Enteral Feeding and Noninvasive Ventilation

In the last decades, noninvasive ventilation (NIV) has been increasingly applied in a growing number of acute care settings and conditions for prevention or treatment of acute respiratory failure (ARF). Its efficacy has been evaluated in several randomized trials, and it is currently considered a first-line treatment in some common conditions such as chronic obstructive pulmonary disease (COPD) exacerbation, cardiogenic pulmonary edema, pneumonia in immunosuppressed patients, and postoperative ARF [1]. However, so far its benefit on survival has not yet been demonstrated for many indications, and its utilization is more and more challenging at least for ARF; physicians’ daily use of NIV in acute care setting and the question of nutritional support for patients on NIV remain a hot topic. Early enteral nutrition (EN) is recommended for mechanically ventilated patients in several studies and guidelines [2]. Enteral nutrition reportedly reduces the duration of mechanical ventilation and hospitalization and enhances patient survival. However, the effects of early EN on NIV have not been investigated extensively. In addition, EN has shown adverse effects, including critical ones. Patients receiving NIV may experience various complications, including airway problems (vomiting, increased sputum, mucus plugging, and atelectasis) and other problems (discomfort, pneumothorax, hypotension, cardiac rhythm disturbances, and anxiety). Enteral nutrition may worsen these complications, especially airway complications, possibly leading to critical problems, such as pneumonia and airway obstruction. Moreover, unlike for invasive ventilation, no methods of airway protection have been established for NIV. Despite the advantages of EN in patients with acute respiratory failure, the effects of EN in patients receiving NIV have not been clarified. Only one study directly related to this topic has been published [3]. In this monocentric retrospective study, the authors analyzed 107 patients over 8 years admitted in their ICU for ARF treated by NIV, 60 with EN and 47 without. The rate of airway complications was significantly higher (53% vs. 32%, P = 0.03), and the median NIV duration was significantly longer (16 vs. 8 days, P = 0.02) in subjects who received EN than in those who did not. No difference in hospital or overall mortality was shown. They concluded that among subjects receiving NIV, EN was associated with increased risk of airway complications but did not affect mortality. Because no conclusion could be drawn from this study, and in the absence of ongoing RCT, a physiological approach must be proposed for daily practice in ICU setting.