NON-INVASIVE VENTILATION AS AN ALTERNA- TIVE, OR TO PREVENT ENDOTRACHEAL INTU- BATION IN ARDS PATIENTS? TWO CASE REPORTS

Aim. Noninvasive positive-pressure ventilation (NIV) is a safe method of improving gas exchange in patients with several types of acute respiratory failure,1 but its application in hypoxemic ALI/ARDS is controversial.2 We report two cases of conscious and collaborative patients with moderate ARDS (3) successfully treated with a helmet-NIV in our ICU. Case report 1. A 17 years-old woman underwent, in one month, four abdominal surgeries, until final total colectomy for Hirschprung disease, complicated by intra-abdominal sepsis. After the last surgery, in fourth day, she developed tachycardia, dyspnea, respiratory rate (RR)=45 breaths/min and bilateral opacities on chest X-ray, so she was admitted to our ICU. Arterial blood gases revealed hypoxemia (PaO2/FiO2=184) and hypocapnia (pCO2=24 mmHg). Hemodynamic was stable with no left ventricular failure (APACHE II score 14). During the first 24 hrs, we used hel- met-NIV (BIPAP: PEEP=5 cmH2O; “delta”ASB=4 cmH2O; FiO2=0.5) until oxygenation improved and RR decreased (PaO2/FiO2=300, RR=30 breaths/min). On the seventh day opacities at the chest X-ray disappeared and the patient was discharged in spontaneous breathing with PaO2/FiO2=500. Case report 2. A 26 years-old woman suffering from anorexia nervosa, BMI=10.93 and immunocompromised, was admit- ted in ICU for hypoglycemic coma. After resolution, she remained at our unit for vital signs monitoring and forced parenteral nutrition. In 13th day, acutely, hyperthermia without leukocytosis, dyspnea (SpO2=92%, RR=42 breaths/min, PaO2/FiO2=124, pCO2=36 mmHg), tachycar-  dia, and bilateral infiltrates on chest X-ray, with stable hemodynamics, appeared (APACHE II score 19). We placed helmet-NIV (BIPAP: PEEP=7 cmH2O, “delta”ASB=9 cmH2O; FiO2=0.5). In the first 36 hrs there was a rapid increase in oxygenation (SpO2=100%, PaO2/FiO2=246, RR=26 breaths/min), but the patient had poor compliance, so we performed small cycles of NIV lasting 2-4 hrs, interrupted by Venturi mask O2-therapy, applying Helmet when desatura- tion occurred. Only in the seventh day there was a sensible improvement of oxygenation (PaO2/FiO2=430) and weaning was carried out until the restoration of physiological breathing and negativity of chest X-ray on the 11th day. Conclusions. The conventional treatment of ALI/ARDS includes endotracheal intubation that is performed when ARDS deteriorate despite aggressive medical management.1 NIV is not generally advisable, but recent studies 2 conside- red it as an alternative treatment in several categories such as hemodynamically stable 4 and immunocompromised patients in which early NIV should decrease the risk of infections, pneumonia and death, linked to the endotracheal tube. Our two cases, despite the mild ARDS, were young patients with low APACHE II. However, the safety issues and the potential damage linked to a NIV failure with an inappropriate delay of intubation are not to be underestimated, that’s why NIV requires a close monitoring in ICU by a skilled staff. References 1. Antonelli M, Conti G, Rocco M et al. A comparison of noninvasive positive- pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429-35. 2. Nava S, Schreiber A, Domenighetti G. Non invasive ventilation for patients with acute lung injury or acute respiratory distress syndrome Respir Care. 2011; 56:1583-8. 3. Hecker M, Seeger W, Mayer K. The Berlin Definition: novel criteria and classifi- cation of ARDS. Med Klin Intensivmed Notfmed. 2012;107:488-90. 4. Rocker GM, Mackenzie MG, Williams B, Logan PM. Noninvasive pressure sup- port ventilation: successful outcome in patients with acute lung injury/ARDS. Chest 1999;115:173-7.