Sedation in patients on noninvasive ventilation

What is your opinion on sedation of patients on noninvasive ventilation (NIV)? In British Thoracic Society guidelines, sedation with morphine is an optional approach in agitated patients receiving NIV. Could you comment on that?

Andreas Freitag: We use sedation – both benzodiazepines as well as narcotics – to facilitate comfort to the patient in the intensive care unit. It is commonly used, especially if the patients are intubated or mechanically ventilated.

People are concerned that if you do a noninvasive route, you might cause respiratory depression and you may actually facilitate or cause demise. I do not think that is true in practice. I think it is important that many of those patients are anxious, many of these patients are frightened. I think what is the origin of the agitation to me is the most important question. If it is pain, narcotics make total sense. If it is dyspnea, uncomfortable breathlessness, small doses of narcotics have been shown to be extremely effective and that is once again the setting of the severe chronic obstructive pulmonary disorder (COPD), as an example.

Benzodiazepines have had a bit of an excess mortality in the setting of something like severe COPD in terms of sedation or anxiety. And I think that is the method, that is the reason why the British Thoracic Society was recommending more low-dose narcotics as opposed to benzodiazepines, but in my experience we have used both. I think the key thing here is to reduce anxiety and stress to the patients while we facilitate what we are actually doing. It is either going to work or it is not going to work. Every patient is different.