NIV and Acute Respiratory Failure in COPD

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NIV in Medicina dUrgenza
Giuseppe Foti Istituto di Anestesia e
Rianimazione Università di Milano-Bicocca Ospedale
S. Gerardo Monza
Montecatini,17 Ottobre 2003
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Classificazione
Sim
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WHY HAVE I TO TRY ?
NIV in COPD
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RATE OF DEATHS



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Incidence of Nosocomial Pneumonia
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WHERE TO PERFORM NIV?
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NIMV IN GENERAL WARDS
Plant LANCET 2000
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Training
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APACHE II
plt0.01
pH at admission

Carlucci et al Intens.Care Med. 200329419-25
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PSV in maschera

• Maschere di diverso tipo e taglia (non siamo
  tutti uguali)
• Luogo dedicato in cui tenere tutto (Maschere,
  nucali, raccordi per sng)
• Ottenere collaborazione del paziente !
• Protezione radice del naso (igiene, revestimenti
  etc.)
• Programmare periodi off
• E PIU DIFFICILE CHE INTUBARE IL PZ. MA NE VALE
  LA PENA

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Ricetta per maskPSV

• PSV/PEEP 10/5
• Pmax 25-30 cmH2O
• SNG non indispensabile !!

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Non Invasive Mechanical Ventilation
Raccordo a gomito ( passaggio SNG )
Nucale
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Perché uso poco la NIV pur curando numerosi pz.
con I.R.A. ed essendo fortemente convinto che
il tubo fa male ??
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Helmet CPAPLo Scafandro

• Rationale
• Physiology
• In Hospital
• Out of Hospital

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PEEP (Positive End Expiratory Pressure) e
Reclutamento alveolare
PEEP 5
PEEP 15
Sim
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Why Helmet CPAP instead of PSV in ARF ?

• As good as
• Inspiratory support is not as crucial
• Problem is hypoxia
• Easy, safe, efficient and cheap
• NO pts. cooperation
• NO pts-machine interaction at high RR
• NO skin necrosis
• NO time limit (safely and easily applied all day
  long)
• Can be implemented outside ICU (ED, CCU, General
  Ward, Ambulance, Home.)

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Not all patients are good candidates for this
therapy because the hermetic face mask discomfort
in anxious patients and the technique requires
intensive attention until patients are adapted to
face mask and ventilatorsMasip et al. THE
LANCET, (2000)356pag.2131
In conclusion, in hypoxemic ARF, NPPV can be
successful in selected populations, with 70 of
patients avoiding intubation
we could apply noninvasive ventilation to the 13
of the 2,770 patients with hypoxemic ARF admitted
to our ICUs.
Antonelli M et al. Intensive Care Med (2001)
271718
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Bias Flow in the Head Tent MUST be gt 30 L/min.
la mamma me lo ha sempre detto di non mettermi
in testa il sacchetto di plastica perché può
soffocarmi!!
Patroniti N., Foti G., Pesenti A. et al. ICM
(2003). 29 1680-87
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EFFICACY OF Helmet CPAP IN THE TREATMENT OF ACUTE
RESPIRATORY FAILURE

• Dipartimento di Anestesia e Rianimazione Ospedale
  S.Gerardo, Monza.

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AIM OF THE STUDYTo evaluate the therapeutic
efficacy of Helmet-CPAP in the treatment of Acute
Respiratory Failure outside the ICU.
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SCAFANDRO
DOPPIO FLUSSIMETRO
FiO2 1, 0.5, 0.35
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• INCLUSION CRITERIA
• PaO2 lt 100 mmHg in reservoir mask
• abnormal chest xRay
• EXCLUSION CRITERIA
• need of immediate tracheal intubation
• presence of more than 2 new organ failure

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PaO2/FiO2Not intubated Vs intubated
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Inability to correct hypoxia was the
principal reason for failure of 79 of CAP, 78
of ARDSexp and 92 of ARDSp
Antonelli, Intensive Care Med, 1999 25 207 A
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PaO2/FiO2 CHF Vs PNM
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RESULTS

• In all general ward pts.Helmet CPAP was feasible
• 27 of patients required intubation (22 in
  CHF, 45 in PNM group)
• Mortality rate 18 (8 among non intubated, 44
  among intubated)

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CPAP nellEPA
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Rationale of CPAP in ACPE
CPAP
? PIT
? FRC
? WOB
? Rit. Ven.
? LVafterload
? PaO2
? Cardiac performance ? pulmonary congestion
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Out of hospital treatment of Acute Pulmonary
Edema by non invasive CPAP

• G. Foti, M. Cazzaniga, E. Valle, M. Sabato, F.
  Apicella, V. Casartelli, G. Fontana, GP Rossi, S.
  Vesconi, A. Pesenti.
• Istituto di Anestesia e Rianimazione, Università
  degli Studi,
• H. S. Gerardo - Monza - Italy
• Servizio di Emergenza Territoriale, presidi di
  Carate e Desio
• SSUEm 118 Brianza

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Out of Hospital Helmet CPAPin Presumed Acute
Pulmonary Edema materials
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30 L/min.
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Oxygenation

lt 0.01
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Results
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Arterial Blood Pressure during CPAP
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Outcome of ACPE pts

• Mortality during transport
• expected 5-13
• Annals of Emergency Medicine Volume 30 Number 4
  October 1997
• observed 0
• Overall mortality
• expected (SAPS 4514) 35
• observed 11.1 (previous study 7-15)

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Outcome of ACPE pts

• Intubation rate
• during transport 0
• hospital 2.2
• Admission
• ICU 0
• CCU 15.6
• General ward 84.4
• Hospital stay
• 10 8 days

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Why SpO2 improves during HelmetCPAP?
Drugs
PEEP
FiO2
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Out of hospital treatment of Acute Pulmonary
Edema by Helmet CPAPPARAMEDICSNO DRUGS

• SSUEm 118 Brianza
• Nurse Coordinator G. Brambilla, RN Director
  G.P. Rossi, MD
• Anesthesia and Intensive Care Institute
• ICU coordinator G. Foti,MD Director Prof. A.
  Pesenti

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Results CPAP (BLS Nurse) March 2001 March
2002
n patients 28
Intubation in ED 1
Mortality during transport 0
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Oxygenation

lt 0.001
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Results March 2001 March 2002
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PROVOCATION

• Role of drugs in the first minutes of tratment of
  severe ACPE is
• MARGINAL

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La CPAP mediante Scafandro non dovrebbe mancare
nellarmamentario terapeutico dellinsufficienza
respiratoria acuta
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Consigli

• CPAP/scafandro nellEPA
• NIV solo se insuccesso CPAP (raro) e dopo
  adeguata esperienza
• NIV (PSV PEEP) nel BPCO riacutizzato
• Face mask, scafandro se mask inefficace
• Cominciatelo subito
• Cominciate con i casi più semplici
• pH gt7.3, cooperativi
• CPAP/Scafandro nellIRA ipossiemica senza MOF
• CAP, atelettasie, versamenti pleurici etc.
• Immunocompromessi

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CONCLUSIONS FROM STUDIES (2)

• BRITISH THORACIC SOCIETY
• Non-invasive Ventilation in Acute Respiratory
  Failure
• Standards of Care Report 2002
• CPAP has been shown to be effective in patients
  with Cardiogenic Pulmonary Oedema who remain
  hypoxic despite maximal Medical management.
• NIV should be reserved for patients in whom
  CPAP is unsuccessful. (B)

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Antonelli, 99 patients(P/F lt 200, RRgt 35b/min,
Active Contraction of AM or PAM, severe
dyspnea) COPD excluded
Overall ARDS mortality 16
Overall ARDS mortality 44
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Summary

• Helmet CPAP should be used as FIRST LINE
  INTERVENTION in treatment of ACPE (In and Out of
  Hospital)
• NIMV may be attempted in ALI-ARDS
• Immunocompromised, Pneumonia
• BE CAREFUL when PaO2 does not improve
• Helmet CPAP may be effective as NIMV in this
  subset of patients and can be applied more easily
  out of ICU

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FENOMENO DI HANG-UP INSPIRATORIO DURANTE NIMV
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Intensive Care Med (2002) 28 1226-1232
NonInvasive PSV in non-COPD patients with ACPE
and severe CAP acute effects and
outcomeG.Domenighetti, R. Gayer, R. Gentilini

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PEEP and cardiac silhouette
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CPAP IN CARDIOGENIC PULMONARY EDEMA
Rasen et al Chest 1985 87 158-162
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IntraThoracicPressure and LV function
AO
Ptm 100-(-20) 120
ITP

• ? effort ? ITP ?Ptm
• ?
• ? LV afterload

LV
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CPAP IN CARDIOGENIC PULMONARY EDEMA
Rasen et al Chest 1985 87 158-162
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IntraThoracicPressure and LV function
AO
Ptm 100-(-5) 105
ITP

• ? effort ? ITP ?Ptm
• ?
• ? LV afterload

LV