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      Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure


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          Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.

          The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.

          This guideline committee developed recommendations for 11 actionable questions in a PICO (population–intervention–comparison–outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.

          This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.


          ERS/ATS evidence-based recommendations for the use of noninvasive ventilation in acute respiratory failure http://ow.ly/NrqB30dAYSQ

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          Most cited references115

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          Weaning from mechanical ventilation.

          Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.
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            Outcomes of extubation failure in medical intensive care unit patients.

            Extubation failure is associated with a poor prognosis, but the respective roles for reintubation per se and underlying disease severity remain unclear. Our objectives were to evaluate the impact of failed extubation, whether planned or unplanned, on patient outcomes and to identify a patient subset at risk for extubation failure. Prospective 1-yr observational study with daily data collection. : Thirteen-bed medical intensive care unit in a teaching hospital. Consecutive patients requiring invasive mechanical ventilation were screened and followed until discharge or death. None. Of 168 planned extubations in 340 patients, 26 (15%) failed. Of these 26 patients, seven (27%) had pneumonia and 13 (50%) died after reintubation. Compared with successfully extubated patients, the patients with failed extubation were not significantly different regarding disease severity, mechanical ventilation duration, or blood gas values. Age and underlying diseases were the only factors associated with extubation failure, and extubation failure occurred in 34% of patients >65 yrs with chronic cardiac or respiratory disease compared with only 9% of other patients (p 65 yrs with underlying chronic cardiac or respiratory disease are at high risk for extubation failure and subsequent pneumonia and death. Contrasting with successful extubation, failed planned or unplanned extubation was followed by marked clinical deterioration, suggesting a direct and specific effect of extubation failure and reintubation on patient outcomes.
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              GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines.


                Author and article information

                Eur Respir J
                Eur. Respir. J
                The European Respiratory Journal
                European Respiratory Society
                August 2017
                31 August 2017
                : 50
                : 2
                : 1602426
                [1 ]Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
                [2 ]Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
                [3 ]Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
                [4 ]Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
                [5 ]Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
                [6 ]Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
                [7 ]Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
                [8 ]Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
                [9 ]Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
                [10 ]Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
                [11 ]Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
                [12 ]Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
                [13 ]Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
                [14 ]Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
                [15 ]Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
                [16 ]Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
                [17 ]Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA
                [18 ]Hofstra Northwell School of Medicine, Hempstead, NY, USA
                Author notes
                Stefano Nava, Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Via Zamboni 33, 40126 Bologna, Italy. E-mail: Stefanava@ 123456gmail.com
                Author information
                Copyright ©ERS 2017
                : 09 December 2016
                : 15 June 2017
                Task Force Report
                ERS/ATS guidelines

                Respiratory medicine
                Respiratory medicine


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