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CAT review: ‘Heliox use in non-invasive COPD ventilation’

CAT review: ‘Heliox use in non-invasive COPD ventilation’

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CAT review: ‘Heliox use in non-invasive COPD ventilation’

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  1. CAT review: ‘Heliox use in non-invasive COPD ventilation’ Dr Andrew J Dalton CT2 South East Scotland

  2. Maurizio M et al. A multicenter, randomised trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease. Crit Care Med 2010; 38:145-151

  3. Background • Helium • Inert gas • Lower dense than nitrogen • Turbulent flow rate is improved by helium use • Helium can be used in upper airway obstruction to improve alveolar ventilation

  4. Background (cont.) • Laminar flow is dependent on viscosity and independent of density • Therefore traditionally helium not thought to be of significant benefit in lower airway obstruction due to prevalence of lamina flow • However more recent studies had suggested there may be a benefit to oxygenation in COPD by reducing the work of breathing Laude EA et al. Am J Respir Crit Care Med. 2006 Apr;173(8):865-70 Jaber S et al. Am J Respir Crit Care Med. 2000 Apr;161(4):1191-1200

  5. Trial • Study: Non-blinded, randomised controlled trial with intention-to-treat analysis • Patients: Recruited from 7 ICUs in France, Tunisia, Italy, Spain over 2 years

  6. Inclusion/Exclusion criteria • Inclusion: • Known/suspected COPD and acute dyspnoea • PaCO2 > 45mmHg (6kPa) • Two of pH < 7.35, PaCO2 < 50mmHg (6.67kPa), respiratory rate >25/minute • Exclusion: • Respiratory arrest, need for immediate intubation, pneumothorax, life expectancy < 1 month, hypoxaemia requiring oxygen > 6L/min, inability to cooperate, upper airway obstruction, facial trauma, haemodynamic instability, pregnancy

  7. Study groups • Control: • n=102 • Noninvasive bi-level airway pressure ventilation (NIV) applied via facemask with FiO2 0.35 • Experimental: • n=102 • NIV applied via facemask with helium-oxygen (HeO2) mixture with FiO2 0.35

  8. Endpoints • Primary • Need for intubation • Secondary • Duration of NIV • Length of hospital stay • Mortality Patients were followed up for 28 days post enrolment

  9. Methods • NIV was applied intermittently for at least 6hrs/day • Each NIV trial lasted between 30mins – 3hrs (depending on clinician judgement) • In between NIV trials patients in both groups breathed air-oxygen • Decision to intubate was based on the presence of predefined criteria, and once intubated all patients were ventilated with air/oxygen

  10. Results • Analysis was performed on all patients in both groups • Chi-squared test used for proportions/rates, Wilcoxon’s rank sum test for ordinal variables, Student’s t test for normal variables, p≤0.05 considered significant

  11. Results (cont.)

  12. Analysis • Intubation rate did not significantly differ • No difference in mortality • No difference in duration of NIV, length of ICU stay (10.6 vs 10.9 days control) or length of hospital stay (19.1 vs 18.5 days control) • Additionally no significant difference noted in arterial blood gases • Subgroup analysis • Intubation rates were lower in patients receiving short NIV duration (<4 days) with heliox (18 of 57 vs 23 of 43, p=0.03) • Was suggested that any possible benefit from helium may be in the early stage of treatment

  13. Summary • No evidence of improved NIV ventilation in COPD with helium in any measured outcome • No change of practice should be initiated based on this study • The authors suggest that any further research should be focussed on the subgroup identified, but no indication is given on how best to identify these patients initially

  14. Thanks Any questions?