Non-invasive ventilation in trauma patients: is there a role?

Background

In the ICU non-invasive ventilation (NIV) allows one to reduce the complications related to endotracheal intubation and mechanical ventilation (e.g. increased infections), and it could improve the outcome of patients in certain clinical conditions. Actually only few trials support the use of NIV in trauma patients and its use is limited in this clinical setting.

Methods

We performed a retrospective evaluation of 29 patients with major trauma admitted to our ICU over a 2-year period from January 2004 to December 2005 (ISS 25.97 ± 10.29, SAPS II 25.31 ± 9.38). All patients had thoracic trauma, and four patients had associated head trauma. Twenty-four patients have been treated with CPAP delivered by helmet, two patients were ventilated with PSV by face mask, two with PSV by TotalFace Mask^®, and one with both PSV by TotalFace Mask^® and CPAP by helmet. The indications for NIV have been: in 21 cases traumatic pulmonary contusion, in four cases atelectasis, in three cases pneumonia and in one case reduction in chest wall compliance. In 18 patients NIV has been employed for weaning from invasive mechanical ventilation, and in the other 11 patients NIV was the first mode of ventilatory assistance. We evaluated the ability of NIV to improve oxygenation (P/F ratio).

Results

Patients have been treated with NIV for 4.41 ± 2.33 days. Twenty-five patients (86.2%) significantly improved oxygenation after NIV (Table 1) (t test; P < 0.001) and were discharged from the ICU. Four patients failed the NIV and were intubated (in two patients NIV had been used for weaning): in this subgroup of patients two died of septic shock from pneumonia. In the subgroup of intubated patients the duration of mechanical ventilation was 7.17 ± 5.02 days and the length of stay in the ICU was 14 ± 5 days. Mortality in the NIV group was 13.8%.

Table 1 (abstract P49)

Conclusions

NIV has proved to ensure adequate oxygenation and to be successful in respiratory assistance of patients with thoracic trauma. It could be considered a valid alternative to endotracheal intubation in trauma patients requiring ventilatory support. Further investigations are needed to evaluate the incidence on outcome and to define indications.