Massimo Antonelli, MD

Dept. of Anesthesiology and Intensive Care

Università Cattolica del Sacro Cuore

Rome - Italy

Conflict of interest Resaerch Grant: Starmed Orion Pfizer Toray Honoraria: Pfizer Covidien Scientific Board: Cubist Covidien Drager Toray

Erwan L’Her, AJRCCM

2005; 172:1112-1118

Antonelli, NEJM 1998;339:429-35 (RCT)

Physiologic Effects of Noninvasive Ventilation during ALI Erwan L’Her, et AL, AJRCCM 2005; 172:1112-1118

Problems

• Require a continuous and prolonged application of pressures to maintain oxygenation

• May need a rapid intubation after NIV failure

• Must be trated in the ICU

Immunocompromised

Noninvasive ventilation for treating ARF in AIDS patients with Pneumocystis carinii pneumonia

Confalonieri M. Intensive Care Med 2002 28 (9): 1233-1238

48 AIDS patients

24 pts (NIV) 24 pts (ETI) P value

N° invasive devices Pneumothorax Positive blood colture Septic Shock Duration of MV LOS in ICU LOS in Hospital SOFA on study day 7 ICU survival 2-month survival 6 month survival

2+2 2 (8.3%) 2 (8%) 6 (25%) 6+2 7+4 13+5 5.7+1.4 75% 58% 25%

5+0 9 (38%) 7 (29%) 13 (54%) 7+1 10+4 24+17 6.5+1.94 38% 21% 16%

0.0001 0.033 0.133 0.078 0.034 0.013 0.004 0.072 0.022 0.020 0.678

RESULTS NIV Standard Treatment p value

Intubation - no./no.total (%) 12/26 (46) 20/26 (77) 0.03

Hematological malignancies 8/15 (53) 14/15 (93) 0.02 Immunosuppressor 3/9 (33) 5/9 (56) 0.32 AIDS 1/2 (50) 1/2 (50) 0.83

Ventilation (D) Total 6 3 6 5 0.59

Ventilation (D) Survivors 5 2 3 5 0.12

LoS in the ICU (D) Survivor 7 3 10 4 0.06

Mortality ICU 38% 69% 0.03

Complications- no. (%) 13 (50) 21 (81) 0.02 Complications death 10 (38) 18 (69) 0.03 V.A.P. and/or Sinusitis -no. (%) 3 (12) 9 (35) 0.05

G. Hilbert, N ENGL J MED 2001; 304(7): 481-486

A trial of Helmet CPAP?

1302 patients with hematological

Malignancies and ARF

1028 (79%) MV with ETI

ICU Deaths 511(49.7%)

GiVITI: Italian Observatory on 300 ICUs Data from the last 2 years

274 (21%) NIV

147(54%) Successful

SAPS II 59 ±17

127 (46%) Failure

SAPS II 60 ± 14

ICU Deaths 28(19%)

ICU Deaths 78 (61%)

Gristina, Antonelli, et Al, Crit Care Med. 2011 Oct;39(10):2232-2239.

Risk factor for failure

At Multivariate analysis two major risks factors for NIMV failure: •SAPS II score (OR=2.012, 95% CI: 1.006–4.026; P=0.04 •ALI/ARDS (OR= 2.266, 95%CI: 1.346–3.816; P=0.002).

Gristina, Antonelli, et Al, Crit Care Med. 2011 Oct;39(10):2232-2239.

Not immunocompromised

6 (21%) ETI

LoS in ICU 1.8±0.7 days

7 (25%) Deaths in ICU

APACHE II 20±5

28 Pts. NIPSV (FM)

14 (50%) ETI

LoS in ICU 6±2 days

6 (21%) Deaths in ICU

APACHE II 18±5

28 Pts Standard MT

P<0.04

Confalonieri, AJRCCM 1999;160:1585-1591

CAP + 2 or >of the following: severe dyspnea, AMC, Parad.AM

RR > 25 b/min, Pa O2 < 68 (FiO2 .4) or P/F < 250 if FiO2 >.5,

PaCO2 > 50, pH < 7.33, COPD pts included

P=NS

Jolliet, Intensive Care Med 2001;27:812-821: non COPD, ARF

due to CAP, PaO2:FiO2 104±48, PaCO2 40±10, APACHE II 13±5

24 CAP Pts

8(34%)successful

Age 37±12 PaO2 80± 15

16(66%) Failures

Age 55 ±15

PaO2 63± 11

8(100%) ICU Survivors 8(50%)Survivors

P<0.05

LoS in ICU and Hospital shorter

P/F 104±48 to 153±49

Noninvasive PSV in non COPD pts with CPE and severe CAP: acute effects and outcome

Domenighetti G. Intensive Care Med (2002) 28: 1226-1232

Prospective observational study

CPE (15 pts) CAP (18 pts)

Time of NIPSV (h) 9.6+6.3 37.3+36

ICU mortality 1(6.6%) 5(28%)

NIPSV failure 1/15 (6.6%) 7/18 (38%)

p

0.04

0.01

ns

Worsening of gas

Hemodynamics

Agitation

1

0

0

3

2

2

NIV in Severe Hypoxemic ARF: A RCT Miquel Ferrer, AJRCCM 2003;168: 1438–1444

46/51(91%) of the NIV pts had pulmonary infiltrates and 19(37%) true PN or ARDS

ICU mortality 18%

The concept of timing

0

20

40

60

80

100

120

CP

E (

n=

99)

Pu

lm c

on

t (n

=72)

Inh

PN

(n

=8)

Ate

lect.

(n

=28)

NP

(n

=18)

AR

DS

p (

n=

27)

CA

P (

n=

38)

AR

DS

exp

(n

=59)

Pu

lm f

ibr/

PE

(n

=5)

No

. o

f p

ati

en

ts

0

10

20

30

40

50

60

70

80

90

100

pe

rce

nta

ge

of

failu

res

N° patients % failures • 354 consecutive patients with hypoxemic ARF

• in 7 Centers (Europe and USA):

• PaO2/FiO2 < 200

breathing O2 (Venturi)

• RR>30, AC accessory muscles or paradoxical abd. Mot.

• COPD excluded

86 ARDS (P/F < 200, bil. Pulm.infiltrates, absence

of LVF)

• 108 (30%) failure

• 264 (70%) success.

Antonelli et Al.

Intensive Care Med

2001;27:1718-28

Multivariate Analysis

• ARDS or PN (OR 3.9, 95% CI 2.3-6.5)

• PaO2:FiO2 1h < 146 (OR 2.65, 95%CI 1.5-4.6)

• SAPS > 35 (OR 1.85, 95%CI 1.1-3.2)

• Age > 40 yr. (OR 1.79, 95%CI 0.92-3.23)

Were all factors independently associated with the risk of failure of NIV

Antonelli Intensive Care Med. 2001; 27:1718-28

Clin Microbiol Infect 2013; 19: 249–256

D 4.2% D 26.5 %

D 24.2 %

7569

2685 (36%)

NIV

1033(37%)

NIV Failure

D 426 (41%)

1652 (63%)

NIV Success

D 145 (9%)

4884(64%)

IMV

D 1522 (31%)

Yrs 2005-2010

NIV FOR PNEUMONIA ON ICU ADMISSION

2018 patients from 37 centers were included in the propensity-score model. Of these, 956 (47%) received NIMV as first approach

Overall, 2823 Pts died in hospital (38.1%). Mortality was higher in the IMV than in the NIMV group (42% vs. 31%; p<0.0001).

300 250 200 150 100 50

Low Tidal Volume Ventilation

Higher PEEP

HFO

Prone Positioning

ECMO

Low – Moderate PEEP

Neuromuscular Blockade

PaO2/FiO2

Increasing Severity of Lung Injury

Mild ARDS Moderate ARDS Severe ARDS

Incr

eas

ing

Inte

nsi

ty o

f In

terv

en

tio

n

NIV

ECCO2-R

iNO

Antonelli, CCM 2007;35(1);18-25

Conclusion

• RT and not RT suggest that NIV could be attempted in CAP1-4,results are however conflicting.

• Failure rate is high

• ICU environment and strict criteria for intubation are mandatory

• The extensive use of NIV for pts with severe CAP cannot be reccommended 5-

7

1. Antonelli, ICM, 2001;27:1718-28 2. Confalonieri, AJRCCM 1999;160:1585-91 3. Hilbert, NEJM 2001; 304(7): 481-486 4. Ferrer 2003;168: 1438–1444

5. Domenighetti, ICM, 2002; 28: 1226-1232 6. Keenan, JAMA 2000;284;2376 7.Carrillo, ICM 2012;38:458-66