Early Inspiratory Effort Assessment by Esophageal Manometry Predicts Noninvasive Ventilation Outcome in De Novo Respiratory Failure. A Pilot Study

• Published in: American journal of respiratory and critical care medicine Vol. 202; no. 4; pp. 558 - 567
• Main Authors: Tonelli, Roberto, Fantini, Riccardo, Tabbì, Luca, Castaniere, Ivana, Pisani, Lara, Pellegrino, Maria Rosaria, Della Casa, Giovanni, D’Amico, Roberto, Girardis, Massimo, Nava, Stefano, Clini, Enrico M., Marchioni, Alessandro
• Format: Journal Article
• Language: English
• Published: United States American Thoracic Society 15.08.2020
• Subjects: Aged; Aged, 80 and over; Clinical outcomes; Critical care; Esophagus - physiopathology; Female; Humans; Inhalation; Male; Manometry; Middle Aged; Noninvasive Ventilation; Original; Pilot Projects; Predictive Value of Tests; Prospective Studies; Respiration; Respiratory failure; Respiratory Insufficiency - physiopathology; Respiratory Insufficiency - therapy; Respiratory therapy; Time Factors; Ventilators; acute respiratory distress syndrome; respiratory failure; transpulmonary pressure; noninvasive mechanical ventilation; esophageal pressure swings
• ISSN: 1073-449X; 1535-4970; 1535-4970
• DOI: 10.1164/rccm.201912-2512OC

The role of inspiratory effort still has to be determined as a potential predictor of noninvasive mechanical ventilation (NIV) failure in acute hypoxic respiratory failure. To explore the hypothesis that inspiratory effort might be a major determinant of NIV failure in these patients. Thirty consecutive patients with acute hypoxic respiratory failure admitted to a single center and candidates for a 24-hour NIV trial were enrolled. Clinical features, tidal change in esophageal pressure (ΔPes), tidal change in dynamic transpulmonary pressure (ΔPl), expiratory Vt, and respiratory rate were recorded on admission and 2-4 to 12-24 hours after NIV start and were tested for correlation with outcomes. ΔPes and ΔPes/ΔPl ratio were significantly lower 2 hours after NIV start in patients who successfully completed the NIV trial (  = 18) compared with those who needed endotracheal intubation (  = 12) (median [interquartile range], 11 [8-15] cm H O vs. 31.5 [30-36] cm H O;  < 0.0001), whereas other variables differed later. ΔPes was not related to other predictors of NIV failure at baseline. NIV-induced reduction in ΔPes of 10 cm H O or more after 2 hours of treatment was strongly associated with avoidance of intubation and represented the most accurate predictor of treatment success (odds ratio, 15; 95% confidence interval, 2.8-110;  = 0.001 and area under the curve, 0.97; 95% confidence interval, 0.91-1;  < 0.0001). The magnitude of inspiratory effort relief as assessed by ΔPes variation within the first 2 hours of NIV was an early and accurate predictor of NIV outcome at 24 hours.Clinical trial registered with www.clinicaltrials.gov (NCT03826797).