Non invasive ventilation and LV dysfunction Fekri Abroug ICU. CHU F.Bourguiba Monastir. Tunisia.
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Transcript of Non invasive ventilation and LV dysfunction Fekri Abroug ICU. CHU F.Bourguiba Monastir. Tunisia.
Non invasive Non invasive ventilation and LV ventilation and LV dysfunctiondysfunction
Fekri Abroug
ICU. CHU F.Bourguiba
Monastir. Tunisia
How can cardiogenic pulmonary edema-inducedHow can cardiogenic pulmonary edema-induced
respiratory dysfunctionrespiratory dysfunction aggravate aggravate cardiac dysfunctioncardiac dysfunction
and circulatory failure ?and circulatory failure ?
Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema
Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure
at inspirationat inspiration
Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema
Hypoxemia Hypoxemia WOB WOB
risks of risks of myocardial myocardial
ischemia ischemia
risks of risks of critical organs critical organs hypoperfusionhypoperfusion
Viires et a. Viires et a. J Clin InvestJ Clin Invest 1983 1983
Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema
HypoxemiaHypoxemia WOBWOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure
at inspirationat inspiration
Increase in LV afterload Increase in LV afterload
Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema
HypoxemiaHypoxemia WOBWOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure
at inspirationat inspiration
risks of risks of myocardial myocardial
ischemia ischemia
Increase in LV afterload Increase in LV afterload
risks of risks of decrease in decrease in
Stroke Volume Stroke Volume
Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema
Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure
at inspirationat inspiration
risks of risks of myocardial myocardial
ischemia ischemia
decrease decrease in CaOin CaO22
risks of risks of critical organs critical organs hypoperfusionhypoperfusion
Increase in LV afterloadIncrease in LV afterload
risks of risks of decrease in decrease in
Stroke Volume Stroke Volume
Risks of aggravation of cardiac dysfunction (vicious circle) Risks of aggravation of cardiac dysfunction (vicious circle)
and of circulatory failureand of circulatory failure
How can positive pressure ventilation improve How can positive pressure ventilation improve
cardiac dysfunctioncardiac dysfunction and circulatory failure and circulatory failure
in patients with cardiogenic pulmonary edema?in patients with cardiogenic pulmonary edema?
Positive pressure ventilation in cardiogenic pulmonary edemaPositive pressure ventilation in cardiogenic pulmonary edema
Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure
at inspirationat inspiration
risks of risks of myocardial myocardial
ischemia ischemia
decrease decrease in CaOin CaO22
risks of risks of critical organs critical organs hypoperfusionhypoperfusion
risks of risks of decrease in decrease in
Stroke Volume Stroke Volume
Postive pressure ventilation by breaking the vicious circle Postive pressure ventilation by breaking the vicious circle prevents aggravation of cardiac dysfunctionprevents aggravation of cardiac dysfunction
and of circulatory failureand of circulatory failure
NIV and Cardiogenic NIV and Cardiogenic Pulmonary edema (CPE)Pulmonary edema (CPE) NIV: important tool in ARF
Reduces the need for invasive ventilation Reduces IMV complications Reduces ICU complications, stay, mortality
CPE common medical emergency NIV increases cardiac output Improves gaz exchange Decreases endotracheal intubation Trends towards decrease in mortality
Clinical goals in CPEClinical goals in CPE
Improve systemic oxygen saturation Reduction in LV preload Reduction in LV afterload
Oxygen through high flow facemask Morphine Diuretics nitrates
CPAP is effective in CPE CPAP is effective in CPE unresponsive to medical Rxunresponsive to medical Rx
Poulton Lancet 1936Poulton Lancet 1936
Increase in inspiratory and expiratory flow and pressure Increases Vt Unloads inspiratory muscles Improves alveolar ventilation Reexpands flooded alveoli Counteracts intrinsic PEEP
Prevents micro-atelectasis Improves the P-V curve relation Increases in intrathoracic pressure reduces the
left ventricular preload and afterload Increases cardiac output in CHF
Both CPAP and bilevel non-Both CPAP and bilevel non-invasive ventilation proved invasive ventilation proved effective in treating CPEeffective in treating CPE
Better than conventional oxygen therapy
Resolution time: p=0.002
N=19N=18
Intubation rate: 5% vs 33% (p=0.037)
130 patients attending the ED for CPE Randomized to
O2: n=65 NIPSV: n=65
Primary endpoint: need for intubation Secondary endpoints: mortality,
physiological variables
Intubation rate: 25% vs 20% (p=0.5)
Mortality: 14% vs 8% (p=0.4)
Subgroup analysis: no difference
P=0.01
CPAP vs Conventional medical CPAP vs Conventional medical treatment: intubation ratestreatment: intubation rates
NNT=7
CPAP vs Conventional medical CPAP vs Conventional medical treatment: death ratestreatment: death rates
NNT=8
BiPAP vs Conventional medical BiPAP vs Conventional medical treatment: intubation ratestreatment: intubation rates
BiPAP vs Conventional medical BiPAP vs Conventional medical treatment: death ratestreatment: death rates
How does CPAP How does CPAP compare with Bi-compare with Bi-PAP?PAP?
CPAP vs BiPAP: intubationCPAP vs BiPAP: intubation
CPAP vs BiPAP: mortalityCPAP vs BiPAP: mortality
36 patients with CPE and hypercapnia (in the ED)
Randomization to CPAP (n=18) or NIPSV (n=18)
Endpoints: Endotracheal intubation Death rate Resolution time (SpO2>96%, BR<30)
Role of NIV in CPE Role of NIV in CPE due to LV diastolic due to LV diastolic dysfunctiondysfunction
In all types of CPE, CPAP improves oxygenation
In LV diastolic dysfunction, this occurs through a decrease of LV diastolic volume (preload) and in MAP
In LV systolic dysfunction, CPAP both decreases preload and increases LVEF
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