Noninvasive Positive Pressure Ventilation as an Adjunct to Extubation in the Burn Patient

Noninvasive positive pressure ventilation (NIPPV) was initially utilized for the management of COPD. In this patient group, NIPPV avoided the need for reintubation in 50 to 70% of patients with severe exacerbations and resulted in decreased mortality and length of hospital stay. Its use has been extended to patients with neuromuscular disease, sleep apnea syndrome, cardiogenic pulmonary edema, and acute hypoxemic nonhypercapnic respiratory failure. It also serves as an adjunct therapy for respiratory insufficiency after extubation.1,–3 As defined by the International Consensus Conference in Intensive Care Medicine,4 NIPPV represents any form of ventilatory support without the use of an endotracheal tube. This includes CPAP, BIPAP, and IPPB. Its goal is to decrease the work of breathing, optimize ventilatory exchange and avoid intubation. Exclusionary criteria include aspiration, hemodynamic instability, mask intolerance, recent facial surgery, and patient ventilatory dissynchrony. Associated side affects are gastric distension, eye irritation/erosion, and skin pressure breakdown. The burn literature is limited with respect to NIPPV and inhalation injury. In a study by Smailes,5 the use of NIPPV avoided endotracheal intubation in 74% of 30 patients experiencing respiratory insufficiency post-extubation, while 23% (7 patients) were reintubated. Only eight patients in this study were diagnosed with inhalation injury. Three patients were reintubated electively due to surgery and four patients were reintubated due to sepsis. These findings are in contrast to other studies6,7 where no improvements were noted in the rate of reintubation, mortality, length of ICU stay or length of ventilatory support when utilized in the first 48 hours post extubation. Esteban et al's multicenter study7 also noted a trend for increased mortality with NIPPV use.