RESUMO
OBJECTIVES: The objective of this study was to assess the effectiveness of noninvasive motion ventilation (NIMV) in patients with chronic obstructive pulmonary disease (COPD), having infectious exacerbation and severe hypercapnic neurological dysfunction in the emergency room. DESIGN: This is a prospective interventional study. SETTING: The study setting was the emergency room at the Military Hospital in Guayaquil, Ecuador. PATIENTS: A total of 24 patients were studied. Twelve patients had acute exacerbation of their chronic obstructive pulmonary disease: they presented at the emergency room with severe neurological dysfunction, with a Glasgow Coma Scale (GCS) score of less than 8 and a pH of less than 7.25. These patients were compared with 12 controls who were being treated with invasive mechanical ventilation (IMV), who were then matched according to their GCS scores, pH status, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and age. INTERVENTIONS: We evaluated the effectiveness and safety of applying a ventilatory strategy based on a biphasic positive airway pressure protocol in the emergency room. MEASUREMENTS AND RESULTS: The pH, PCO2, and GCS scores, measured during the first 3 h, were predictors of success for the application of NIMV treatment (P<0.05). Mortality was 33.3 and 16.7% for the IMV and the NIMV groups, respectively (P=0.01). Days of IMV were 5.60+/-1.2 versus 3.6+/-1.1 for NIMV (P=0.006). Days of hospitalization were 11.1+/-4.7 for the IMV group and 6.5+/-1.9 for the NIMV group (P=0.001). The cumulative survival rates at 6 months were 71.4 and 80% for the IMV and NIMV groups, respectively (P=0.80). CONCLUSION: We consider that severe neurological dysfunction and pH of less than 7.25 do not constitute absolute contraindications to the use of NIMV. This kind of management can be implemented in the emergency room with favorable results.
Assuntos
Serviço Hospitalar de Emergência , Hipercapnia/terapia , Ventilação com Pressão Positiva Intermitente , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Estudos de Casos e Controles , Cuidados Críticos/métodos , Humanos , Hipercapnia/complicações , Tempo de Internação , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/complicações , Testes de Função Respiratória , Análise de SobrevidaRESUMO
INTRODUCTION: Hypercapnic coma secondary to acute respiratory failure (ARF) is considered to be a contraindication to the use of treatment with noninvasive positive-pressure ventilation (NPPV). However, intubation exposes these patients to the risk of complications such as nosocomial pneumonia, sepsis, and even death. PATIENTS AND METHODS: We performed a prospective, open, noncontrolled study to assess the outcomes of NPPV therapy in patients with a Glasgow coma scale (GCS) score of = 8 points due to ARF. The primary goal of the study was to determine the success of NPPV therapy (defined as a response to therapy allowing the patient to avoid endotracheal intubation, and to survive a stay in the ICU and at least 24 h on a medical ward) in patients with hypercapnic coma, compared to those who started NPPV therapy while awake. The secondary goal of the study was to identify the variables that can predict a failure of NPPV therapy in these patients. RESULTS: A total of 76 coma patients (80%) responded to NPPV therapy, and 605 patients with GCS scores > 8 responded to therapy (70%; p = 0.04). A total of 25 coma patients died in the hospital (26.3%), and 287 noncoma patients died in the hospital (33.2%; p = 0.17). The variables related to the success of NPPV therapy were GCS score 1 h posttherapy (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.53 to 3.53) and higher levels of multiorgan dysfunction, as measured by the maximum sequential organ failure assessment index score reached during NPPV therapy (OR, 0.72; 95% CI, 0.55 to 0.92). CONCLUSIONS: We concluded that selected patients with hypercapnic coma secondary to ARF can be treated as successfully with NPPV as awake patients with ARF.