recent advances in niv
TRANSCRIPT
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.
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
