Recent Advances in NIV
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
ERS National Delegate of ...
NPPV: definition
Any form of ventilatory support applied without
the use of an endotracheal tube considered to
include:
*C...
Ventilators for NIV: Not all are
useful in each indication
Standard interfaces
Facial masks
advantages:
– sufficient ventilation also
during mouth breathing
– sufficient ventilation...
Nasal masks
advantages:
– better comfort
– good seal
– coughing is possible
– communication is possible
disadvantages:
– e...
Nasal prong/nasal pillow systems
for patients with
claustrophobia
for patients with allergies
against straps
for low to mo...
total-face masks
• Safe interface for acute respiratory
insufficiency with high pressures
• well tolerated by the patients...
helmet
• well tolerated by the patient
• no direct contact to the skin of
the face
• large dead space
• may influence the ...
mouthpieces
• simple and cheap
• short-interval alternative
interface for long-term
ventilated patients
Custom-made masks
...
Physiologic evaluation of three
different interfaces
cohort: 26 stable patients with hypercapnic COPD or interstitial lung...
*COPD
*Obesity
*Neuromuscular disease & chest
wall deformity
Rationale for ventilatory assistance
 Respiratoryload
 Respiratorymuscles
capacity
Alveolar hypoventilation
 PaO2 and ...
Mechanical ventilation unloads the
respiratory muscles
Respiratory load Respiratory muscles
Mechanical
ventilation
NIV - Meta-analysis (n=8)
NPPV resulted in
– decreased mortality ,
– decreased need for ETI .
Greater improvements within ...
NIV v invasive ventilation
In the NPPV group, 48% patients avoided
intubation, survived, and had a shorter
duration of ICU...
YONIV Study - outcome by enrolment
pH
0
10
20
30
40
50
pH < 7.3 pH >= 7.3
Con fail
NIV fail
Con died
NIV died
Plant et al ...
Change in practice over time
1992-1996 (mean pH = 7.25+/-0.07) 1997-1999
(7.20+/-0.08; P<0.001).
> 1997 - risk of failure ...
Late failure
n=137 Acute exacerbations of COPD
23% deteriorated after 48 hours
Late failure predicted by low ADL scores,
p...
Neuromuscular disease / scoliosis
Hypercapnia
Normocapnia with reduced vital capacity and
tachypnoea
Don’t forget
– Upper ...
NIV – when and where?
COPD – designated NIV service
– pH < 7.35
– pH < 7.30
Neuromuscular disease / chest wall deformity
–...
THE RATIONALE
LV failure
Pulmonary
edema

Pulmonary
compliance
 Airway
resistance
 Negative
Intrathoracic
Pressure
Swing

Work of
br...
LV failure
Pulmonary
edema
 Pulmonary
compliance
 Airway
resistance
 Negative
Intrathoracic
Pressure
Swing
 LV
transmu...
Rasen et al: Chest 1985; 87: 158-162
Negative intrathoracic pressure swings during CPE
Pes
(cmH20)
0
-20
IntraThoracicPressure
and
LV function
AO
LV
ITP  effort =  ITP = Ptm

 LV afterload
100
-20
Ptm = 100-(-20) = 120
CPAP IN CPE
Rasen et al: Chest 1985; 87: 158-162
Pes
(cmH20)
0
-20
Spontaneous breathing CPAP 15 cmH20
IntraThoracicPressure
and
LV function
AO
LV
ITP  effort =  ITP =  Ptm

 LV afterload
100
-5
Ptm = 100-(-5) = 105
Rationale of positive pressure
ventilation in CPE
Positive Pressure
 ITP  FRC
Pre-load
 Venous return
 LVafterload
 ...
Intervention
*Standard nitrate, diuretic and opioid therapy
*Consent + Randomised for 2 hours to:
-Standard oxygen therapy...
Randomised n = 1156
Treated
n = 367
7 day
n = 367
Treated
n = 346
7 day
n = 343
Treated
n = 356
30 day
n = 352
30 day
n = ...
Mortality (Oxygen alone vs NIV)
1.0
0.9
0.8
0 10 20 30
Days
Cumulative
Survival
Standard
Oxygen Therapy
Non-invasive
Venti...
Primary Outcome: Mortality
Standard
Therapy
Non-
Invasive
Ventilation
OR 95% CI P Value
7-Day 9.8% 9.5% 0.97 0.63 -
1.48
0...
Standard NIV
Patients, n= 13 13
PaO2/FiO2 ratio
Baseline 155 143
Bronchoscopy 139 261
1 hour after 140 176
Antonelli et al...
Intensive Care Med 2003; 29:126-129
Chest 1997; 112:1466-1473
ACUTE AND CHRONIC NPPV
IN CHILDREN
Brigitte Fauroux
Pediatric Pulmonology & Research unit INSERM U 719
Armand Trousseau Ho...
Interface adapted
for the child
Conclusion
 NPPV represents a logical therapeutic option in
disorders characterised by alveolar hypoventilation
– Neuromu...
ERS School Course
“Noninvasive Positive Pressure Ventilation”
Hanover, Germany
13. Feb. 2009
NIV in weaning: based on and ...
Non-invasive ventilation in
acute hypoxic respiratory
failure: Pro
Hanover, 13th February, 2009
Miquel Ferrer, MD
RIICU, D...
Severe Community-Acquired Pneumonia
Clin Infect Dis. 2007;44 Suppl2:S27-S72
1 Major or 3 Minor Criteria
Pneumonia is assoc...
NIV in acute COPD: correlates for
success
AmbrosinoN. Thorax1995;50:755-7
NIV failure
Other Pneumonia
%
0
20
40
60
n=8
p=0...
NIV failure in acute hypoxemic respiratory
failure
AntonelliM. Intensive Care Med 2001; 27:
• Eight ICUs
• n=354:
• Succes...
Non-invasive ventilation and
pneumonia
but, …..
is NIV effective in patients with pneumonia?
???
Conclusion:
Patients with...
NIV in severe community-acquired
pneumonia
 Prospective, randomised, controlled
 Severe CAP (ATS criteria).
 Standard t...
Improving
End-Of-Life Care
Decision-making
In the ICU
Palliation
of symptoms
Dyspnea
Management
NIV in Palliation and Onco...
Don’t forget contraindications for
NIV
Am J Respir Crit Care Med 2001;163:283-91
Need for immediate intubation:
Cardiac or...
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
Recent advances in NIV
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Recent advances in NIV

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Recent advances in NIV

  1. 1. Recent Advances in NIV Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University ERS National Delegate of Egypt
  2. 2. 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
  3. 3. Ventilators for NIV: Not all are useful in each indication
  4. 4. 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)
  5. 5. Nasal masks advantages: – better comfort – good seal – coughing is possible – communication is possible disadvantages: – effective in nose breathing only – good co-operation is necessary Standard interfaces
  6. 6. Nasal prong/nasal pillow systems for patients with claustrophobia for patients with allergies against straps for low to moderate pressures only (< 20 cmH2O) Standard interfaces
  7. 7. total-face masks • Safe interface for acute respiratory insufficiency with high pressures • well tolerated by the patients Standard interfaces
  8. 8. 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 Standard interfaces
  9. 9. mouthpieces • simple and cheap • short-interval alternative interface for long-term ventilated patients Custom-made masks • for long-term ventilation • if standard masks are not tolerated Standard interfaces
  10. 10. 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 facial mask / nasal mask / nasal prongs 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
  11. 11. *COPD *Obesity *Neuromuscular disease & chest wall deformity
  12. 12. Rationale for ventilatory assistance  Respiratoryload  Respiratorymuscles capacity Alveolar hypoventilation  PaO2 and  PaCO2 Abnormal ventilatorydrive
  13. 13. Mechanical ventilation unloads the respiratory muscles Respiratory load Respiratory muscles Mechanical ventilation
  14. 14. NIV - Meta-analysis (n=8) NPPV resulted in – decreased mortality , – decreased need for ETI . Greater improvements within 1 hour in – pH . – PaCO2 . – RR . Complications associated with treatment and length of hospital stay were also reduced with NPPV Lightowler, Elliott, Wedzicha& Ram BMJ 2003;326:185
  15. 15. NIV v invasive ventilation In the NPPV group, 48% patients avoided intubation, survived, and had a shorter duration of ICU stay than intubated patients (p=0.02). One year following hospital discharge, the NPPV group had fewer patients readmitted to the hospital (65% vs. 100%; p = 0.016) or requiring de novo permanent oxygen supplementation (0% vs. 36%; p < 0.01). Conti et al Intensive Care Med 2002; 28:1701
  16. 16. YONIV Study - outcome by enrolment pH 0 10 20 30 40 50 pH < 7.3 pH >= 7.3 Con fail NIV fail Con died NIV died Plant et al Lancet 2000; 355:1931-5
  17. 17. Change in practice over time 1992-1996 (mean pH = 7.25+/-0.07) 1997-1999 (7.20+/-0.08; P<0.001). > 1997 - risk of failure pH <7.25 three fold lower than in 1992-1996. > 1997 ARF with a pH >7.28 were treated in Medical Ward (20% vs 60%). Daily cost per patient treated with NIV (€558+/- 8 vs €470+/-14,P<0.01) Carlucci et al Intens Care Med 2003; 3:419-25
  18. 18. Late failure n=137 Acute exacerbations of COPD 23% deteriorated after 48 hours Late failure predicted by low ADL scores, pH and co-morbidity at admission Moretti et al Thorax 2000; 55:819-25
  19. 19. Neuromuscular disease / scoliosis Hypercapnia Normocapnia with reduced vital capacity and tachypnoea Don’t forget – Upper airway – Aspiration – Occult cardiac disease – Secretion management (cough assist)
  20. 20. NIV – when and where? COPD – designated NIV service – pH < 7.35 – pH < 7.30 Neuromuscular disease / chest wall deformity – hypercapnia – reduced VC with normal CO2 – Will usually require long term domiciliary NIV Obesity – Hypercapnia with acidosis (probably as for COPD) – NIV success - consider switch back to CPAP (or no ventilatory support)
  21. 21. THE RATIONALE
  22. 22. LV failure Pulmonary edema  Pulmonary compliance  Airway resistance  Negative Intrathoracic Pressure Swing  Work of breathing  CO  PaO2 Respiratory muscle fatigue  DaO2 +  PaCO2
  23. 23. LV failure Pulmonary edema  Pulmonary compliance  Airway resistance  Negative Intrathoracic Pressure Swing  LV transmural pressure  O2 Cost of breathing  LV afterload +
  24. 24. Rasen et al: Chest 1985; 87: 158-162 Negative intrathoracic pressure swings during CPE Pes (cmH20) 0 -20
  25. 25. IntraThoracicPressure and LV function AO LV ITP  effort =  ITP = Ptm   LV afterload 100 -20 Ptm = 100-(-20) = 120
  26. 26. CPAP IN CPE Rasen et al: Chest 1985; 87: 158-162 Pes (cmH20) 0 -20 Spontaneous breathing CPAP 15 cmH20
  27. 27. IntraThoracicPressure and LV function AO LV ITP  effort =  ITP =  Ptm   LV afterload 100 -5 Ptm = 100-(-5) = 105
  28. 28. Rationale of positive pressure ventilation in CPE Positive Pressure  ITP  FRC Pre-load  Venous return  LVafterload  PTM  PaO2  WOB  Cardiac performance  pulmonary congestion
  29. 29. 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
  30. 30. Randomised n = 1156 Treated n = 367 7 day n = 367 Treated n = 346 7 day n = 343 Treated n = 356 30 day n = 352 30 day n = 348 30 day n = 325 30 day n = 344 Patient Withdrawal n = 0 Patient Withdrawal n = 3 Patient Withdrawal n = 4 Patient Withdrawal n = 1 Refused Retrospective consent n = 18 Patient Withdrawal n = 4 Refused Retrospective consent n = 14 Patient Withdrawal n = 1 Refused Retrospective consent n = 17 Potentially eligible n = 1874 Refused initial consent n=68 Too sick to consent n=125 Unable to consent n=18 Clinician choice n=23 Known previous randomisation n=32 No equipment n=15 Randomisation service problem n=33 Other n=41 Screened n = 1511 Recruited n = 1069 Protocol Violations n=44 Duplicates n=43
  31. 31. Mortality (Oxygen alone vs NIV) 1.0 0.9 0.8 0 10 20 30 Days Cumulative Survival Standard Oxygen Therapy Non-invasive Ventilation P=0.685
  32. 32. Primary Outcome: Mortality Standard Therapy Non- Invasive Ventilation OR 95% CI P Value 7-Day 9.8% 9.5% 0.97 0.63 - 1.48 0.869 30- Day 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. 33. Standard NIV Patients, n= 13 13 PaO2/FiO2 ratio Baseline 155 143 Bronchoscopy 139 261 1 hour after 140 176 Antonelli et al, Chest 2002; 121: 1149 Indication: Pneumonia
  34. 34. Intensive Care Med 2003; 29:126-129
  35. 35. Chest 1997; 112:1466-1473
  36. 36. ACUTE AND CHRONIC NPPV IN CHILDREN Brigitte Fauroux Pediatric Pulmonology & Research unit INSERM U 719 Armand Trousseau Hospital Paris - France Noninvasive Positive Pressure Ventilation ERS School Courses Pisa - Italy - 2005 Inserm Institut national de la santé et de la recherche médicale
  37. 37. Interface adapted for the child
  38. 38. Conclusion  NPPV represents a logical therapeutic option in disorders characterised by alveolar hypoventilation – Neuromuscular disorders – Dynamic upper airway obstruction – Cystic fibrosis – Hypoxic RF, cardiogenic pulmonary edema ?  Future research – Define the criteria for starting NPPV and the benefit of NPPV in children • in the acute and chronic setting • according to the underlying disease – Improve the ventilators and interfaces – Evaluate the long term benefit of NPPV in childen
  39. 39. ERS School Course “Noninvasive Positive Pressure Ventilation” Hanover, Germany 13. Feb. 2009 NIV in weaning: based on and beyond studie Prof. Dr. B. Schönhofer
  40. 40. Non-invasive ventilation in acute hypoxic respiratory failure: Pro Hanover, 13th February, 2009 Miquel Ferrer, MD RIICU, Dept. Pneumology, Hospital Clínic, IDIBAPS, CibeRes, Barcelona, Spain. miferrer@clinic.ub.esmail:-E
  41. 41. Severe Community-Acquired Pneumonia Clin Infect Dis. 2007;44 Suppl2:S27-S72 1 Major or 3 Minor Criteria Pneumonia is associated with poor outcome in patients receiving NIV *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 Minor CriteriaMajor Criteria
  42. 42. NIV in acute COPD: correlates for success AmbrosinoN. Thorax1995;50:755-7 NIV failure Other Pneumonia % 0 20 40 60 n=8 p=0.019 n=5 Retrospective analysis 59 episodes of ARF in 47 COPD patients NIV success: 46 NIV failure: 13 Predictors for NIV failure: Higher PaCO2 at admission Worse functional condition Reduced treatment compliance Pneumonia
  43. 43. NIV failure in acute hypoxemic respiratory failure AntonelliM. Intensive Care Med 2001; 27: • Eight ICUs • n=354: • Success: 246 • Failure: 108
  44. 44. Non-invasive ventilation and pneumonia but, ….. is NIV effective in patients with pneumonia? ??? Conclusion: Patients with pneumonia causing ARF and needing NIV are among those with worst outcome
  45. 45. NIV in severe community-acquired pneumonia  Prospective, randomised, controlled  Severe CAP (ATS criteria).  Standard treatment vs ST + NPPV. n: 28 + 28 = 56 ConfalonieriM. Am J Respir Crit Care Med 1999;160:1585-91 Overall population NIV Control % 0 20 40 60 p=0.03 n=6 n=14 COPD + Hypercapnia NIV Control % 0 20 40 60 Non-COPD + Non-hypercapnia NIV Control 0 20 40 60 n=0 n=6 n=6 n=8 p=0.005 p=0.73 Intubation rate
  46. 46. Improving End-Of-Life Care Decision-making In the ICU Palliation of symptoms Dyspnea Management NIV in Palliation and Oncology
  47. 47. Don’t forget contraindications for NIV Am J Respir Crit Care Med 2001;163:283-91 Need for immediate intubation: Cardiac or respiratory arrest Respiratory pauses +  alertness + gasping Psychomotor agitation  sedation Massive aspiration Inability to manage secretions Other limitations for NIV: Severe non-respiratory organ failure Face surgery, trauma or deformity Upper airway obstruction Inability to cooperate/protect the airways

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