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la NIV IN ACUTO

Rehab:give a chance to dyspnea. la NIV IN ACUTO. Dott. M Vitacca FERS Divisione di Pneumologia ICS S.Maugeri IRCCS Lumezzane (BS) Italy. Severe. ARF Severity. Mild To moderate. Not established. TO AVOID ETI. TO PREVENT. ALTERNATIVE to ETI. Meaning of NIV use. COPD CHF/CPE.

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la NIV IN ACUTO

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  1. Rehab:give a chance to dyspnea la NIV IN ACUTO Dott. M Vitacca FERS Divisione di Pneumologia ICS S.Maugeri IRCCS Lumezzane (BS) Italy

  2. Severe ARF Severity Mild To moderate Not established TO AVOID ETI TO PREVENT ALTERNATIVE to ETI Meaning of NIV use

  3. COPD CHF/CPE PNA Asthma OHS NMD UAO post-op post-extub trauma ARDS MOF IPF Tight UAO

  4. IDENTIFY PATIENTS (according to location ?) 1. Clinical abnormalities - moderate to severe dyspnea - RR > 24 b/min in COPD - RR > 30 – 35 b/min in AHRF - accessory muscle use, paradoxal breathing 2. Gas exchange abnormalities - PaCO2 > 45 mmHg, pH < 7.35 - PaO2/FiO2 < 250 mmHg Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

  5. IL PAZIENTE IPOSSICO

  6. CPAP : Respiratory Effects CPAP intrathoracic alveolar PEEPi pressure pressure compensation Shunt FRC work of breathing Improve gas atelectasis Exchange hypoxemia Pelosi Chest 1996 Pelosi Anesthesiology 1999

  7. Effect of CPAP on lung expansion With CPAP ZEEP

  8. CPAP: Cardiovascular Effects Positive Pressure  ITP  FRC  WOB  LVafterload PTM  PaO2 • Pre-load  Venous return  Cardiac performance  pulmonary congestion

  9. Non invasive CPAP to treat PE or CHF

  10. Non-invasive positive pressureventilation (CPAP orbilevel NPPV) forcardiogenicpulmonaryedema (Cochrane Review) Vital FMR. et al., 2008 hospital mortality NIV/CPAP vs 02

  11. Non-invasive positive pressureventilation (CPAP orbilevel NPPV) forcardiogenicpulmonaryedema (Cochrane Review) Vital FMR. et al., 2008 endotracheal intubation rate NIV/CPAP vs 02

  12. Endotracheal intubation or Non invasive CPAP/PPV to treat Postoperative Hypoxiemic Respiratory Failure ?

  13. Patients scheduled for elective major abdominal surgery (§) and general anesthesia who met a PaO2/FiO2 < 300 after 1 h at 30% (Venturi mask ) in the recovery room. • (§) Opening abdominal wall and viscera exposition > 90 minutes with laparotomic or subcostal incision . Helmet CPAP 10 cmH2O (104 pts) Venturi Mask (105 pts)

  14. Endotracheal intubation or Non invasive CPAP/PPV to treat Hypoxiemic Respiratory Failure (Pneumonia or ARDS) ?

  15. HYPOXEMIC ARF (ARDS) IMMUNOCOMPETENT PATIENTS STUDIES [*= RCT ] n Particularities Mask Mode SUCCESS MeduriChest 1996 41 PaO2/FiO2 =110F PS/PEEP 66 % WysockiChest 1995 *42 F PS/PEEP 38 % Patrick AJRCCM 199611 Intubation C NPAV 73 % AntonelliNEJM 1998 *64 Intubation CF PS/PEEP 69 % Rocker Chest 1999 12 ALI / ARDS F PS/PEEP 50 % PaO2/FiO2 = 102 Confalonieri1999 *56 Comm. PN F PS/PEEP 79 vs 50% DelclauxJAMA 2000* 123 PaO2/FiO2  300F CPAP 66 vs 61 % FerrerAJRCCM 2003 * 105 PaO2/FiO2 =102F PS/PEEP 75 vs 48% RANGE DI SUCCESSO = 38-79 %!

  16. Acute RespiratoryFailure in Patients withSevereCommunity-acquiredPneumonia Confalonieri M., et al. 1999; 160:1585-1591 COPDNon COPD NIV Standard p NIV Standard p (n = 12) (n = 11) (n = 16) (n = 17) SUCCESS100 % 45 % 0.005 63 % 53 % 0.73 ICU Stay(days) 0.25 ± 2.1 7.6 ± 2.2 0.02 2.9 ± 1.8 4.8 ± 1.7 0.44 HospitalStay 14.9 ± 3.4 22.5 ± 3.5 0.13 17.9 ± 2.9 15.1 ± 2.8 0.48 HospitalDeath 1 (8.3%) 2 (18.2%) 0.59 6 (37.5%) 4 (23.5%) 0.47

  17. NIV / IMMUNOSUPPRESSEDPATIENTS STUDIES * = R.C.T n Particularities Mask Mode SUCCESS Bedos 66 AIDS. F CPAP 66 % CCM 1999 Pneumocystis Confalonieri 48 AIDS. (P.tis) F PS/PEEP 67 % ICM 2002 intubationcriteria Antonelli40 Solid Organ F PS/PEEP 80 % JAMA 2000 * Transplantation(vs 30 %) Tognet 18 Hematological NF PS/PEEP 33 % Clin I C 1994ACV Conti 16 Hematological N PS/PEEP 69 % ICM 1998 intubationcriteria Hilbert 64 Hematological F CPAP 25 % CCM 2000Neutropenia Hilbert 52 Hemato-Neutropenia F PS/PEEP 54 % NEJM, 2001 * Drug Immunosup.(vs 23%) AIDS RANGE DI SUCCESSO = 33-80 %!

  18. Frat JP, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–2196. NIV (full face mask) was compared with high-flow nasal oxygen (HFNO) and standard oxygen in a three-way randomized controlled trial on patients with ARDS (PaO2/FIO2, 300). Although the main outcome, intubation rate, was not different in the whole cohort, it was significantly lower with HFNO in the subgroup with PaO2/FIO2 less than 200.

  19. Keenan SP, et al.; Canadian Critical Care Trials Group/Canadian Critical Care Society Noninvasive Ventilation Guidelines Group. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ 2011;183:E195–E214. Ferguson ND, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012;38:1573–1582. Recent NIV guidelines have made no recommendation for NIV use in acute lung injury or pneumonia or have suggested its use only for mild ARDS !

  20. IL PAZIENTE IPERCAPNICO

  21. 1.0 0 > flow RESISTANCES V’ (L/m) Pdi (cmH2O) 40 0 PTP-PEEPidyn PTP-res + PTP-el excessive loading HYPERINFLATION (High PEEPi-dyn), COPD > 40%

  22. AJRCCM 164:638-42,2001

  23. Riacutizzazione acidotica di BPCO Terapia medica + O2 con VM q.b. per SpO2 89-92% Ripetizione di EGA pH > 7.35 >7.30 pH < 7.35 pH < 7.30 pH < 7.20 NIV non indicata

  24. NIV consigliata l’80% dei pazienti migliora comunque con terapia standard Ogni 10 pazienti trattati con NIV si evita 1 ETI; NIV migliora la dispnea >7.30 pH < 7.35 NIV fortemente consigliata Senza NIV 1 paziente su 2 necessita di ETI NIV migliora la sopravvivenza pH < 7.30 NIV molto fortemente consigliata 1 paziente su 2 comunque fallisce la NIV Tuttavia con la NIV migliora l’outcome in ospedale e soppravvivenza a 1 anno pH < 7.20

  25. 1998; 113 27 pazienti con pH 7.35 Mortality: NIV 4/16 vs ST: 0/11 P=0.13 Tempo dell’ETI dall’arrivo in PS: NIV: 26 h vs 4.8 h in ST P=0.055 Attento monitoraggio e rapido accesso a struttura per ETI in caso di mancata risposta

  26. Patients with Glasgow Coma Score <= 8

  27. Eighty-two patients aged >75 years (mean age 81.3 ± 3.5 years) were randomised to receive NIV or SMT.

  28. PRINCIPALI CRITICITA’ 1. Potenzialeimpatto del ritardo di applicazione NIV dopoilricovero: 232 H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later. in pz con la peggioreacidosiall’ingresso(GR1), dopo 1 h <50% NIV, 30% dopointervallo di almeno 3 h In pazienti GR2 (acidosipeggiorata al 2° controllo) <25% NIV in 1 h e 48% a 3 h 1077 patients received NIV (11%), 55% had a pH <7.26 30% patients with persisting respiratory acidosis did not receive NIV. 2. Indicazionialla NIV e mortalità: Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis. 34% deipz con ph 7,26-7,35 non hannoricevuto NIV, 18% di questisonomorti 3. Mancanza di un action plan: 12% deicasitrattati con NIV (chesono poi deceduti) senza action plan in caso di fallimentodella NIV

  29. the correct time to stop

  30. WEAK COUGH AND HYPER-SECRETIONS • SEVERE ENCEPHALOPATHY • INTOLERANCE AND AGITATION • PATIENT-VENTILATORY ASYNCHRONIES • EXCESSIVE LEAKS • DISCOMFORT • SLEEP DISTURBANCES • HYPERGLICAEMIA • LOW ADLs • POOR RESPONSE OF ABG AND RR • HIGH SCORES OF SEVERITY OF ILLNESS NEED OF ETI: range → 5-60% Courtesy of dott Scala

  31. BTS Guideline of NIMV in ARF Thorax 2002; 57: 192-211 Time to stop NIV for failure • no improvement or deterioration in consciousness • no improvement in ABG • severe complications • severe pneumonia on chest X-ray • 2° intrahospital failure with necessity of NIV • copiuos secretion • more than 18 continous hours of NIV for more than 4 days • nasal bridge erosion • intolerance to ventilator

  32. Perchè fallisce la NIV ? Perchè si sbaglia paziente Perchè non si rispettono le controindicazioni Perchè si sbaglio maschera Perchè si sbaglio modalità di ventilazione Perchè si sbaglio il settaggio Perchè il paziente non supporta più la NIV Perchè non miglioranono i gas Perchè vi è cattiva interazione con il ventilatore Perchè dà un senso di falsa sicurezza

  33. La giusta location

  34. Timing is all… • Start early but not too early (Barbe study) • You are too late if… • Pt on verge of respiratory arrest • Pt severely hypoxaemic (PaO2/FiO2 < 75) • Pt comatose or hugely agitated • Medically unstable: acute MI, GI bleed, shock • What is your unit’s ‘door to mask’ time? • What are the main limitations? Simonds ERS school

  35. Il training adeguato

  36. Reasons for low use of NIV in acute hospitals: US survey No. of responses 20 10 0 Poor previous experience Hospital staff inadequately trained Equipment not appropriate Physicians lack of experience Other Maheshwari v et al Chest 2006:129: 1226-33

  37. Monitoraggio

  38. Ventilatory Monitoring • Respiratory pattern • Pt-ventinteraction • Availabilityof ETI • in case of NIV failure Courtesy of dott Scala

  39. 100 – 75 % 49 -25 % 24 -0 % 74 -50 % Percentage of patients who fail NIV Eur Respir J 2005; 25:348-355

  40. Ventilatory Monitoring • Respiratory pattern • Pt-ventinteraction • Availabilityof ETI • in case of NIV failure

  41. But if you could see the neural activity of the patient….. With S. Navacourtesy

  42. Am J RespirCrit Care Med. 2001 Feb;163(2):540-77 Almost all the side effects of NIV are due to problems with interfaces

  43. 80-100% Air Leaks

  44. Look for a balance betweenleaks and comfort Courtesy of dott Scala

  45. Pressure sores

  46. Interface rotation strategy Conti G et al. RespirMed 2007; 52:1463-71 Girault C et al. Crit Care Med 2009; 37:124-31 Courtesy of dott Scala

  47. Conclusion 1 • Caution to use NIV in patients with «de novo» ARF • NIV in patients with ARF and COPD even in case of hypercapnic coma • I intubate my patient without delay when he meets criteria for intubation (RR > 40 under NIV, hemodynamic instability…) • 4. In patients with chronic lung disease and with persistent respiratory failure (RR >30 and pH < 7.30), I don’t extend NIV beyond 3-12 h (?)

  48. Conclusion 2 1. on ventilators: Good screen with clear traces Algorythm able to depict the presence of asynchrony and warn the clinicians 2. Non-invasive monitoring of gas exchange during NIV 3. sleep architecture monitoring

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