Mechanical Ventilation Acute Heart FailureMechanical Ventilation Patient Interface Circuit...
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Abdo Khoury MD, MScDM Abdo Khoury MD, MScDM Research Group on Ventilation Inserm 808 CIC-IT Research Group on Ventilation Inserm 808 CIC-IT Department of Emergency Medicine & Critical Care Department of Emergency Medicine & Critical Care Franche-Comté University - Medical & Trauma Center, Besançon - France Franche-Comté University - Medical & Trauma Center, Besançon - France Mechanical Ventilation Mechanical Ventilation in in Acute Heart Failure Acute Heart Failure [email protected] [email protected]
Transcript of Mechanical Ventilation Acute Heart FailureMechanical Ventilation Patient Interface Circuit...
Abdo Khoury MD, MScDMAbdo Khoury MD, MScDMResearch Group on Ventilation Inserm 808 CIC-ITResearch Group on Ventilation Inserm 808 CIC-IT
Department of Emergency Medicine & Critical CareDepartment of Emergency Medicine & Critical CareFranche-Comté University - Medical & Trauma Center, Besançon - FranceFranche-Comté University - Medical & Trauma Center, Besançon - France
Mechanical VentilationMechanical Ventilationinin Acute Heart FailureAcute Heart Failure
[email protected]@chu-besancon.fr
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Conflicts of InterestConflicts of Interest
None for this presentation None for this presentation
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Acute Heart Failure
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European Journal of Heart Failure (2012) 14, 803–869European Journal of Heart Failure (2012) 14, 803–869
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McMurray JJ, N Engl J Med 2010;362: 228–238McMurray JJ, N Engl J Med 2010;362: 228–238Shah AM, Lancet 2011;378:704–712Shah AM, Lancet 2011;378:704–712
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European Journal of Heart Failure (2012) 14, 803–869European Journal of Heart Failure (2012) 14, 803–869
Acute Respiratory FailureIn Heart Failure
It is due to:
•Hypoxemia (intrapulmonary shunt)•Increased work of breathing•Augmented O2 consumption•and ultimately leads to muscle fatigue
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• Reduced work of breathing from improved pulmonary compliance
• Increased cardiac output from reduced pre-load and after-load
• Reduced mitral regurgitation
• Unloads the respiratory muscles
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Effect of Mechanical Ventilation
Jean-Damien Ricard and Damien Roux 2007Jean-Damien Ricard and Damien Roux 2007
Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2
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Mechanical VentilationMechanical Ventilation
PatientPatient InterfaceInterface CircuitCircuit Respiratory Respiratory DeviceDevice
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The patient: Which Indications?The patient: Which Indications?
Critical Care Assembly of the American Thoracic Society (ATS)Critical Care Assembly of the American Thoracic Society (ATS)European Respiratory Society (ERS)European Respiratory Society (ERS)European Society of Intensive Care Medicine (ESICM) European Society of Intensive Care Medicine (ESICM) Société de Réanimation de Langue Française Société de Réanimation de Langue Française (SRLF)(SRLF)
ParisParis
12 October, 200612 October, 2006
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SRLF, SFAR, SPLF, Paris Octobre 2006SRLF, SFAR, SPLF, Paris Octobre 2006
Grade 1Grade 1 Exacerbation of Exacerbation of COPDCOPDCardiogenic PECardiogenic PE
The patient: Which Indications?The patient: Which Indications?
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European Journal of Heart Failure (2012) 14, 803–869European Journal of Heart Failure (2012) 14, 803–869Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2
Jean-Damien Ricard and Damien Roux 2007Jean-Damien Ricard and Damien Roux 2007
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The respiratory devices: The respiratory devices: Which Modes?Which Modes?
• PPSV modePPSV mode– COPDCOPD grade 1grade 1
• PPSV mode or CPAP (together with PPSV mode or CPAP (together with optimal medical treatment!!!)optimal medical treatment!!!)– Cardio PECardio PE grade 1grade 1
• BiPAPBiPAP• VACVAC
SRLF, SFAR, SPLF, Paris Oct 2006SRLF, SFAR, SPLF, Paris Oct 2006Dr A. Khoury 12
Continuous Continuous Flow DeviceFlow Device
CPAPCPAP
A. Khoury, EuSEM, Munich Sept 2008A. Khoury, EuSEM, Munich Sept 2008Dr A. Khoury
WhisperFlowWhisperFlow BoussignacBoussignac
Elisée 350Elisée 350Continuous Positive Continuous Positive Airway PressureAirway PressureCPAPCPAP
A. Khoury, EuSEM, Munich Sept 2008A. Khoury, EuSEM, Munich Sept 2008Dr A. Khoury
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Pressure Support VentilationPressure Support Ventilation
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FailureRisk
PS 5 20 cmH2O
LeaksIncomfortIndication?
Respiratory distressWOB
PEEP 5 10 cmH2O
Total = PS+PEEP 10 25 cmH2O
+
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PSVPSVKey for success…Key for success…
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SRLF, SFAR, SPLF, Paris Octobre 2006SRLF, SFAR, SPLF, Paris Octobre 2006
Inadequate environment, insufficient expertiseInadequate environment, insufficient expertise
Non compliant, agitated patient reluctant to the techniqueNon compliant, agitated patient reluctant to the technique
Coma (but hypercapnic of CRespF patient) Coma (but hypercapnic of CRespF patient)
Which Contra-IndicationsWhich Contra-Indications
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Cardiogenic Pulmonary Edema:Cardiogenic Pulmonary Edema:
PPSV v/s CPAPPPSV v/s CPAP
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• Medline & Embase randomised Clinical trials from 1980 till 2008
• 10 studies• 1153 patients• 3 different statistical models (fixed effects, random
effects and exact method).
Outcome : intubation rate, the hospital mortality & the occurrence of MIOutcome : intubation rate, the hospital mortality & the occurrence of MI
NIPSV as effective and safe as NIPSV as effective and safe as CPAP in CPE ? CPAP in CPE ?
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Agarwal R, Aggarwal A N, Gupta D, Agarwal R, Aggarwal A N, Gupta D, Singapore Med J 2009; 50(6) : 595Singapore Med J 2009; 50(6) : 595
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↓↓Intubation RateIntubation Rate ↓↓Hospital MortalityHospital Mortality
NIPSV as effective and safe as NIPSV as effective and safe as CPAP in CPE ? CPAP in CPE ?
Agarwal R, Aggarwal A N, Gupta D, Agarwal R, Aggarwal A N, Gupta D, Singapore Med J 2009; 50(6) : 595Singapore Med J 2009; 50(6) : 595Dr A. Khoury 21
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Less Myocardial InfarctionLess Myocardial Infarction
NIPSV as effective and safe as NIPSV as effective and safe as CPAP in CPE ? CPAP in CPE ?
Agarwal R, Aggarwal A N, Gupta D, Agarwal R, Aggarwal A N, Gupta D, Singapore Med J 2009; 50(6) : 595Singapore Med J 2009; 50(6) : 595Dr A. Khoury 22
Dr A. Khoury IEMCC Istanbul 2013 23Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2
Dr A. Khoury IEMCC Istanbul 2013 24Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2Mehta, RESPIRATORY CARE • FEBRUARY 2009 VOL 54 NO 2
Mortality
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Intubation Rate
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There were important methodological limitations in many of the trials, such as lack of blinding and inclusion of only a proportion of patients who presented with ACPE, which restricts the generalizability of these results to all patients with ACPE.
It remains to be determined in the current era of ACPE therapy whether CPAP or NIV confer a mortality benefit. At this time we cannot conclude that NIV offers any advantages over CPAP.
Type of ventilator
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Carteaux, Chest 2012; 142(2):367–376
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Valve Leakage pT Trg msec 226 ±162 347±107 < 10-6
P min Trg cm H2O
-1,35±0,28 -0,96±0,2 <10-6
PTP Trigger 141±123 198±55 < 10-3
Tinsp msec 1±0,2 1±0,2 NSVT insp ml 723±227 562±155 < 10-6
T 90% PEP msec 138±197 146±304 NS
PSPS BIPAPBIPAP
A. KhouryA. Khoury J Crit Care. 2008 Sep;23(3):449J Crit Care. 2008 Sep;23(3):449
Respiratory Circuit? Respiratory Circuit?
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PPSV PPSV (valves)(valves)
Trigger: 140ms
Volume: 1057 mlVolume: 1057 ml
A. KhouryA. Khoury J Crit Care. 2008 Sep;23(3):449J Crit Care. 2008 Sep;23(3):449
Trigger: 280ms
Volume: 800 mlVolume: 800 ml
BIPAP BIPAP (leakage)(leakage)
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Physiological effects of different Physiological effects of different interfacesinterfaces during noninvasive ventilation for acute during noninvasive ventilation for acute respiratory failure*respiratory failure*Amanda Tarabini Fraticelli, MD; François Lellouche, MD; Erwan LAmanda Tarabini Fraticelli, MD; François Lellouche, MD; Erwan L’Her, MD; ’Her, MD; Solenne Taillé, BioMedEng; Jordi Mancebo, MD; Laurent Brochard, MDSolenne Taillé, BioMedEng; Jordi Mancebo, MD; Laurent Brochard, MD
Crit Care Med 2009 Crit Care Med 2009 Vol. 37, No. 3Vol. 37, No. 3
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• The internal volume of the masks had no apparent short-term:
• dead space effect on gas exchange• minute ventilation • patient’s effort
• So with the exception of mouthpiece, interfaces may be interchangeable provided adjustment of the ventilatory device parameters are performed.
Crit Care Med 2009 Vol. 37, No. 3Crit Care Med 2009 Vol. 37, No. 3
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Where?Where?Key determinant for successKey determinant for success
•Dedicated personnelDedicated personnel
•Specific Training of the team +++ (RN, Physiotherapist…)Specific Training of the team +++ (RN, Physiotherapist…)
•Clear guidelines for implementing NIVClear guidelines for implementing NIV
Intensive Care Unit Intensive Care Unit
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Possible in ED ???Possible in ED ???
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• Yes !!!!
Akihiro Shirakabe, Akihiro Shirakabe, Journal of Cardiology (2011) Journal of Cardiology (2011) 5757, 107—114, 107—114
Heart Failure
In the ED…In the ED…
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Pre hospital ?Pre hospital ?
IEMCC Istanbul 2013Williams B, Prehosp Disaster Med. 2013;28(1):1-10, Epub, Ahead of print Williams B, Prehosp Disaster Med. 2013;28(1):1-10, Epub, Ahead of print
• Cochrane, Medline, EMBASE, and CINAHL >> end of May 2012.
• CPAP in the prehospital environment, specifically in the treatment of heart failure and ACPE
• 1,253 articles, 12 of which met the inclusion criteria.
• Reduced short-term mortality as well as reduced rates of endotracheal intubation
• Improve patient vital signs during prehospital transport and reduce myocardial damage.
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Mobile Intensive Care Unit Mobile Intensive Care Unit (SAMU)(SAMU)
•Dedicated Personnel•Trained
•Indications
•Lab facilities (EPOC)
Pre hospital ?Pre hospital ?
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Pre hospital ?Pre hospital ?
CPAP DevicesCPAP Devices
• Boussignac® (Vygon)
• CPAP Systems (Vital Signs, inc)
• WhisperFlow® (Respironics)
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Pre hospital ?Pre hospital ?
Elisée 250Elisée 250 Hamilton T1Hamilton T1 Oxylog 3000Oxylog 3000
Weinmann Weinmann medumatmedumat Monnal T 60
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What about if NIV fails?Intubation and invasive MV without delay if:
•ARF with respiratory exhaustion•Hemodynamic instability•Cardiogenic shock•Impaired consciousness•Severe cardiac arrhythmias
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Invasive MV
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European Journal of Heart Failure (2012) 14, 803–869European Journal of Heart Failure (2012) 14, 803–869Jean-Damien Ricard and Damien Roux 2007Jean-Damien Ricard and Damien Roux 2007
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Conclusion• NIV is an excellent indication for Heart Failure patientsNIV is an excellent indication for Heart Failure patients• Unless contraindicationUnless contraindication
• Closely watch the initial phase of NIV to quickly predict Closely watch the initial phase of NIV to quickly predict success or failuresuccess or failure
• The earliest its used, the better the outcomesThe earliest its used, the better the outcomes• Impacts long time survivalImpacts long time survival
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Thank you for your Thank you for your attention…attention…
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Acknowledgement:Acknowledgement:
Pr D. Robert; Pr G. Capellier; Pr Samir JaberPr D. Robert; Pr G. Capellier; Pr Samir JaberDr A. Khoury 41
