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TURKISH THORACIC SOCIETY 9TH ANNUAL CONGRESS ANTALYA, TURKEY 22, APRIL, 2006

TURKISH THORACIC SOCIETY 9TH ANNUAL CONGRESS ANTALYA, TURKEY 22, APRIL, 2006. Main symposia Noninvasive mechanical ventilation (NIMV) Status in the world. Peter C Gay MD Associate Professor Mayo Clinic College of Medicine Rochester, MN. Outline. Historical Overview of NIMV Use

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TURKISH THORACIC SOCIETY 9TH ANNUAL CONGRESS ANTALYA, TURKEY 22, APRIL, 2006

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  1. TURKISH THORACIC SOCIETY9TH ANNUAL CONGRESSANTALYA, TURKEY22, APRIL, 2006 Main symposia Noninvasive mechanical ventilation (NIMV) Status in the world Peter C Gay MD Associate Professor Mayo Clinic College of Medicine Rochester, MN

  2. Outline • Historical Overview of NIMV Use • Comment on Hospital and Home Use • Review Practice Patterns Worldwide • United Kingdom, France, Switzerland, Italy, Hong Kong, USA • NIMV Practice Changes over Time • Factors that Promote/Hinder NIMV Use • How to better use NIMV in my area?

  3. History of NIMV for ARF • Earliest use of PAP- CPAP in CHF pts (Lancet 1936) • Delivered through vacuum cleaner exhaust circuit • Rideau first to utilize a mask attached to a ventilator in Duchenne’s MD (Abstract 1983)

  4. Early NIMV Use

  5. Design, Setting, and Subjects:  Prospective cohort of consecutive adult pts admitted to 361 ICUs who received MV for >12 hrs in March of 1998. Data collected at initiation of MV and daily thereafter. Results:  15,757 pts admitted, total of 5183 (33%) received MV for mean (SD)= 5.9 (7.2) days Mean LOS in ICU was 11.2 (13.7) days Overall ICU mortality was 30.7% (1590 pts) Characteristics and Outcomes in Adults Receiving Mechanical Ventilation:28-Day International StudyA Esteban. JAMA. 2002. Vol 287(3): 345-355

  6. Vent Modes in Pts Receiving MV28-Day International Study Ventilator Modes Used Each Day During the Course of Mechanical Ventilation

  7. Survey of NIMV in pts with acute exacerbations of COPD in the UK M J Doherty. Thorax 1998;53:863-866 • METHODS: Questionnaire sent to consultants from 268 hospitals inquiring about availability and details of use of NIMV • RESULTS: • Showed NIMV available in 48% of hospitals • Hospitals using NIMV: • Served larger populations • Had more respiratory physicians • Large regional variation in the availability of NIMV.

  8. Survey of NIMV in pts with acute exacerbations of COPD in the UK M J Doherty. Thorax 1998;53:863-866 • RESULTS: • Hospitals without NIMV gave reasons: • Lack of consultant training in 53%, other staff training in 63%, financial in 63%, doubt of NIMV benefit in 15% • In NIMV hospitals, practice varied greatly: 68% centers treated <20 pts/yr with NIMV, 9% treated >60 pts/yr. • CONCLUSIONS: • Equipment for NIMV available in <50% of acute hospitals in UK. Where available, generally underused. • Lack of training, problems with funding are given as reasons for failure to use NIMV

  9. Noninvasive vs Conventional Mechanical Ventilation:An epidemiologic surveyCarlucci A. AJRCCM 163:874-880, 2001 • Prospective survey over 3 weeks among 42 French ICUs to assess incidence and effectiveness of NIMV in clinical practice. • Pts requiring ventilatory support for acute respiratory failure (ARF), with endotracheal intubation (ETI) or NIMV included. • Ventilatory support required in 689 pts • 581 with ETI and 108 (16%) with NIMV (35% of patients not intubated on admission)

  10. Noninvasive vs Conventional Mechanical Ventilation:An epidemiologic surveyCarlucci A. AJRCCM 163:874-880, 2001 • Reasons for all mechanical ventilation were: • Hypoxemic (48%), Coma (30%), Hypercapnic (15%), Cardiogenic Pulmonary Edema (7%) • NIMV use: • Never used in coma pts (excluded from analysis) • 50% of pts with hypercapnic ARF • 27% of pts with pulmonary edema • 14% of pts with hypoxemic ARF • NIMV was followed by ETI in 40% of cases.

  11. Noninvasive vs Conventional Mechanical Ventilation:An epidemiologic surveyCarlucci A. AJRCCM 163:874-880, 2001 • The incidence of both nosocomial pneumonia (10% vs 19%, p= 0.03), and mortality (22% vs 41%, p< 0.001) was lower in NIMV pts than in those with ETI. • Success of NIMV associated with: • Lower risk of pneumonia (OR = 0.06) • Death (OR = 0.16) • In NIMV pts, SAPS II, poor clinical tolerance predicted ETI. • Conclusion: • NIMV successful in selected patients, associated with a lower risk of pneumonia and death than is ETI • Failure of NIMV associated with a longer length of stay.

  12. Changes in practice of NIMV in Italian COPD patients over 8 years A Carlucci. ICM 2003 Vol 29(3): 419-425 • RICU Pavia, Italy from opening 1992 to 99. • Material and methods: • Assessed rate of NIMV success, severity of disease, and associated costs while staff and equipment did not change. • Results: • Failure constant over yrs (Mean= 17.2%). • Severity of ARF, defined by admit pH, APACHE II worsened during yrs. • Statistical change point identified at 1997 by change in severity of admit pH: 1992–1996 (mean pH =7.25 vs 7.20) vs 1997–1999

  13. %Pts with pH >7.28 treated outside the RICU in 8 yrs P<0.001 for linear trend analysis

  14. Changes in practice of NIMV in COPD patients over 8 years A Carlucci. ICM 2003 Vol 29(3): 419-425 • Results: 1997–1999 • Risk of failure for pts with a pH<7.25 3X higher in 1992–96. • Increased episodes of ARF with pH>7.28 treated in the Medical Ward (20% vs 60%). Allowed significant reduction of daily cost/pt with NIMV (p<0.01) • Conclusions: • Over time, experience with NIMV may allow more severely ill pts to be treated with equal rate of success. Daily cost/pt of NIMV can be reduced by treating less severely ill patients outside the RICU

  15. Changing Patterns in Long-term NIMV 7-Year Prospective Study in Lake Geneva, Switzerland Jean-Paul Janssens. Chest. 2003;123:67-79 • Design:Prospective 7-yr study (1992 to 2000) home NIMV pts treated for chronic hypercapnic respiratory failure. • Patients: Total 211 pts • COPD (58 pts) • Restrictive pulmonary disorders (post-TB (23 pts) • Neuromuscular diseases [NM] (28 pts) • Post-polio (12 pts) • Kyphoscoliosis [KYPH], (19 pts) • Obesity-hypoventilation syndrome [OHS], (71 pts) • Results: • OHS, NM, and KYPH pts had highest, COPD pts had the lowest probability of pursuing NPPV. Overall compliance rate high (85%). • Since 1994, COPD and OHS most frequent indications for NPPV, increasing regularly, while other indications remained stable.

  16. Diagnoses and Trends

  17. Changing Patterns in Long-term NIMV 7-Year Prospective Study in Lake Geneva, Switzerland Jean-Paul Janssens. Chest. 2003;123:67-79 • Results: • Pressure-cycled replaced volume-cycled ventilators • Hospitalization rates decreased in all groups after initiating NIMV comparing the year before NIMV • Up to 2 years in COPD pts and 5 years in non-COPD patients. • Conclusion: • Major changes in patient selection for NIMV during study with a marked increase in COPD and OHS • Shift toward less expensive ventilators and decreased hospitalizations after NIMV have had positive impact on cost-effectiveness of NIMV in chronic respiratory failure pts

  18. Home Mechanical Ventilation in Hong Kong CM Chu, Eur Respir J 2004; 23:136-141 • Retrospective survey of diseases and outcomes in Hong Kong. • 249 pts (156 males, mean age 62.7±13.8 yrs) treated since 1980, 197 (79%) continued HMV at survey, 2.9 users/100,000 people • 3-yr HMV continuation rate= 66.2%. 95% treated with bilevel pressure support (n=236). Death main reason for stopping HMV • Diagnoses: • COPD 48.6% • Restrictive thoracic disorders 15.3%, Post-TB fibrothorax 12% • Neuromuscular disorder 3.2%, Mixed pathologies and other 4.4% • Complicated OSA/OHS 4.4%, COPD/OSA overlap 8.8%, Severe OSA (CPAP intolerant) 4%

  19. Proportion of Pts Continuing HMV in Hong Kong Restrictive thorax disorders (- - -), OSA (…), and COPD (–––) Started after acute HRF (––) vs other indications (…)

  20. Trend for HMV New cases (–– - - ––), withdrawn cases (–– - ––) and cumulative number of home ventilation (observed (–––) and predicted (- - - )).

  21. Early Anecdotal Reports Replaced with Randomized Clinical Trials Assure Benefit Veteran Users and Education Plans Availability and Cost Barriers Falling Newer and Better Equipment Recognized Value of RC Driven Protocols International Consensus Conference in Intensive Care Medicine: NIMV in ARF. AJRCCM, Jan 2001; 163: 283-291 Evolution of NIMV

  22. Noninvasive Ventilation for ARF at Mayo

  23. BiPAP (Bilevel Pressure)

  24. Full Face Masks

  25. NPPV Cart

  26. NPPV CART

  27. Nasal Bridge Skin Breakdown

  28. Mayo NPPV Algorithm

  29. SUMMARY • NIMV has become the treatment of choice for many types of home and hospital pts • NIMV may still be underutilized due to: • Unfamiliarity and Limited Availability • Pt selection and practice patterns have evolved over time with rapid rise in use • NIMV equipment changes favorable • Development and implementation of RC driven protocols will optimize NIMV use

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