Non invasive ventilation in COPD management.pptx
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Non invasive ventilation in COPD management.pptx
- 1. NIVin COPD Dr Subhajit Ghosh
- 2. Definition • Non‐invasiveventilation(NIV)referstothe deliveryof mechanicalventilationtothelungs usingtechniques thatdo not require an invasive artificial airway(ETT,TT)
- 3. T ypesofNIV • NegativepressureNIV – MainmeansofNIV duringthe1sthalfof the 20thcentury – Extensivelyusedduring polioepidemics – T ankventilator“iron lung” – Cuirass,Jacketventilator, Hayekoscillator • PositivepressureNIV – Positivepressure delivered throughmaskcase – CP AP&BiPAP
- 4. NegativePressureVentilation(NPV) • Negativepressureventilatorsapplyanegativepressure intermittentlyaroundthepatient’sbodyorchestwall • Thepatient’shead(upperairway)isexposedtoroom air • Negativepressureisappliedintermittentlytothe thoracicarea resultinginapressuredroparoundthe thorax • Thisnegativepressureistransmittedtothepleural spaceand alveolicreatingapressuregradientbetween theinsideofthe lungsandthemouth
- 6. NIV‐ Advantages • Noninvasiveness – Flexibilityininitiatingandremovingmechanical ventilation – Allowsintermittentapplication – Improvespatientcomfort – Reducestheneedfor sedation – Oralpatency • Preservesspeech,swallowingandexpectoration, reducestheneedfornagastrictubes
- 7. Advantag es • Avoidtheresistiveworkimposedbythe endotrachealtube • Avoidsthecomplicationsofendotracheal intubation – Early(localtrauma,aspiration) – Late(injurytohypopharynx,larynx,andtrachea, nosocomialinfections) • Reducesinfectiouscomplications‐pneumonia, sinusitis, sepsis • Lesscost
- 8. Mechanismofaction • Reductionininspiratorymuscleworkand avoidanceofrespiratorymusclefatigue • Tidalvolumeisincreased • CP APcounterbalancestheinspiratorythreshold work relatedtointrinsicPEEP . • NIVimprovesrespiratorysystemcomplianceby reversingmicroatelectasisofthelung • Enhancedcardiovascularfunction – Afterloadreductiond/t increasedintrathoracic pressure
- 11. Disadvantag es • System – Slowercorrectionofgasexchangeabnormalities – Increasedinitialtimecommitment – Gastricdistension(occursin< 2 %patients) • Mask – Airleakage – Transienthypoxemiafromaccidentalremoval – Eyeirritation – Facialskinnecrosis–mostcommoncomplication • Lackofairwayaccessandprotection – Suctioningofsecretions – Aspiration
- 12. Levelsofevidence • A – MultipleRCT s – Recommended • B – AtleastoneRCT – Weakerevidence • C – Caseseries/reports – Canbetriedbutwithclosemonitoring
- 13. Indications • Airway obstruction – COPD(Evidence A) – FacilitationofweaninginCOPD(EvidenceA) – Asthma(B) – ExtubationfailureinCOPD(B) – CysticFibrosis(C) – OSA/obesityhypoventilation(C) – Upperairwayobstruction(C)
- 14. NIV&stableCOPD • NIVincreasinglyusedinstableverysevere COPD • NIV+O2therapy– inselectedpatientswith pronounceddaytimehypercapnia • Clearbenefitsinbothsurvival&riskof hospital admissioninpatientswithbothCOPD&OSA GlobalinitiativeforChronicObstructiveLungDisease(GOLD) update 2013
- 16. Concludes • DatafromgoodqualityRCT sshowbenefitof NIVas 1st line intervention inadditionto usualmedical caretoARF2°toanacute exacerbationofCOPDin all suitablepatients • Use early inthecourseofrespiratoryfailure and beforesevereensues,asameansof reducing the likelihoodofendotracheal intubation, treatment failure andmortality
- 17. NIVinCOPDexacerbation • Multiple RCT ssupportasuccessrateof80‐ 85% • Hasbeenshowntoimprove respiratory acidosis ( pH& pCO2) • Respiratoryrate,WOB,severityof breathlessness, complicationslikeVAP ,length ofhospitalstay (Evidence A) • Mortality&intubationratesare reduced(EvidenceA) GOLDupdate2013
- 18. NIVinCOPDexacerbation • Indications for NIV – atleast one of the following – Respiratory acidosis (pH<7.35 &/or PaCO2) – Severe dyspnea with clinical signs s/o respiratory muscle fatigue, increased WOB or both • Use of respiratory accessory muscles • Paradoxical motion of abdomen • Intercostal retraction GOLDupdate2013
- 19. NIV in AECOPD • VBGvs.ABG • TIIRespiratoryfailure – AECOPD – UseofBipap • Lotsofanecdotes • Pleaseaskquestions!
- 20. ABG vs.VBG • pHa-vdifference= 0.04 – VBGpHof7.30,‘true’pHcouldbe7.26to 7.34 • pCO2a-vdifference= 8.02 – pvCO252,paCO2couldbebetween44to 60
- 21. • CanVBGreplaceABGaspartofinitial assessmentin AECOPD? • PairedABG-VBGsamplesin234patientswithAECOPDinUK tertiary hospital • Goodagreement: pH HCO3 • • • If SpO2>80%thenagreementOKwithSaO2 • ABGsamplingmorepainfulandmoreattempts (!)
- 23. Flowchart
- 24. VBGvs.ABG • VBGisanexcellentscreening tool – ~2/3rdsofAECOPDinthispopulation– nilfurther • Assoonassomeoneissick(lowpH)– they needaABG
- 25. Respiratoryfailure • Type1 =failure of oxygentransfer – Measurablegapbetweenalveolarandcapillary PO2 – Duetoshuntthroughnon-ventilatedalveoli • Type2=failure of ventilation – i.e.notenoughairreachingalveoli – NotenoughO2in – NotenoughCO2out
- 27. NIV-Bipap • Treatmentofchoiceforpersistenthypercapnic respiratoryfailureandacidosis(usingABG) – Notoptimisedwithconventionalmedicaltherapy – i.e. CONTROLLEDOXYGENTHERAPY NEBS ORALSTERODS ANTIBIOTICS (&thecause)
- 28. • PaCO2isinverselyproportionaltominute volume(VE) • VE=TVxRR • NIVtreatsmechanicalrespiratoryfailure,NOT the underlyingcause NIV-Bipap
- 29. Acute ExacerbationCOPD Treatthecause Maximummedicaltherapy CONTROLLEDOXYGENTHERAPY If PaO2>60– reduceO2 &repeatABG30-60mins If PaO2<50,andstillacuteTII failure,despite controlled O2therapyandmaximalmedical therapy: - mayrequireNIV Inform Resp Team/ ICU Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? PerformABG Type I PaO2 < 60 PaCO2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates Respiratory Failure? ScreeningVBG If pH<7.35performABG
- 30. Acute ExacerbationCOPD ite dical Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) Respiratory Failure? PerformABG s level effort MAXIMUM MED -CONTROLLED -Salbutamol neb necessary) -Ipatropium nebu -Prednisolone 30 (hydrocortisone -Antibiotics* -Consider iv theo -Consider chest physio -Treat other causes of respiratory compromise (see above) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO2 <8 PH < 7.35 and PCO2 <6.0 PCO2 > 6.0 Reduced consciou Reduced respiratory INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates ICAL THERAPY Treatthecause Maximummedicaltherapy OXYGEN THERAPY CONTROLLEDOXYGENTHERAPY ulised 5mg (back to back if If paO2>8.0– reduceO2 lised 500mcg QDS &repeatABG30-60mins mg PO OD (7-14 days) If paO2<7.0,andstillacuteTII failure,desp ONLY if oral route not available controlledO2therapyandmaximalme therapy: phylines (care in CVS co-morbidity) - mayrequireNIV Inform RHC Why AECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion(s) CVS (failure / arrhythmia / ACS) PE GI Other – must have a cause
- 31. Acute ExacerbationCOPD Treatthecause Maximummedicaltherapy CONTROLLEDOXYGENTHERAPY If PaO2>60– reduceO2 &repeatABG30-60mins If PaO2<50,andstillacuteTII failure,despite controlled O2therapyandmaximalmedical therapy: - mayrequireNIV Inform RespTeam Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? PerformABG Type I PaO2 < 60 PaCO2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates
- 32. Acute ExacerbationCOPD Treatthecause Maximummedicaltherapy CONTROLLEDOXYGENTHERAPY If PaO2>60– reduceO2 &repeatABG30-60mins If PaO2<50,andstillacuteTII failure,despite controlled O2therapyandmaximalmedical therapy: - mayrequireNIV Inform RespTeam Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? PerformABG Type I PaO2 < 60 PaCO2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates
- 33. Acute ExacerbationCOPD Inform RHC Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? el fort MAXIMU -CONTRO -Salbutam necessar -Ipatropiu -Prednisol (hydroco -Antibiotic -Consider -Consider chest physio -Treat other causes of respiratory compromise (see above) Respiratory Failure? Pneumothorax Pleural effusion PerformABG CVS (failure/ arrhythmia / ACS) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO2 <8 PH < 7.35 and PCO2 <6.0 PCO2 > 6.0 Reduced conscious lev Reduced respiratory ef INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates M MEDICAL THERAPY Treatthecause Maximummedicaltherapy LLED OXYGEN THERAPY CONTROLLEDOXYGENTHERAPY ol nebulised 5mg (back to back if If paO2>8.0– reduceO2 y) &repeatABG30-60mins m nebulised 500mcg QDS one 30mg PO OD (7-14 days) If paO2<7.0,andstillacuteTII failure,despite rtisone ONLY if oral route not available controlledO2therapyandmaximal medical s* therapy: iv theophylines (care in CVS co-morbidity) - mayrequireNIV MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available) -Antibiotics* -IV theophylines ?? (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise
- 34. Acute ExacerbationCOPD Treatthecause Maximummedicaltherapy CONTROLLEDOXYGENTHERAPY If PaO2>60– reduceO2 &repeatABG30-60mins If PaO2<50,andstillacuteTII failure,despite controlled O2therapyandmaximalmedical therapy: - mayrequireNIV Inform RespTeam Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? PerformABG Type I PaO2 < 60 PaCO2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates
- 35. Acute ExacerbationCOPD lure, ximal • Warning signs? INFORM ITU WhyAECOPD? FIND ACAUSE nia? vel ffort MAXIMU -CONTR -Salbutam necessar -Ipatropiu -Predniso (hydroc -Antibioti -Conside -Consider chest physio -Treat other causes of respiratory compromise (see above) Respiratory Infective – bronchitis / pneumo Failure? Pneumothorax Pleural effusion PerformABG CVS (failure/ arrhythmia / ACS) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO2 <8 PH < 7.35 and PCO2 <6.0 PCO2 > 6.0 Reduced conscious le Reduced respiratory e INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates M MEDICAL THERAPY • Treat the cause • Maximum medical therapy OLLED OXYGEN THERAPY • CONTROLLED OXYGEN THERAPY ol nebulised 5mg (back to back if • If paO2 > 8.0 – reduce O2 y) • & repeat ABG 30-60 mins m nebulised 500mcg QDS • If paO2 < 7.0, and still acute T II fai lone 30mg PO OD (7-14 days) despite controlled O2 therapy and ma ortisone ONLY if oral route not available medical therapy: cs* r iv theophylines (care in CVS co-morbidity) • - may require NIV • Inform RHC ACUTE TII RESPIRATORY FAILURE • Treat the cause • Maximum medical therapy • CONTROLLED OXYGEN THERAPY • If paO2 > 60 – reduce O2 & repeat ABG 30-60 mins • If paO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV • Inform Resp Team • Warning signs? INFORM ITU
- 36. Acute ExacerbationCOPD ,despite controlledO2therapyandmaximalmedical therapy: • - mayrequireNIV • Inform RespTeam • Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion ACS) e Respiratory Failure? us level ory effort MAXIMUM MEDIC -CONTROLLED O -Salbutamol nebuli necessary) -Ipatropium nebulis -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) PerformABG CVS (failure/ arrhythmia / PE Other – must have a caus No respiratory Type I Acute Type 2 Warning signs: failure PO2 <8 PH < 7.35 and PCO2 <6.0 PCO2 > 6.0 Reduced conscio Reduced respirat INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates AL THERAPY • Treatthecause • Maximummedicaltherapy XYGEN THERAPY • CONTROLLEDOXYGENTHERAPY sed 5mg (back to back if • If paO2>8.0– reduceO2 ed 500mcg QDS • &repeatABG30-60mins • If paO2<7.0,andstillacuteTIIfailure Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU
- 37. Treatthecause Maximummedicaltherapy CONTROLLEDOXYGENTHERAPY If paO2>60– reduceO2 &repeatABG30-60mins If paO2<50,andstillacuteTII failure,despite controlled O2therapyandmaximalmedical therapy: - mayrequireNIV Inform RespTeam Warningsigns?INFORMITU WhyAECOPD? FIND ACAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? PerformABG Type I PaO2 < 60 PaCO2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates Acute ExacerbationCOPD
- 40. COPD • Known COPD.ED.Vwheezy+ S O B • R R3 5 • 6ltsO2mask pH7.32 pO275 pCO257 Bic22 BE–2 Sats95% AcuteTII RespFailure T oomuchO2 - 28%venturimask
- 43. ControlledOxygen • 20%ofptsacidoticonarrivalwill correcttheir pHto normalregardlessofseverityofinitial acidosis[Plant.Thorax, 2000] • But only when you treat the underlyingcause for the respiratory failure
- 44. COPD 28%O2 • pH7.31 • paO2 56 • paCO266 • BIC30 • Sats88%
- 45. COPD 28%O2 • pH7.31 • paO2 56 • paCO266 • BIC30 • Sats88% AcuteTII respfailure (acuteonchronic) - OptimalO2? - OptimalmedicalRx? NIV
- 46. 60c $3000
- 47. RationaleofNIV • Increaseinminutevolume • Reductionofworkofbreathing • ForAECOPD: – Preventsintubation[Nava,2006;Kerran2003,Plant2000] – Reducesmortality [Nava,2006;Kerran2003,Plant2000]
- 48. Indications • Acutetype2respiratoryfailuredueto COPD • Mild (7.31-7.35)/ Moderate(7.25-7.3)/Severe( <7.25) • pH>7.35– NIVunhelpful[Kerran2005]
- 49. Contra-indications: • Cardiacorrespiratoryarrest • Additionalorganfailure • Inabilitytoprotectairway/ clearsecretions • Bulbarweakness Misc: • Facialsurgery,injury • Upperairwayobstruction • Undrainedpneumothorax
- 50. Importantriders • Nocontra-indicationabsoluteif NIVisceiling measure • Fornon-COPDTII RFcriticalcare/ resp/ pulm phys teamshouldbeinvolved early
- 51. PersistentlyelevatedCO2: PotentialCauses • Checkchestexpansion/ airentry • Maintenanceofairway – sputumretention? – Posture/ consciouslevel • Maskleak – Checkwithhandaroundmask – Considerfull facemask • Re-breathing – Checkatleast4cmEPAP – Expiratoryport • Patient/ ventilatorsynchronisation
- 52. PersistentlyelevatedCO2: PotentialCauses • Checkchestexpansion/ airentry • Maintenanceofairway – sputumretention? – Posture/ consciouslevel • Maskleak – Checkwithhandaroundmask – Considerfull facemask • Re-breathing – Checkatleast4cmEPAP – Expiratoryport • Patient/ ventilatorsynchronisation Check patient Check kit
- 53. PersistentlyelevatedCO2: Ventilatoradjustments • ↑ IPAP Obese Poorchestwallorlungcompliance • ↓ EPAPto4cm(unlesssuspectUAclosure) • If patientexhaustedor↓RRconsider mandatory(timed)mode,but.....
- 54. O2remainslowdespite↓CO2 • ↑ FiO2 (butsamerulesapply…) • ↑ EPAP • Re-consider thediagnosis
- 55. SuddendeteriorationonNIV • Pneumothorax • PE • Arrhythmias/ MI • Others…
- 58. Escalationoftherapy • Mustbedocumentedineverycase • ?SuitableforMV • ?Resuscitationstatus • If yes discusswithITUoncommencementof therapyif pH<7.25orotherwiseindicated
- 59. Successfulcases • Responders:ventilatedasmuchaspossiblein the first24hours • Breaksshouldbegivenforfood,physio,drugs • Greaterneedforventilationovernight
- 60. NIVfailure • Occursinaround20% • Variouscauses: – Physiologicaldeterioration/ failuretoimprove – Intolerance/ agitation – Patient’swishtowithdraw • If noimprovementwithin1-2hours,seek advice • AdmissionpH<7.2&2hrsa~er<7.2– failure predicted(NEJM editorial2004)
- 61. ‘YorkshireNIV’experience[Plant.Lancet2000] • pH> 7 . 3 5 • pH< 7 . 3 5 - > 7 . 3 • pH< 7 . 3 • pH< 7 . 2 -NIVnotindicated -80% will getbetter withconventionalRx - NNTavoidETT=10 -50% willdeteriorate withoutNIV - NIVimprovessurvival - 50% deteriorate -Betterhospitaloutcome &1 yearsurvival
- 62. ‘YorkshireNIV’experience[Plant.Lancet2000] • pH>7.35 • pH<7.35->7.3- - NIVnotindicated 80% will getbetter x withconventionalR - NNT avoid ETT=10 • pH<7.3 - 50% willdeteriorate withoutNIV - NIV improvessurvival • pH<7.2 -50% deteriorate -Betterhospitaloutcome &1 yearsurvival NIVadvised NIVstronglyadvised
- 63. Summary:AECOPDmanagement • AtriskofTII respfailure? – ScreeningVBG • ABG • Findthecause • CONTROLLEDOXYGEN • Givesometimefornebsetc.to work (peopleusedtosurvivebeforeNIV!) • WearetoopessimisticaboutMV &COPD [Wildman,2007]
- 64. Questions?