NIV and Acute Respiratory Failure in COPD

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NIV and Acute Respiratory Failure in COPD Powered By Docstoc
					NIV in Medicina d’Urgenza
Giuseppe Foti
Istituto di Anestesia e Rianimazione Università di Milano-Bicocca Ospedale S. Gerardo Monza

Montecatini,17 Ottobre 2003

Classificazione

Ventilazione Artificiale
Non Invasiva Mask/Casco
PSV CPAP

Invasiva
Supporto Totale
Pressometrico

Supporto Parziale
SIMV PSV BIPAP PAV CPAP

Volumetrico

Sim

NIV in COPD
WHY HAVE I TO TRY ?

% of Deths
10 20 30 40 0

Bott

*

Brochard

*
*

Kramer

RATE OF DEATHS

CT
Barbè

VNI
Celikel Plant Thys

*

Incidence of Nosocomial Pneumonia
30

24

Incidence of Pneumonia (%)

19
20

ETI NIV

10
10

8

0

All

Hypercapnic RF

WHERE TO PERFORM NIV?

NIMV IN GENERAL WARDS
236 randomized

118 standard therapy

118 NIMV

32 intubated

86 success

18 intubated

100 success

24

12

died

died
Plant LANCET 2000

Training

30

20

10

0 92 93 94 95 96 97 98 99

7,4 7,35 7,3 7,25 7,2 7,15 7,1
92 93 94 95 96 97 98 99

p<0.01 *

PSV in maschera
• Maschere di diverso tipo e taglia (non siamo tutti uguali) • Luogo dedicato in cui tenere tutto (Maschere, nucali,
raccordi per sng)

• • • •

Ottenere collaborazione del paziente ! Protezione radice del naso (igiene, revestimenti etc.) Programmare periodi off E’ PIU’ DIFFICILE CHE INTUBARE IL PZ. MA NE VALE LA PENA

Ricetta per maskPSV
• PSV/PEEP = 10/5 • Pmax = 25-30 cmH2O
– SNG non indispensabile !!

Non Invasive Mechanical Ventilation
Raccordo a gomito ( passaggio SNG )

Nucale

NIV N=20

Standard Treatement N=20

P

Intubation Rate Length of stay in ICU in survivors, days, mean (sd) Severe Sepsis and septic shock after study entry No. of Deaths in ICU

4 (20%) 6 (3) 4(20%) 4
(20%)

14 (70%) 9 (4) 10(50%) 10
(50%)

.002 .03 .05 .05

Perché uso poco la NIV pur curando numerosi pz. con I.R.A. ed essendo fortemente convinto che il tubo fa male ??

Helmet CPAP: Lo Scafandro
•Rationale •Physiology •In Hospital •Out of Hospital

PEEP
(Positive End Expiratory Pressure)

e

Reclutamento alveolare

PEEP = 5

PEEP = 15
Sim

Why Helmet CPAP instead of PSV in ARF ?
• As good as:
– Inspiratory support is not as crucial – Problem is hypoxia

• Easy, safe, efficient and cheap
– – – – – NO pts. cooperation NO pts-machine interaction at high RR NO skin necrosis NO time limit (safely and easily applied all day long) Can be implemented outside ICU (ED, CCU,
General Ward, Ambulance, Home.)

“Not

all patients are good candidates for this therapy because the hermetic face mask discomfort in anxious patients and the technique requires intensive attention until patients are adapted to face mask and ventilators”
Masip et al. THE LANCET, (2000)356;pag.2131

“In conclusion, in hypoxemic ARF, NPPV can be successful in selected populations, with 70% of patients avoiding intubation… we could apply noninvasive ventilation to the 13% of the 2,770 patients with hypoxemic ARF admitted to our ICUs.”
Antonelli M et al. Intensive Care Med (2001) 27:1718

Bias Flow in the Head Tent MUST be > 30 L/min.
14 12 1200

PCO2insp (mmHg)

10 8 6 4 2 0 20

“la mamma me lo ha sempre detto di non mettermi in testa il sacchetto di plastica perché può soffocarmi!!”

PCO2insp. TV

1000 800 600 400 200 0

30

40

50

Bias Flow (L/min)
Patroniti N., Foti G., Pesenti A. et al. ICM (2003). 29: 1680-87

TV (ml)

EFFICACY OF Helmet CPAP IN THE TREATMENT OF ACUTE RESPIRATORY FAILURE

Dipartimento di Anestesia e Rianimazione Ospedale S.Gerardo, Monza.

AIM OF THE STUDY
To evaluate the therapeutic efficacy of Helmet-CPAP in the treatment of Acute Respiratory Failure outside the ICU.

SCAFANDRO

DOPPIO FLUSSIMETRO

FiO2 = 1, 0.5, 0.35

INCLUSION CRITERIA
• PaO2 < 100 mmHg in reservoir mask

• abnormal chest xRay

EXCLUSION CRITERIA
• need of immediate tracheal intubation

• presence of more than 2 new organ failure

PaO2/FiO2
Not intubated Vs intubated
450 400
PaO2/FiO2 (mmHg)

not intubated intubated

350 300 250 200 150 100 50 0
reservoir mask 3 hours last step

* * *
§

§

* p<0,05
§: p<0,005 not intubated Vs intubated

No.of Patients 30 25 20 15 10 5 0 0-6 h n=4 n 7-12 h n=4

Time of intubation

13-24 h
n=25

25-48h n=40

49-72 h n=15

Time

>72h n=20  n

Inability to correct hypoxia was the principal reason for failure of 79% of CAP, 78% of ARDSexp and 92% of ARDSp

Inability to correct hypoxia Inability to manage secretions Mask intolerance

Inability to correct dyspnea Hemodynamic instability

Antonelli, Intensive Care Med, 1999; 25: 207 A

PaO2/FiO2
CHF Vs PNM
250 200 150 100 50 0 CHF PNM

* (p<0,02) *

PaO2/FiO2 (mmHg)

PaO2/FiO2 (reservoir mask-3 hours)

RESULTS
•In all general ward pts.Helmet CPAP was feasible •27% of patients required intubation
(22% in CHF, 45% in PNM group)

•Mortality rate: 18% (8% among non
intubated, 44% among intubated)

CPAP nell’EPA

Antonelli M et al Intensive Care Med (2001) 27:1718

Rationale of CPAP in ACPE
CPAP  PIT
 Rit. Ven.

 FRC
 PaO2

 LVafterload

 WOB

 Cardiac performance  pulmonary congestion

Out of hospital treatment of Acute Pulmonary Edema by non invasive CPAP
G. Foti, M. Cazzaniga, E. Valle, M. Sabato, F. Apicella, V. Casartelli, G. Fontana, GP Rossi, S. Vesconi, A. Pesenti.
• Istituto di Anestesia e Rianimazione, Università degli Studi, H. S. Gerardo - Monza - Italy • Servizio di Emergenza Territoriale, presidi di Carate e Desio • SSUEm 118 Brianza

Out of Hospital Helmet CPAP in Presumed Acute Pulmonary Edema: materials

30 L/min.

110 100 90

*
O2 reservoire CPAP

SpO2 80 % 70
60 50 40 Modo

* < 0.01

Results:
O2 Reservoire CPAP HR MAP Wet rales score 11124 11530 3.60.7 10315 10118 1.70.8
< .01 < .01 <.01

Arterial Blood Pressure during CPAP
300 250
200

Systolic BP
(mmHg)

150
100 50

PAS pre preCPAP

PAS CPAP Duringpost

0

Outcome of ACPE pts:
• Mortality during transport
• expected = 5-13%
Annals of Emergency Medicine Volume 30 * Number 4 * October 1997

• observed = 0%

• Overall mortality
• expected (SAPS 45±14) = 35% • observed = 11.1% (previous study = 7-15%)

Outcome of ACPE pts:
• Intubation rate
• during transport 0% • hospital 2.2%

• Admission
• ICU 0% • CCU 15.6% • General ward 84.4%

• Hospital stay
• 10 ± 8 days

Why SpO2 improves during HelmetCPAP?

FiO2

PEEP

Drugs

Out of hospital treatment of Acute Pulmonary Edema by Helmet

: PARAMEDICS
CPAP

NO DRUGS
• SSUEm 118 Brianza
Nurse Coordinator : G. Brambilla, RN Director: G.P. Rossi, MD

•Anesthesia and Intensive Care Institute
ICU coordinator: G. Foti,MD Director: Prof. A. Pesenti

Results CPAP (BLS + Nurse) March 2001 – March 2002 n° patients Intubation in ED Mortality during transport 28 1 0

110 100 90 SpO2 80 % 70 60 50 40
* < 0.001

*

98,4 78,7

O2 reservoir CPAP con scafandr o Lineare

Modo

Results:
March 2001 – March 2002

VITAL PARAMETERS SpO2
%

O2 + reservoir

CPAP upon arrival in ED

P value < .001 < .001

79 ± 19.2
27,1 ± 8.6

98,4 ± 4.3
19 ± 6.7

RR
bpm

HR
bpm
Mean Arterial Pressure
mmHg

121,9 ± 13.8
118,9 ± 20.7

111 ± 14.7
108,7 ± 16.5

< .001
0.013

PROVOCATION:
Role of drugs in the first minutes of tratment of severe ACPE is :

MARGINAL

La CPAP mediante Scafandro non dovrebbe mancare nell’armamentario terapeutico dell’insufficienza respiratoria acuta

Consigli :
• CPAP/scafandro nell’EPA
– NIV solo se insuccesso CPAP (raro) e dopo adeguata esperienza

• NIV (PSV +PEEP) nel BPCO riacutizzato
– Face mask, scafandro se mask inefficace – Cominciatelo subito – Cominciate con i casi più semplici
• pH >7.3, cooperativi

• CPAP/Scafandro nell’IRA ipossiemica senza MOF
– CAP, atelettasie, versamenti pleurici etc. – Immunocompromessi

CONCLUSIONS FROM STUDIES (2)
BRITISH THORACIC SOCIETY
“Non-invasive Ventilation in Acute Respiratory Failure” Standards of Care Report 2002

“…CPAP has been shown to be effective in patients with Cardiogenic Pulmonary Oedema who remain hypoxic despite maximal Medical management. NIV should be reserved for patients in whom CPAP is unsuccessful.” (B)

Antonelli, 99 patients
(P/F < 200, RR> 35b/min, Active Contraction of AM or PAM, severe dyspnea) COPD excluded

33 Pts NIV Helmet

66 Pts NIV Mask Hystorical matched controls 9 (14%) ARDS 4(45%) Avoided ETI 100% Survival 5(55%) Intubated 4(80%) Mortality

6(18%) ARDS 4 (67%) Avoided ETI 100% Survival 2 (33%) Intubated 50% Mortality

Overall ARDS mortality 16%

Overall ARDS mortality 44%

Summary:
• Helmet CPAP should be used as FIRST LINE INTERVENTION in treatment of ACPE (In and Out of Hospital) • NIMV may be attempted in ALI-ARDS
– Immunocompromised, Pneumonia – BE CAREFUL when PaO2 does not improve – Helmet CPAP may be effective as NIMV in this subset of patients and can be applied more easily out of ICU

FENOMENO DI “HANG-UP” INSPIRATORIO DURANTE NIMV

NonInvasive PSV in non-COPD patients with ACPE and severe CAP: acute effects and outcome
Intensive Care Med (2002) 28: 1226-1232

G.Domenighetti, R. Gayer, R. Gentilini

Variable
Intubation ICU stay (days) Cumulative NIPSV hrs.

ACPE (n=15)

CAP (n=18)

P-value

1 3.5±3.7 9.6 ±6.3

7 8.3 ±7.8 37.2 ±36

0.04 0.04 0.01

PEEP and cardiac silhouette

Senza PEEP

Con PEEP

CPAP IN CARDIOGENIC PULMONARY EDEMA

Rasen et al: Chest 1985; 87: 158-162

IntraThoracicPressure and LV function
AO
Ptm = 100-(-20) = 120  effort =  ITP = Ptm

ITP


LV 100 -20  LV afterload

CPAP IN CARDIOGENIC PULMONARY EDEMA

Rasen et al: Chest 1985; 87: 158-162

IntraThoracicPressure and LV function
AO
Ptm = 100-(-5) = 105  effort =  ITP = Ptm

ITP


LV 100 -5  LV afterload


				
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