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Controversial Issues in NIV

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  • 1. Controversial Issues in Non-Invasive Ventilation Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases ,Assiut University
  • 2. The normal ventilatory balance Ventilatory drive Respiratory load Respiratory muscles capacity
  • 3. Respiratory Failure Abnormal Ventilatory drive   Respiratory muscles capacity   Respiratory load 
  • 4. Mechanical ventilation unloads the respiratory muscles Respiratory load Mechanical ventilation Respiratory muscles
  • 5. 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
  • 6. Ventilators for NIV: Not all are useful in each indication
  • 7. 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)
  • 8. Standard interfaces Nasal masks advantages: – better comfort – good seal – coughing is possible – communication is possible disadvantages: – effective in nose breathing only – good co-operation is necessary
  • 9. 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)
  • 10. Standard interfaces total-face masks • Safe interface for acute respiratory insufficiency with high pressures • well tolerated by the patients
  • 11. 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
  • 12. Standard interfaces Custom-made masks • for long-term ventilation • if standard masks are not tolerated mouthpieces • simple and cheap • short-interval alternative interface for long-term ventilated patients
  • 13. 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 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
  • 14. Frequency of adverse effects and complications of NIPPV % occurrence Mehta et al. Am J Respir Crit Care Med 2001;163:540-577
  • 15. Interfaces available for adults Acute respiratory failure Chronic respiratory failure Facial mask 63% 6% Nasal mask 31% 73% Nasal prongs 6% 11% Mouth piece 0% 5%
  • 16. THE RATIONALE
  • 17. LV failure  PaCO2  CO  DaO2 Pulmonary edema  Pulmonary compliance +  Airway resistance  PaO2  Negative Intrathoracic Pressure Swing Respiratory muscle fatigue  Work of breathing
  • 18. LV failure  LV afterload Pulmonary edema  Pulmonary compliance +  Airway resistance  LV transmural pressure  Negative Intrathoracic Pressure Swing  O2 Cost of breathing
  • 19. Negative intrathoracic pressure swings during CPE Pes (cmH20) 0 -20 Rasen et al: Chest 1985; 87: 158-162
  • 20. IntraThoracicPressure and LV function AO ITP Ptm = 100-(-20) = 120  effort =  ITP = Ptm   LV afterload LV 100 -20
  • 21. Pes (cmH20) CPAP IN CPE Spontaneous breathing CPAP 15 cmH20 0 -20 Rasen et al: Chest 1985; 87: 158-162
  • 22. IntraThoracicPressure and LV function AO ITP Ptm = 100-(-5) = 105  effort =  ITP =  Ptm   LV afterload LV 100 -5
  • 23. Rationale of positive pressure ventilation in CPE Positive Pressure  ITP Pre-load  Venous return  FRC  LVafterload  PaO2  PTM  Cardiac performance  pulmonary congestion  WOB
  • 24. CPAP vs. standard treatment in acute pulmonary oedema CPAP total Rasasen, 1985 Bersten, 1991 Lin, 1995 intubated died Standard treatment total intubated died mortality intubation rate 20 6 3 20 12 6 -15% -30% 19 0 2 20 7 4 -9.5% -35% 50 8 4 50 18 6 -4% -20% 89 14 9 90 37 16 -6.6% -26% Pang D et al.: Chest 1998; 114: 1185-92
  • 25. Noninvasive Ventilation in Cardiogenic Pulmonary Edema A Multicenter Randomized Trial Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437 • Multi-centre, randomized, prospective study with 130 patients with respiratory insufficiency. • Setting: emergency room. • Intervention: standard treatment with drugs and high flow oxygen versus standard treatment and NIV (nPSV).
  • 26. Noninvasive Ventilation in Cardiogenic Pulmonary Edema A Multicenter Randomized Trial Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437
  • 27. Noninvasive Ventilation in Cardiogenic Pulmonary Edema A Multicenter Randomized Trial Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437 Results: • Similar intubation rate in both arms. • Patients receiving NIV had a significantly better improvement of PaO2/FiO2 within the first 30 minutes and within the first 3 hours of treatment. • Hypercapnic patients: Significantly shorter time to normalisation of PaCO2; lower intubation rate with NIV (2/33 vs. 9/33). • Hypocapnic patients: Significantly higher intubationfrequency.
  • 28. Noninvasive Ventilation in Cardiogenic Pulmonary Edema A Multicenter Randomized Trial Nava S, et al. Am J Respir Crit Care Med 2003;168:1432-1437 Pi 14,5 ± 21,1 mbar; Pe 6,1 ± 3,2 mbar mean ventilation time: 11,4 ± 3,6 hrs
  • 29. Multicentre clinical trial: Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51. primary endpoint: death within 7 days primary endpoint: death or intubation within 7 days
  • 30. Multicentre clinical trial: Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A , et al. N Engl J Med. 2008 Jul 10;359(2):142-51.
  • 31. 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
  • 32. Primary Outcome: Mortality Standard Therapy NonInvasive Ventilation OR 95% CI P Value 7-Day 9.8% 9.5% 0.97 0.63 1.48 0.869 30Day 16.7% 15.4% 0.93 0.65 1.32 0.685 7-day mortality, non-recruited 9.9% No interaction with disease severity
  • 33. NIV in Stable COPD: Pro
  • 34. BGA (m m H g A BG ) mmHg PaC O 2 (m m H g ) 100 PaO 2 100 9 00 9 8 8 00 70 70 NPPV (assPCV) 60 - mean IPAP 30 50 50 40 ±4 mbar - mean bf 60 ±2 /min 23 3 4 00 1 2 30 3 5 9 Z e it ( T a g e ) 1 2 3 5 ZDays e) eit (T ag 9 Windisch W. et al. Respir Med 2002; 96:572-5
  • 35. PaCO2 [m m H g] NPPV Controls P a C O 2 d u rin g s p o n ta n e o u s b re a th in g 58 P = 0.26 56 54 NPPV (assPCV) - mean IPAP 31 ±7 mbar - mean bf 52 ±2 /min 21 50 P < 0.001 48 46 baseline 0 0,5 1 3 7 11 15 [hours] T im e after cessatio n o f n o ctu rn al N P P V Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260
  • 36. Tidal volume [L] V T d u rin g s p o n ta n e o u s b re a th in g 0,70 P < 0.05 NPPV Controls 0,65 P = 0.28 0,60 NPPV (assPCV) - mean IPAP 31 ±7 mbar - mean bf 0,55 ±2 /min 21 0,50 baseline 0 0,5 1 3 7 11 15 [hours] T im e after cessatio n o f n o ctu rn al N P P V Windisch W. et al. Respir Physiol Neurobiol 2006; 150:251-260
  • 37. NPPV (assPCV) - mean IPAP 28 ±6 mbar - mean bf ±3 /min 21 N = 34 2-year survival: 86% Windisch W. et al. Chest 2005; 128:657-6
  • 38. N = 141 NPPV (assPCV) - mean IPAP 20 ±4 mbar - mean bf ±4 /min 20 BMI <20 kg/m2 = 21% Budweiser S. et al. Respir Care 2006; 51:126-132
  • 39. Windisch W. et al. J Clin Epidemiol 2003; 56:752-759 Windisch W. et al. J Clin Epidemiol 2008; 61:848-853 Severe Respiratory Insufficiency Questionnaire SRI ATS homepage: http://www.atsqol.org/sections/instruments/pt/pages/sri.html
  • 40. • Multicenter Study (N = 135) • Outcomes: - Quality of life (SF-36; SRI) - Side effects - Hospitalisations - Compliance - Physiological parameters T0 (baseline) T1 Months T12 Windisch W. Eur Respir J 2008; 32:1328-1336
  • 41. SRI-Summary Scale (SRI-SS) 65 IPAP/EPAP (mbar) P < 0.001 restrictive thoracic 20/3 19/4 P < 0.001 neuromuscular 25/1 P < 0.001 COPD 55 kulär Changes in SRI-SS independent from the underlying disease MANOVA; F=0,62; P=0,65. 45 T0 T1 T0 COPD T12 T1 RTD T12 NMD Windisch W. Eur Respir J 2008; 32:1328-133
  • 42. suppl. O2 (2.3 L/min) suppl. O2 (2.3 L/min) + NPPV (29/4 mbar, 20/min) Dreher M. et al. Eur Respir J 2007; 29: 930-936
  • 43. Six-minute walking test suppl. O2 suppl. O2 + NPPV P < 0 .0 0 1 85 P < 0 .0 0 1 110 80 100 90 70 P a O 2 (m m H g ) P a O 2 (m m H g ) PaO2 (mmHg) 75 65 60 55 80 70 60 50 50 45 m ean PaCO22 (mmHg) 50 BDS Walking distance (m) b e fo re a fte r P < 0.001 m ean 53 m ean 50 6 P < 0.001 209 P < 0.05 b e fo re a fte r N.S. m ean 51 4 252 Dreher M. et al. Eur Respir J 2007; 29: 930-936
  • 44. Rehab Rehab + NPPV Duiverman ML. et al. Thorax 2008; 63:1052-10
  • 45. ERS Congress 2008 in Berlin A randomised trial of home non-invasive ventilation vs. sham ventilation in survivors of acute hypercapnic respiratory failure in COPD. Chu CM et al. Eur Respir J 2008; 32(Suppl.52):38s. •42 COPD patients were randomised to receive either NPPV or sham ventilation following acute NIV • At days 120 patients were free of acute hypercapnic respiratory failure: • 81% NPPV group • 33% sham ventilation Nocturnal non-invasive positive pressure ventilation (NIPPV) in stable hypercapnic COPD patients – a randomized controlled trial. Funk GC et al. Eur Respir J 2008; 32(Suppl.52):37s. • 26 COPD patients received NIPPV over 6 months following mechanical ventilation on the ICU • After 6 months patients were randomised to stop NIPPV or to continue NPPV • Discontinuation of NIPPV caused clinical worsening (resumption of NPPV or ICU admission)
  • 46. NIV in Stable COPD: con
  • 47. Home NIV not recommended
  • 48. (Casanova et al Chest 2000;118:1582-90)
  • 49. Hospitalisation following NPPV-establishment LTOT: +27% NPPV + LTOT: -45% ICU-Admission n.s following NPPV-establishment LTOT: -20% NPPV + LTOT: -75% n.s Clini E. et al. Eur Respir J 2002; 20:529-538
  • 50. LTOT SURVIVAL NPPV THE ITALIAN MULTICENTRE STUDY ON NONINVASIVE POSITIVE PRESSURE VENTILATION IN COPD PATIENTS mesi Clini et al ERJ 2001
  • 51. COPD
  • 52. HOSPITAL ADMISSIONS Total hospital admissions (nr/pt/year) ICU admissions (nr/pt/year) 2 4 3,5 Follow-back 3 Follow-up 1,5 2,5 1 2 1,5 0,5 1 0,5 0 0 LTOT NPPV LTOT Clini et al ERJ 2001 NPPV
  • 53. Nocturnal NIPPV for at least three months in hypercapnic patients with stable COPD had no consistent clinically or statistically significant effect on lung function, gas exchange, respiratory muscle strength, sleep efficiency or exercise tolerance.
  • 54. Annane, D; Chevrolet, JC; Chevret, S; Raphael, JC Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database of Systematic Reviews. Issue 1, 2001 Current evidence about the therapeutic benefit of mechanical ventilation is weak, but consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term, and in two small studies survival was prolonged. Mechanical ventilation should be offered as a therapeutic option to patients with chronic hypoventilation due to neuromuscular diseases.
  • 55. IPS 15 cmH2O PEEP 3 cmH2O IPS 16 cmH2O PEEP 3 cmH2O v v
  • 56. K. Marquis et al. AJRCCM 2002; 166:809-813
  • 57. NORMAL Surface 118.5 cm2 COPD Surface 79.6 cm2 S. Bernard et al. AJRCCM 1998; 158:629-634
  • 58. Exercise in COPD patients: PSV reduces inspiratory effort Maltais et al. Am J Respir Crit Care Med, 1995; 151:1027
  • 59. PSV 10 cmH2O ( ) PSV 5 cmH2O ( ) van 't Hul et al ERJ 2006
  • 60. Lack of additional effect of adjunct of assisted ventilation to pulmonary rehabilitation in mild COPD patients L. Bianchi, K. Foglio, R. Porta, P. Baiardi, M. Vitacca, N. Ambrosino (% Peak Work rate) PAV 110 Training intensity 120 SB 100 90 80 70 60 50 40 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Training session (days) Respiratory Med, 2002; 96:359-367 “Assisted ventilation during training sessions…., was not well tolerated by all patients and gave no additional physiological benefit in comparison with exercise training alone.“
  • 61. No clinically or statistically significant effect on survival, hospital admission, lung function, respiratory muscle strength As an adjunct to exercise training in selected patients with severe COPD, NIV may produce modest additional improvements in exercise performance Future research should primarily focus on adequate patient selection and recognition of the mechanisms through which NIV may work
  • 62. Severe acute hypoxemic respiratory failure Severe AHRF  Often need ETI-IMV IMV   morbidity and mortality Main goal of NIV: Avoid ETI Avoidance of endotracheal intubation Improved morbidity and mortality? • Heterogeneous clinical condition • Results of studies on NIV unrelated to CPE are inconsistent
  • 63. Severe Community-Acquired Pneumonia Major criteria Minor criteria • 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 1 Major or 3 Minor Criteria Clin Infect Dis. 2007;44 Suppl 2:S27-S72 Pneumonia is associated with poor outcome in patients receiving NIV
  • 64. NIV in acute COPD: correlates for success N IV failure  Retrospective analysis  59 episodes of ARF in 47 COPD patients • NIV success: 46 • NIV failure: 13  Predictors for NIV failure: n=5 60 40 % 20 • Higher PaCO2 at admission • Worse functional condition • Reduced treatment compliance • Pneumonia p=0.019 n=8 0 O ther Pneum onia Ambrosino N. Thorax 1995;50:755-7
  • 65. NIV failure in acute hypoxemic respiratory failure • Eight ICUs • n=354: • Success: 246 • Failure: 108 Antonelli M. Intensive Care Med 2001; 27: 1718-28
  • 66. Non-invasive ventilation and pneumonia Conclusion:  Patients with pneumonia causing ARF and needing NIV are among those with worst outcome but, ….. is NIV effective in patients with pneumonia? ???
  • 67. NIV in severe community-acquired pneumonia  Prospective, randomised, controlled  Severe CAP (ATS criteria).  Standard treatment vs ST + NPPV. n: 28 + 28 = 56 In tu b atio n rate O verall population 60 p=0.03 N on-C O PD + N on-hypercapnia C O PD + H ypercapnia n=14 60 p = 0.005 n=6 p = 0.73 60 n=8 40 40 % 40 20 n=6 20 % n=6 20 n=0 0 0 N IV C ontrol N IV C ontrol 0 N IV C ontrol Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91
  • 68. NIV in severe community-acquired pneumonia  Shorter length of stay only in COPD patients with hypercapnia 2-m o n th m o rtality 60 p =0.05 p=N S n=5 60 n=6 % n=7 p =0.71 60 n=10 40 % N on-C O PD + N on-hypercapnia C O PD + H ypercapnia O verall population 40 20 40 n=1 n=5 20 20 0 0 N IV C ontrol N IV C ontrol 0 N IV C ontrol Confalonieri M. Am J Respir Crit Care Med 1999;160:1585-91
  • 69. CPAP in severe hypoxemic ARF  250 123 patients: 54% pneumonia, 34% cardiac disease • 34/62 CPAP + O2 • 33/61 O2 alone P aO 2 /F iO 2 C PA P + O 2 Intubation O 2 alone 200 p< 0.001 150 100 B aselin e 40 60' after R esp irato ry rate 30 p< 0.001 Delclaux C. JAMA 2000;284:2352 20 B aselin e 60' after
  • 70. NIV in severe AHRF: Intubation rate  Prospective, randomised, controlled, 3 centres  N=105. Pneumonia: 34 (32%) A LI/A R D S Pneum onia O verall population p = 0.467 100 100 p = 0.017 n= 11 80 80 p=0.010 % 60 40 60 100 60 40 n= 5 20 0 % 0 40 N IV n = 13 100 20 80 % 0 N IV C ontrol n= 6 80 20 n = 28 n= 8 C ontrol 100 C ardiogenic pulm onary edem a 80 60 p > 0.999 40 20 C ontrol Thoracic traum a p = 0.333 60 n= 5 40 n= 1 n= 2 0 Ferrer M et al. Am J Respir Crit Care Med 2003;168:1438 N IV 20 n= 1 0 N IV C ontrol N IV C ontrol
  • 71. NIV in severe AHRF: ICU mortality A LI/A R D S Pneum onia O verall population p = 0.569 100 100 p = 0.030 80 80 % p=0.028 40 n= 3 100 80 % 0 N IV C ontrol 60 60 20 C ontrol N IV 100 C ardiogenic pulm onary edem a 80 p > 0.999 40 20 n= 5 0 N IV n=9 n= 7 40 0 n = 21 20 n= 8 60 20 % 80 40 60 100 60 Thoracic traum a p = 0.515 40 n= 1 n= 2 0 20 C ontrol n= 3 n= 0 0 N IV C ontrol N IV C ontrol Ferrer M et al. Am J Respir Crit Care Med 2003; 168:1438
  • 72. NIV as an alternative to ETI in severe AHRF Intubated patients  Patients with ETI predefined criteria  NIV vs intubation+IMV ETI-IM V Patients w ith com plications 80 p < 0.05 p < 0.001 n= 11 N IV n= 32 0 20 40 60 80 100 % 30 n = 21 n=8 p < 0.01 60 % 40 N IV E T I-IM V 20 n = 12 (% ) 10 20 n=2 n=1 0 n=0 0 N IV E T I-IM V Pneum onia Sinusitis Antonelli M et al. N Engl J Med 1998;339:429-35
  • 73. NIV in immunosuppressed patients with pulmonary infiltrates and AHRF
  • 74. NIV in immunosuppressed patients with pulmonary infiltrates and ARF • Early administration of NIV: 26 NIV vs 26 control – Haematological + neutropenia (BMT, chemotherapy) – Immunosuppressor therapy (transplant, steroids) – AIDS Intubation 100 p = 0 .0 3 H o sp ital m o rtality 100 80 (% ) 80 60 60 40 40 20 20 0 p = 0 .0 2 0 N IV C o n tro l NIV vs control: • Faster improvement of hypoxemia • Less severe complications N IV C o n tro l Hilbert G. N Engl J Med 2001;344:481
  • 75. NIV in ARF after solid organ transplant • Solid organ transplant: lung, liver, renal • Incidence of ARF in postop. period: 21% • Patients: 20 NIV vs 20 control Intubation 100 p = 0 .0 0 2 IC U m ortality 100 p = 0 .0 5 NIV vs control: 80 (% ) 80 60 60 40 40 • Less severe complications 20 20 • Hospital mortality unchanged 0 0 N IV C o n tro l • Faster improvement of hypoxemia N IV C o n tro l Antonelli M. JAMA 2000;283:235
  • 76. NIV in AHRF: A systematic review • RCTs on standard treatment with and without NIV • Not due to cardiogenic pulmonary oedema Endotracheal intubation Absolute risk reduction: 23% (10-35%) Keenan S. Crit Care Med 2004;32:2516 ICU mortality Absolute risk reduction: 17% (8-26%) Trial results significantly heterogeneous
  • 77. Why is NIV more effective than CPAP in severe hypoxemic ARF?
  • 78. Physiologic effect of CPAP and NIV in ALIARDS  10 patients with indication for NIV  Short-term effects of: • CPAP 10 cmH2O • 2 combinations of NIV: PSV 10–PEEP 10; PSV 15-PEEP 5 R espiratory rate 34 PaO 2 /FiO 2 270 240 32 210 30 180 * 28 * 150 26 * 120 In it ia l PCPA 10 0 -1 0 V 1 5 -5 V1 PS PS F in al In it ia l P CPA -1 0 0 -1 0 V 1 5 -5 V1 PS PS F in al L’Her E. Am J Respir Crit Care Med 2005;172:1112-8
  • 79. CPAP and NIV in ALI-ARDS: Work of breathing, neuromuscular drive and dyspnea PTPdi 400 300 200 * * 100 In it ia l CPA P -1 0 0 -5 1 0 -1 S V 1 5 SV P P F in al P 0.1 4 3  PSV + PEEP is needed to reduce inspiratory muscle effort * 2 * 1 In it ia l P CPA -1 0 0 -1 0 V 1 5 -5 V1 PS PS F in al  CPAP improves oxygenation but fails to unload the respiratory muscles  PSV levels of 10 and 15 cmH2O provide similar L’Her E et al. unloading but differ in their effects on Am J Respir Crit Care Med 2005;172:1112-8 dyspnea
  • 80. Different efficacy of NIV in severe pneumonia (no hypercapnia, no COPD) 200 A rterial hypoxem ia 40 B aseline severity 25 100 15 20 10 50 10 0 0 Ferrer'03 80 60 % 20 30 C onfalonieri'99 ET Intubation 5 0 Ferrer'03 60 p<0.05 C onfalonieri'99 H ospital m ortality p<0.05 40 40 20 20 0 0 Ferrer'03 C onfalonieri'99 Ferrer'03 C onfalonieri'99 A P A C H E -II 150 S A P S -II P a O 2 /F iO 2 p=0.05 NIV G roup Control G roup
  • 81. Don’t forget contraindications for NIV  Need for immediate intubation: • • • • • Cardiac or respiratory arrest Respiratory pauses +  alertness + gasping Psychomotor agitation  sedation Massive aspiration Inability to manage secretions • • • • Severe non-respiratory organ failure Face surgery, trauma or deformity Upper airway obstruction Inability to cooperate/protect the airways  Other limitations for NIV: Am J Respir Crit Care Med 2001;163:283-91
  • 82. Ventilators for NIV: Not all are useful in each indication
  • 83. Summary  Lower likelihood to need ETI when NIV is added to standard medical treatment in severe AHRF  Effects of NIV on mortality are less evident  Different efficacy of NIV among different populations:  Pneumonia with severe hypoxemia and causing COPD exacerbation  The routine use of NIV in all patients with severe AHRF is not supported  CPAP: No evidences on benefits in AHRF (post-op excluded)  Facilities for close monitoring and rapid intubation are advised
  • 84. NIV in Acute Respiratory Failure CONTRA • Acute Respiratory Failure could have different pathophysiology • Clinical Studies does not reflect real life and exclude the more severly ill patients • NIV in hypoxemic patients cause potential harm, the risk-benefit-ratio is not positive ERS Postgraduate Course NIV Hannover 2009
  • 85. ERS Postgraduate Course NIV Hannover 2009
  • 86. Crit Care Med 2004; 32:2516 –2523 • Conclusion: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure. ERS Postgraduate Course NIV Hannover 2009
  • 87. NIV in Acute Respiratory Failure • Meta-Analysis of RCT of patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema • interventions compared noninvasive ventilation and standard therapy with standard therapy alone • outcomes included – need for endotracheal intubation, – length of intensive care unit or hospital stay – intensive care unit or hospital survival. Keenan SP. Crit Care Med 2004; 32:2516 –2523 ERS Postgraduate Course NIV Hannover 2009 Author Year No.of pts Wysocki 1995 41 Confalioneri 1999 33 (out of 56) Martin 2000 32 (out of 61) Antonelli 2000 31 (out of 40) Hilbert 2001 52 Ferrer 2003 75 (out of 105) Auriant 2001 48
  • 88. Risk of Endotracheal Intubation Keenan SP. Crit Care Med 2004; 32:2516 –2523 ERS Postgraduate Course NIV Hannover 2009 Length of ICU Stay
  • 89. ERS Postgraduate Course NIV Hannover 2009
  • 90. NIV in immunosuppressed patients • Randomized trial in 52 immunosuppressed patients with pulmonary infiltrates, fever and hypoxemic respiratory failure • Group A: Standard treatment (Antimicrobial agents, diuretics, bronchodilators, immunosuppressive agents, heparine s.c.) • Group B: Standard + NIPPV NIPPV Setting: Vt 7 ml/kg, PEEP til 10 cm H2O duration of NIPPV: at least 45 min. every 3 hours Hilbert G et al. N Engl J Med 2001; 344: 481-7 ERS Postgraduate Course NIV Hannover 2009
  • 91. NIV in immunosuppressed patients Outcome NIV Standard p RR Intubation 12/26 20/26 0.03 0.60 12 4 0.02 initial improve in pO2 / FiO2 sustained improve in pO2 / FiO2 death on ICU 13 5 0.02 10/26 18/26 0.03 0.56 death in hospital 13/26 21/26 0.02 0.62 Death in the hospit al Hilbert G et al. N Engl J Med 2001; 344: 481-7 ERS Postgraduate Course NIV Hannover 2009
  • 92. NIV in immunosuppressed patients • Exclusion Criteria – hemodynamic instability (RRsyst < 80 mmHg) – ECG: Ischemia or ventricular arrhythmia – cardiac failure – COPD – pCO2 > 55 mmHg, pH < 7.35 – multiorgan failure – deterioration in neurological status (GCS < 8) Hilbert G et al. N Engl J Med 2001; 344: 481-7 ERS Postgraduate Course NIV Hannover 2009
  • 93. Severe Hypoxemic Respiratory Failure Basic Disease Patient Demographics: • Pneumonia (34) • Cardiogenic Pulmonary Oedema (30) • Thoracic trauma (17) • ARDS (15) • others (9) Ferrer M, et al. Am J Respir Crit Care Med 2003;168:1438-1444 ERS Postgraduate Course NIV Hannover 2009
  • 94. NIV Failure Antonelli M. Intensive Care Med 2001;27:1718-28 100 120 80 100 No. of patients 70 80 60 50 60 40 30 40 20 20 10 0 ERS Postgraduate Course NIV Hannover 2009 Pu lmF ib r/PE Fibrosis ARDSe x p ARDSexp CAP CAP ARDSp ARDS p NP Nosok. Pneum Ate le c t Atelektasis In h PN Inhalation Pneuomitis Pu lmc o n t Thoracic trauma CPE CPE 0 Failure Rate in % 90
  • 95. NIV in transplantation patients • 40 pts. undergoing solid organ transplantation with acute respiratory failure • Design: prospective, randomised • Group A: Standard Therapy Group B: Standard Therapy + NIPPV • Primary Endpoint: Need for Endotracheal Intubation • Secondary Endpoint: ICU mortality, Length of ICU stay and ventilatory assistance Antonelli M. JAMA 2000; 283: 235-41 ERS Postgraduate Course NIV Hannover 2009
  • 96. NIV – Real Life • Evaluation of all 449 patients receiving NPPV for a 1-yr period for acute or acute on chronic respiratory failure – – – – – • • • • cardiogenic pulmonary edema (n = 97) AECOPD (n = 87) non-chronic obstructive pulmonary disease acute hypercapnic respiratory failure (n = 35) postextubation respiratory failure (n = 95) acute hypoxemic respiratory failure (n = 144) Intubation rate was 18%, 24%, 38%, 40%, and 60%, respectively, Hospital mortality for patients with acute hypoxemicrespiratory failure who failed NPPV was 64%. Variables associated with NPPV failure – – – – SAPS II (OR 1.07) Glasgow Coma Scale (OR, 0.76) PaO2/FIO2 ratio (OR, 0.98) serum albumin (OR, 0.30) Schettino G. Crit Care Med 2008; 36:441 –447 ERS Postgraduate Course NIV Hannover 2009
  • 97. Schettino G. Crit Care Med 2008; 36:441 –447 ERS Postgraduate Course NIV Hannover 2009
  • 98. Conditions associated with NIV failure in acute hypoxemic ARF ERS Postgraduate Course NIV Hannover 2009
  • 99. NIV in ARDS • • • • • • Prospective, multiple-center cohort study Three European intensive care units having expertise with NPPV 147 patients on NPPV NPPV improved gas exchange and avoided intubation in 79 patients (54%) Avoidance of intubation was associated with – – • Intubation was more likely – – – • less VAP (2% vs. 20%) lower ICU mortality rate (6% vs. 53%) in patients who were older had a higher SAPS II needed a higher level of PEEP and PSV SAPS II >34 and a PaO2/FIO2 <175 after 1 hr of NPPV were independently associated with NPPV failure and need for ETI Antonelli M. Crit Care Med 2007; 35:18 –27 ERS Postgraduate Course NIV Hannover 2009
  • 100. Postextubation ARF • • • • Randomised, controlled study 37 centres, 8 countries MV < 48h Respiratory Failure in between 48 h after extubation • NIV – Vt 5ml/kg BW – Goal: SaO2 > 90% • Vs. Standardtherapie – O2-Insufflation – Physiotherapy Esteban A. NEJM 2004; 350: 2452-60 ERS Postgraduate Course NIV Hannover 2009
  • 101. Postextubation ARF Mortality 25 % (NIV) vs. 14 % (O2) RR for death for NIV 1,78 (95% CI 1,03 – 3,20) ERS Postgraduate Course NIV Hannover 2009 Esteban A. NEJM 2004; 350: 2452-60
  • 102. Non invasive Ventilation in ALI • Prospective cross over study • 10 pts. with acute lung injury – paO2/FiO2 < 300 mmHg (mean 132, PCO2 41 mmHg) – SaO2> 92% under NIV – RRsyst > 90 mmHg • Objective: To assess the short term efffects of non invasive ventilation and CPAP L´Her E. AJRCCM 2005; online August 4 ERS Postgraduate Course NIV Hannover 2009
  • 103. Non invasive Ventilation in ALI • Prospective cross over study • 10 pts. with acute lung injury – paO2/FiO2 < 300 mmHg (mean 132, PCO2 41 mmHg) – SaO2> 92% under NIV – RRsyst > 90 mmHg • Objective: To assess the short term efffects of non invasive ventilation and CPAP L´Her E. AJRCCM 2005; online August 4 ERS Postgraduate Course NIV Hannover 2009
  • 104. ARMA trial - major outcome parameters ARMA trial, 2000 NEJM 342:1301, ERS Postgraduate Course NIV Hannover 2009
  • 105. ALVEOLI trial - outcome ALVEOLI trial, 2004 NEJM 351:327, ERS Postgraduate Course NIV Hannover 2009
  • 106. NIV in ARDS Antonelli M. Crit Care Med 2007; 35:18 –27 ERS Postgraduate Course NIV Hannover 2009
  • 107. ILA in ARDS • Retrospective analysis of extracorporal interventional lung assist (ILA) • 90 pts. with ARDS in a tertiary university center • Before, 2 and 24 hrs after implementation – – – – Improvement in Oxygen Normalisation of pCO2 73 of 90 pts. survived Complication Rate 24.4% Bein T. CCM 2006: 34: 1372-77 ERS Postgraduate Course NIV Hannover 2009
  • 108. ILA in Postoperative ARDS • 7 Patients with postoperative ARDS in Barcelona, Spain – 5 pneumonectomy – 2 lobectomy • 29% of CO perfuse ILA • No Change in Hemodynamics • Improvement in Respiratory Function • Decrease in Il-6 • 6 of 7 pts. survived in comparision to 2 of 9 in a historical cohort Iglesias M. Ann Thorac Surg 2008: 85: 237-44 ERS Postgraduate Course NIV Hannover 2009

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