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NIPPV for cardiogenic pulmonary edema

NIPPV for cardiogenic pulmonary edema. Dr Romain Pirracchio, MD Anesthesiology & Critical Care Lariboisière University Hospital University Paris 7 Diderot romain.pirracchio@lrb.aphp.fr. ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416. European guidelines.

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NIPPV for cardiogenic pulmonary edema

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  1. NIPPV for cardiogenic pulmonary edema Dr Romain Pirracchio, MD Anesthesiology & Critical Care Lariboisière University Hospital University Paris 7 Diderot romain.pirracchio@lrb.aphp.fr

  2. ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416 European guidelines

  3. LV Dysfonction VICIOUS CIRCLE Impairment in alveolar gas exchanges Impairment in ventilatory mechanic shunt Pleural Pressure WOB Hypoxemia preload afterload VO2 DO2 MvO2

  4. LV Dysfonction Nitrates diuretics Inotropes Vasodilators O2 Impairment in alveolar gas exchanges Impairment in ventilatory mechanic shunt Pleural Pressure WOB Hypoxemia ? précharge preload afterload VO2 DO2 MvO2

  5. Alveolar recrutment  WOB pressure • Inspiratory drops in pleural pressure • Afterload cardiac output preload PPV effects on heart-lung interaction

  6. CPAP • Effects on cardiac failure Naughton, Circulation 1995 Lin, Chest 1995 • Effects on respiratory failure :  WOB,  pulm compliance,  FRC,  intubations Lenique, AJRCCM 1997 Bersten, NEJM 1991 Rasanen, Am J Cardiol 1985 • Non invasive vs Invasive PPV:  pulmonary infections Girou, JAMA 2000 Antonelli, N Eng J Med 1998

  7. CPAP & Cardiac output ZEEP PEEP7.5 ZEEP PEEP10

  8. CPAP & central venous saturation 100 90 80 70 50 40 30 SV (ml) 70 - 50 - 30 - CPAP 1 4 2 3 15 20 SvO2 PCWP (mmHg) 1: dobu 2: dobu + IAoCPB 3: dobu + IAoCPB + Enoximone 4: dobu + IAoCPB + CPAP Pery N, Chest 1991

  9. CPAP & WOB Lenique, AJRCCM 1997

  10. A randomised study of Out-of-Hospital CPAP for Acute Cardiogenic Pulmonary Oedema: physiological and clinical effects. 3 questions : • Benefit of CPAP applied early and alone ? • Benefit of adding medical treatment to CPAP ? • Effects of an early CPAP withdrawal ? Pirracchio et al. Eur Heart J, in press

  11. Patients • Pre-hospital, prospective, randomised study • Inclusion : • Severe cardiogenic pulmonary edema (SpO2 90% with O2 15 L/mn) • Non inclusion : • History of COPD, asthma • Coma • Cardiogenic shock • Valvular stenosis Pirracchio et al. Eur Heart J, in press

  12. Venturi CPAP device Vital Signs (Gamida) PEEP valve Venturi flux generator FiO2 monitor

  13. Protocol « Early CPAP » T0 T15’ T30’ T45’ O2 + MT OUTCOME CPAP 7.5 cmH2O CPAP 7.5 cmH2O + MT DCS, HR, RR, BP, SpO2, blood gases « Late CPAP » T15’ T30’ T45’ T0 O2 + MT O2 + MT CPAP 7.5 cmH2O + MT Pirracchio et al. Eur Heart J, in press

  14. Pirracchio et al. Eur Heart J, in press

  15. Early CPAP Late CPAP * p<0.05 early CPAP vs late $ p<0.05 early CPAP T15 vs T0 Evolution of Dyspnea Clinical Score 10 9 * 8 7 6 DCS 5 4 3 $ 2 1 T45 T0 T15 T30 Pirracchio et al. Eur Heart J, in press

  16. Early CPAP Late CPAP * p<0.05 CPAP early vs late $p<0.05 CPAP early T15 vs T0 Arterial blood gases 130 * 55 * $ * 110 50 (mmHg) (mmHg) 90 45 70 40 PaCO2 PaO2 50 35 $ 30 30 T0 T15 T30 T45 T0 T15 T30 T45

  17. Outcome • Intubation : (p=0.01) • « early CPAP  » : n=6 • « late CPAP » : n=16 • Inotropes : (p=0.02) • « early CPAP » : n=0 • « late CPAP » : n=5 • In hospital mortality : (p=0.05) • « early CPAP » : n=2 • « late CPAP » : n=8 Pirracchio et al. Eur Heart J, in press

  18. CPAP or BiPAP (BLPAP) ?

  19. CPAP vs BiPAP ? • CPAP > BiPAP ? • Metha, Crit Care Med 1997 : • BiPAP associated with more AMI ++ • BiPAP > CPAP ? • Chadda, Crit Care Med 2002 : BiPAP>CPAP • CPAP = BiPAP +++ • Bellone, Crit Care Med 2005 • Moritz, Ann Emerg Med 2007 • Ferrari, Chest 2007 in press (No difference in AMI +++)

  20. Metaanalyses BiPAP et VNI Massip, JAMA 2005

  21. Metaanalyses BiPAP vs VNI Massip, JAMA 2005

  22. CPAP or BiPAP • On scene or in the ER: • CPAP for CPE (G1+) • BiPAP can be used : • For CPE or COPD , • ONLY by trained teams and with ventilators allowing NIPPV (G2+) Consensus SFAR, SPLF, SRLF 2006 • CPE even with hypercarbia => CPAP COPD => BiPAP Consensus ATS-ESICM-SRLF-ERS 2000

  23. Conclusion • PPV is the only way to break the vicious circle due to deleterious heart-lung interactions • PPV improves the outcome • CPAP and BiPAP have similar results • As more simple, CPAP might be used as first line ventilatory therapy for CPE out of the ICU

  24. Respiratoy muscles consumption 20 - 15 - 10 - 5 - 0 - rest Respiratory failure Blood flow dedicated to respiratory muscles (mL/100 gr/Lof cardiac output)

  25. CPAP « Boussignac »

  26. CPAP « Venturi »

  27. EFFETS CARDIOVASCULAIRES DE LA VENTILATION MÉCANIQUE "Pompe dans la pompe" POMPE RESPIRATOIRE PRESSION ALVEOLAIRE  POSTCHARGE VD:  RVP  PRECHARGE VG:  VES VD Cap. Pulm. PRESSION THORACIQUE (Ppl) POMPE CARDIAQUE VD VG PVC  POSTCHARGE VG:  PtmVG  elastance Ao  gradient PIT-PIA  PRECHARGE VD:  Résistances veineuses  gradient par  POD PRESSION ATMOSPHERIQUE TISSUS PMS

  28. Metaanalyses BiPAP vs VNI Ho KM, Crit Care, 2006

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