Nutrition management for critically ill patients requiring non-invasive ventilation: a scoping review protocol

The definition of critical illness varies in the international literature; however, it is often considered to be the need for one or more organ supports that cannot be provided in a ward-based setting (1). One aspect of organ support is respiratory support (2). Invasive mechanical ventilation (IMV) – the insertion of a tube into the trachea to mechanically support or replace spontaneous breathing – is considered ‘advanced’ respiratory support. While in many instances it is conducive to patient survival, it is also associated with a number of complications, such as infection, nosocomial pneumonia and pneumothorax (3, 4). Accordingly, the past two decades have seen a trend towards the increased use of non-invasive ventilation (NIV) (5-8) – via external devices such as helmets, face masks, oro-nasal masks and nasal masks – to support respiratory function. This change in practice has been aided by technical advancements in the ventilatory equipment used to deliver NIV and a greater understanding of physiology and pathophysiology (9). While it was previously thought that patients requiring NIV were not as sick as their invasively ventilated counterparts, recent data has demonstrated a statistically significant increase in the use of NIV despite a simultaneous increase in the injury severity of ICU admissions across a five year period from 2009-2013 (8). International clinical guidelines for the nutrition management of critically ill patients provide recommendations on nutrition risk screening, initiation and mode of nutrition delivery, energy and protein targets, and formulae composition (10-13). Oral intake is stated as, where possible, the preferred delivery route, with enteral nutrition (EN) – the delivery of liquid formula via a transnasal tube – recommended for patients unable to establish oral intake within 48 hours of admission (10, 11). Given the position of the endotracheal tube and the regular need for sedatives during IMV – these recommendations can be applied in practice. Despite this, patients receiving IMV in the ICU typically only receive ~50% of nutrition requirements (14). For patients receiving NIV, early evidence suggests nutrition adequacy may be even lower at 42 (±5) % of nutrition requirements (15); yet – the four key international guidelines do not directly address nutrition management in patients receiving NIV, despite the growth in this population. The application of these four guidelines in practice to the nutrition management of patients receiving NIV is also challenging. Oral intake during NIV is feasible, but the removal of the NIV mask to facilitate this can compromise respiratory function (16). The presence of a transnasal tube for enteral nutrition can result in an air leak from the NIV apparatus, also causing subsequent respiratory compromise (17). Further, enteral nutrition has been reported to be associated with airway complications, and longer durations of both NIV and hospitalisation (18). Parenteral nutrition (PN) is an alternate mode to gastrointestinal nutrition delivery and is usually provided directly into a vein. It is not subject to the delivery issues with EN and is less frequently interrupted, but there have been concerns with increased complications and cost compared to EN (19, 20). PN has typically been reserved for patients with a non-functioning gastrointestinal tract and thus, to date, has not been explored in this population group. With the increased use of NIV in ICU, acquiring an understanding of nutrition management during NIV is clearly pressing in order to improve the clinical care for these patients. A preliminary search was conducted and no current or underway scoping or systematic reviews on the topic were identified. One systematic review and meta-analysis was registered – ‘Efficacy and safety of tube feeding during NIV’. While this systematic review demonstrates the growing interest in this area, it addresses a clearly defined, specific aspect of nutrition management compared to the broad aims of the proposed scoping review outlined here. It also demonstrates the importance of undertaking a scoping review to first map and understand the literature that has recently been published on the topic to inform the direction of future research. The key objective for this scoping review will be the identification of literature and key themes related to the nutrition management of adult critically ill patients requiring NIV. The two review questions will be; What published literature currently exists on nutrition management of critically ill adults requiring NIV? What are the key themes in the literature relating to the nutrition management of critically ill adults requiring NIV? References: 1. Intensive Care Society. Levels of Critical Care for Adult Patients. London. 2002 [cited 2021 Jun 22]. Available from: https://icmwk.com/wp-content/uploads/2014/02/Revised-Levels-of-Care-21-12-09.pdf. 2. Kacmarek RM. The Mechanical Ventilator: Past, Present, and Future. Respir Care. 2011;56(8):1170-1180. 3. Popat B, Jones AT. Invasive and non-invasive mechanical ventilation. Medicine. 2012;40(6):298-304. 4. Gay PC. Complications of noninvasive ventilation in acute care. Respir Care. 2009;54(2):246-57. 5. MacIntyre N, Rackley C, Khusid F. Fifty Years of Mechanical Ventilation-1970s to 2020. Crit Care Med.2021;49(4):558-74. 6. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170- 7. Demoule A, Chevret S, Carlucci A, Kouatchet A, Jaber S, Meziani F, et al. Changing use of noninvasive ventilation in critically ill patients: trends over 15 years in francophone countries. Intensive Care Med. 2016;42(1):82-92. 8. Lilly CM, Swami S, Liu X, Riker RR, Badawi O. Five-Year Trends of Critical Care Practice and Outcomes. Chest. 2017;152(4):723-35. 9. Dellaca’ RL, Veneroni C, Farre’ R. Trends in mechanical ventilation: are we ventilating our patients in the best possible way? Breathe (Sheff). 2017;13(2):84. 10. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. 11. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211. 12. Reintam Blaser A, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM, et al. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med. 2017;43(3):380-98. 13. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355-73. 14. Ridley EJ, Peake SL, Jarvis M, Deane AM, Lange K, Davies AR, et al. Nutrition Therapy in Australia and New Zealand Intensive Care Units: An International Comparison Study. JPEN Journal of Parenter Enteral Nutr. 2018;42(8):1349-57. 15. Chapple L-a, Gan M, Louis R, Yaxley A, Murphy A, Yandell R. Nutrition-related outcomes and dietary intake in non–mechanically ventilated critically ill adult patients: A pilot observational descriptive study. Aust Crit Care. 2020;33(3):300-8. 16. Terzi N, Darmon M, Reignier J, Ruckly S, Garrouste-Orgeas M, Lautrette A, et al. Initial nutritional management during noninvasive ventilation and outcomes: a retrospective cohort study. Crit Care. 2017;21(1):293. 17. So EC, Chen YH, Wong KL, Poon PW, Huang BM. A new mask designed for patients implanted with a nasogastric tube. Med Eng Phys. 2008;30(8):1020-3. 18. Kogo M, Nagata K, Morimoto T, Ito J, Sato Y, Teraoka S, et al. Enteral Nutrition Is a Risk Factor for Airway Complications in Subjects Undergoing Noninvasive Ventilation for Acute Respiratory Failure. Respir Care. 2017;62(4):459. 19. Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004;20(10):843-8. 20. Elke G, van Zanten AR, Lemieux M, McCall M, Jeejeebhoy KN, Kott M, et al. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care. 2016;20(1):117.

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