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NIV and Acute Respiratory Failure in COPD

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Slide 1 :

NIV in Medicina d’Urgenza Giuseppe Foti Istituto di Anestesia e Rianimazione Università di Milano-Bicocca Ospedale S. Gerardo Monza Montecatini,17 Ottobre 2003

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Classificazione Sim

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WHY HAVE I TO TRY ? NIV in COPD

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RATE OF DEATHS * * *

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Incidence of Nosocomial Pneumonia

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WHERE TO PERFORM NIV?

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NIMV IN GENERAL WARDS Plant LANCET 2000

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Training

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APACHE II pH at admission p<0.01 * Carlucci et al Intens.Care Med. 2003;29:419-25

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PSV in maschera Maschere di diverso tipo e taglia (non siamo tutti uguali) Luogo dedicato in cui tenere tutto (Maschere, nucali, raccordi per sng) Ottenere collaborazione del paziente ! Protezione radice del naso (igiene, revestimenti etc.) Programmare periodi off E’ PIU’ DIFFICILE CHE INTUBARE IL PZ. MA NE VALE LA PENA

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Ricetta per maskPSV PSV/PEEP = 10/5 Pmax = 25-30 cmH2O SNG non indispensabile !!

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Non Invasive Mechanical Ventilation Nucale Raccordo a gomito ( passaggio SNG )

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Perché uso poco la NIV pur curando numerosi pz. con I.R.A. ed essendo fortemente convinto che il tubo fa male ??

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Helmet CPAP:Lo Scafandro Rationale Physiology In Hospital Out of Hospital

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PEEP (Positive End Expiratory Pressure) e Reclutamento alveolare PEEP = 5 PEEP = 15 Sim

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Why Helmet CPAP instead of PSV in ARF ? As good as: Inspiratory support is not as crucial Problem is hypoxia Easy, safe, efficient and cheap NO pts. cooperation NO pts-machine interaction at high RR NO skin necrosis NO time limit (safely and easily applied all day long) Can be implemented outside ICU (ED, CCU, General Ward, Ambulance, Home.)

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“Not all patients are good candidates for this therapy because the hermetic face mask discomfort in anxious patients and the technique requires intensive attention until patients are adapted to face mask and ventilators”Masip et al. THE LANCET, (2000)356;pag.2131 “In conclusion, in hypoxemic ARF, NPPV can be successful in selected populations, with 70% of patients avoiding intubation… we could apply noninvasive ventilation to the 13% of the 2,770 patients with hypoxemic ARF admitted to our ICUs.” Antonelli M et al. Intensive Care Med (2001) 27:1718

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Bias Flow in the Head Tent MUST be > 30 L/min. “la mamma me lo ha sempre detto di non mettermi in testa il sacchetto di plastica perché può soffocarmi!!” Patroniti N., Foti G., Pesenti A. et al. ICM (2003). 29: 1680-87

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EFFICACY OF Helmet CPAP IN THE TREATMENT OF ACUTE RESPIRATORY FAILURE Dipartimento di Anestesia e Rianimazione Ospedale S.Gerardo, Monza.

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AIM OF THE STUDYTo evaluate the therapeutic efficacy of Helmet-CPAP in the treatment of Acute Respiratory Failure outside the ICU.

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SCAFANDRO DOPPIO FLUSSIMETRO FiO2 = 1, 0.5, 0.35

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INCLUSION CRITERIA PaO2 < 100 mmHg in reservoir mask abnormal chest xRay EXCLUSION CRITERIA need of immediate tracheal intubation presence of more than 2 new organ failure

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PaO2/FiO2Not intubated Vs intubated

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Inability to correct hypoxia was the principal reason for failure of 79% of CAP, 78% of ARDSexp and 92% of ARDSp Antonelli, Intensive Care Med, 1999; 25: 207 A

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PaO2/FiO2 CHF Vs PNM PaO2/FiO2 (reservoir mask-3 hours)

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RESULTS In all general ward pts.Helmet CPAP was feasible 27% of patients required intubation (22% in CHF, 45% in PNM group) Mortality rate: 18% (8% among non intubated, 44% among intubated)

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CPAP nell’EPA

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Antonelli M et al Intensive Care Med (2001) 27:1718

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Rationale of CPAP in ACPE CPAP ? PIT ? FRC ? Rit. Ven. ? LVafterload ? PaO2 ? WOB ? Cardiac performance ? pulmonary congestion

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Out of hospital treatment of Acute Pulmonary Edema by non invasive CPAP G. Foti, M. Cazzaniga, E. Valle, M. Sabato, F. Apicella, V. Casartelli, G. Fontana, GP Rossi, S. Vesconi, A. Pesenti. Istituto di Anestesia e Rianimazione, Università degli Studi, H. S. Gerardo - Monza - Italy Servizio di Emergenza Territoriale, presidi di Carate e Desio SSUEm 118 Brianza

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Out of Hospital Helmet CPAPin Presumed Acute Pulmonary Edema: materials

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30 L/min.

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* Oxygenation * < 0.01

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Results:

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Arterial Blood Pressure during CPAP

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Outcome of ACPE pts: Mortality during transport expected = 5-13% Annals of Emergency Medicine Volume 30 * Number 4 * October 1997 observed = 0% Overall mortality expected (SAPS 45±14) = 35% observed = 11.1% (previous study = 7-15%)

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Outcome of ACPE pts: Intubation rate during transport 0% hospital 2.2% Admission ICU 0% CCU 15.6% General ward 84.4% Hospital stay 10 ± 8 days

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Why SpO2 improves during HelmetCPAP? PEEP FiO2 Drugs

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Out of hospital treatment of Acute Pulmonary Edema by Helmet CPAP:PARAMEDICSNO DRUGS SSUEm 118 Brianza Nurse Coordinator : G. Brambilla, RN Director: G.P. Rossi, MD Anesthesia and Intensive Care Institute ICU coordinator: G. Foti,MD Director: Prof. A. Pesenti

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Results CPAP (BLS + Nurse) March 2001 – March 2002 n° patients 28 Mortality during transport 0 Intubation in ED 1

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* < 0.001 * Oxygenation

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Results: March 2001 – March 2002

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PROVOCATION: Role of drugs in the first minutes of tratment of severe ACPE is : MARGINAL

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La CPAP mediante Scafandro non dovrebbe mancare nell’armamentario terapeutico dell’insufficienza respiratoria acuta

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Consigli : CPAP/scafandro nell’EPA NIV solo se insuccesso CPAP (raro) e dopo adeguata esperienza NIV (PSV +PEEP) nel BPCO riacutizzato Face mask, scafandro se mask inefficace Cominciatelo subito Cominciate con i casi più semplici pH >7.3, cooperativi CPAP/Scafandro nell’IRA ipossiemica senza MOF CAP, atelettasie, versamenti pleurici etc. Immunocompromessi

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CONCLUSIONS FROM STUDIES (2) BRITISH THORACIC SOCIETY “Non-invasive Ventilation in Acute Respiratory Failure” Standards of Care Report 2002 “…CPAP has been shown to be effective in patients with Cardiogenic Pulmonary Oedema who remain hypoxic despite maximal Medical management. NIV should be reserved for patients in whom CPAP is unsuccessful.” (B)

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Antonelli, 99 patients(P/F < 200, RR> 35b/min, Active Contraction of AM or PAM, severe dyspnea) COPD excluded Overall ARDS mortality 16% Overall ARDS mortality 44%

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Summary: Helmet CPAP should be used as FIRST LINE INTERVENTION in treatment of ACPE (In and Out of Hospital) NIMV may be attempted in ALI-ARDS Immunocompromised, Pneumonia BE CAREFUL when PaO2 does not improve Helmet CPAP may be effective as NIMV in this subset of patients and can be applied more easily out of ICU

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FENOMENO DI “HANG-UP” INSPIRATORIO DURANTE NIMV

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Intensive Care Med (2002) 28: 1226-1232 NonInvasive PSV in non-COPD patients with ACPE and severe CAP: acute effects and outcomeG.Domenighetti, R. Gayer, R. Gentilini

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CPAP IN CARDIOGENIC PULMONARY EDEMA Rasen et al: Chest 1985; 87: 158-162

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IntraThoracicPressure and LV function AO LV ITP ? effort = ? ITP = ?Ptm ? ? LV afterload Ptm = 100-(-20) = 120

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CPAP IN CARDIOGENIC PULMONARY EDEMA Rasen et al: Chest 1985; 87: 158-162

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IntraThoracicPressure and LV function AO LV ITP ? effort = ? ITP = ?Ptm ? ? LV afterload Ptm = 100-(-5) = 105

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we could apply noninvasive ventilation to the 13% of the 2770 patients with hypoxemic ARF .... “Non more we could apply noninvasive ventilation to the 13% of the 2770 patients with hypoxemic ARF .... “Non-invasive Ventilation in Acute Respiratory Failure” ... less