controlled clinical trial . SETTING Medical intensive care unit ( 19 beds ) in an urban teaching hospital . PATIENTS Patients requiring mechanical ventilation ( n = 321 ) . INTERVENTIONS Patients were r and omly assigned to receive either protocol -directed sedation ( n = 162 ) or non- protocol -directed sedation ( n = 159 ) . MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs ( 95 % confidence interval , 41.0 - 90.0 hrs ) for patients managed with protocol -directed sedation and 117.0 hrs ( 95 % confidence interval , 96.0 - 155.6 hrs ) for patients receiving non- protocol -directed sedation . Kaplan-Meier analysis demonstrated that patients in the protocol -directed sedation group had statistically shorter duration s of mechanical ventilation than patients in the non- protocol -directed sedation group ( chi-square = 7.00 , p = .008 , log rank test ; chi-square = 8.54 , p = .004 , Wilcoxon 's test ; chi-square = 9.18 , p = .003 , -2 log test ) . Lengths of stay in the intensive care unit ( 5.7+/-5.9 days vs. 7.5+/-6.5 days ; p = .013 ) and hospital ( 14.0+/-17.3 days vs. 19.9+/-24.2 days ; p < .001 ) were also significantly shorter among patients in the protocol -directed sedation group . Among the 132 patients ( 41.1 % ) receiving continuous intravenous sedation , those in the protocol -directed sedation group ( n = 66 ) had a significantly shorter duration of continuous intravenous sedation than those in the non- protocol -directed sedation group ( n = 66 ) ( 3.5+/-4.0 days vs. 5.6+/-6.4 days ; p = .003 ) . Patients in the protocol -directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non- protocol -directed sedation group ( 10 of 162 patients [ 6.2 % ] vs. 21 of 159 patients [ 13.2 % ] , p = .038 ) . CONCLUSIONS The use of protocol -directed sedation can reduce the duration of mechanical ventilation , the intensive care unit and hospital lengths of stay , and the need for tracheostomy among critically ill patients with acute respiratory failure OBJECTIVE To discuss the optimal time for extubation and sequential non-invasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation .  METHODS 24 patients received invasive ventilation for 3 days were r and omly assigned to receive noninvasive ventilation ( study group ) or to continue the weaning process with invasive ventilation ( control group ) . The incidence of ventilator-associated pneumonia ( VAP ) , the incidence of death , the duration of ventilation , the hospitalization were analyzed in two groups . RESULTS Between study group and control group , the incidence of VAP was 0/12 vs 7/12 , P = 0.027 ; the incidence of death was 0/12 vs 3/12 , P = 0.217 ; the continued duration of ventilation after invasive ventilation for 3 days was ( 7 + /- 5 ) days vs ( 15 + /- 12 ) days , P < 0.05 ; the hospitalization was ( 16 + /- 6 ) days vs ( 25 + /- 12 ) days , P < 0.05 , respectively . CONCLUSIONS In COPD patients with exacerbated respiratory failure who received invasive ventilation  , invasive ventilation for 3 days followed by noninvasive ventilation may decrease the incidence of VAP , shorten the duration of ventilation and hospitalization Background : Endotracheal intubation and mechanical ventilation ( MV ) are often needed in patients of chronic obstructive pulmonary disease ( COPD ) with acute hypercapnic respiratory failure . The rate of weaning failure is high and prolonged MV increases intubation associated complications . Objective : To evaluate the role of Noninvasive ventilation ( NIV ) in weaning patients of chronic obstructive pulmonary disease ( COPD ) from MV , after T piece trial failure . Design : A prospect i ve , r and omized , controlled study was conducted in a tertiary care centre . 30 patients of acute exacerbation of COPD with acute on chronic hypercapnic respiratory failure , who were mechanically ventilated , were included in the study A T-piece weaning trial was attempted once the patients achieved satisfactory clinical and biochemical parameters . After T-piece failure , defined as pH < 7.35 , PaCO2 > 50 mmHg , PaO2 < 50 mmHg , HR > 100/min , RR > 35 , patients were r and omized to receive either NIV or PSV . Results : Demography , severity of disease and clinical profiles were similar in both groups . No significant difference between the two groups in duration of MV ( 6.20 ± 5.20 days vs. 7.47 ± 6.38 days , P > 0.05 ) , duration of weaning ( 35.17 ± 16.98 and 47.05 ± 20.98 hours , P > 0.05 ) or duration of ICU stay ( 8.47 ± 4.79 and 10.80 ± 5.28 days , P > 0.05 ) in Gp I and Gp II , respectively . Five patients developed VAP in the PSV group , where as only one patient had pneumonia in the NIV group . Lesser number of deaths in the NIV group at discharge from ICU ( 3 vs. 5 patients , respectively ) and at 30 days ( 5 vs. 9 patients , respectively ) , it did not achieve statistical significance ( P > 0.05 ) . Conclusion : NIV is as useful as PSV in weaning and can be better in weaning failure especially in COPD for earlier weaning , decrease ICU stay , complications and mortality Purpose The use of noninvasive ventilation ( NIV ) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure ( hypoxemic ARF ) has never been explored . This pilot study aims to assess the feasibility of early extubation followed by immediate NIV , compared conventional weaning , in patients with resolving hypoxemic ARF . Methods Twenty consecutive hypoxemic patients were r and omly assigned to receive either conventional weaning or NIV . The changes in arterial blood gases and respiratory rate were compared between the two groups at 1 , 12 , 24 and 48 h. Differences in the rate of extubation failure , ICU and hospital mortality , number of invasive-ventilation-free-days at day 28 , septic complications , number of tracheotomies , days and rates of continuous intravenous sedation , and ICU length of stay were also determined . Results No patient interrupted the study protocol . Arterial blood gases were similar during invasive mechanical ventilation , 1 h after NIV application following extubation , and after 12 , 24 and 48 h. Respiratory rate was higher after 1 h in the NIV group , but no different after 12 , 24 and 48 h. The number of invasive-ventilation-free-days at day 28 was 20 ± 8 ( min = 0 , max = 25 ) days in the treatment group and 10 ± 9 ( min = 0 , max = 25 ) days in the control group ( p = 0.014 ) . The rate of extubation failure , ICU and hospital mortality , tracheotomies , septic complications , days and rates of continuous sedation , and ICU length of stay were not significantly different between the two groups . Conclusions In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF Prolonged duration of endotracheal mechanical ventilation ( ETMV )  is associated with an increased morbidity and mortality in intensive care unit ( ICU ) patients . The aim of this study was to assess the usefulness of noninvasive ventilation ( NIV ) as a systematic extubation and weaning technique to reduce the duration of ETMV in acute-on-chronic respiratory failure ( ACRF ) . Among 53 consecutively intubated patients admitted for ACRF , we conducted a prospect i ve , r and omized controlled trial of weaning in 33 patients who failed a 2-h T-piece weaning trial ( 2 h-WT ) although they met simple criteria for weaning . Conventional invasive pressure support ventilation ( IPSV ) was used as the control weaning technique in 16 patients ( IPSV group ) , and NIV was applied immediately after extubation in 17 patients ( NIV group ) . The two weaning groups were similar for type of chronic respiratory failure ( CRF ) , pulmonary function data , age , Simplified Acute Physiology Score ( SAPS II ) , and severity of ACRF on admission . The characteristics of the two groups were also similar at r and omization . In the IPSV group , 12 of 16 patients ( 75 % ) were successfully weaned and extubated , versus 13 of 17 ( 76.5 % ) in the NIV group ( p = NS ) . NIV like IPSV significantly and similarly improved gas exchange in relation to that achieved during 2 h-WT ( p < 0.05 ) . The duration of ETMV was significantly shorter in the NIV ( 4.56 + /- 1.85 d ) than in the IPSV group ( 7.69 + /- 3.79 d ) ( p = 0 . 004 ) . NIV also reduced the mean period of daily ventilatory support , but increased the total duration of ventilatory support related to weaning ( 3.46 + /- 1.42 d , versus 11.54 + /- 5.24 d with NIV ; p = 0 . 0001 ) . Most patients in the IPSV group developed complications related to ETMV and /or the weaning process , but the difference was not significant ( nine of 16 versus six of 17 ) . The duration s of ICU and hospital stays and the 3-mo survival were similar in the two groups . In conclusion , NIV permits earlier removal of the endotracheal tube than with conventional IPSV , and reduces the duration of daily ventilatory support without increasing the risk of weaning failures .  NIV should be considered as a new and useful systematic approach to weaning in patients with ACRF who are difficult to wean To assess the efficacy of noninvasive ventilation ( NIV ) in patients with persistent weaning failure , we conducted a prospect i ve , r and omized , controlled trial in 43 mechanically ventilated patients who had failed a weaning trial for 3 consecutive days . This trial was stopped after a planned interim analysis . Patients were r and omly extubated , receiving NIV ( n = 21 ) , or remained intubated following a conventional-weaning approach consisting of daily weaning attempts ( n = 22 ) . Compared with the conventional-weaning group , the noninvasive-ventilation group had shorter periods of invasive ventilation ( through tracheal intubation ) ( 9.5 + /- 8.3 vs. 20.1 + /- 13.1 days , p = 0.003 ) and intensive care unit ( ICU ) ( 14.1 + /- 9.2 vs. 25.0 + /- 12.5 days , p = 0.002 ) and hospital stays ( 27.8 + /- 14.6 vs. 40.8 + /- 21.4 days , p = 0.026 ) , less need for tracheotomy to withdraw ventilation ( 1 , 5 % vs. 13 , 59 % , p < 0.001 ) , lower incidence of nosocomial pneumonia ( 5 , 24 % vs. 13 , 59 % , p = 0.042 ) and septic shock ( 2 , 10 % vs. 9 , 41 % , p = 0.045 ) , and increased ICU ( 19 , 90 % vs. 13 , 59 % , p = 0.045 ) and 90-day survival ( p = 0.044 ) . The conventional-weaning approach was an independent risk factor of decreased ICU ( odds ratio : 6.6 ; p = 0.035 ) and 90-day survival ( odds ratio : 3.5 ; p = 0.018 ) . Earlier extubation with NIV results in shorter mechanical ventilation and length of stay , less need for tracheotomy , lower incidence of complications , and improved survival in these patients BACKGROUND AND METHODS The role of noninvasive positive-pressure ventilation delivered through a face mask in patients with acute respiratory failure is uncertain . We conducted a prospect i ve , r and omized trial of noninvasive positive-pressure ventilation as compared with endotracheal intubation with conventional mechanical ventilation in 64 patients with hypoxemic acute respiratory failure who required mechanical ventilation . RESULTS Within the first hour of ventilation , 20 of 32 patients ( 62 percent ) in the noninvasive-ventilation group and 15 of 32 ( 47 percent ) in the conventional-ventilation group had an improved ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen ( PaO2:FiO2 ) ( P=0.21 ) . Ten patients in the noninvasive-ventilation group subsequently required endotracheal intubation . Seventeen patients in the conventional-ventilation group ( 53 percent ) and 23 in the noninvasive-ventilation group ( 72 percent ) survived their stay in the intensive care unit ( odds ratio , 0.4 ; 95 percent confidence interval , 0.1 to 1.4 ; P=0.19 ) ; 16 patients in the conventional-ventilation group and 22 patients in the noninvasive-ventilation group were discharged from the hospital . More patients in the conventional-ventilation group had serious complications ( 66 percent vs. 38 percent , P=0.02 ) and had pneumonia or sinusitis related to the endotracheal tube ( 31 percent vs. 3 percent , P=0.003 ) . Among the survivors , patients in the noninvasive-ventilation group had shorter periods of ventilation ( P=0.006 ) and shorter stays in the intensive care unit ( P=0.002 ) . CONCLUSIONS In patients with acute respiratory failure , noninvasive ventilation was as effective as conventional ventilation in improving gas exchange and was associated with fewer serious complications and shorter stays in the intensive care unit Endotracheal intubation and mechanical ventilation are often needed in patients with acute exacerbations of chronic obstructive pulmonary disease . Respiratory muscle weakness , hypercapnia , hypoxia , and malnutrition are common in these patients , and they may receive prolonged mechanical ventilation , which has associated risks [ 1 , 2 ] . The duration of mechanical ventilation is influenced not only by the cause of disease but also by the ventilatory strategy chosen [ 3 , 4 ] . Patients receiving invasive ventilation  are prone to developing nosocomial pneumonia and ventilator-associated pneumonia , with a high mortality rate [ 5 - 8 ] . Noninvasive ventilation may be a good alternative approach for patients with chronic obstructive pulmonary disease . However , in a recent multicenter study by Brochard and colleagues [ 9 ] , only 29 % of patients admitted to intensive care units were eligible for noninvasive ventilation . Nonetheless , noninvasive mechanical ventilation remains the first line intervention in patients with hypercapnic respiratory failure [ 10 ] in the absence of gross neurologic impairment . Some uncontrolled studies [ 11 - 13 ] have shown that noninvasive ventilation may also be useful in facilitating the weaning process in patients who require prolonged mechanical ventilation . The aim of our multicenter , r and omized study was to evaluate the effectiveness of a new weaning approach in patients with chronic obstructive pulmonary disease . This approach consisted of 24 to 48 hours of traditional ventilation delivered through an endotracheal tube followed by noninvasive pressure support ventilation . We compared the results obtained by using this strategy with those produced by using the same ventilatory mode delivered invasively . End points of the study were duration of mechanical ventilation , duration of intensive care unit stay , incidence of nosocomial pneumonia , and 60-day survival rate . Methods Patients A two-group , parallel , r and omized , controlled trial was carried out in patients known to have chronic obstructive pulmonary disease . All patients known to have this disease who were admitted for acute relapse of their disease at three intensive care units and who needed intubation were eligible for the study . Acute relapse was defined as respiratory acidosis ( pH 7.33 while breathing room air ) ; elevated bicarbonate levels ; hypoxemia ( Pao 2 45 mm Hg while breathing room air ) ; and severe dyspnea in the absence of an objective ly documented cause , such as pneumonia [ 14 , 15 ] or 1 of 11 nonoperative respiratory diagnoses ( excluding chronic obstructive pulmonary disease ) found in the Acute Physiology , Age , and Chronic Health Evaluation ( APACHE ) III [ 16 ] . Fifty-six percent of patients needed immediate  endotracheal intubation . Intubation  was delayed in 44 % of patients ; in these patients , an initial attempt at noninvasive ventilation had failed . To make the decision of whether to intubate as objective as possible , we established criteria extrapolated from the study by Brochard and coworkers [ 9 ] . Major criteria for intubation were respiratory arrest , loss of consciousness , psychomotor agitation requiring sedation , hemodynamic instability with systolic blood pressure less than 70 mm Hg or greater than 180 mm Hg , and a heart rate of 50 beats/min or less with loss of alertness . Minor criteria were a respiratory rate that was more than 35 breaths/min and was higher than the value recorded on admission , an arterial pH that was 7.30 or less and was lower than the value recorded on admission , a PaO ( 2 ) less than 45 mm Hg despite oxygen supplementation , deterioration of one or more points in the neurologic score of the scale of Kelly and Matthay [ 17 ] , and presence of a weak cough reflex with accumulation of secretions . The presence of one major criterion was considered an indication for immediate intubation . In patients undergoing an initial attempt at noninvasive ventilation , the presence of two minor criteria after 1 hour of treatment or less was considered to indicate the need for intubation . Patients were excluded from the study if they had concomitant severe diseases , such as neurologic diseases other than hypercapnic encephalopathy ; cancer and other systemic diseases ; cardiac arrest ; cardiogenic pulmonary edema ; cardiogenic shock ; aortic aneurysm ; acute myocardial infa rct ion ; gastrointestinal perforation , obstruction , or bleeding ; sepsis ; trauma ; metabolic coma ; diabetic ketoacidosis ; drug overdose ; coagulopathy ; and other hematologic diseases . Postoperative patients were also excluded . Patients were prospect ively recruited from three hospitals in Montescano , Gussago , and Novi Ligure , Italy . Of the 68 patients referred to the participating centers and intubated for acute respiratory failure , 50 ( 74 % ) were enrolled . Eighteen patients were excluded at the time of possible r and omization : Eight ( 12 % ) had a successful T-piece weaning trial at the time of r and omization , 6 ( 9 % ) had altered neurologic status , and 4 ( 6 % ) were hemodynamically unstable . The protocol was approved by each hospital 's ethics committee . Patients or their relatives gave informed consent to the study . Study Protocol Intubation was done via the orotracheal route . After intubation , all patients were ventilated in controlled mode with intensive care unit ventilators for the first 12 hours ; during the first 6 to 8 hours , the patients were se date d and curarized and their airway secretions were suctioned frequently . St and ard setting s for controlled ventilation were used : tidal volume , approximately 8 to 10 mL/kg ; respiratory rate , 12 to 16 breaths/min ; and an inspired oxygen fraction ( Fio 2 ) as required to obtain an Sao 2 of about 95 % ( 41 % 0.05 % ) . Patients were then given pressure support ventilation ( 21 2 cm H2O ) for an additional 24 to 36 hours . Extrinsic positive end-expiratory pressure was added when intrinsic positive end-expiratory pressure was clinical ly suspected . At the end of this brief period of invasive ventilation , a T-piece weaning trial was carried out in patients who were judged to have reached satisfactory neurologic status , had a body temperature of 37 C or less , were hemodynamically stable , and had an Sao 2 of 88 % or more for an FiO ( 2 ) of 40 % during a brief discontinuation of mechanical ventilation . We considered the T-piece trial to have failed if patients had any of the following : a respiratory rate more than 35 breaths/min , a PaO ( 2 ) less than 50 mm Hg for an Fio 2 of 40 % , heart rate  more than 145 beats/min or sustained increase or decrease in the  heart rate of more than 20 % ,  severe arrhythmia , systolic blood pressure  more than 180 mm Hg or less than 70 mm Hg , agitation , anxiety  , or diaphoresis  . Patients in whom the weaning trial failed and who did not meet any of the aforementioned exclusion criteria were r and omly assigned to receive noninvasive ventilation or to continue the weaning process with invasive pressure support ventilation . The study was design ed to enroll all eligible patients over a specified 18-month period . R and om assignment was done by using opaque , sealed , numbered envelopes . A post hoc analysis was performed to confirm the validity of the r and omization . To detect any possible differences in the two groups at enrollment , the 50 patients were divided according to the r and om assignments , survival or death , and successful and unsuccessful weaning . Immediately after failure of the T-piece weaning trial , patients were reconnected to the ventilator in pressure support ventilation mode until the previous Paco 2 and pH values were reached ( 30 to 60 minutes ) and the respiratory rate under ventilation was 30 breaths/min or less . Patients in the noninvasive ventilation group were then extubated and switched to noninvasive pressure support ventilation with a face mask ( Gibeck Respiration AB , Uppl and s-Vasby , Sweden ) and the same ventilator . The patients ' heart rate , electrocardiograms , Sao 2 , and blood pressure were monitored continuously , and a physician was present to intubate patients again , if necessary . Patients received ventilation  with a level of pressure support ( 19 2 cm H2O ) that was adjusted to achieve satisfactory blood gases and a respiratory rate of less than 25 breaths/min . During the first 48 hours after extubation , noninvasive ventilation was delivered until it was well tolerated ( 20 to 22 hours per day ) , spaced by periods of spontaneous inhalation of oxygen only during meals and to expectorate . The level of pressure support was decreased by 2 or 4 cm H2O per day in patients with good tolerance ; patients were allowed to breathe spontaneously . At least two trials of spontaneous breathing of gradually increased duration were attempted each day . To assess weaning from noninvasive ventilation as objective ly as possible , the following criteria recorded after at least 3 hours of spontaneous breathing were established : Sao 2 of 90 % or more with an Fio 2 of 40 % or less , pH of 7.35 or more , respiratory rate less than 35 breaths/min , hemodynamic stability , absence of severe dyspnea , and depressed neurologic status . The absence of even one of these criteria was considered failure to wean , and the patient was reconnected to the ventilator ( which was always set at its maximal trigger sensitivity ) . Weaning was considered successful if reintubation or noninvasive ventilation was not required within 72 hours of suspension of ventilation . In intubated patients who received pressure support ventilation , the pressure was titrated to achieve a breathing frequency of 25 breaths/min or less . Pressure support ventilation was initially set at 17.6 2.1 cm H2O . For patients who received invasive ventilation , the level of pressure support was gradually decreased and intermittent trials of spontaneous breathing were performed twice a day by using a T-tube circuit or a continuous-flow circuit with a continuous positive airway pressure of less than 5 cm H2O [ 4 ] . The weaning criteria were the same as those used for noninvasive ventilation .  Arterial blood gases OBJECTIVE To determine the incidence , risk factors , outcome , and pathogens of  ventilator-associated pneumonia ( VAP ) in a cardiac surgical intensive care unit ( ICU ) . DESIGN Prospect i ve study . SETTING Escorts Heart Institute and Research Centre , New Delhi , India . PARTICIPANTS Nine hundred fifty-two consecutive patients undergoing cardiac operations who received intermittent positive-pressure ventilation ( IPPV ) .  INTERVENTIONS All patients were assigned into  VAP ( n = 25 ) and non-VAP ( n = 927 ) groups . MEASUREMENTS AND MAIN RESULTS Risk factors and other variables were analyzed with univariate and multivariate analysis . Of the 952 patients studied , 25 ( 2.6 % ) had VAP . On univariate analysis , significant risk factors were emergency surgery , chronic obstructive pulmonary disease ( COPD ) , reintubation , coma , steroid treatment , intra-aortic balloon counterpulsation ( IABC ) , enteral feedings , tracheostomy , acute physiology , age , and chronic health evaluation ( APACHE II ) score , prior antibiotics , and IPPV hours . On multivariate analysis , IPPV hours ( 153.75 + /- 114.44 v 19.65 + /- 7.99 ; p < 0.001 ) and  steroids  ( 20 % v 0 % ; p < 0.001 ) were independent predictors of VAP . The most common pathogens isolated were Pseudomonas aeruginosa ( 22 ) , Escherichia coli ( 10 ) , Klebsiella pneumoniae ( 4 ) , Staphylococcus species ( 4 ) , and Acinetobacter species ( 2 ) . The mortality rate in VAP was 16 % as compared with 0.2 % in non-VAP cases ( p < 0.001 ) . CONCLUSION These data suggest that by univariate analysis the risk factors for VAP were emergency surgery , COPD , reintubation , coma , steroid treatment , IABC , enteral feedings , tracheostomy , APACHE II score , prior antibiotics , and IPPV hours . On multivariate analysis , only IPPV hours and steroids were independent predictors of VAP . Pseudomonas aeruginosa is the most common pathogen associated with VAP , and the mortality is increased with VAP Objective : To observe the nosocomial infection ( NI ) distribution in ventilated patients of a single intensive care unit ( ICU ) according to the kind of control of the upper airways :  noninvasive positive pressure ventilation ( NPPV ) versus endotracheal intubation ( ETI ) . Setting : ICU of a general hospital . Design : Prospect i ve clinical and epidemiologic survey . Patients : In the period December 1994–March 1997 , 761 patients were included who needed mechanical ventilation for more than 48 h : 129 were ventilated by NPPV ( NPPV group ) , 607 were intubated ( ETI group ) and 25 required intubation after a period of NPPV ( NPPV-ETI group ) . Measurements and results : The data used were prospect ively collected according to the NI epidemiologic surveillance protocol of “ C. CLIN Sud Est , Réa Sud Est ” , France . NI included a ventilator-associated pneumonia ( VAP ) , catheter-related infection , urinary tract infection and bacteremia . Occurrence of NI was estimated by the density of incidence . Covariate-adjusted NI and VAP risk factors were assessed by the Cox model . The incidence density of total NI was lower for NPPV than for ETI ( 14.2 versus 30.3 per 1000 patient-days , p < 0.01 ) . The Cox model showed that the use of noninvasive ventilation , adjusted to the severity of illness ( SAPS II ) , reduced not only the VAP risk ( hazard ratio ( HR ) = 4.07 ) but also the NI risk ( HR = 1.95 ) . Conclusion : The use of NPPV reduces the risk of VAP and NI , compared to ETI , irrespective of the severity of the patient 's illness The aim of the study was the determination of the influence of ventilation modes on the consumption of analgesics and sedatives , duration of intubation and pulmonary gas exchange .  Assist/controlled m and atory ventilation ( S-CMV , 123 patients ) , synchronized intermittent m and atory ventilation ( S-IMV , 431 patients ) and biphasic positive airway pressure ventilation ( BIPAP , 42 patients ) were compared in a prospect i ve , controlled , open clinical trial over an 18-month period . Five hundred and ninety-six adult patients with normal pulmonary function before surgery and uneventful course following coronary artery bypass graft surgery were studied . Patients ventilated with BIPAP had a significantly shorter mean duration of intubation ( 10.1 h , P < 0.05 ) than patients treated with S-IMV ( 14.7 h ) and S-CMV ( 13.2 h ) . In the S-CMV group , 39.9 % of the patients required single or multiple doses of midazolam  , but only 13.5 % in the S-IMV group and 9.5 % in the BIPAP group . The mean total amount of midazolam administered to these patients was significantly higher in the S-CMV group ( 8.8 mg ) than in the S-IMV group ( 6.6 mg , P < 0.05 ) and in the BIPAP group ( 4.3 mg , P < 0.05 ) . The consumption of pethidine and piritramide did not differ between S-CMV and S-IMV , but was significantly lower during BIPAP ( P < 0.05 ) . After extubation the patients ' PaCO2 was highest in the S-CMV group . We conclude that ventilatory support with BIPAP reduces the consumption of analgesics and sedatives , and the duration of intubation . The possibility of unrestricted spontaneous breathing in all phases of the respiratory cycle is considered to be the reason . BIPAP seems to be an alternative to S-CMV and S-IMV in short-term ventilated patient OBJECTIVE To evaluate the application of sequential noninvasive following invasive mechanical ventilation in chronic obstructive pulmonary disease ( COPD ) patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window . METHODS From November 2001 to October 2004 , 76 case of COPD patients with severe respiratory failure due to pulmonary infection were intubated and recruited in the study . When the pulmonary infection was significantly controlled ( the time of pulmonary infection control was called PIC window ) by the antibiotic and comprehensive therapy , all cases were r and omized into noninvasive veatiation group ( NIV ) and control group . The early extubation was conducted and followed by noninvasive mechanical ventilation via facial mask with bilevel positive airway pressure mode immediately in the NIV group . Conventional invasive synchronized intermittent m and atory ventilation ( SIMV ) plus pressure support ventilation ( PSV ) was used as the weaning technique in the control group . RESULTS Thirty eight cases among 76 patients were in the NIV group , and the rest in the control group . The NIV group and the control group had similar age , sex , APACHE scores , RR , HR , MAP , PaO2 and PaCO2 at the time of commencement and PIC window ( P > 0.05 ) . The time of PIC window was ( 7.5 + /- 1.9 ) d in the NIV group , and ( 8.0 + /- 2.5 ) d in the control group ( P > 0.05 ) . In the NIV group , the duration s of invasive mechanical ventilation ( MV ) and total MV were ( 7.5 + /- 1.9 ) d and ( 12.5 + /- 4.0 ) d respectively , while the duration s were ( 23.5 + /- 9.5 ) d in the control group ( P < 0.05 ) . The duration s of RICU stay and hospital stay were shorter than that in the control group . The incidence of ventilation associated pneumonia ( VAP ) was 18.4 % ( 7/38 ) in the NIV group , 39.5 % ( 15/38 ) in the control group respectively ( P < 0.05 ) . The incidence of reintubation was 13.2 % ( 5/38 ) in the NIV group , 34.2 % ( 13/38 ) in the control group respectively ( P < 0.05 ) . Hospital mortality was 7.9 % ( 3/38 ) in the NIV group , and 28.9 % ( 11/38 ) in the control group ( P < 0.05 ) . CONCLUSION In those COPD patients requiring intubation and mechanical ventilantion who have severe respiratory failure due to pulmonary infection , sequential noninvasive following invasive mechanical ventilation at the appearance of PIC window can significantly reduce the MV duration , the length of RICU stay and hospital stay , and decrease the occurrence of VAP , reintubation and hospital mortality as well . So it is an efficient strategy to be generalized To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia ( VAP ) in intensive care unit ( ICU ) patients , we conducted a prospect i ve , matched cohort study . Patients expected to be ventilated for > 48 h were prospect ively followed for the development of VAP . To determine the excess ICU stay and mortality attributable to VAP , we matched patients with VAP to patients who did not develop clinical ly suspected pneumonia . We also conducted sensitivity analyses to examine the effect of different population s , onset of pneumonia , diagnostic criteria , causative organisms , and adequacy of empiric treatment on the outcome of VAP . One hundred and seventy-seven patients developed VAP . As compared with matched patients who did not develop VAP , patients with VAP stayed in the ICU for 4.3 d ( 95 % confidence interval [ CI ] : 1.5 to 7 . 0 d ) longer and had a trend toward an increase in risk of death ( absolute risk increase : 5.8 % ; 95 % CI : -2.4 to 14.0 d ; relative risk ( RR ) increase : 32.3 % ; 95 % CI : -20.6 to 85.1 % ) . The attributable ICU length of stay was longer for medical than for surgical patients ( 6 . 5 versus 0.7 d , p < 0.004 ) , and for patients infected with " high risk " organisms as compared with " low risk " organisms ( 9.1 d versus 2.9 d ) . The attributable mortality was higher for medical patients than for surgical patients ( RR increase of 65 % versus -27.3 % , p = 0 . 04 ) . Results were similar for three different VAP diagnostic criteria . We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients . The attributable risk of VAP appears to vary with patient population and infecting organism RATIONALE The use of noninvasive ventilation ( NIV ) as an early weaning/extubation technique from mechanical ventilation remains controversial . OBJECTIVES To investigate NIV effectiveness as an early weaning/extubation technique in difficult-to-wean patients with chronic hypercapnic respiratory failure ( CHRF ) . METHODS In 13 intensive care units , 208 patients with CHRF intubated for acute respiratory failure ( ARF ) who failed a first spontaneous breathing trial were r and omly assigned to three groups : conventional invasive weaning group ( n = 69 ) , extubation followed by st and ard oxygen therapy ( n = 70 ) , or NIV ( n = 69 ) . NIV was permitted as rescue therapy for both non-NIV groups if postextubation ARF occurred . Primary endpoint was reintubation within 7 days after extubation . Secondary endpoints were : occurrence of postextubation ARF or death within 7 days after extubation , use of rescue postextubation NIV , weaning time , and patient outcomes . MEASUREMENTS AND MAIN RESULTS Reintubation rates were 30 , 37 , and 32 % for invasive weaning , oxygen-therapy , and NIV groups , respectively ( P = 0.654 ) . Weaning failure rates , including postextubation ARF , were 54 , 71 , and 33 % , respectively ( P < 0.001 ) . Rescue NIV success rates for invasive and oxygen-therapy groups were 45 and 58 % , respectively ( P = 0.386 ) . By design , intubation duration was 1.5 days longer for the invasive group than in the two others . Apart from a longer weaning time in NIV than in invasive group ( 2.5 vs. 1.5 d ; P = 0.033 ) , no significant outcome difference was observed between groups . CONCLUSIONS No difference was found in the reintubation rate between the three weaning strategies . NIV decreases the intubation duration and may improve the weaning results in difficult-to-wean patients with CHRF by reducing the risk of postextubation ARF . The benefit of rescue NIV in these patients deserves confirmation
BACKGROUND Noninvasive ventilation has been studied as a means of reducing complications among patients being weaned from invasive mechanical ventilation .
We sought to summarize evidence comparing noninvasive and invasive weaning and their effects on mortality .