Efectividad y seguridad de la ventilación no invasiva en el tratamiento del shock cardiogénico

Abstract

Cardiogenic shock (CS) is considered the most severe type of heart failure, requiring hemodynamic support and, in many cases, respiratory support. Traditionally, the treatment for severe acute respiratory failure (ARF) has involved invasive mechanical ventilation (IMV). With the introduction of non-invasive mechanical ventilation (NIV), many patients with acute cardiogenic pulmonary edema can be effectively treated without the need for endotracheal intubation. NIV has been widely used in patients with ARF due to heart failure. However, current recommendations consider CS as a contraindication for the use of NIV. We hypothesized that NIV can be used with a high degree of efficacy and safety in CS patients who quickly stabilize with vasoactive drugs. Objectives. The main objective of this study is to analyze the effectiveness of NIV in patients with ARF due to CS. As secondary objectives, we studied the safety of NIV for the patient, risk factors for failure of NIV, and factors related to in-hospital mortality. Methodology. Prospective observational cohort study with one-year follow-up. The study was conducted in a intensive care unit (ICU) of a university hospital from 1997 to 2021. All CS patients who consecutively admitted in ICU with respiratory failure at admission or during hospitalization, requiring non-invasive ventilatory support, were included. Demographic, clinical, laboratory, severity-related, and patient outcome variables, as well as ventilation technique data, were recorded. NIV failure was defined as the need for endotracheal intubation and/or death in the ICU. Univariate and multivariate analyses were used to compare variables. Odds ratios were calculated for independent predictor variables. Survival analysis for one-year mortality was conducted. Propensity score matching was performed using the nearest-neighbor model without replacement, with a 1:1 ratio, matching each CS patient treated with NIV with a patient treated with IMV. Results. NIV treatment for ARF in CS has an acceptable effectiveness, with a 50% success rate of the technique. Independent risk factors for NIV failure were the presence of acute coronary syndrome as a trigger for CS, originating from the hospital ward, a high SOFA and HACOR score at one hour after began NIV. NIV related complications are common but mostly mild. Independent predictors for in-hospital mortality were age, the presence of acute coronary syndrome as a trigger for CS, originating from the hospital ward, greater dependency, no improvement in hemodynamic, respiratory, and neurological parameters after NIV, greater multiorgan dysfunction, and NIV failure. However, patients who received and tolerated ACE inhibitors and oral beta-blockers once hemodynamic stability was achieved were associated with increased survival. The use of NIV in CS patients improves mortality in the ICU, in-hospital, and at one year compared to patients who required IMV. The benefit of NIV appears to be limited to the early stages of CS (Stage C). Conclusions. The use of NIV in CS is effective in avoiding endotracheal intubation in a significant percentage of cases. Multiple variables are associated with NIV failure and in-hospital mortality. CS patients benefit from NIV, especially in the early stages of cardiogenic shock.