<<

SECTION REPORT What Is the Best Agent for NIV CRITICAL CARE MEDICINE Intolerance? Yi Li, MD and Andrew W Phillips, MD MEd FAAEM

respiratory distress. His SpO2 was 85% on 6L NC so additional airway support was needed Summary: Limited evidence but theoretically a but he was unable to tolerate NRB or BiPAP good choice. Patients should mentally travel to due to agitation. He was given their happy places. 5mg IV and 2mg IV with minimal Ketamine, a phencyclidine derivative, acts as improvement. During shift change he removed Introduction a agent primarily by blocking the the mask, desaturated and suffered a hypoxic N-methyl-D-aspartate (NMDA) receptor. It pro- espiratory failure is a common cause of cardiac arrest. emergency department (ED) presenta- vides both and sedative effects and Rtion in both pediatric and adult patients. What went wrong? can provide depending on dosing. In Invasive ventilation is associated with multiple First, let us review the current sedative options contrast to , ketamine preserves pharyn- hemodynamic, infectious, and respiratory and their evidence. geal and laryngeal protective reflexes, lowers complications that require and ICU airway resistance, increases lung compliance, Opioids admission. Noninvasive ventilation (NIV) pro- and is less likely to produce respiratory depres- vides respiratory support by applying positive Summary: infusion seems to work but sion. Hemodynamically, ketamine results in pressure to conscious patients, often avoiding respiratory rate and mental status need to be increased and pressure due to intubation.1 However, one of the risk factors for carefully monitored. Buyer beware. its sympathomimetic effect which may provide NIV failure is intolerance. It was reported that Opioids remain the mainstay of pharmacologic additional advantage in managing respiratory about 5% of patients on NIV experienced intol- management of dyspnea that is refractory to failure patients with hypotension.10 Emergence erance which is associated with higher rate of disease-modifying treatment because of their reaction, however, may trigger if the pa- intubation and mortality.2 ability to suppress respiratory drive.5 Opioids tient is not mentally prepared when ketamine is are commonly used in mechanically ventilated administered. There are currently two available There are multiple factors that contribute to NIV patients in the ICU and are one of the most case reports discussing ketamine use during intolerance, including the type and severity of commonly used sedative/analgesic NIV - one in asthma exacerbation and another respiratory failure, the underlying disease, inter- during NIV.4 The combined effects of analgesia in acute decompensated heart failure.11,12 face (mask) tolerance, hemodynamic instability, and sedation make it easier for physicians to Currently there are no studies comparing ket- neurological status deterioration, and poor pa- use them if the cause of NIV intolerance is un- amine with other . tient–ventilator synchrony.3 A prospective, inter- clear. However, respiratory and he- national, multicenter study showed that about modynamic effects are less desirable in NIV, a 20% of patients received analgesic or sedative modality that is dependent on respiratory drive. Summary: Theoretically and in-practice a good drugs during NIV.4 Sedation and analgesia can Newer machines have backup ventilation, but choice if the heart rate and blood pressure can mitigate the effects of psychological stress and it is not a consistently reliable feature. Several tolerate it. pain thus potentially improving NIV tolerance. opioids were studied in the past to facilitate NIV But data on sedative or analgesic agent use in Dexmedetomidine acts as an α2 adreno- tolerance, including , , remi- NIV remains limited. Agent selection is really at receptor with , sedative, fentanil, and .4 Intravenous morphine the physician’s judgement. and some analgesic effects. Like ketamine, infusion was found to be effective in improving dexmedetomidine does not cause respiratory Neurocognitive disorders such as developmen- NIV compliance in acute pulmonary edema depression. The main adverse effects of dex- tal delay and can present additional caused by heart failure.6 Two European studies are bradycardia and hypoten- challenges in managing NIV tolerance as well. found that improved NIV tolerance sion, so it should be used cautiously in patients In this article, we discuss a hypothetical case of safely in patients with respiratory failure.7,8 One with hemodynamic instability. Multiple studies a patient with concomitant neurodevelopment study showed sufentanil helped induce awake have demonstrated that dexmedetomidine and respiratory distress requiring NIV, empha- sedation without significant adverse effects can be used safely in pediatric respiratory sizing pearls and pitfalls. but did not comment on whether it improved failure patients to facilitate NIV tolerance.13-16 In NIV tolerance.9 There is currently no evidence adults, there are reports of successful use of Case presentation suggesting fentanyl can improve NIV tolerance. dexmedetomidine to improve ventilator-patient A 24-year-old man with a history of autism None of the studies went into detail about ad- and morbid obesity presented to the ED in verse effects. >>

COMMON JULY/AUGUST 2020 17 SECTION REPORT CRITICAL CARE MEDICINE comorbidities, allergies, and the cause of NIV Summary: Theoretically helpful but no intolerance. The ideal agent should be able to synchronization among patients with acute evidence. improve NIV tolerance without further respira- respiratory failure.17-19 Compared to , tory deterioration. dexmedetomidine seems to be superior in Antipsychotics are usually dopamine antago- terms of maintaining sedation with fewer dose nists that are commonly used to treat agitation Case conclusion adjustments.20,21 In addition to common medical in the ICU and ED. Despite their potential Is there a better sedation option than the B-52? (and likely frequent off-label use for NIV), etiologies of respiratory failure, dexmedetomi- Probably ketamine or dexmedetomidine, but dine was also found to improve NIV tolerance currently there is no data evaluating whether in blunt chest trauma patients.22 One study failed to show improvement of NIV tolerance with dexmedetomidine, although the sample Sedation and analgesia can mitigate the size was small (n=33) and both arms could effects of psychological stress and pain thus receive midazolam and fentanyl, which prob- potentially improving NIV tolerance. ably negated the effects of dexmedetomidine.23 Overall, it seems that dexmedetomidine is safe and probably effective during NIV.

Benzodiazepines Summary: Often used, barely studied. Get the endotracheal tube ready if adding to opioids. are that bind to GABA receptors. Despite being the most Several factors need to be considered in selecting the most used sedative/analgesic drugs during NIV (particularly midazolam),4 benzodiazepines appropriate sedative agent, including hemodynamic and do not have an analgesic effect and increase respiratory status, comorbidities, allergies, and the cause of the risk of delirium. There is very limited data NIV intolerance. on use during NIV to facilitate tolerance. One case report showed suc- no matter which agent, an infusion rather than cessful use of lorazepam in severe asthma antipsychotics can improve NIV tolerance. 24 bolus injection. The combined use of haloperi- exacerbation requiring NIV. It is unclear if the Theoretically they would slow psychomotor ac- dol and lorazepam might be associated with benefit of benzodiazepines outweighs the risks. tivity without reducing respiratory drive. Of note, increased mortality and there are no data sup- Benzodiazepines such as midazolam might be antipsychotics can cause extrapyramidal effects porting use to facilitate NIV. Given a good choice if the cause of NIV intolerance which could potentially worsen NIV tolerance. is clearly identified as anxiety and the patient’s that the patient had been hemodynamically respiratory status can be closely monitored. Combination of sedatives and stable but with severe hypoxemia, efforts could have been made to achieve adequate sedation without compromising respiratory status. Summary: Not a good idea. Summary: Milk of amnesia is well known for Current available data suggest that single use hypotension and apnea; it requires very careful References of analgesic or sedative during NIV does not observation. 1. Masip, J., et al., Indications and practical have an apparent effect on outcome. However, approach to noninvasive ventilation in acute Propofol activates central GABA receptors in a study comparing analgesic only, sedative heart failure. European Heart Journal, 2017. and is an intravenous that is com- only, and combined use during NIV, the com- 39(1): p. 17-25. monly used for sedation of agitated adult ICU bined had higher mortality.4 2. Liu, J., et al., Noninvasive Ventilation patients. Propofol is well known to cause hypo- Intolerance: Characteristics, Predictors, and tension and apnea. However, there are a few So, what is the best sedative agent? Outcomes. Respir Care, 2016. 61(3): p. 277- studies showing potential safe use of propofol The answer is there is no single sedative agent 84. in adult patients to facilitate NIV at very low that is optimal for every patient.27 Several 3. Garofalo, E., et al., Recognizing, quantifying and managing patient-ventilator asynchrony infusion doses.25,26 factors need to be considered in selecting in invasive and noninvasive ventilation. Expert the most appropriate sedative agent, includ- Rev Respir Med, 2018. 12(7): p. 557-567. ing hemodynamic and respiratory status, >>

18 COMMON SENSE JULY/AUGUST 2020 SECTION REPORT CRITICAL CARE MEDICINE

4. Muriel, A., et al., Impact of sedation and 13. Shein, S.L., Dexmedetomidine During 21. Senoglu, N., et al., Sedation during noninvasive analgesia during noninvasive positive pressure Noninvasive Ventilation: Different Acuity, with dexmedetomidine ventilation on outcome: a marginal structural Different Risks?Pediatr Crit Care Med, 2018. or midazolam: A randomized, double-blind, model causal analysis. Intensive Care Med, 19(4): p. 373-375. prospective study. Curr Ther Res Clin Exp, 2015. 41(9): p. 1586-600. 14. Shutes, B.L., et al., Dexmedetomidine 2010. 71(3): p. 141-53. 5. Campbell, M.L., Dyspnea. Critical Care as Single Continuous Sedative During 22. Deletombe, B., et al., Dexmedetomidine to Nursing Clinics, 2017. 29(4): p. 461-470. Noninvasive Ventilation: Typical Usage, facilitate noninvasive ventilation after blunt 6. Nakayama, M., A. Ishii, and Y. Yamane, Hemodynamic Effects, and Withdrawal. chest trauma: A randomised, double-blind, [Novel strategy of noninvasive positive Pediatr Crit Care Med, 2018. 19(4): p. 287- crossover, placebo-controlled pilot study. pressure ventilation by intravenous morphine 297. Anaesth Crit Care Pain Med, 2019. 38(5): p. hydrochloride infusion for acute cardiogenic 15. Venkatraman, R., et al., Dexmedetomidine 477-483. pulmonary edema: two case reports]. J for Sedation During Noninvasive Ventilation 23. Devlin, J.W., et al., Efficacy and safety of Cardiol, 2006. 48(2): p. 109-14. in Pediatric Patients. Pediatr Crit Care Med, early dexmedetomidine during noninvasive 7. Constantin, J.M., et al., Remifentanil-based 2017. 18(9): p. 831-837. ventilation for patients with acute respiratory sedation to treat noninvasive ventilation failure: 16. Piastra, M., et al., Dexmedetomidine is failure: a randomized, double-blind, placebo- a preliminary study. Intensive Care Med, 2007. effective and safe during NIV in infants and controlled pilot study. Chest, 2014. 145(6): p. 33(1): p. 82-7. young children with acute respiratory failure. 1204-1212. 8. Rocco, M., et al., Rescue treatment for BMC Pediatr, 2018. 18(1): p. 282. 24. Cappiello, J.L. and M.B. Hocker, Noninvasive noninvasive ventilation failure due to interface 17. Demuro, J.P., M.N. Mongelli, and A.F. ventilation in severe acute asthma. Respir intolerance with remifentanil analgosedation: a Hanna, Use of dexmedetomidine to facilitate Care, 2014. 59(10): p. e149-52. pilot study. Intensive Care Med, 2010. 36(12): noninvasive ventilation. Int J Crit Illn Inj Sci, 25. Clouzeau, B., et al., Fiberoptic bronchoscopy p. 2060-5. 2013. 3(4): p. 274-5. under noninvasive ventilation and propofol 9. Conti, G., et al., Sedation with sufentanil in 18. Takasaki, Y., T. Kido, and K. Semba, target-controlled infusion in hypoxemic patients receiving pressure support ventilation Dexmedetomidine facilitates induction of patients. Intensive Care Med, 2011. 37(12): p. has no effects on respiration: a pilot study.Can noninvasive positive pressure ventilation for 1969-75. J Anaesth, 2004. 51(5): p. 494-9. acute respiratory failure in patients with severe 26. Clouzeau, B., et al., Target-controlled infusion 10. Erstad, B.L. and A.E. Patanwala, Ketamine for asthma. J Anesth, 2009. 23(1): p. 147-50. of propofol for sedation in patients with analgosedation in critically ill patients. J Crit 19. Akada, S., et al., The efficacy of noninvasive ventilation failure due to low Care, 2016. 35: p. 145-9. dexmedetomidine in patients with noninvasive tolerance: a preliminary study. Intensive Care 11. Verma, A., et al., Ketamine Use allows ventilation: a preliminary study. Anesth Analg, Med, 2010. 36(10): p. 1675-80. Noninvasive Ventilation in Distressed Patients 2008. 107(1): p. 167-70. 27. Battistoni, I., et al., [Noninvasive ventilation with Acute Decompensated Heart Failure. 20. Huang, Z., et al., Dexmedetomidine versus and sedation: evidence and practical tools for Indian J Crit Care Med, 2019. 23(4): p. 191-192. midazolam for the sedation of patients with its utilization]. G Ital Cardiol (Rome), 2017. 12. Kiureghian, E. and J.M. Kowalski, Intravenous noninvasive ventilation failure. Intern Med, 18(6): p. 513-518. ketamine to facilitate noninvasive ventilation in 2012. 51(17): p. 2299-305. a patient with a severe asthma exacerbation. Am J Emerg Med, 2015. 33(11): p. 1720.e1-2.

CCMS Resources Join the Critical Care Medicine Section of AAEM and benefit from the below resources. Critical Care Speakers Mentoring Program Critical Care Hacks COVID-19 Resources Exchange In addition to the traditional This video library provides The CCMS Council has created This member benefit is a resource mentor-mentee relationship, quick resources for different and gathered resources specific for conference organizers to recruit CCMS offers several critical care medicine topics. to helping members during the top-quality speakers in critical care opportunities for mentors and Watch today! COVID-19 pandemic. Join our medicine. All speakers must be mentees to create something listerv to connect. members of the Critical Care Medicine together. Apply today to become Section of AAEM. Join today! a mentor or mentee!

Learn more: www.aaem.org/get-involved/sections/ccms/resources

COMMON SENSE JULY/AUGUST 2020 19