NIV: ipossiemico

NIV:

ipossiemico

Dott Michele Vitacca Divisione Pneumologia Riabilitativae Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)

DAY I 4.45 pmEmergency Room

• 49 year old woman, professional vocalist at the Scala;

•BMI=21

• Emergency Room for dyspnea (onset 24 hr before), thoracic pain and Fever

• Previous history: Known to have “mild” emphysema treated with LABA and ICS. No major complains when she sings. No PFTs available

DAY I 4.55 pm Emergency Room

• Kelly 1 (normal sensorium)• Some bilateral crackles• 24 breaths/min. No recruitment accessory muscles• SaO2 94% with FiO2 50% (Venturi mask)• BP= 90/45 mmHg• HR= 124 b/m

• Body T.= 38.8° •Waiting for chemical examinations, Chest X-ray, Urinary culture

DAY I 5.15 pm Emergency Room

• Hb 12.5 g/dl

• Ht 43%

• WBC 27.000

• Albumin 3gr %

• Cl- 110

• Na+ 144

• K+ 3.1

• Creat 1.2

• ABG with a FiO2 of 50%:

pH 7.37PaCO2 48 mmHgPaO2 75 mmHg PaO2/FiO2= 150

Chest X-ray

What would you do?

1. Perform a CPAP trial in the ER

2. Transfer the patient to a “protected” environment

3. Perform a NIV trial (by Bilevel mode) in the ER

Definition ofACUTE RESPIRATORY FAILURE

PaO2/FiO2 < 300

PaO2/FiO2 ratio of 150 is a sign of SEVERE hypoxia necessitating Intensive monitoring and treatment

High-Dependency Respiratory Unit

DAY I 6.30 pm

Started therapy with:

- Ciprofloxacin 500 mg x 2/die

- Clarytromycicn 500 mg x 2/die

- Methilpredisolone 40 mg/die

- Aspirin 500 mg ev

DAY I 8.30 am

Kelly 1

Body T= 37.9°

Respiratory rate= 28 breaths/min

Minimal recruitment of accessory muscles

ABG on Venturi mask 50%pH 7.33

PaCO2 51 mmHg

PaO2 65 mmHG with FiO2 Venturi 50%

PaO2/FiO2= 105 mmHg

Bic 28.4

BE 4.3

NIV should be started!

She has become more hypoxic and hypercapnic

Which mode?

1. CPAP

2. PSV + extPEEP

3. PSV without extPEEP

USE PSV + CPAP or extPEEP!

-

• Greater improvement of hypoxia

• Greater reduction of diaphragmatic effort

• Greater reduction of dyspnea

Which interface?

1. Nasal Mask

2. Full Face Mask

3. Helmet

DAY II 10.30 am• NIV is started: PSV + CPAP ICU ventilator with leak compensation

Full face maskFollowing settings: FiO2= 21% PS= 18 cmH20 CPAP= 8 cmH20 to get a SaO2>88%, then increase FiO2 to get a SaO2 > 93% “Final” FiO2= 45%

ABG 1hr after NIV

pH 7.39

PaCO2 31 mmHg

PaO2 71 mmHG

Bic 3

BE 26.2

SaO2 92%

PaO2/FiO2= 157

Are we happy?

1. Yes because ABG 1 hr after NIV predict a good prognosis

2. No because a PaO2/FiO2 < 200 after 1 hr of NIV is associated with a higher NIV failure in ARF

3. Yes, but caution should be excercised because the diagnosis of CAP is independently associated with a higher risk of NIV failure

Antonelli et al.

27;2001pag.1718-28

This observational study shows that the outcomes of NIV during hypoxic RFmay differ according to the underlying pathologies. The likelihood of failure is very low in patients affected by Cardiogenic Pulmonary Edema but it is very high in patients with CAP.

DAY III…. continuing story

• The patient was continuously monitored

• ABG were taken after 1hr and then every 3 hrs for the following 12 hrs

• She tolerated NIV well and the last ABG during spontaneous breathing showed:

• pH= 7.39

• PaCO2 37 mmHg

• PaO2 82 mmHG (with a FiO2= 35%)

• PaO2/FiO2=235

• Respiratory rate= 16 breaths/min

Remember:she was also a COPD patient

0

10

20

30

40

50

60

70

COPD non-COPD COPD non-COPD

NIV

STANDARD

Intubation 2-months mortality

%

The message to take home

NIV used in a protected environment may PREVENT endotracheal

intubation in HYPOXIC patients with pneumonia, but ONLY in those

patients with pre-existing COPD

IN THE FOLLOWING DAYS….

• She improved daily and NIV was stopped on day 4, after having progressively reduced the duration of its application

I

VA/Q. .

PaO2

The 3 major determinants of hypoxemia

1st: the composition ofInspired air (gas):Low FiO2

3rd: the composition ofMixed venous blood: LowPvO2

2nd: quality and capacity of the gasexchanger: V/Q mismatching

PAO2= (Pb-PH2O=) x 0.21-PACO2/R

v

Common Causes of Hypoxemic Respiratory Failure

• Pneumonia

• Cardiogenic pulmonary edema

• Acute respiratory distress syndrome

• Aspiration of gastric contents

• Multiple trauma

• Immunocompromised host with pulmonary infiltrates

• Pulmonary embolism

Neurological Signs and Symptoms of Hypoxia

PaO2, mmHg Signs and Symptoms of Hypoxia

30 to 50 Loss of critical judgment, confusion, delirium (resembling alcohol intoxication), tremors, asterixis

25 to 35 Somnolence, obtundation, myoclonic jerks, seizures

20 to 25 Loss of consciousness

< 20 Death

F. Laghi and M. Tobin 2013

Ma funziona sul serio la NIV ?

CPAP

intrathoracic alveolar PEEPipressure pressure compensation

Shunt FRC work of breathing

Improve gas atelectasisExchange hypoxemia

CPAP : Respiratory Effects

Pelosi Chest 1996Pelosi Anesthesiology 1999

Positive Pressure

ITP FRC

Pre-load Venous return

LVafterload

PTM

PaO2 WOB

Cardiac performance pulmonary congestion

CPAP: Cardiovascular Effects

Non invasive CPAP to treat

PE or CHF

Non-invasive positive pressure ventilation (CPAP or bilevelNPPV) for cardiogenic pulmonary edema

(Cochrane Review)Vital FMR. et al., 2008

hospital mortality

NIV/CPAP vs 02

Non-invasive positive pressure ventilation (CPAP or bilevelNPPV) for cardiogenic pulmonary edema

(Cochrane Review)Vital FMR. et al., 2008

endotracheal intubation rate

NIV/CPAP vs 02

New Variable: HYPERCAPNIA

CPE – Risk Factors for NIV Failure

Masip J. ICM 2003; 29: 1921-8

Arterial pressure and hypercapnia

CPE – Risk Factors for NIV Failure

Masip J. ICM 2003; 29: 1921-8

New Variable: ACIDOSIS

Endotracheal intubation or

Non invasive CPAP/PPV to treat

Postoperative Hypoxiemic Respiratory

Failure ?

Patients scheduled for elective major abdominal surgery (§) and general anesthesia who met a PaO2/FiO2 < 300 after 1 h at 30% (Venturi mask ) in the recovery room.

•(§) Opening abdominal wall and viscera exposition > 90 minutes with laparotomic or subcostal incision .

VenturiMask(105 pts)

Helmet CPAP10 cmH2O(104 pts)

Endotracheal intubation or


Hypoxiemic Respiratory Failure (Pneumonia or

ARDS) ?

Predictors of failure of noninvasive ventilation in acute hypoxiemic patients

100

50

0 ACPE COPD ARF

NIV

Effi

ciency

(%

)

Antonelli ICM 2001 Pelosi Eur Emerg J 2000

HYPOXEMIC ARF (ARDS) IMMUNOCOMPETENT PATIENTSHYPOXEMIC ARF (ARDS) IMMUNOCOMPETENT PATIENTS

STUDIES [**= RCT ] n Particularities Mask Mode SUCCESSSUCCESS

Meduri Chest 1996 41 PaO2/FiO2 = 110110 F PS/PEEP 66 %

Wysocki Chest 1995 ** 42 F PS/PEEP 38 %

Patrick AJRCCM 1996 11 Intubation C N PAV 73 %

Antonelli NEJM 1998 ** 64 Intubation CIntubation C F PS/PEEP 69 %

Rocker Chest 1999 12 ALI / ARDSALI / ARDS F PS/PEEP 50 %

PaO2/FiO2 = 102

Confalonieri 1999 ** 56 Comm. PN F PS/PEEP 79 vs 50%

Delclaux JAMA 2000 ** 123 PaO2/FiO2 300 300 F CPAP 66 vs 61 %

Ferrer AJRCCM 2003 ** 105 PaO2/FiO2 = 102102 F PS/PEEP 75 vs 48%

COPD Non COPD NIV Standard p NIV

Standard p (n = 12) (n = 11) (n = 16) (n = 17)

SUCCESSSUCCESS 100100 % 45 45 % 0.005 6363 % 53 53 %

0.73

ICU Stay (days) 0.25 ± 2.1 7.6 ± 2.2 0.02 2.9 ± 1.8 4.8 ±

1.7 0.44

Hospital Stay 14.9 ± 3.4 22.5 ± 3.5 0.13 17.9 ± 2.9 15.1 ±

2.8 0.48

Hospital Death 1 (8.3%) 2 (18.2%) 0.59 6 (37.5%) 4 (23.5%)

0.47

Acute Respiratory Failure in Patients with Severe Acute Respiratory Failure in Patients with Severe Community-Community-

acquired Pneumoniaacquired Pneumonia

Confalonieri M., et al. 1999Confalonieri M., et al. 1999; 160:1585-1591

NIVNIV / / IMMUNOSUPPRESSEDIMMUNOSUPPRESSED PATIENTSPATIENTS

STUDIES * * = R.C.T n ParticularitiesParticularities Mask Mode SUCCESS

Bedos 66 AIDS. F CPAP 66 % CCM 1999 Pneumocystis

Confalonieri 48 AIDS. (P.tis) F PS/PEEP 67 %

ICM 2002 intubation intubation criteria

Antonelli 40 Solid Organ F PS/PEEP 80 % JAMA 2000 ** Transplantation (vs 30 %)

Tognet 18 Hematological N F PS/PEEP 33 %Clin I C 1994 ACV

Conti 16 Hematological N

PS/PEEP 69 %ICM 1998 intubationintubation criteria

Hilbert 64 Hematological F CPAP 25 %CCM 2000 Neutropenia Hilbert 52 HematoHemato-Neutropenia F PS/PEEP 54 %NEJM, 2001 ** Drug Drug Immunosup. (vs 23%)

AIDS


pandemic influenzae?

64/337 (19%) Used NIV

43/64 (67%) NIV Success

64/337 (19%) Used NIV


67/94 (71%) Used NIV


67/94 (71%) Used NIV


177/489 (37%) Used NIV


177/489 (37%) Used NIV


Nicolini et al MAS 60/98 (61%) Used NIV


60/98 (61%) Used NIV


ICU mortality

%0 20 40 60 80 100

Trauma

CPE

Extrapulmonary ARDS

Pulmonary ARDS

HAP

CAP

NIV-successNIV-failure

n=7

n=10

n=7

n=0

n=0

n=18

n=9

n=1

n=4

n=0

n=33

n=8

NIV failure associated with extremely high risk of death

Shock, metabolic acidosis (BE < -2.5 mEq/L), and severe hypoxemia (PaO2/FiO2< 150 mmHg)

Only 33% NIPPV success !!

< 150 after 1hr NPPV

Failure rate: 70%

• Patients with shock: 100%

Independent predictors of NIV failure (excluded patients with shock):

• Metabolic acidosis

• Severe hypoxemia

p<0.01

Mortality in patientsfailing NIV

Actual Predicted

%

0

20

40

60

80

100

Predictors of failure: NIV for hypoxaemic respiratory failure

Diagnosis of ARDS or pneumonia SAPS ≥35 Lower PaO2/FIO2 (100 or below) Low pH Age >40 years Septic shock Multiorgan system failure Failure to improve PaO2/FIO2 >146 within first

hour

Antonelli et al. Intensive Care Med 2001; 27: 1718–28Rana et al. Crit Care 2006; 10: R79

La vita reale

% NIV use according to different pathologies

% OF USE

HELMET MASK p

HOURS OF CONTINUOUS NIV

36 ± 29 26 ± 13 0.05

ETI BECAUSE OFINTOLERANCE

0 8 0.05

COMPLICATIONS RELATED TO NIV (Skin necrosis, Gastric Distension, Eye irritation)

0 14 0.002

Crit Care Med 2002;30:602-608

Use of masks’ type in the different scenarios

Crimi et al ERJ 2008

Rotating interface strategy…

• Should NIV/CPAP be administered to all patients with CPE?

• NO– Those with ventilatory failure – Early use is recommended

• NO superiority for survival• YES for physiology/patient distress

– But increased discomforteconomic advantage,

– Patients needing intubation (plan action when failure)– Which mode?

• CPAP in normocapnic and NIV in hypercapnic patients with cardiogenic pulmonary oedema improves oxygenation more rapidly than standard therapy

– More focus on aetiology, cardiac rhythm– The Helmet may contribute to the application of NIV

outside the ICU in patients who do not tolerate the mask

NIV/CPAP in CPE

NON INVASIVE RESPIRATORY SUPPORT IN HYPOXIEMIC ACUTE RESPIRATORY FAILURE ?

• High percentage of failures• Late resolution• Difficult “invasive” diagnostic procedures (BAL, Brush)• Risk to delay ETI

Take care of:• Accurate selection of the patients: - PaO2/FiO2 > 150 mmHg, - Lobar densities at chest X- Ray or CT - Absence of hemodynamic shock (BE > -2.5 mEq/L)• Empiric Antibiotic Treatment (Protocols !)• Non invasive fast diagnostic tests (Urinary antigens, etc.)• Hemocoltures• Don’t push to hard (stop NIV if PaO2/FiO2< 150 at 1-2 hrs)

NIV: ipossiemico

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