physiological changes in heart failure in posistive pressure ventiation

1. VENTILATION IN ACUTE HEART
FAILURE

2. Definition
2013 ACCF/AHA Guideline for the Management of Heart Failure

3. Classification of Heart Failure
2013 ACCF/AHA Guideline for the Management of Heart Failure

5. Diagnostic Criteria
Eur J of Heart Failure 2012; 14; 803-869
Eur Heart Journal 2012; 33; 1787-1847

6. Symptoms & Signs
Eur J of Heart Failure 2012; 14; 803-869
Eur Heart Journal 2012; 33; 1787-1847

7. Diagnosis
• History and Physical examination
• Blood Investigations
CBC, RFT, LFT, S. ELECTROLYTES (LOE C)
• Cardiac biomarkers – Diagnostic and prognostic
BNP/ NT Pro BNP (LOE A)
2013 ACCF/AHA Guideline for the Management of Heart Failure

8. Non Invasive Cardiac Imaging
2013 ACCF/AHA Guideline for the Management of Heart Failure

9. Pathophysiology

10. Sequence of events

11. GOALS OF TREATMENT

12. Treatment algorithm
Eur J of Heart Failure 2012; 14; 803-869
Eur Heart Journal 2012; 33; 1787-1847

13. HEART LUNG INTERACTION

14. Fink.. Textbook of criti care; 5th
Edition; 536-537

15. Fink.. Textbook of criti care; 5th
Edition; 536-537

16. ITP
NIV
FRC
RV
preload
LV
afterload PaO2
WOB
CARDIAC PERFORMANCE
PULMONARY CONGESTION
↓ Negative Pleural Pressure
↓ Resp. Muscle O2 Demand
Effects of NIV

17. Indications
• CPAP/NIV are recommended in addition to standard medical
treatment in cases of cardiogenic pulmonary edema (Level 1)*
• CPAP/NIV are equally effective in cardiogenic pulmonary edema
(Level I)*
• Preferable in associated hypercapnic respiratory failure (Level 2)
• CPAP or PS + PEEP has been shown improvement in arterial
blood gases, respiratory frequency and reduction in
endotracheal intubation rate
•NIV guideline ;ISCCM; 2013
•*Sean P et al CMAJ 2011; 183; E 195-214

18. Indications
• CPAP vs BIPAP - both to be equally effective in the treatment
of acute cardiogenic pulmonary edema*
• CPAP/BIPPA does not increase rate of myocardial infarction**
*Chadda K et al CCM 2002; 30: 2457-2461
*Bellone A et al CCM 2004; 32: 1860-1865
•**Mehta S et al ICM 2005; 31; 757-9

19. Contraindications
•Inability to protect airway
•Comatose, confused, agitated, bulbar weakness
•Hemodynamic instability
•Inability to fix interface
•Non co-operative patient
•Severe GI symptoms
•Severe hypoxia
•Copious secretions
•No proven indications
•Lack of trained persons
•NIV guideline ;ISCCM; 2013

20. Initial settings
EPAP
•Same as PEEP / CPAP
•Needed for proper trigger, prevent atelectasis, reduce
mechanical dead space
•Start with 4-5cm, watch patient & ventilator, trigger
•Gradually increase by 1-2cm
•Increase IPAP also by same value, maintain driving pressure
IPAP
•Not same as PS, IPAP is PAP, IPAP minus EPAP is PS
•In ICU ventilator PS plus PEEP is PAP
•Start with 8-10cm, gradually increase till target TV

21. Other Settings
•Rise time
•Ramp
•Trigger
•Alarms
•Ti min & max
•Explain to patient

22. Monitoring during NIV
•Look at patient, ventilator, interface, bed side monitor, ABG
•patient – Comfort, conscious level
•Chest expansion
•Accessory muscles
•Synchrony
•Interfaces – leak, tightness
•Trigger, volume delivered, cycling
•HR, RR, SpO2, BP
•ABG – pCO2, pH, pO2
at base line, 1-2hrs after, then based on response

23. Complications
• Delay in intubation and worsening of prognosis
• Major desaturation and cardiac arrest
• Aspiration – 5%
• Hypotension
• Pneumothorax - if pressure >25 in bulla & # ribs
• Severe hypotension – In patients with hypovolemia and right
heart involvement

24. Invasive Ventilation
• Patient is not improoving for next 2-3 hours
• Worsening hypoxia
• Worsening Shock
• Worsening WOB
• Contraindication for NIV

25. Invasive Ventilation
- Different modes of ventilator (VCV, PCV, IRV etc)*
No difference in Cardiac Output if Tidal Volume and PEEP
are at same level
- No difference between total or partial ventilatory mode*
- Usually PEEP is high (same as EPAP/CPAP)
- Lung protective ventilation**
“There is increasing and convincing evidence that the
use of lower tidal volumes during mechanical ventilation of
patients without ARDS prevents against ventilator-induced lung
injury”
**Arya Serpa et al Curr Opin Crit Care 2015; 21; 65-73
*Fink.. Textbook of criti care; 5th
Edition; 536-537

26. Effect of weaning on CV
Spontaneous breathing
decreases intrathoracic
pressure
Reduced trans-mural
pressure increases
LV afterload
LV Failure
Increased
Oxygen extraction
Venous
desaturation
Hypoxia
Pulmonary
hypertension
RV Failure
Anesthesiology 1988; 69:171–179
AJRCCM 1998;158:1763–1769.
Chest 2001; 120:375S–395S

27. Weaning
• Extubation to NIV is preferable with other cardiac support like
Dobutamine
• NIV can be recommended in patients after extubation who
have a high risk of developing respiratory failure and
reintubation (age>65 yrs, APACHE II>12at the time of
extubation, cardiac failure at the time of intubation
(Level I)(reduce extubation failure but reintubation rate was
nonsignificant)
Ferer M et al Am. J.Resp.Crit. Care Med 2006; 173:164-170

28. NIV & Weaning
Effective
when used
prophylactically
in selected
patients
post-extubation;
COPD
Elderly
High APACHE
APE as cause
Sampath S,
ESICM abstract 2007
NIV better NIV worse
Jiang-1999
Nava-2005
Ferrer-2006
AA El Solh- 2006

29. NIV in Chronic Heart
Failure
• CPAP in chronic heart failure*
- Improve LV function
- Alleviate symptoms of CHF
- Improve oxygenation
- Reduce sleep related breathing disorder**
• Incidence of Obstructive and Central sleep apnea are high in patients
with chronic heart failure ***
• CPAP vs Adaptive Servo Ventilation - ?? Both are equal
*Sunil Nadar et al Int J Cardiology 2005; 99; 171-185
**Arzt M et al Chest 2005; 127; 794-802
***Owen D at el Canadian J Cardiology 2015 31: 898-908
***Tadamitsu et al J Cardiac Failure 2014: 20: 152-152

30. • For more information on HEART LUNG
INTERACTION please visit…
www.heart_lung.org