Download as PDF, PPTX
More Related Content
NIV in CHF
- 1. NIV in congestiveheart failure from acute to chronic 臺大醫院 胸腔內科 簡榮彥 20190324
- 2. Congestive hart failurewith pulmonary edema • Imbalance of starling forces • Increased pulmonary capillary pressure • Decreased plasma oncotic pressure • Increased negative interstitial pressure • Lymphatic obstruction • Idiopathic mechanism
- 3. Heart-Lung interactions • Therespiratory muscles have to generate large negative swings in pleural pressure to start inspiratory flow and maintain adequate tidal volumes • This increase in negative intrathoracic pressure aggravates pulmonary edema by increasing both preload and afterload
- 4. Effects of positiveairway pressure RV LV Ppleural ParteryPvein • Ppleural ↑ ➔ (Partery - Ppleural) ↓ ➔ ↓ After-load • Ppleural ↑ ➔ (Pvein - Ppleural) ↓ ➔ ↓ Venous return ➔ ↓ Pre-load
- 5.
- 6. Physiologic effects ofpositive intrathoracic pressure Respiratory • Recruitment of collapsed alveoli → ↑Functional residual capacity • Maintenance continuously opened alveoli → Gas exchange during the whole respiratory cycle • Intra-alveolar pressure against edema • ↓ Work of breathing • ↑ Oxygenation Cardiovascular • ↓ Venous return →↓RV preload → ↓LV preload • ↑ Pulmonary vascular resistance → ↑RV afterload → RV enlargement →↓ LV Compliance • ↓ LV afterload (↓ systolic wall stress) • ↓ Systemic blood pressure → ↓Cardiac output European Heart Journal (2018) 39, 17–25
- 7.
- 8. Effects of positiveairway pressure on hemodynamics World J Cardiol 2014 November 26; 6(11): 1175-1191
- 9.
- 10. Effects of CPAPin CHF AM J RESPIR CRIT CARE MED 1997;155:500-505 PAWP In 9 patients with acute left heart failure (PAOP ~ 18 mm Hg, and CI ~ 2.8 l/min/m2)
- 11. Effects of CPAPin CHF AM J RESPIR CRIT CARE MED 1997;155:500-505 Pressure- Time index Respiratory muscles C R
- 12. Effects of CPAPin CHF - Decrease negative swings in intrathoracic pressure - AM J RESPIR CRIT CARE MED 1997;155:500-505
- 13. AM J RESPIRCRIT CARE MED 1997;155:500-505 Effects of CPAP in CHF - Decrease work of breathing -
- 14. Hemodynamic effects ofCPAP in CHF Stroke volume index AM J RESPIR CRIT CARE MED 1997;155:500-505 • No significant change in SVI • Mean transmural filling pressures decreased significantly with CPAP, suggesting a better cardiac performance
- 15. Potential Mechanisms ofCPAP and NIV in Patients With Acute Cardiogenic Pulmonary Edema • CPAP • Reduced work of breathing • Increased cardiac output from reduced pre-load and after-load • Reduced mitral regurgitation • Increased functional residual capacity • Reduced atelectasis • Reduced right-to-left intrapulmonary shunt • NIV • Same benefits as CPAP • Unloads the respiratory muscles Respir Care 2009;54(2):186 –195
- 16. Three Interventions inCardiogenic Pulmonary edema (3CPO) trial • 26 emergency rooms, United Kingdom • 1069 patients • Standard oxygen therapy, 367 patients • CPAP (5 to 15), 346 patients • NIPPV (IPAP, 8 to 20; PEEP, 4 to 10), 356 patients N Engl J Med 2008;359:142-51
- 17. 3CPO trial N EnglJ Med 2008;359:142-51
- 18. 3CPO trial N EnglJ Med 2008;359:142-51
- 19.
- 20. • No effectin intubation rate and short-term mortality
- 21. Meta-analysis • NIV decreasedmortality (RR 0.80, 95% CI 0.66–0.96; moderate certainty) BIPAP CPAP Eur Respir J 2017; 50: 1602426
- 22. Meta-analysis • NIV decreasedthe need for intubation (RR 0.60, 95% CI 0.44–0.80; low certainty) BIPAP CPAP Eur Respir J 2017; 50: 1602426
- 23. Not completing treatment •Rate of not completing treatment: BIPAP > CPAP
- 24. Higher AMI inBiPAP than CPAP Crit Care Med 1997; 25:620-628
- 25. Meta-analysis NIV is notassociated with increased myocardial infarction Eur Respir J 2017; 50: 1602426
- 26. Predicting the successof noninvasive positive pressure ventilation in emergency room for patients with acute heart failure • 343 patients Journal of Cardiology (2011) 57, 107—114
- 27. BiPAP-Synchrony BiPAP-Vision Predicting thesuccess of noninvasive positive pressure ventilation in emergency room for patients with acute heart failure Cut-off: pH value of 7.20 Cut-off: pH value of 7.03 Journal of Cardiology (2011) 57, 107—114
- 28. Should a trialof CPAP prior to hospitalization be used to prevent deterioration in patients with ARF due to cardiogenic pulmonary edema ?
- 29. A trial ofCPAP prior to hospitalization Eur Respir J 2017; 50: 1602426
- 30. BIPAP vs CPAP •CPAP has some advantages over bilevel NIV • Simpler technology • Easier synchronization • Less expensive equipment • The current evidence summary demonstrates significant benefit of both interventions compared with standard care, and insufficient evidence to recommend one modality over the other Eur Respir J 2017; 50: 1602426
- 31. Most trials ofboth CPAP and NIV generally excluded patients with acute myocardial infarction that required revascularization with thrombolytics or invasive procedures !
- 32. Non-invasive ventilation inacute heart failure syndromes European Heart Journal (2018) 39, 17–25
- 33. NIV in Chronicheart failure • NIV improved LVEF in chronic CHF Canadian Respiratory Journal 2016, Article ID 3915237
- 34. NIV in Chronicheart failure • NIV did not reduce mortality in chronic CHF Canadian Respiratory Journal 2016, Article ID 3915237
- 35. NIV in Chronicheart failure Canadian Respiratory Journal 2016, Article ID 3915237
- 36.
- 37. NIV strategy accordingto different heart failure conditions World J Cardiol 2014 November 26; 6(11): 1175-1191
- 38. Take home messages •In patient with acute CHF with pulmonary edema (1) NIV decreases the need for intubation (2) NIV reduced hospital mortality (3) NIV is not associated with increased myocardial infarction (4) CPAP and NIV have similar effects, but CPAP has some advantages • NIV can be used for patients with cardiogenic pulmonary edema in the pre-hospital setting • NIV improved LVEF and BNP but did not improve overall mortality in patients with chronic heart failure Patients in cardiogenic shock were excluded in trials Many trials excluded patients requiring acute revascularization Some have excluded patients with acute coronary syndrome
- 39. Thanks for yourattention
- 40. NIV in Chronicheart failure • In the present meta-analysis, use of NPPV plus SMT improved LVEF and reduced plasma BNP level but did not improve overall mortality in patients with chronic heart failure.
- 41. Indication of positiveairway pressure for each condition World J Cardiol 2014 November 26; 6(11): 1175-1191
- 43. Heart-Lung interactions ● Effectof Intrathoracic Pressure ● Systemic venous return ● Left ventricular afterload 43