Here is a quick wee of our hot take on the HAPPEN Trial on NIPPV for Acute Exac. of COPD. I got Josh Farkas and Alex Bracey to discuss
The Trial
Happen Trial
What was the Criteria for Intubation
The primary outcome was the need for endotracheal intubation during hospitalization, which was defined by the prespecified criteria of (1) arterial pH level of less than 7.25 with a Paco2 level that increased by more than 20% compared with the baseline level or Pao2:Fio2 of less than 100 mm Hg; and (2) the presence of at least 1 of the following: clinical signs suggestive of severely decreased consciousness (eg, coma, delirium), use of accessory respiratory muscles or thoracoabdominal paradoxical movement, excessive respiratory secretions, aspiration or vomiting, bleeding in upper gastrointestinal tract, severe hemodynamic instability without response to fluid resuscitation and low-dose vasoactive agents, or ventricular or supraventricular arrhythmias; or (3) cardiac or respiratory arrest. Daily assessment of the need for endotracheal intubation was performed. Two independent experts who were blinded to the intervention confirmed the need for endotracheal intubation based on these criteria. In cases of disagreement, a third expert helped make the final decision.
What are your thoughts–put them in the comments section below…
Additional Study Mentioned re: 6 ml vs. 10 ml
Now on to the Wee…
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hi Guys,
I really enjoyed that discussion. What masks are each of you using for your NIV patients, and do you find a difference between the full face masks versus the masks covering the nose and mouth in terms of fit/comfort?
still using just nose/mouth–do not have access to helmet or full face
Completely agree with Josh’s summarizing points in the later half of the episode here. Assisting a patients spontaneous breaths to 15 ml is better than forcing a higher respiratory rate to achieve the same minute ventilation. We have an annual workshop with an experienced (old) RT from a highly specialized weaning/ respiratory centre and he always taught us those aggressive strategies (go high on the ipap, respiratory rate always below the patients spontaneous rate, almost normalize CO2 even if the pt is adapted to a CO2 of 60). This always sounded counter-intuitive and not evidence based, because „>10ml tidal volume… Read more »
agree with all of that! i wouldn’t put a rate on patients with airtrapping, but my experience with these hypercapneic encephalopathy patients is that they are not airtrapping, they are not autopeeping. So I am left in the same place of not understanding who this therapy is actually intended for. And I would never normalize a CO2 in these pts, that’s plum crazy.
I think it’s particularly relevant that this study was conducted at the height of COVID in China, when there was every incentive in place to avoid intubation and ICU admission. The fact that patients could be crossed over to the experimental arm also muddies the waters… Overall though, I do agree with your guests that the trial does demonstrate the relative safety of more aggressive NIV, and that we really should be titrating and optimizing our therapy as the pathology evolves.
Really excellent discussion, with take-home point that you can very often get away with not intubating hypercapneic patients (without concomitant hypoxemic ALI) by using BIPAP for up to a few days. I would like to emphasize point made by Matthias Rosenbaum below, that you can use NIV with a gastric tube. I have found this practice to be OFTEN contested depending on the acuity and RT experience in an ICU, and really shouldn’t be. Of note the authors say that “Abdominal distension occurred more frequently in the high-intensity NPPV group (37.4% [55/147]) compared with the low-intensity NPPV group (25.5% [39/153]).”… Read more »
The practice in this study seems similar to the standard practice in the UK (see BTS/ICS guidelines). And as to increasing the ipap instead of the rr, in this cohort (acidotic but not somulent, alert) they are usually breathing fast (and an improving rr is something you look for to gauge improvement), so there’s not much room to increase the rr. And because they’re generally more alert they don’t tolerate additional mandatory breaths very much.
thanks Andrew!