recent advances in niv

Recent Advances in NIV

Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University

ERS National Delegate of Egypt

NPPV: definition

Any form of ventilatory support applied without

the use of an endotracheal tube considered to

include:

*CPAP with or without pressure support

*Volume- and pressure- cycled systems

*Proportional assist ventilation (PAV).

AJRCCM 2001; 163:283-91

Ventilators for NIV: Not all are useful in each indication

Standard interfaces

Facial masks

advantages:

– sufficient ventilation also during mouth breathing

– sufficient ventilation in patients with limited co-operation

disadvantages:

– coughing is difficult

– skin lesions (bridge of the nose)

Nasal masks

advantages:

– better comfort

– good seal

– coughing is possible

– communication is possible

disadvantages:

– effective in nose breathing only

– good co-operation is necessary

Standard interfaces

Nasal prong/nasal pillow systems

for patients with

claustrophobia

for patients with allergies

against straps

for low to moderate

pressures only

(< 20 cmH2O)

Standard interfaces

total-face masks

• Safe interface for acute respiratory insufficiency with high pressures

• well tolerated by the patients

Standard interfaces

helmet

• well tolerated by the patient

• no direct contact to the skin of

the face

• large dead space

• may influence the triggering of

the patient; use with CPAP

• very noisy

Standard interfaces

mouthpieces

• simple and cheap

• short-interval alternative

interface for long-term

ventilated patients

Custom-made masks

• for long-term ventilation

• if standard masks are not

tolerated

Standard interfaces

Physiologic evaluation of three

different interfaces

cohort: 26 stable patients with hypercapnic COPD or interstitial lung disease.

intervention: three 30 minute tests in two ventilatory modes with

facial mask / nasal mask / nasal prongs Conclusions: NIPPV was effective with all interfaces. patients‘ tolerance: nasal mask > facial mask or nasal prongs pCO2 reduction: facial mask or nasal prongs > nasal mask

Navalesi P et al. Crit Care Med 2000;28:2139-2140

*COPD

*Obesity

*Neuromuscular disease & chest

wall deformity

Rationale for ventilatory assistance

Respiratory load

Respiratory muscles

capacity

Alveolar hypoventilation

PaO2 and PaCO2

Abnormal

ventilatory drive

Mechanical ventilation unloads the

respiratory muscles

Respiratory load Respiratory muscles

Mechanical

ventilation

NIV - Meta-analysis (n=8)

NPPV resulted in

– decreased mortality ,

– decreased need for ETI .

Greater improvements within 1 hour in

– pH .

– PaCO2 .

– RR .

Complications associated with treatment and length of

hospital stay were also reduced with NPPV

Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185

NIV v invasive ventilation

In the NPPV group, 48% patients avoided intubation, survived, and had a shorter duration of ICU stay than intubated patients (p=0.02). One year following hospital discharge, the NPPV group had fewer patients readmitted to the hospital (65% vs. 100%; p = 0.016) or requiring de novo permanent oxygen supplementation (0% vs. 36%; p < 0.01).

Conti et al Intensive Care Med 2002; 28:1701

YONIV Study - outcome by enrolment

pH

0

10

20

30

40

50

pH < 7.3 pH >= 7.3

Con fail

NIV fail

Con died

NIV died

Plant et al Lancet 2000; 355:1931-5

Change in practice over time

1992-1996 (mean pH = 7.25+/-0.07) 1997-1999 (7.20+/-0.08; P<0.001).

> 1997 - risk of failure pH <7.25 three fold lower than in 1992-1996.

> 1997 ARF with a pH >7.28 were treated in Medical Ward (20% vs 60%).

Daily cost per patient treated with NIV (€558+/-8 vs €470+/-14,P<0.01)

Carlucci et al Intens Care Med 2003; 3:419-25

Late failure

n=137 Acute exacerbations of COPD

23% deteriorated after 48 hours

Late failure predicted by low ADL scores, pH and co-morbidity at admission

Moretti et al Thorax 2000; 55:819-25

Neuromuscular disease / scoliosis

Hypercapnia

Normocapnia with reduced vital capacity and tachypnoea

Don’t forget

– Upper airway

– Aspiration

– Occult cardiac disease

– Secretion management (cough assist)

NIV – when and where?

COPD – designated NIV service

– pH < 7.35

– pH < 7.30

Neuromuscular disease / chest wall deformity

– hypercapnia

– reduced VC with normal CO2

– Will usually require long term domiciliary NIV

Obesity

– Hypercapnia with acidosis (probably as for COPD)

– NIV success - consider switch back to CPAP (or no ventilatory support)

THE RATIONALE

LV failure

Pulmonary

edema

Pulmonary

compliance

Airway

resistance

Negative

Intrathoracic

Pressure

Swing

Work of

breathing

CO

PaO2 Respiratory

muscle

fatigue

DaO2

+

PaCO2

LV failure

Pulmonary

edema

Pulmonary

compliance

Airway

resistance

Negative

Intrathoracic

Pressure

Swing

LV

transmural

pressure

O2

Cost of

breathing

LV afterload

+

Rasen et al: Chest 1985; 87: 158-162

Negative intrathoracic pressure swings during CPE

Pes (cmH20)

0

-20

IntraThoracicPressure

and

LV function

AO

LV

ITP effort = ITP = Ptm

LV afterload

100

-20

Ptm = 100-(-20) = 120

CPAP IN CPE

Rasen et al: Chest 1985; 87: 158-162

Pes

(cmH20)

0

-20

Spontaneous breathing CPAP 15 cmH20

IntraThoracicPressure

and

LV function

AO

LV

ITP effort = ITP = Ptm

LV afterload

100

-5

Ptm = 100-(-5) = 105

Rationale of positive pressure ventilation in CPE

Positive Pressure

ITP FRC

Pre-load Venous return

LVafterload PTM

PaO2 WOB

Cardiac performance pulmonary congestion

Intervention

*Standard nitrate, diuretic and opioid therapy

*Consent + Randomised for 2 hours to:

-Standard oxygen therapy (by facial mask)

-CPAP (5 cmH2O to a max 15 cmH2O)

-NIPPV (8/4 cmH2O to a max 20/10

cmH2O)

*Fi02 0.6

Randomised n = 1156

Treated

n = 367

7 day

n = 367

Treated

n = 346

7 day

n = 343

Treated

n = 356

30 day

n = 352

30 day

n = 348

30 day

n = 325

30 day

n = 344

Patient

Withdrawal

n = 0

Patient

Withdrawal

n = 3

Patient

Withdrawal

n = 4

Patient

Withdrawal

n = 1

Refused

Retrospective

consent

n = 18

Patient

Withdrawal

n = 4

Refused

Retrospective

consent

n = 14

Patient

Withdrawal

n = 1

Refused

Retrospective

consent

n = 17

Potentially eligible n = 1874

Refused initial consent n=68

Too sick to consent n=125

Unable to consent n=18

Clinician choice n=23

Known previous randomisation n=32

No equipment n=15

Randomisation service problem n=33

Other n=41

Screened n = 1511

Recruited n = 1069

Protocol Violations n=44

Duplicates n=43

Mortality (Oxygen alone vs NIV)

1.0

0.9

0.8

0 10 20 30

Days

Cumulative

Survival

Standard

Oxygen Therapy

Non-invasive

Ventilation

P=0.685

Primary Outcome: Mortality Standard

Therapy

Non-

Invasive

Ventilation

OR

95% CI

P Value

7-Day

9.8%

9.5%

0.97

0.63 -

1.48

0.869

30-

Day

16.7%

15.4%

0.93

0.65 -

1.32

0.685

7-day mortality, non-recruited 9.9%

No interaction with disease severity

Standard NIV

Patients, n= 13 13

PaO2/FiO2 ratio

Baseline 155 143

Bronchoscopy 139 261

1 hour after 140 176

Antonelli et al, Chest 2002; 121: 1149

Indication: Pneumonia

Intensive Care Med 2003; 29:126-129

Chest 1997; 112:1466-1473

ACUTE AND CHRONIC NPPV

IN CHILDREN

Brigitte Fauroux

Pediatric Pulmonology & Research unit INSERM U 719

Armand Trousseau Hospital

Paris - France

Noninvasive Positive Pressure Ventilation

ERS School Courses

Pisa - Italy - 2005

Inserm

Institut national

de la santé et de la recherche médicale

Interface adapted

for the child

Conclusion

NPPV represents a logical therapeutic option in disorders characterised by alveolar hypoventilation

– Neuromuscular disorders

– Dynamic upper airway obstruction

– Cystic fibrosis

– Hypoxic RF, cardiogenic pulmonary edema ?

Future research

– Define the criteria for starting NPPV and the benefit of NPPV in children

• in the acute and chronic setting

• according to the underlying disease

– Improve the ventilators and interfaces

– Evaluate the long term benefit of NPPV in childen

ERS School Course

“Noninvasive Positive Pressure Ventilation”

Hanover, Germany

13. Feb. 2009

NIV in weaning: based on and beyond studies Prof. Dr. B. Schönhofer

Non-invasive ventilation in acute hypoxic respiratory

failure: Pro

Hanover, 13th February, 2009

Miquel Ferrer, MD RIICU, Dept. Pneumology, Hospital Clínic, IDIBAPS, CibeRes, Barcelona, Spain.

miferrer@clinic.ub.esmail: -E

Severe Community-Acquired Pneumonia

Clin Infect Dis. 2007;44 Suppl 2:S27-S72

1 Major or 3 Minor Criteria

Pneumonia is associated with poor outcome in patients

receiving NIV

*Mechanical ventilation

*Septic shock

Respiratory rate >30 min-1

PaO2/FiO2 <250

Bilateral or multilobar

SBP <90 mmHg *

BUN >25 Platelets <100,000

Leukocytes <4,000

Confusion

Hypothermia

Minor Criteria Major Criteria

NIV in acute COPD: correlates for success

Ambrosino N. Thorax 1995;50:755-7

NIV failure

Other Pneumonia

%

0

20

40

60

n=8

p=0.019n=5

Retrospective analysis

59 episodes of ARF in 47

COPD patients

NIV success: 46

NIV failure: 13

Predictors for NIV failure:

Higher PaCO2 at

admission

Worse functional

condition

Reduced treatment

compliance

Pneumonia

NIV failure in acute hypoxemic respiratory failure

Antonelli M. Intensive Care Med 2001; 27:

1718-28

• Eight ICUs • n=354:

• Success: 246 • Failure: 108

Non-invasive ventilation and pneumonia

but, …..

is NIV effective in patients with pneumonia?

???

Conclusion: Patients with pneumonia causing ARF and

needing NIV are among those with worst

outcome

NIV in severe community-acquired pneumonia

Prospective, randomised, controlled

Severe CAP (ATS criteria).

Standard treatment vs ST + NPPV. n: 28 + 28 = 56

Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91

Overall population

NIV Control

%

0

20

40

60p=0.03

n=6

n=14

COPD +Hypercapnia

NIV Control

%

0

20

40

60

Non-COPD +Non-hypercapnia

NIV Control0

20

40

60

n=0

n=6

n=6

n=8

p=0.005p=0.73

Intubation rate

Improving

End-Of-Life Care

Decision-making

In the ICU

Palliation

of symptoms

Dyspnea

Management

NIV in Palliation and Oncology

Don’t forget contraindications for NIV

Am J Respir Crit Care Med 2001;163:283-91

Need for immediate intubation: Cardiac or respiratory arrest

Respiratory pauses + alertness + gasping

Psychomotor agitation sedation

Massive aspiration Inability to manage secretions

Other limitations for NIV: Severe non-respiratory organ failure

Face surgery, trauma or deformity

Upper airway obstruction Inability to cooperate/protect the airways