Thread by @WhistlingDixie4

🫁 Over the past years we have started using NIV more and more for respiratory fairly …practice changed under pressure

But now we’ve taken a breath

When do we use NIV and more importantly …when do we move on?

Follow along for debate #LIVES2022

Bellani says that any T1RF normally warrants a trial of helmet free flowing CPAP to see if they improve by monitoring with RR and paO2

Jaber says no, just get the FiO2 to >92% and then get them to ICU and see what you need…NIV..HiFlo etc

So now what if the patient is on 30L/min and SaO2 not achieving outcomes….

Roca says to asks if the situation is flow dependent (eg work of breathing) then he would first try actual HiFlo (60L/min)

And they ask should we ask patient?

Roca says yes, even considering loss of

?reliable patient insight with C19, asking is still important

Bellani talks about monitoring and says that low paCO2 in these patients is important and shouldn’t be ignored…

He feels people often forget to use the CO2

Jaber reminds us any patient on NIV needs intubation plan. If you’re doing trial NIV need to have *looked at* airway

and I presume also know if you *would* offer intubation, which seems a bigger deal to me - as a famous wizard said, pick when what is right and what is easy

but nobody mentions that

Then Gattinoni asks how we decide to shift plans and know that mechanical ventilation is now the least dangerous approach…when the patient just stays the same / small change

Bellani says it depends on the FiO2 and if the P/F is around 20 then we *can* wait and see…but that

It also depends what the diagnosis is because that dictates if you have a treatment that’s likely to lead to improvement over time

And then we mentioning proning…

Papazian said he would try proning in a cooperative patient - says 95% the literature though I’d about C-19

But they ask why?? does this just not delay intubation?

…Papazian says recent trials have shown differences in rate of ventilation, but not in mortality

But Roca says the meta-trial showed that awake prone positioning did *not* change the time to failing (intubation)

So they press the panel to be specific about when they pick the time to intubate

Roca says you can never take a decision based on a number

The number identifies the risk
—> points towards ROX score

Highlights respiratory rate as a monitor

mdcalc.com/calc/10302/rox…

Bellani said the central point is that awake prone positioning should NOT be used to rescue failing NIV …it is for ‘stable’ or safe patients.

He mentions this position as a possible alternative ncbi.nlm.nih.gov/pmc/articles/P…

An audience member asks whether recent experience means we need to reassess our targets… allowing permissive hypoxaemia

Bellani believes the risk of induced lung injury in these circumstances is too high

And we then leave pts to crash in middle of the night with no reserve

…in these situations there is no benefit to not intubating them

So it’s not about the fact SaO2 is ~85% but about the injury/process that’s behind that number

Gattinoni - we don’t often die from gas exchange, we die from the cost of the process that got you there

The decision is what is right or wrong

It’s what is less harmful

An audience member asks why not use awake sedation to mitigate for self induced lung disease ….Bellani says yes, they sometimes use low dose dexmeditomidine or remifentanyl (only in the ICU)

So to close there is no second answer but Gattinoni says we need to ask

What is the stress of the strain we apply?
What lung volumes?
At which cost to pressure?
And at which rate?

And until we measure all of these together, we are driving at night

#LIVES2022 (end)