Appendix

Modifed Delphi analysis of the guideline “The use of non-invasive lung ventilation”

Recommendation number Statement to be changed Suggested change Explanation for the authors of the recommendations
1 In a patient with acute respiratory failure, based on the pathophysiology of respiratory failure, the technology of non-invasive mechanical ventilation (NIMV) and data from evidence-based medicine studies, its use is recommended for the following pathologies:
  1. Expiratory closure of the small airway (chronic obstructive pulmonary disease — COPD) — the patient is recommended oxygen therapy in combination with moderate PEEP / CPAP to facilitate expiratory flow and moderate inspiratory pressure to relieve the respiratory muscles.
  2. Hypoxemic (parenchymatous) ARF with a low potential for alveoli recruitment (pneumonia, pulmonary contusion, pulmonary embolism with the development of infarction pneumonia, condition after lung resection) — the patient is recommended oxygen therapy in combination with low PEEP / CPAP and low inspiratory pressure (Pinsp, IPAP, PS) to unload the respiratory muscles
  3. Hypoxemic ARF with a low potential for alveoli recruitment in combination with immunosuppression (pneumocystis pneumonia, ARF in oncohematology, ARF after solid organ transplantation) — the patient is recommended oxygen therapy in combination with moderate PEEP / CPAP and moderate inspiratory pressure to unload the respiratory muscles.
  4. Acute left ventricular insufficiency and cardiogenic pulmonary edema — the patient is recommended oxygen therapy in combination with moderate PEEP / CPAP to reduce the pump work of the left ventricle and moderate inspiratory pressure to unload the respiratory muscles
  5. Prevention of postoperative atelectasis in high-risk patients (obesity, immunosuppression, COPD with hypercapnia, thoracic surgery) — the patient is recommended moderate PEEP / CPAP for prophylaxis.
 In a patient with acute respiratory failure, the use of non-invasive mechanical ventilation is recommended for the following critical conditions:
  1. Expiratory airway closure (chronic obstructive pulmonary disease — COPD) — oxygen therapy in combination with PEEP/CPAP to facilitate expiratory flow and moderate inspiratory pressure to relieve respiratory muscles.
  2. Hypoxemic (parenchymatous) ARF with a low potential for alveoli recruitment (pneumonia, pulmonary contusion, pulmonary embolism with the development of infarction pneumonia, condition after lung resection) — oxygen therapy in combination with PEEP / CPAP and low inspiratory pressure to unload the respiratory muscles
  3. Hypoxemic ARF with a low potential for alveoli recruitment in combination with immunosuppression (Pneumocystis pneumonia, ARF in oncohematology, ARF after solid organ transplantation) — the patient is recommended oxygen therapy in combination with PEEP / CPAP and moderate inspiratory pressure to unload the respiratory muscles
  4. Acute left ventricular failure and cardiogenic pulmonary edema — oxygen therapy in combination with PEEP / CPAP to reduce the pump work of the left ventricle by reducing its pre- and afterload and moderate inspiratory pressure to unload the respiratory muscles.
  5. Prevention of postoperative atelectasis in high-risk patients (obesity, immunosuppression, COPD with hypercapnia, thoracic surgery) — PEEP/CPAP for the prevention of atelectasis
Specify the PEEP/CPAP values. Clarify or give clinical examples of immunosuppressive conditions.

For example: NIV can be successfully used in immunosuppressive conditions, for example, in severe pneumonia [Hilbert G., Gruson D., Vargas F., et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001; 344(7): 481–7], hypoxemic respiratory failure in [Rathi N.K., Haque S.A., Nates R., et al. Noninvasive positive pressure ventilation vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure in cancer patients. J Crit Care. 2017; 39: 56–61], Graft-versus-host reactions [Cortegiani A., Madotto F., Gregoretti C., et al. Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database. Crit Care. 2018; 22(1): 157].

NIV reduces in-hospital and 30-day mortality in immunodeprimed patients [Wang T., Zhang L., Luo K., et al. Noninvasive versus invasive mechanical ventilation for immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis. BMC Pulm Med. 2016; 16(1): 129].

At the same time, immunosuppressive conditions are not predictors of NIV ineffectiveness and do not lead to an increased risk of tracheal intubation [Coudroy R., Pham T., Boissier F., et al. Is immunosuppression status a risk factor for noninvasive ventilation failure in patients with acute hypoxemic respiratory failure? A post hoc matched analysis. Ann Intensive Care. 2019; 9(1): 90. DOI: 10.1186/s13613-019-0566-z]
2 In patients with acute respiratory failure who are indicated for NIVL, its use is recommended only under the following conditions: preservation of consciousness, the ability to cooperate with staff, the absence of claustrophobia (when using helmets) and the functioning of the entire mechanism of coughing up sputum In patients with ARF, the use of non-invasive mechanical ventilation is recommended only under the following conditions: preservation of consciousness, the ability to cooperate with staff, the absence of claustrophobia (with the use of helmets) and the ability to cough up phlegm  
4 In patients with ARF, the use of NIV instead of oxygen therapy (through a face mask or cannula) is recommended to improve gas exchange, reduce respiratory activity and improve prognosis in the following conditions: exacerbation of COPD (with the development of moderate respiratory acidosis (7.35 > pH > 7.25) and compensated ARF)   Supplement the information with the criteria of compensated ARF
6 In patients with severe exacerbation of bronchial asthma, NIV is not recommended, drug therapy in combination with oxygen therapy is indicated, and with the progression of ARF (life-threatening asthma), only invasive mechanical ventilation is recommended, NIV is contraindicated In severe exacerbation of bronchial asthma, drug and oxygen therapy are indicated. With the progression of the condition — invasive mechanical ventilation. NIV is contraindicated.  
8 In patients with hypoxemic (parenchymal) ARF, non-invasive mechanical ventilation is recommended with a combination of low alveoli recruitment with slightly reduced or normal compliance of the lungs and chest wall (primary pathology of the lung parenchyma) as first-line therapy, especially in immunosuppressed patients; It is possible that high-flow oxygen therapy has an advantage in this category of patients. These conditions include: community-acquired pneumonia with an initial oxygenation index of more than 150 mm Hg. In patients with hypoxemic (parenchymal) ARF, non-invasive mechanical ventilation is recommended with a combination of low alveoli recruitment with slightly reduced or normal compliance of the lungs and chest wall (primary pathology of the lung parenchyma) as first-line therapy, especially in patients with immunosuppression (perhaps high-flow oxygen therapy has an advantage in this category of patients) In the context of new data on NIV in a new coronavirus infection, remove the indication of the presence of an oxygenation index of more than 150 mm Hg
11 In patients at risk (COPD with hypercapnia, obesity with hypercapnia, congestive heart failure) after surgery, NIV is recommended to prevent the development of post-extubation ARF, it leads to a decrease in the frequency of tracheal intubations and a decrease in mortality; the use of non-invasive mechanical ventilation in these groups of patients with already developed post-extubation ARF is ineffective and can lead to delayed tracheal intubation and worsening of the prognosis In patients at risk (COPD with hypercapnia, obesity with hypercapnia, congestive heart failure) after surgery, NIV is recommended to prevent the development of ARF, it leads to a decrease in the frequency of tracheal intubations and a decrease in mortality  
12 Non-invasive respiratory support is not recommended in the following cases (confidence level of evidence 3, level of persuasiveness of recommendations B):

1) lack of spontaneous breathing (apnea);
2) unstable hemodynamics (hypotension, ischemia or myocardial infarction, life-threatening arrhythmia, uncontrolled arterial hypertension);
3) inability to provide airway protection (coughing and swallowing disorders) and high risk of aspiration;
4) excessive bronchial secretion;
5) signs of impaired consciousness (excitation or depression of consciousness), the patient's inability to cooperate with medical personnel;
6) facial trauma, burns, anatomical abnormalities that prevent the mask use;
7) severe obesity;
8) the patient's inability to remove the mask from the face in case of vomiting;
9) active bleeding from the gastrointestinal tract;
10) upper airway obstruction;
11) discomfort from the mask;
12) upper respiratory tract surgery 		NIV is not recommended in the following cases:

1) lack of spontaneous breathing (apnea);
2) unstable hemodynamics (hypotension, ischemia or myocardial infarction, life-threatening arrhythmia, uncontrolled arterial hypertension);
3) inability to provide airway protection (coughing and swallowing disorders) and high risk of aspiration;
4) excessive bronchial secretion;
5) signs of impaired consciousness (excitation or depression of consciousness, score according to RASS > + 1 or from –3 to –5), the patient's inability to cooperate with medical personnel;
6) facial trauma, burns, anatomical abnormalities that prevent the mask use;
7) severe obesity;
8) the patient's inability to remove the mask from the face in case of vomiting;
9) active GI bleeding;
10) upper airway obstruction;
11) discomfort from the mask;
12) upper respiratory tract surgery 		The amended text is in italics in paragraph 5, represented by data from the RASS scale (level of certainty of evidence 2, level of persuasiveness of recommendations B) [9–11]
17 In patients with anticipated difficult tracheal intubation, the use of high-flow oxygenation is recommended, as this reduces the incidence of desaturation during tracheal intubation In patients with anticipated difficult tracheal intubation, the use of high-flow oxygenation is recommended  
18 In patients undergoing palliative care high-flow oxygenation is recommended as this avoids mechanical ventilation In patients undergoing palliative care HFO is recommended as mechanical ventilation is not indicated for this category of patients  
Table 1. Proposed changes in the provisions of the methodological recommendation