Use of sedation for non-invasive ventilation: The international non-invasive ventilation and dexmedetomidine in critically ill adults (index) survey.

Abstract

INTRODUCTION Non-invasive ventilation (NIV) is a common tool used to treatment acute respiratory failure (ARF). Compared to NIV, invasive mechanical ventilation (IMV) is associated with an increased risk of both morbidity and mortality, nosocomial infections, a longer hospital stay, and increased health care costs.1-4 Hypothetically, sedation may improve NIV tolerability, thereby preventing intubation. To date, there is a paucity of highquality evidence that examines the use of sedatives to improve NIV tolerance. Likewise, there are no clinical practice guidelines that discuss the use of sedatives in NIV. This international survey of practicing intensivists serves to outline the values and preferences of NIV-Associated sedation use in the adult critical care setting. OBJECTIVES Without clear guidelines, practice patterns may be affected by real or perceived risk and lead to asymmetric adoption of sedation during NIV. Therefore, we hypothesize there is significant variation in practice surrounding the use of sedatives to improve NIV compliance, mainly due to lack of evidence. Our primary aim was to assess if sedatives are used at all during NIV. Our secondary aims were to: 1) identify factors that affected willingness to use sedatives; 2) report intensivist's attitudes towards sedation use during NIV; and 3) evaluate current self-reported practices regarding dexmedetomidine use during NIV. METHODS We followed recommended practices of survey design.5 We first completed a literature review on the use of sedatives during NIV, and then we held a focus group consisting of ten intensivists from around the globe to identify the scope of domains. Questions were posed in a format intended to allow for generalizations regarding individual clinical practice (e.g., I conduct this practice never, rarely, half the time, usually, always). All questions were closed-ended questions without free-Text. To test our survey questions, we administered an electronic copy of a six-item clinical sensibility questionnaire to seven intensivists, at varying stages of their career, working in various units, throughout the world, who had methodologic and clinical expertise. The survey was revised based on results. We used REDCap to electronically distribute the survey to four countries (Australia, New Zealand, Saudi Arabia, and Canada). We distributed the surveys exclusively through four local societies (our sampling frame): The Saudi Critical Care Society, the Australia and New Zealand Intensive Care Society (Clinical Trials Group), Canadian Critical Care Society, and the Canadian Critical Care Trials Group. We invited practicing intensivists to complete the survey between January 2022 and March 2022. RESULTS One hundred and forty intensivists reported they would not give a sedative to prevent NIV intolerance when a patient is not agitated. Of the intensivists that would give a sedative to treat NIV intolerance for patients with hypoxemic respiratory failure, most respondents reported using opioids in some form. Benzodiazepines and antipsychotics were also commonly preferred. Dexmedetomidine was primarily used as an infusion in surveyed answers. Sedation for hypercarbic and hypoxic respiratory failure was largely the same. Propofol and ketamine were rarely used. Respondents were asked which factors reduce their likelihood of providing sedation during NIV. Reasons included a lack of institutionalized protocol for NIV sedation during NIV, fear of oversedation leading to intubate, hemodynamic instability, sedative co-Administration, and patientspecific variables such as age and organ failure. Most respondents felt a large randomized controlled trial (RCT) on dexmedetomidine for sedation during NIV would change their practice. CONCLUSION This international survey of 140 physicians served to explore common practices involving NIV sedation in the critical care setting. The survey demonstrates equipoise as there was large practice variation in which sedative, if any, are used to improve NIV intolerance. The main reported concern over use of sedatives was risk of oversedation linked to respiratory depression and inadvertent need for IMV, and lack of institutional protocols for implementation of sedation during NIV. Physicians strongly supported future research in the field, including an RCT addressing use of dexmedetomidine for NIV sedation.