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Treatment in Advanced Disease: NIMV and Transplantation

Treatment in Advanced Disease: NIMV and Transplantation. Dr Gul Gursel Gazi University School of Medicine Department of Pulmonary Diseases. NIMV in COPD. Acute exacerbations Stable COPD Weaning failure Extubation failure. In acute exacerbations. Indications Acidosis(pH<7.35)

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Treatment in Advanced Disease: NIMV and Transplantation

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  1. Treatment in Advanced Disease: NIMV and Transplantation Dr Gul Gursel Gazi University School of Medicine Department of Pulmonary Diseases

  2. NIMV in COPD • Acute exacerbations • Stable COPD • Weaning failure • Extubation failure

  3. In acute exacerbations Indications • Acidosis(pH<7.35) • Hypercapnia PaCO2>45-60 mmHg • Respiratory frequency>24 breaths /min Contraindications • Respiratory arrest • Cardiovascular instability (hypotension, arrhythmias, myocardial infarction) • İmpaired mental status • Somnolence • İnability to cooperate • Copius and/or viscous secretions with high aspiration risk • Recent facial or gastrooesophageal surgery • Craniofacial trauma and/or fixed nasopharingeal abnormality • Burns • Extreme obesity ATS/ERS TASK FORCE Eur Respir J 2004; 23:932-946

  4. NIMV should be delivered; • pH<7.35 • intermediate ICU, High Dependency unit • pH<7.25 • in the ICU • With nasal or oronasal mask • CPAP(4-8 cmH2O) and PSV(10-15 cmH2O) ATS/ERS TASK FORCE Eur Respir J 2004; 23:932-946

  5. Noninvasive positive pressure ventilation to treat hypercapnic coma secondary to respiratory failure • Aim • to investigate the success of NPPV therapy in patients with hypercapnic coma (GCS<8 due to ARF) • To identify the variables that can predict a failure of NPPV therapy in these patients Diaz Chest 2005; 127:952-960

  6. Succes and hospital mortality in patients with and without coma at start of NPPV

  7. The variables related to the succes of NPPV • GCS 1 h posttherapy • OR:2.32; 95% CI:1.53-3.53) • and higher levels of multiorgan dysfunction(SOFA) • OR:0.72; 95% CI, 0.55-0.92)

  8. Is there a place for NIMV in Stable COPD ? • Symptoms(fatigue,dyspnea, morning headache • Physiologic criteria • a. PaCO2≥55 mmHg • b.PaCO2 50-54 mmHg and nocturnal desaturation(SpO2≤88% for 5 min while receiving O2 therapy 2≥L/min • c.PaCO2 50-54 mmHg and hospitalization related to recurrent(2≥ in a 12 month period) episodes of hypercapnic respiratory failure Consensus conference Chest 1999; 116:521-534

  9. Incidence of home mechanical ventilation • In Sweden 541 patients (6.1/100000 inhabitants) on 1 January 1996 • 3-4% of them had COPD • Res Med 2000; 94:135-138 • Hong Kong Study • 48% of all patients is COPD • 8.8% of COPD+OSAS • ERJ 2004; 23: 136-141

  10. The use of NIMV in stable COPD has been controversial • Gas exchange • Pulmonary function • Air-trapping • Exercise tolerance • Sleep efficiency • Respiratory muscle strength • Quality of life • Hospitalisation • Mortality

  11. In weaning • NIMV after failed T-piece (spontan- breathing trial) is associated with; • Shorter duration of MV, length of ICU hospital stay • Fever tracheotomies • Better ICU survival and 90 day survival • Fewer reintubations • Lower incidence of nosocomial pneumonia and septic shock Nava S Ann Intern Med 1998;128:721-728, Gitault C Am J Respir Crit Care Med 1999;160:86-92 Ferrer MAm J Respir Crit Care Med 2003;168:70-6

  12. NIMV in postextubation respiratory failure • These studies suggest that the early use of NIV in avoiding respiratory failure after extubation is useful in selected patients, and especially in patients with chronic respiratory disorders Hilbert G Eur Respir J1998;11:1249-1353 Keenan SP JAMA 2002; 287:3238-3244 Esteban N Eng J Med 2004; 350:2452-2460 Nava S Crit Care Med 2005;33:2565-70 Ferrer M Am J Respir Crit Care Med 2006

  13. LUNG TRANSPLANTATION 2005 J Heart Lung Transplant 2005;24: 945-982

  14. 1767 1602 1703 1564 1464 1477 1377 1457 1368 1229 1089 922 708 418 189 83 15 46 13 NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE 2005 ISHLT J Heart Lung Transplant 2005;24: 945-982

  15. AGE DISTRIBUTION OF ADULT LUNG TRANSPLANT RECIPIENTS(1/1985-6/2004) 2005 J Heart Lung Transplant 2005;24: 945-982

  16. ADULT LUNG TRANSPLANTATIONIndications By Year (Number) 2005 J Heart Lung Transplant 2005;24: 945-982

  17. Survival benefit of transplantation in COPD? • Posttransplant survival time is not long enough to justify this group of patients undergoing transplantation • Candidate selection has been imprecise • Lancet 1998;351:24-27

  18. Median wait time 46 months • Patients should be listed when the 4 year mortality rate from their underlying primary disease exceeds the 4 year posttransplant mortality rate • http://www.ustransplant .org

  19. We need for a better understanding of the natural history of all advanced lung diseases to enable the appropriate selection of candidates who are most likely to benefit from transplantation.

  20. Lung Transplantation indications • FEV1< 25% of predicted(without reversibility) • And/or PaCO2≥55 mmHg and/or elevated PAP levels with progressive deterioration(eg cor pulmonale) • Preference to those patients with elevated PaCO2 with progressive deterioration who require long term O2 therapy Am J Respir Crit Care Med 1998;158:335-339

  21. Patient allocation FEV1 alone OR • FEV1+ • Other PFT results • Dyspnea • Weigt loss • Exercise intolerance • Hospitalizations • Lung morphology BODE< 7 have 5 year survival rates of 50% which is more than can be expected from transplantation N Eng J Med 2004;350:1005-1012

  22. If the patient might be an appropriate candidate for lung volume reduction surgery (LVRS)

  23. NETT, NEJM 2003; 348:2059-73

  24. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival (Transplants: January 1994 - June 2003) P < 0.0001 2005 J Heart Lung Transplant 2005;24: 945-982

  25. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2004) *Other includes: Sarcoidosis: 2% Bronchiectasis: 0.7% Congenital Heart Disease: 0.2% LAM: 0.8% OB (non-ReTx): 0.6% Miscellaneous: 5% 2005 J Heart Lung Transplant 2005;24: 945-982

  26. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2004) *Other includes: Re-Tx: 2% Congenital Heart Disease: 2% LAM: 1.3% OB (non-ReTx): 1.3% Miscellaneous: 5% 2005 J Heart Lung Transplant 2005;24: 945-982

  27. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By Diagnosis(Transplants: January 1994 – June 2003) Survival comparisons COPD vs. IPF: p < 0.0001 Alpha-1 vs. CF: p = 0.0248 Alpha-1 vs. IPF: p < 0.0001 Alpha-1 vs. PPH: p = 0.0021 CF vs. COPD: p = 0.0006 CF vs. IPF: p < 0.0001 CF vs. PPH: p < 0.0001 CF vs. Sarcoidosis: p = 0.0007 Note: Other comparisons are not statistically different. 2005 J Heart Lung Transplant 2005;24: 945-982

  28. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By Diagnosis(Transplants: January 1994 – June 2003) 2005 J Heart Lung Transplant 2005;24: 945-982

  29. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By Procedure Type (Transplants: January 1990 – June 2003)Diagnosis: Alpha-1 Antitrypsin Deficiency P = 0.0007 N at risk at 10 years is 44 for Single Lung and 23 for Double Lung. 2005 J Heart Lung Transplant 2005;24: 945-982

  30. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By Procedure Type and Median Age (Transplants: January 1990 – June 2003)Diagnosis: Alpha-1 Antitrypsin Deficiency p = 0.22 N at risk at 5 years: Single Lung, <50 = 140; Double Lung, <50 = 126; Single Lung, 50+ = 97; Double Lung, 50+ = 45 2005 J Heart Lung Transplant 2005;24: 945-982

  31. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Procedure Type (Transplants: January 1990 – June 2003) Diagnosis: Emphysema/COPD P < 0.0001 2005 J Heart Lung Transplant 2005;24: 945-982

  32. ADULT LUNG TRANSPLANTS (1995-6/1999)Risk Factors for 5 Year Mortality (N=5,637) 2005 J Heart Lung Transplant 2005;24: 945-982

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