Downloaded 121 times
![Am J Respir Crit Care Med 1999;160:1585-15
*
PaCO2 [mmHg]
Intubation [%]
ICU – length of stay [d]
2-Mo-moratliy [%]
NIV Standard
73
0
<1
11
68
55
8
63
32
38
3
43
34
47
5
33
NIV Standard
*p < 0.05
COPD (n = 23) Non-COPD (n = 33)
* *
*
* *](https://image.slidesharecdn.com/nivinacuesettings-160924232947/75/NIV-in-Acute-settings-45-2048.jpg)
Uploaded byGamal Agmy
NIV in Acute settings
1) NIV is effective for acute hypercapnic respiratory failure caused by COPD exacerbations to prevent intubation and reduce mortality. 2) NIV is most effective when started early in respiratory failure before severe acidosis develops. It improves blood gases and respiratory status within 1-2 hours. 3) While NIV success rates are high initially, late failure can still occur in around 23% of patients and is associated with increased mortality if intubation is then required. Close monitoring is needed.
More Related Content
Similar to NIV in Acute settings
NIV in Acute settings
- 2. NIV in AcuteSettings Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
- 5. Rationale for ventilatoryassistance Respiratoryload Respiratorymuscles capacity Alveolar hypoventilation PaO2 and PaCO2 Abnormal ventilatorydrive
- 6. Mechanical ventilation unloadsthe respiratory muscles Respiratory load Respiratory muscles Mechanical ventilation
- 12. Severe Mild To moderate Not established COPD exacerbation Post-extubation COPD exacerbation Hypoxemic Post-extubation COPD Exacerbation Hypoxemic Weaning DNI order Meaning of NIVuse ARF Severity TO PREVENT TO AVOID ETI ALTERNATIVE to ETI
- 13. 300 250 200150 100 50 Low Tidal Volume Ventilation Higher PEEP HFO Prone Positioning ECMO Low – ModeratePEEP Neuromuscular Blockade PaO2/FiO2 Increasing Severity of Lung Injury Mild ARDS Moderate ARDS Severe ARDS IncreasingIntensityofIntervention NIV ECCO2-R iNO The case of ARDS
- 14. Ventilators for NIV:Not all are useful in each indication
- 15. 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)
- 16. Nasal masks advantages: – bettercomfort – good seal – coughing is possible – communication is possible disadvantages: – effective in nose breathing only – good co-operation is necessary Standard interfaces
- 17. Nasal prong/nasal pillowsystems for patients with claustrophobia for patients with allergies against straps for low to moderate pressures only (< 20 cmH2O) Standard interfaces
- 18. total-face masks • Safeinterface for acute respiratory insufficiency with high pressures • well tolerated by the patients Standard interfaces
- 19. helmet • well toleratedby 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
- 20. mouthpieces • simple andcheap • short-interval alternative interface for long-term ventilated patients Custom-made masks • for long-term ventilation • if standard masks are not tolerated Standard interfaces
- 21. Physiologic evaluation ofthree 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
- 23. The respiratory System LungsRespiratory Pump Pulmonary Failure • PaO2 • PaCO2 N/ Ventilatory Failure • PaO2 • PaCO2 Hypoxic Respiratory Failure Hypercapnic Respiratory Failure
- 24. Lungs Respiratory Pump Pulmonary Failure • PaO2 •PaCO2 N/ Ventilatory Failure • PaO2 • PaCO2 Hypoxic Respiratory Failure Hypercapnic Respiratory Failure The respiratory System
- 25. CNS breathing center 1. motorneuron PNS 2. motor neuron Motor endplate neuromuscular junction Inspiratory respiratory muscles Rib cage Pleural pressure Alveolar pressure INSPIRATION Respiratory pump
- 26. CNS breathing center 1. motorneuron PNS 2. motor neuron Motor endplate neuromuscular junction Inspiratory respiratory muscles Rib cage Pleural pressure Alveolar pressure INSPIRATION Respiratory drive disturbances Neuromuscular disorders ALS, Myasthenia gravis, Duchenne Muscular Dystrophy, myopathy Mechanical disturbances hyperinflation, rib cage deformities Thoracic instability Reduced compliance Increased airway resistance
- 27. Jolley CJ andMoxham J. Eur Respir Rev 2009; 18:112,1-14
- 28. • Diaphragm flattening •Diaphragm prestretching • Systemic involvement • Inflammation • Steroids • VIDD • Co-morbidities • Heart failure • Pulmonary hypertension • Diabetes • Shortening of inspiration • Airway obstruction • Dynamic hyperinflation • Intrinsic PEEP • Thoracic prestretching • Increased ventilatory demand • pulmonary failure • anemia • heart failure COPD Jolley CJ and Moxham J. Eur Respir Rev 2009; 18:112,1-14
- 29. Evans TW. IntensiveCare Med 2001; 27:166-178
- 30.
- 31. NIV success within 1-2 hours ? Improveme nt forseveral days ? Weaning from NIV Spontaneou s breathing NIV Start NIV in acute hypercapnic failure - successful intervention
- 32. Rationale for Non-invasive Ventilation(NIV) to improve respiratory function and symptoms • blood gases • dyspnea • respiratory rate to avoid intubation and related complications • ventilator-associated pneumonia (VAP) - i.e. tube associated pneumonia • local complications related to tube (early & late) • complications related to catheterization • tracheostomy and weaning failure to improve outcome • to reduce length of ICU and hospital stay • mortality
- 33. NIV: Further advantages Intermittentapplication Improved clearance of secretion Communication Swallowing No or mild sedation
- 34. NIV = MECHANICALVENTILATION ! RATIONALE : NIV improves oxygenation Antonelli et al. NEJM 1998; 339:429-35 NIV increases VT and unloads diaphragm Brochard et al. Am Rev Respir Dis 1989; 139:513-2
- 35. NIV decreases nosocomialinfections Girou E, Schortgen F, Delclaux C, et al. JAMA 2000, 284, 2361-7
- 37. Level Pathophysiology High (several RCT) COPDExacerbation Acutecardiogenicfailure Weaning & Postextubation faulire in COPD Medium Asthma bronchiale Cysticfibrosis Avoiding extubation failure Do-not-intubateorder Low ARDS (Acuterespiratorydistress syndrome) NIV in acute hypercapnic failure Level of evidence
- 38. NIV IN ACUTEHYPERCAPNIC FAILURE CAUSED BY COPD
- 39. MORTALITY OF PATIENTSWITH COPD REQUIRING INVASIVE MECHANICAL VENTILATION FOR ACUTE RESPIRATORY FAILURE study year In-hospital Mortality, % Knaus 1989 42 Stauffer et al 1993 33 Rieves et al 1993 43 Seneff et al 1995 32 Brochard et al 1995 29 Corrado et al 1998 27 Hill et al 1998 49
- 40. NIV bei AE-COPD Behandlungvon 8 Patienten, um 1 Leben zu retten BMJ 2003, 25; 326: 185
- 41. Lightowler JV. etal. BMJ 2003; 326:185- • NIV prevents intubation (NNT = 5) • NIV reduces mortality (NNT = 8) NNT = number needed to treat
- 42. META-ANALYSIS (N=8) • NIVresulted in – decreased mortality (RR 0.41; 95% CI 0.26, 0.64), – decreased need for ETI (RR 0.42; 95%CI 0.31, 0.59) • Greater improvements within 1 hour in – pH (WMD 0.03; 95%CI 0.02, 0.04), – PaCO2 (WMD -0.40 kPa; 95%CI -0.78, - 0.03), – RR (WMD –3.08 bpm; 95%CI –4.26, -1.89). • Complications associated with treatment (RR 0.32; 95%CI 0.18, 0.56) and length of hospital stay were also reduced with NPPV (WMD – 3.24 days; 95%CI –4.42, -2.06) Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185
- 43. Lightowler JV. etal. BMJ 2003; 326:185- 189 Conclusions NIV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients. NIV should be tried early in the course of respiratory failure and before severe acidosis, to reduce mortality, avoid endotracheal intubation, and decrease treatment failure. first line pH: 7.20–7,35 Improves outcome NIV:
- 44. Confalonieri, et al.AJRCCM 1999; 160: 1585-1591 • 56 Pats with Pneumonia • 23 COPD - 33 non-COPD • Prospektive RCT: - PSV + Standard-treatment - O2 + Standard-treatment
- 45. Am J RespirCrit Care Med 1999;160:1585-15 * PaCO2 [mmHg] Intubation [%] ICU – length of stay [d] 2-Mo-moratliy [%] NIV Standard 73 0 <1 11 68 55 8 63 32 38 3 43 34 47 5 33 NIV Standard *p < 0.05 COPD (n = 23) Non-COPD (n = 33) * * * * *
- 46. NIV in weaning:Early extubation NIV in the weaning of patients with respiratory failure due to COPD
- 47. NIV in weaning:Early extubation 24-36 hrs of PSV 50 patients 2 hr T-piece trial failed Randomized NIV to 25 br/min, ABGs 6 by 2-4 cmH20/day SBT 2 x/day IPSV to 25 br/min, ABGs “gradually” 6 CPAP or T piece, 2 x/day Nava et al. Ann Intern Med 1998;128:721-8 NIV in the weaning of patients with respiratory failure due to COPD
- 48. Invasive MV NIV Weaning success with NIV NIV in the weaning of patients with ARF due to COPD Nava et al. Ann Intern Med. 1998;128:721-8 NIV in weaning: Early extubation
- 49. NIV to weanfrom respirator in stable COPD Nava et al. Ann Intern Med 1998;128:721-8 Invasive Non-invasive MV days 17 10* ICU days 24 15* 60d wean success 68% 88% * 60 d survival 72% 92% * Pneumonia 25% 0% * wean failure: death from MV and reintubation in 72h
- 50. NIV success within 1-2 hours ? Improveme nt forseveral days ? Weaning from NIV Spontaneou s breathing NIV Start NIV IN ACUTE HYPERCAPNIA Early Failure Early NIV-failure Intubation
- 51. Ineffective ventilation Failing synchrony NIV-failure NIV IN ACUTEHYPERCAPNIA Failure
- 52. Moretti M. etal. Thorax 2000;55:819-82 N= 137 Patients with NIV success* *NIV > 24 Std. N= 31 Patients with late NIV-failure after primary NIV-success* 23% Acute exacerbation of COPD after 48 hours Mortality IMV 53%, continuing NIV 92% (NIV group pH 7.1 IMV 7.29) Late failure predicted by low ADL scores, pH and co-morbidity at admission
- 53. Moretti M. etal. Thorax 2000;55:819-8 Late NIV failure: • lower pH at admission • higher complication rates • ICU-Mortality • 92% when NIV was continued • 53% when intubation was performe
- 54. Invasive MV insteadof NIV - in terms of clinical issues Invasive MV Lavage bei Hypersecretion Unloading respir. muscles Improvement of neurophysiologic situation Aim: Extubation after 2-3 day - with/without consecutive NIV Massive hypersecretion Massive Load on respir. muscles Neurophysiologic disaster
- 56.
- 59. Thoraco-Restriction & Neuromuscular disease Obesity Palliation Specialindication for NIV in acute hypercapnia in Non-COPD patients
- 60. Flandreau G etal. Management and long-term outcome of patients with chronic neuromuscular disease admitted to the intensive care unit for acute respiratory failure: a single-center retrospective study. Respir Care 2011; 56: 953 – 960 Special indication for NIV in acute hypercapnia Neuromuscular disease
- 61. Intermittent NIV to recondition respiratory muscles Bronchoscopy Physiotherapy NIV& aggressive secretion management
- 62. DNI: Do notintubate • Aims –Reduced Dyspnea –Improved quality of life („Comfort“) –Buy time INDICATION: NIV IN PALLIATION
- 63.
- 65.
- 66. LV failure Pulmonary edema Pulmonary compliance Airway resistance Negative Intrathoracic Pressure Swing Work of breathing CO PaO2 Respiratory muscle fatigue DaO2 + PaCO2
- 67. LV failure Pulmonary edema Pulmonary compliance Airway resistance Negative Intrathoracic Pressure Swing LV transmural pressure O2 Cost of breathing LV afterload +
- 68. Rasen et al:Chest 1985; 87: 158-162 Negative intrathoracic pressure swings during CPE Pes (cmH20) 0 -20
- 69. IntraThoracicPressure and LV function AO LV ITP effort = ITP = Ptm LV afterload 100 -20 Ptm = 100-(-20) = 120
- 70. CPAP IN CPE Rasenet al: Chest 1985; 87: 158-162 Pes (cmH20) 0 -20 Spontaneous breathing CPAP 15 cmH20
- 71. IntraThoracicPressure and LV function AO LV ITP effort = ITP = Ptm LV afterload 100 -5 Ptm = 100-(-5) = 105
- 72. Rationale of positivepressure ventilation in CPE Positive Pressure ITP FRC Pre-load Venous return LVafterload PTM PaO2 WOB Cardiac performance pulmonary congestion
- 73. Targets of ventilationin cardiogenic pulmonary oedema • improvement of oxygenation • improvement of respiratory acidosis • reduction of work of breathing • improvement of cardiac performance • reduction of patient’s distress
- 74. NIV and obesity:in the acute setting
- 75. OHS: Definition - Obesity(BMI 30 kg/m2) - Hypercapnia (PaCO2 45 mmHg) - Sleep-disordered breathing Thomas Nast, The Pickwick Papers
- 76. OHS: Clinical Presentation Middle-aged 2:1 male-to-female Extremely obese Significant sleep-disordered breathing (fatigue, hypersomnolence, snoring, AM headache)
- 78.
- 81. Conclusions Multiple organ failureand pneumonia were the main factors associated with NIV failure and death in morbidly obese patients in hypoxic ARF. On the opposite, NIV was constantly successful and could be safely pushed further in case of severe hypercapnic acute respiratory decompensation of OHS.
- 82. Potential goals ofnoninvasive ventilation (NIV) in severe acute asthma. Dean R Hess Respir Care 2013;58:950-972 (c) 2012 by Daedalus Enterprises,Inc.
- 83. Bronchoscope inserted throughthe swivel adaptor of a face mask for noninvasive ventilation. Dean R Hess Respir Care 2013;58:950-972 (c) 2012 by Daedalus Enterprises,Inc.
- 84. Monitoring of NIVin the acute setting
- 85. AIMS Goals of monitoring Typesof monitoring Setting for monitoring Goals of monitoring Types of monitoring Setting for monitoring
- 86. Why we needMonitoring during MV? To Assess the effectiveness of MV in -Unloading respiratory muscles -Correcting gas exchange abnormalities -Improving alveolar ventilation To Identify complications during MV -correlated with MV -correlated with ARF To predict patient’s outcome in terms of -Survival -Dependence on MV -Autonomy in performing ADLs
- 87. Is Monitoring lessimportant during NIV? Airways not protected Presence of leaks Lack of sedation Use outside ICU
- 88. Which goals ofMonitoring during NIV? To Assess the effectiveness of NIV in -Unloading respiratory muscles -Correcting gas exchange abnormalities -Improving alveolar ventilation -Patient-ventilatory synchrony To Identify complications during NIV -correlated with NIV -correlated with ARF To predict patient’s outcome in terms of - NIV failure (i.e. Need of ETI) -Survival -Dependence on MV -Autonomy in performing ADLs To Assess the effectiveness of NIV in -Unloading respiratory muscles -Correcting gas exchange abnormalities -Improving alveolar ventilation -Patient-ventilatory synchrony To Identify complications during NIV -correlated with NIV -correlated with ARF To predict patient’s outcome in terms of - NIV failure (i.e. Need of ETI) -Survival -Dependence on MV -Autonomy in performing ADLs
- 89. AIMS Goals of monitoring Typesof monitoring Setting for monitoring
- 90. Availability of ETI • incase of NIV failure Ventilatory Monitoring • Respiratory pattern • Pt-vent interaction
- 91.
- 92.
- 93. HOOVER SIGN ACCESSORY RESPIRATORY MUSCLESPARADOXYCAL BREATHING Howis the patient breathing?
- 94. Bott J. etal. Lancet 1993; 341:1555-7 Monitoring Dyspnea NIV SMT VAS
- 95. CarlucciA. et alAm J Respir Crit Care Med Patient’s Cooperation and Sensorium NIV OUTCOME
- 96.
- 97. Levels of Hypercapnic Encephalopathyand NIV failure KELLY=1 KELLY=2 KELLY=3 KELLY>3 Scala R. et al, Chest. 2005;128(3):1657-66
- 98.
- 99. Roche-Campo F etal., Crit Care Med 2010 Delirium
- 100.
- 101. TECHNICAL LIMITATIONS • Poorperipheral perfusion • Movements artifacts • Haemoglobinopathies • Nail polish • Hyperbilirubinemia (> 15 mg/dL) Pulse-oximetry CONTINUOUSMONITORING OF OXYGENATION DURINGNIV AND SPONTANEOUS BRETAHING PHYSIOLOGICAL LIMITATIONS • Variable PaO2/SpO2 correlation • Lack of information on PaCO2
- 102.
- 103. ETCO2 Expiratory Capnography LIMITED APPLICATIONin NIV -Leaks -Additional dead space (Interface) -Variable Circuit -Variable Expiratory system (single- limb)
- 104. 46 pts withARF under NIV (Range PaCO2: 33-91 mmHg) -TCM4: trunk PtCO2 sensor Under-estimation of PaCO2 in pts with greater hypercapnia (PaCO>60 mmHg)
- 105. TREND OF TC-PCO2 KocherS et al, J Clin Monitor Comput 2004 Domingo Ch et al, Arch Bronchoneumol 2006
- 106. Arterial blood gas-analysis Goldstandard Oxygenation status (PaO2/FiO2 ratio) Ventilatory status (PaCO2) Metabolic status (pH/HCO3) Co-oximetry (COHb) Weak points: -Invasive procedure -Spot data Prognostic value -Baseline -After 1-2 hrs -Late failure
- 107. Antonelli M. etal. Crit Care Med 2007;35(1):18-25 PaO2/FiO2 during NIV in ARDS
- 108. pH at baselinein COPD exacerbations Nava S. et al., Intensive Care Med 2006; 32(3):361-70.
- 109. Respiratory Rate andNIV failure Confalonieri M et al.
- 110. How to assessRR on spont breathing? Clinical evaluation Impedenzometry Capnography Pnemotacograph
- 111. Schettino G. etal., Crit Care Med 2008;36(2):441-7 Reasons for NIV failure Cardiovascular monitoring (ECG, NIBP, PR)
- 112. Helpful in Understanding thecauses of nocturnal desaturations Re-Setting the ventilator Janssens JP et al. Thorax 2011;66(5):438-45 Sleep monitoring
- 113.
- 114.
- 115.
- 116.
- 117.
- 118.
- 119. Am J RespirCrit Care Med. 2001 Feb;163(2):540-77 Almost all the side effects of NIV are due to problems with interfaces
- 120.
- 121. Monitor the tightnessof the mask
- 122. LOOK FOR ABALANCE BETWEEN LEAKS AND COMFORT
- 123. Ventilator monitoring: numeric dataand curves
- 124. Berg KM etal., Respir Care 2012;57:1548-54 Respiratory pattern and NIV Failure INTUBATION aRSBI= RR/exp- TV during NIV Exp TV = pt TV HOW COULD WE MONITOR exp-TV and RR DURING NIV?
- 125. Monitoring: ready accessto ETI and CPR
- 126. Non-invasive ventilation failure inthe acute patient
- 127. What is theNIV failure? Need for tracheal intubation and death When does it happen? Immediate: < 1 hr Early : 1- 48 hrs Late: > 48hrs
- 128. NIV FAILURE (%) ImmediateEarly Late 17 68 15
- 129. How to ReduceAir Leaks During NIV Proper interface type and size Proper securing system Mask-support ring Comfort flaps Tube adapter Hydrogel or foam seals Chin strap Lips seal or mouth taping Nava S et al. Respiratory Care 2009; 54: 71-82 Mask occlusion pressure = Pmask-fit – Paw
- 131. How to Reducethe Risk of Skin Damage During NIV Proper harness and tightening Skin and mask hygiene ava S et al. Respiratory Care 2009;54:71-82 Nasal-forehead spacer • To reduce the pressure on the bridge of the nose Forehead and skin pads • To obtain the most comfortable position Cushioning system between mask prong and forehead Remove patient’s dentures when making impression for moulded mask In home care, replace the mask according to the patient’s daily use
- 132.
- 133. Risk for skinlesion
- 134. A possible solution:the total face mask
- 135. Another solution: the “Helmet” Courtesyof Dr. Stefano Nava (Bologna, Italy)
- 136. • Not alwaysappear where expected!!! Pressure ulcer
- 137. Predictors of failure:NIV for hypercapnic respiratory failure Advanced age Higher acuity of illness (APACHE score) Uncooperative Poor neurological score Unable to coordinate breathing with ventilator Large air leaks Edentulous Tachypnoea (>35/min) Acidaemia (pH <7.18) Failure to improve pH, heart and respiratory rates or Glasgow Coma Score within the first 2 hours Soo Hoo et al. Crit Care Med 1994; 22: 1253–61 Ambrosino et al. Thorax 1995; 50: 755–7 Confalonieri et al. Eur Respir J 2005; 25: 348–55
- 138. Non-COPD conditions: Pneumonia(n=37) Neuromusculoskeletal disorders (n=11) Pulmonary oedema (n=9) Bronchiectasis (n=5) Sepsis (n=3) Asthma (n=3)
- 139. Outcomes of NIVin non-COPD patients by specific diagnosis
- 140. At admission • 1,033consecutive patients •Success rate: 797 (77%)
- 141. After 2 hof NIV
- 142. • Eight ICUs •n=354: • Success: 246 • Failure: 108 Other predictors of failure: Higher SAPS Lower PaO2/FIO2 and failure to improve Low pH Older age Septic shock, MOF
- 143. Common reasons forNIV failure Environmental/caregiver team factors • Lack of skilled, experienced caregiver team • Poor patient selection • Lack of adequate monitoring Selection guidelines for NIV in the acute setting Appropriate diagnosis with potential reversibility (COPD, congestive heart failure, …..) Establish need for ventilatory assistance: • Moderate to severe respiratory distress and • Tachypnoea (>24/min for COPD, >30/min for CHF) • Accessory muscle use or abdominal paradox motion • Blood gas derangement: pH <7.35, PaCO2 >45, or PaO2/FiO2 <300
- 144. Contraindications of NIV Respiratory or cardiac arrest Too unstable patient: • Shock • Myocardial infarction requiring intervention • Uncontrolled ischemia or arrhythmias • Uncontrolled upper GI bleed • Non-evacuated pneumothorax Unable to protect airway* • Excessive secretions • Poor cough • Impaired swallowing *Relative contraindications? Aspiration risk* • Distended bowel; obstruction or ileus • Frequent vomiting Uncooperative or agitated* Unable to fit mask Recent upper airway or oesophageal surgery Multiple organ system failure (>2)
- 145. Common reasons forNIV failure Patient-related factors • Intolerance • Mask problems: • Discomfort • Poor fit • Skin ulceration • Claustrophobia • Agitation • Excessive secretions, inability to protect airway • Progression of underlying disease
- 146. Approach to theagitated/intolerant patient using NIV
- 147. Common reasons forNIV failure Technical factors • Inadequate equipment • Failure to ventilate • Failure to oxygenate • Patient–ventilatorasynchrony • Air leaks
- 148. Successful NIV: Important factors More likely with a good team • A skilled, experienced staff helps to optimize outcomes The underlying disease is an important determinant • Selecting appropriate patients and monitoring them closely Severity at presentation Change in physiology after a short period of NIV • If failure to ventilate or oxygenate, rapidly assess for reversible contributing factors • Be prepared to intubate without undue delay if rapid reversal cannot be achieved (particularly in hypoxemic patients) A systematic approach to troubleshooting can help