insufficienza respiratoria andrea vianello fisiopatologia e terapia intensiva respiratoria ospedale...
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Insufficienza Respiratoria
Andrea VianelloAndrea VianelloFisiopatologia e Terapia Intensiva RespiratoriaFisiopatologia e Terapia Intensiva Respiratoria
Ospedale – Università di PadovaOspedale – Università di Padova
AirwayInflammatio
n
Airwaynarrowing &obstruction
Shortened
muscles curvatur
e
FrictionalWOB
musclestrength
VT
PaCO2
pH PaO2
Gastrapping
Auto-PEEP
VCO2
VE
ElasticWOB
VA
AirwayInflammatio
n
Airwaynarrowing &obstruction
Shortened
muscles curvatur
e
FrictionalWOB
musclestrength
VT
PaCO2
pH PaO2
Gastrapping
Auto-PEEP
VCO2
VE
ElasticWOB
VA
Steroids
Abx
BDs
usa i farmaci e bene !usa i farmaci e bene !usa i farmaci e bene !usa i farmaci e bene !
Teophylline
AirwayInflammatio
n
Airwaynarrowing &obstruction
Shortened
muscles curvatur
e
FrictionalWOB
musclestrength
VT
PaCO2
pH PaO2
Gastrapping
Auto-PEEP
VCO2
VE
ElasticWOB
VA
PEEP
MV
Steroids
Abx
MVMV
BDs
usa i farmaci e bene !usa i farmaci e bene !usa i farmaci e bene !usa i farmaci e bene !
Teophylline
Non-Invasive
Ventilation““a form of a form of ventilatory ventilatory support that support that avoids airway avoids airway invasion”invasion”
Hill et al Crit Care Med 2007; 35:2402-7Hill et al Crit Care Med 2007; 35:2402-7
NIV - Meta-analysis (n=8)
• NPPV resulted 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; 326:185Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185
49 pazienti con IRA in BPCO dopo fallimento terapia medica, pH 49 pazienti con IRA in BPCO dopo fallimento terapia medica, pH 7.27.2
• Simili durata di permanenza in ICU, durata VM, complicanze Simili durata di permanenza in ICU, durata VM, complicanze generali, mortalità in ICU, e mortalità in ospedalegenerali, mortalità in ICU, e mortalità in ospedale
• con NIV 48% evitano ETI, sopravvivono con permanenza in ICUcon NIV 48% evitano ETI, sopravvivono con permanenza in ICU inferioreinferiore vs pazienti VM invasiva (P=0.02) vs pazienti VM invasiva (P=0.02)
• A 1 anno: NIV inferiore riospedalizzazione (65% vs 100% A 1 anno: NIV inferiore riospedalizzazione (65% vs 100% P=0.016) e minor frequenza di riutilizzo supplemento di P=0.016) e minor frequenza di riutilizzo supplemento di ossigeno (0% vs 36%) ossigeno (0% vs 36%)
Studio caso-controllo: 64 paz. con IRA trattati con NIV pH = 7.18Studio caso-controllo: 64 paz. con IRA trattati con NIV pH = 7.18
• 40/64 (62%) fallimento NIV (RR con NIV - 38%) 40/64 (62%) fallimento NIV (RR con NIV - 38%)
• Simili mortalità in ICU, e mortalità in ospedale; durata di Simili mortalità in ICU, e mortalità in ospedale; durata di permanenza in ICU e post ICU, ma:permanenza in ICU e post ICU, ma:
• Inferiori complicanze (P=0.01) e probabilità di rimanenere in Inferiori complicanze (P=0.01) e probabilità di rimanenere in VM (P=0.056)VM (P=0.056)
• Se NIV efficace (24/64 = 38%) Se NIV efficace (24/64 = 38%) migliore sopravvivenza e ridotta migliore sopravvivenza e ridotta permanenza in ICUpermanenza in ICU vs pazienti VM invasiva vs pazienti VM invasiva
NIV: 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 Intensive Care Med 2003; 3:419-25
Epidemiology•Rationale: evidence supporting use
of NIV varies widely for different causes of ARF.
•Population: 11,659,668 cases of ARF from the Nationwide Inpatient Sample during years 2000 to 2009;
•Objectives: To compare utilization trends and outcomes associated with NIV in patients with and without COPD.
•Rationale: The patterns and outcomes of NIV use in patients hospitalized for AECOPD nationwide are unknown.
•Population: 7,511,267 admissions for acute AE occurred from 1998 to 2008;
•Objectives: To determine the prevalence and trends of NIV in AECOPD.
Use of NIPPV or IMV as first-line respiratory Use of NIPPV or IMV as first-line respiratory support in patients hospitalized with support in patients hospitalized with
AECOPDAECOPD
Goals of NIVcan they be reached?
NIV is time consuming, needs proper equipment, enough staff with sufficient expertise.
time technical equipmentstaff expertise
predict success of NIV
Definition of the three levels of care
European Task Force on Respiratory Intermediate Care Survey Corrado et al, ERJ 2002;20:1343-50
Appropriatezza di utilizzo della Ventilazione Non-Appropriatezza di utilizzo della Ventilazione Non-Invasiva in ambito pneumologico nell’assistenza ai Invasiva in ambito pneumologico nell’assistenza ai pazienti con BroncoPneumopatia Cronica Ostruttiva pazienti con BroncoPneumopatia Cronica Ostruttiva
in fase acuta.in fase acuta.
Appropriatezza di utilizzo della Ventilazione Non-Appropriatezza di utilizzo della Ventilazione Non-Invasiva in ambito pneumologico nell’assistenza ai Invasiva in ambito pneumologico nell’assistenza ai pazienti con BroncoPneumopatia Cronica Ostruttiva pazienti con BroncoPneumopatia Cronica Ostruttiva
in fase acuta.in fase acuta.
Rate of NIV failure is extremely different according to study design,
severity of illness and level of monitoring
• Evaluation of all 449 patients receiving NPPV for a 1-yr period for acute or acute on chronic RF– CPE (n=97) – AECOPD (n=87)– non-COPD acute hypercapnic
RF (n=35) – postextubation RF (n=95)– acute hypoxemic RF (n=144)
• Intubation rate was 18%, 24%, 38%, 40%, and 60%, respectively
• Hospital mortality for patients with acute hypoxemic RF who failed NPPV was 64%
Schettino G. Crit Care Med 2008; 36:441-7
NIV – Real Life
Reasons for low rate of IMV use after NPPV, compared to clinical
trial:
• End of life decision to not accept IMV
• Patients died before IMV could be started
• Good selection of appropriate patients
• High mortality rate (≈30%) ;↑ over time
• OR for death:1.63, compared to those initially on IMV
• ↑hospital stay
• Nearly one third of patients for whom there is the best evidence base for NIV did not receive it– Admission pH < 7.26: 66% received NIV
compared to 34% pH 7.26 to 7.34. – Similar lowest pH
• Significant proportion had a metabolic acidosis• Hospital mortality was 25% (270/1077) for
patients receiving NIV but 39% (86/219) for those with late onset acidosis
• “The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector
Reasons for high mortality rate in patients transitioned to IMV
• Increased use of NIPPV in patients difficult to ventilate?
• Continuation of NIPPV despite a lack of early improvement?
Aetiology of NIV failureA. Failure to adequately
ventilate/oxygenateA. Delayed NIV treatment
B. Inappropriate ventilatory technique
C. Patient’s clinical condition
B. Dependence on non-invasive
support
Lack of improvement of acute illness
C. Complications
NIV failure is predicted by:- Advanced age- High acuity illness on admission (i.e. SAPS-II
>34)- Acute respiratory distress syndrome- Community-acquired pneumonia with or without
sepsis- Multi-organ system failure
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
NIV in acute COPD: correlates for success
Ambrosino N, Thorax 1995;50:755-7Ambrosino N, Thorax 1995;50:755-7
NIV failure
Other Pneumonia
%
0
20
40
60
n=8
p=0.019n=5
NIV complicationsComplication Incidenc
e (%)
MajorAspiration pneumonia <5
Haemodinamyc collapse Infrequent
Barotrauma Rare
MinorNoise 50-10
CO2 rebreathing 50-100
Discomfort 30-50
Claustrophobia 5-20
Nasal skin lesions 2-50
Mask selection - a crucial issue!
Noise (50-100%)Noise (50-100%)
COCO22 rebreathing (50-100%) rebreathing (50-100%)
Leak/Discomfort (30-50%)Leak/Discomfort (30-50%)
Claustrophobia (5-20%)Claustrophobia (5-20%)
Nasal skin lesions (2-50%)Nasal skin lesions (2-50%)
• Respiratory arrest• Inability to tolerate the device, because of
claustrophobia, agitation or uncooperativeness• Inability to protect the airway, due to
swallowing impairment• Excessive secretions not sufficiently
managed by clearance techniques• Recent upper airway surgery
NIV should not be used in:
Transition to IMV: when is in the interest of a patient?
• Hospital mortality: 64% (Schettino, 2008)• Mortality rate: 30%; prolonged
hospitalization (Chandra, 2011)• Great hospital mortality (Walkey, 2013)
Transition to IMV(personal experience, 2011-2013)
Number of subjects 62
Age (mean ± SD) , yrs 65.4±19.3
Gender (males, females) 26, 36
Ineffective NIV, n (%) Severe hypercapnia Severe hypoxemia
52 (83.8)25 (42.4)21 (35.6)
Dependence on NIV, n (%)
8 (13.3)
NIV complication, n (%) 2 (3.4)
Tracheotomy, n (%) 16 (28.8)
Outcome , n (%) Died during hosp Discharged from hosp
41 (66.1)21 (33.9)
Kaplan-Meier function of survival according to baseline condition
Mean survival:NM/CW = 305.58±36.9COPD = 53.90±7.3 ILD = 31.13±7.8
] p=0.0176] p<0.0001
Kaplan-Meier function of survival for dichotomus age (50 and >50)
Median survival:50 = 380.0 d (95%CI, 15.0 to n.c.)>50 = 45.0 d (95%CI,24.0 to 54.0)
] p=0.0071
Remarks
• Mortality rate among patients transitioned to IMV is very high;
• The outcome of patients with ILD is extremely poor.
Should IPF/COPD patients be excluded from IMV after failing a NIV trial?
Use of a novel veno-venous extracorporeal carbon dioxide removal system as an alternative to endotracheal intubation in a lung transplant
candidate with acute respiratory failure.
Submitted to Respiratory Care