2-vni_na_icc_lr_2011

Non-Invasive Positive Pressure

Ventilation in Heart Failure Patients:

For Who, Wy & When?

Quais os doentes com insuficiência cardíaca

que beneficiam de ventilação não-invasiva?

L u i s R a p o s o

U N I C A R V | H o s p i t a l d e S a n t a C r u z | C H L O

REUNIÃO CONJUNTA DOS GRUPOS DE ESTUDO

DE CUIDADOS INTENSIVOS CARDÍACOS E DE

FISIOPATOLOGIA DO ESFORÇO E

REABILITAÇÃO CARDÍACA

O L H Ã O | 2 7 e 2 8 d e J a n e i r o 2 0 1 2

Increasing prevalence of chronic kidney dysfunction

NIV has been has an important clinical role in

both acute decompensate congestive HF & in

chronic stable patients with BDS

Acute/decompensated heart failure (mostly ALE)

Basic pathophysiology of cardiogenic acute lung edema

Beneficial effects of positive pressure ventilation

CPAP vs BiPAP vs Standard of Care

Chronic/stable heart failure

Cardio-respiratory interactions & BDS in chronic HF patients

Potential benefits of positive pressure ventilation

Non-Invasive Positive Pressure Ventilation

Definition

Basic principles & practical setup and hints


Acute/decompensated heart failure



CPAP vs BiPAP vs Standard of Care





Definition





Increased hospital stay and costs

Increased mortality


Non-Invaive positive pressure ventilation (NPPV) is a way

of assuring positive pressure in the airways throughout

the entire respiratory cycle without intubation

Trauma to the oro-pharynx and airway

Excessive hypotension

Arrythmia

Inability to cough: accumulation of respiratory debris

Nosocomial pneumonia

Dysphonia, granuloma formation…

NIV AVOIDS the risks associated with ETI

Poulton EP, Lancet 1936;228:981-983

NPPV is not a new concept: it’s use began

during the first half of the 20th century





Bi-level Positive Airway Pressure

(IPAP + EPAP)

Continuous Positive Airway Pressure

(CPAP)

Pressure regulated volume ventilation






The most commonly used method: minimal training

Relatively simple, “portable” devices

Not “true” mechanical ventilation, as inspiratory

effort depends entirely on the patient

Positive pressure produced by a unidirectional valve:

may use a “fan” or O2 (Boussignac) to generate

flow/pressure

Mixture in the facial mask may facilitate

re-inspiration of CO2 (caution in hypercapneic pts!)





Less commonly used: requires more extensive

training, team experience & more expensive

equipment

Usually employs typical ICU ventilators

Helps inspiratory effort with patient triggered

preset pressure during inspiration (IPAP)

Theoretically “more physiological”

Allows higher tidal volumes (potential advantage in hypercapneic/acidotic pts!)

Bi-level Positive Airway Pressure





CPAP vs BiPAP vs Standard of care





Definition






Pulmonary Edema is a frequent manifestation

of Heart Failure & halves a dire prognosis

Available at

http://www.escardio.org/guidelines-surveys/ehs/heart-failure/Documents/EHS_HFII_MainPublication.pdf

30 European countries;

133 centres;

3580 pts


Positive pressure improves ventilation by

counteracting the pathophysiological pathways

in acute cardiogenic lung edema

Opens flooded & collapsed alveoli

Increases functional residual capacity

Decreases “dead space”

Decreases intra-pulmonary shunt

Increases tidal volume


Kelly et al. Eur Heart J 2002;23:1379-1386

Randomised controlled trial of continuous positive airway pressure and

standard oxygen therapy in acute pulmonary oedema; effects on plasma

brain natriuretic peptide concentrations.




CPAP

O2


Raposo L, Rev Port Cardiol, 2003; 22 (Supl III): III-102 (Abstract)





Positive pressure ventilation has

favorable effects on the loading conditions

of the failing Left Ventricle


23 trials

1985-2003

Evidence from RCTs and Meta-analysis

strongly favors the use of NPPV for the

treatment of acute decompensated HF/APE

Despite theoretical advantages, overall, BiPAP

does not seem to bee superior to CPAP

Critical Care 2006, 10:R69 (doi:10.1186/cc4905)

Available at: http://ccforum.com/content/10/2/R69

Despite theoretical advantages, BiPAP dit not prove

to be superior to CPAP in hypercapneic patients

Critical Care 2006, 10:R69 (doi:10.1186/cc4905)

Available at: http://ccforum.com/content/10/2/R69

The largest RCT to date, failed to show a

significant reduction in mortality with either

method of NPPV vs standard medical care Multicenter, open, prospective, RCT

Standard O2 therapy

CPAP (5-15 cm H20)

NIPPV (IPAP 8-20 cm H2O / EPAP 4-10 cm H2O)

N=1609 pts

147.362 records, with 114,756 (78%) cases of ADHF admitted from the ED

Ventilation in 2,430 pts (6.5%) - 1,760 (72.4%) NIV & 670 (27.6%) ETI without an NIV trial.

1,688 (95.9% of NIV pts) managed only by NIV (NIV success)

72 (4.1% of NIV) failed NIV and subsequently received ETI (NIV failure).

Despite guideline recommendation NPPV use

in the management of APE is heterogeneous


Available at

http://www.escardio.org/guidelines-surveys/ehs/heart-failure/Documents/EHS_HFII_MainPublication.pdf

Despite guideline recommendation NPPV use

in the management of APE is heterogeneous

~20% NPPV

When to use & how to do it?

Indications for Noninvasive Ventilation Indications

• Inadequate response to initial standard therapy

• At risk for endotracheal intubation

• Respiratory rate ≥ 30

• Persistent 02 saturation ≤ 90% or PaO2/FiO2<200 on >4 L/min oxygen

• Mild hypercapnia (CO2<45 mmHG) or acidosis (ph<7.3) - preferably IPAP?

• Sense of respiratory muscle fatigue

Contraindications

• Lack of training

• Apnea & Hemodynamic instability

• Inability to protect the airway and Uncontrollable vomiting

• Abnormal facial anatomy

• Recent GI or upper airway surgery (< 7 days)

• Altered mental status or uncooperative and inability to tolerate the mask

• Need for immediate ETI due to worsening instability

• Very severe obstructive airway disease



• Start with 5-7.5 cm H20

• Increase in increments of 2 cm H20, as tolerated and indicated

• FiO2 >40%

Bi-Level Positive Airway Pressure / Noninvasive Pressure Support Ventilation

• Initial inspiratory pressure of 8–10 cm H20

• Increase in increments of 2–4 cm H20 (Max ~20 cm H20) aiming at TV>7ml/Kg

• Initial expiratory pressure of ~4-5 cm H20

• Maximum inspiratory pressure is 24 cm H20 and expiratory pressure 20 cm H20

• FiO2 >40%

Noninvasive Ventilation Settings


Improvement Criteria

• Heart rate <100 bpm

• Respiratory rate <30/min

• Ability to maintain SpO2>90% on spontaneous breathing FiO2 <40-50% (mask)

• Improvement in dyspneia, without use of ancillary muscles

Factors associated with the success of noninvasive ventilation

• Patient-ventilator synchrony /acceptance of the technique by the patient

• Glasgow coma score over 9 & APACHE II score < 21.

• Few secretions

• No pneumonia

• baseline Hypercapnia and initial pH above 7.1

• Good response in the 1st hour of T/ with correction of acidosis & hypoxemia

• Arterial hypertension at baseline

Monitoring and withdraw





CPAP vs BiPAP vs Standard of care





Definition





Sleep Disordered Breathing (SDB) is highly

prevalent in chronic HF patients and is associated

with poor QOL and increased mortality

80% prevalence

Sleep Disordered Breathing (SDB) is highly

prevalent in chronic HF patients and is associated

with poor QOL and increased mortality

Impact of CPAP Treatment

Adjusted HR 2.9 (95% CI 1.1-3-5; p=0.0023)

296 CHF patients

Median LVEF=33%

In-lab polysomnography

In Chronic HF patients with SDB, treatment effect

of nocturnal CPAP is higher in those with the

central type of sleep apnea – The CANPAP Trial

258 HF patients with Central sleep apnea (nº episodes of apnea/hypopnea 40±16 per hour of sleep)

Ejection fraction 24.5±7.7%

FUP 3 months

Increase in the 6 min walk test distance

Decrease in norepinephrine

No benefit in hard clinical endpoints (mortality & transplant rate)

In Chronic HF patients with SDB, treatment effect

of nocturnal CPAP is higher in those with the

central type of sleep apnea – The CANPAP Trial

HR 0.37 (95% CI 0.14-0.96; p=0.043)

vs control (nonCPAP pts)

Aorta

Conclusions & Take-Home messages

NPPV provides excellent clinical results when proper patient selection

is accounted for and treatment is initiated early in an adequate

“window of opportunity” by an experienced team

It can dramatically improve ventilation and cardiac performance

(except in severe diastolic dysfunction, hypovolemia or severe LV systolic failure)

NIV is associated with highly significant reductions in the need for ETI

(up to 55%!) and may reduce early mortality

Either technique appears equally effective, but CPAP is cheaper, easer

to use and requires less training

There is no clear cut evidence that NPSV actually increases the risk of

new myocardial infarction, but caution is advised when treating

acute MI or severe CAD patients (increase in LV transmural pressure….)

2-vni_na_icc_lr_2011

Documents

patient positive pressure

volume ventilation

chronic stable patients

true mechanical ventilation

heart failure patients

entire respiratory cycle

n e i r o

p o s o u n