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Noninvasive Mechanical Ventilation,Prone position, surfactant and NO

Noninvasive Mechanical Ventilation,Prone position, surfactant and NO. Gül Gürsel Gazi University School of Medicine, ICU of Department of Pulmonary Diseases.

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Noninvasive Mechanical Ventilation,Prone position, surfactant and NO

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  1. Noninvasive Mechanical Ventilation,Prone position, surfactant and NO Gül GürselGazi University School of Medicine, ICU of Department of Pulmonary Diseases

  2. The use of a low-tidal volume(6ml/kg predicted body weight), plateau pressure-limited strategy has been demonstrated to reduce mortality from 40 to 31%. Is there a role for NIMV in ARDS? Impact of fluid and catheter strategy on outcome. What is the role of prone position? Pharmacologic therapies?? Corticosteroids Surfactant NO

  3. Is there a role for NIMV in ARDS? A meta-analysis Agarval et al Resp Med 2006

  4. The addition of NIMV to standard care in the setting of ARDS did not reduce the rate of endotracheal intubation and had no effect on ICU survival

  5. Exclusion criteria • Coma, seizures or nerological disturbances • Hemodynamic or ECG instability • Active bleeding • Need for endotracheal intubation (secretions, to protect airways) • Recent facial trauma, gastroesophageal surgery • More than 2 organ failures

  6. During the 25 months • 5888 patients were admitted to the ICUs of the 3 centers • 459(8%) met ARDS criteria • 332(69%) were admitted as intubated or required immediate intubation • 147(31%) were eligible for study participation and received NIMV • 69 primary ARDS • 78 secondary ARDS

  7. <31% of patients with ARDS are treated with NPPV. • NIMV was succesful in avoiding intubation in 79 (%54) patients. • Avoidance of intubation was associated with a lower insidence of septic complications and increased ICU survival. • SAPSII>34 and a PaO2/FiO2<175 after 1 hr of NIMV were independently associated with the need for endotracheal intubation.

  8. Changes in P/F over time in patients avoided or required intubation 35% 48%

  9. Timing to endotracheal intubation. 70% of NIMV failures were intubated within 48 hrs of initiating NIMV

  10. Risk Factors for NIMV Failureobservational cohort study • 54 patients with ARDS • 38(70.3%) failed, among them all 19 patients with shock • In logistic regression restricted to patients without shock • Metabolic acidosis (OR:1.27, 95%CI:1.03-0.07 per U of BD) • Severe hypoxemia(OR:1.03, 95%CI:1.01-0.05, per U decrease in p/f) Rana S et al, CC 2006;10(3)R79

  11. AIM • To evaluate the effects of various NIMV settings on • Dyspnea • respiratory mechanics • Work of breathing • Respiratory drive • arterial blood gases in patients with ALI

  12. Dyspne score assessment

  13. Both PSV settings reduced neuromuscular drive, unloaded the inspiratory muscles, and improved dyspnea • CPAP used alone was unable to reduce inspiratory effort • A PEEP level of 10 cmH2O improved oxygenation compared with initial/final baseline and with PEEP 5 cmH2O • The geatest improvement in dyspnea was obtained with the highest level of PSV

  14. Prone Position • Proning improves oxygenation in 70% of ARDS patients.

  15. PRONE POSITION • Effect of prone position in ARDS • Reduction in shunt • Perfusion is preferentially directed to dorsal lung regions • The gravitational pleural pressure gradient is more uniform • Pleural pressure is reduced in dependent regions • The regional ventilation/perfusion ratio is more uniform and better matched • Improved airway drainage • Improved lymphatic drainage

  16. Randomized controlled trials evaluating prone positioning in ARDS 1- N Eng J Med 2001;345:568-573 2- JAMA 2004;292:2379-2387 3- Am J Respir Crit Care Med 2006;173:1233-1239

  17. Effectes of the prone position on ventilator induced lung injury • Authors measured lung stress as the transpulmonary plateau pressure and lung strain as tidal volume/EELV ratio and found both of them were reduced with the prone position. • The probabbility of VALI can be reduced by the prone position • Mentzelopoulos SD, et al Eur Respir J 2005; 25:534-544

  18. Am J Respir Crit Care Med 2006;173:1233-1239

  19. Despite leading to short-term improvements in oxygenetation, prone positioning during MV has failed to improve mortality rates in multiple randomized controlled trials and can not be recommended for the broad population of patients requiring MV due to ARDS. However for those patients who has severe persistent hypoxemia PP may be considered as a rescue therapy.

  20. FLUID MANAGEMENT • Pulmonary edema, even when noncardiogenic in origin, increases with a rise in hydrostatic pressures. • A modest decrease in pulmonary vascular pressure could reduce the quantitiy of pulmonary edema in experimental studies. • Increased EVLW has been associated with poor outcome in ARDS patients. • Balancing the risks of increased edema vs those of decrease vital organ perfusion with a lower intravascular pressure has remained difficult.

  21. Calfee CS et al Chest 2007; 131:913-920

  22. NHLBI FACTT Fluid And Catheter Treatment Trial. N Eng J Med 2006; 354:2564-75 • Utility of catheterization with a CVC vs PAC • Liberal fluid management vs conservative fluid management

  23. Mortality Rate • PAC group 27.4%; CVC group, 26.3; p=0.69; 95% CI for difference -4.4 to 6.6%) • Conservative fluid management arms • Had significantly more ventilator free days • More significant improvements in pulmonary physiology • PEEP, Pplat, PaO2/FiO2, oxygenation index, lung injury score • More ICU free days • 2.9% reduction in the 60-day mortality rate(p:0.30) • No difference in incidence or prevalance of shock or RRT

  24. SURFACTANT THERAPY Spragg RG, et al. N Eng J Med 2004; 351:890

  25. INHALED NO • Selective pulmonary vasodilation and improvement ventilation-perfusion mismatch

  26. Pharmacotherapies investigated as possible treatment for ALI/ARDS

  27. CONCLUSION • 30% of ARDS patients may benefited from NIMV • Conservative fluid management strategy may increase ventilator-free days, CVC or PAC does not influence outcome • Prone position may be useful in as rescue therapy in a patient with severe hypoxemia but does not improve survival • Corticosteroids, surfactant and NO are ineffective in improving outcomes.

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