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Roberto CosentiniGruppo NIV

Fondazione IRCCS Ca’ Granda Policlinico - Milano Varese, 06.03.15

Gruppo NIV Policlinico - MI

Gruppo NIV Policlinico - MI

Gruppo NIV Policlinico - MI

Quale di questi NON vorresti incontrare?

Quale di questi NON vorresti incontrare?

Quale di questi NON vorresti incontrare?

AH 38.9ºCAdmitted for AECBAcute pancreatitis

AH 38.9ºC Admitted for AECBAcute pancreatitis

AH 38.9ºC Admitted for AECBAcute pancreatitis

AH 38.9ºC Admitted for AECBAcute pancreatitis

210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

AH 38.9ºC Admitted for AECBAcute pancreatitis

210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

AH 38.9ºC Admitted for AECBAcute pancreatitis

210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

history

DG

phys. exam.

Tx

imaging

history

DG

phys. exam.

Tx

imaging

history

DG

phys. exam.

site of care

Tx

imaging

Admitted for AECBAcute pancreatitis

90/60 122r 36’ 85%

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

?

2008, 6:16

ARDS and Lung US

Mantuani D et al.

2008, 6:16

ARDS and Lung US

Mantuani D et al.

ARDS ACPE

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

NIV?

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

NIV?

1 h after NIV (IPAP 20 EPAP 8 FiO2 .6)

76 ys, severe emphysema

Dec 4, 2013: admission for AECB

Dec, 13:BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

Acute pancreatitis Progressive dyspnoea

VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

NIV?

1 h after NIV (IPAP 20 EPAP 8 FiO2 .6)

pH 7.31 pCO2 47 pO2 60 HCO3 23

?

?

?

• 12 episodi di ALI/ARDS in 10 pazienti

• In pazienti emodinamicamente stabili, la NIV ha una elevata percentuale di successo (50%)

• Considerare NIV nelle fasi precoci dell’ALI/ARDS.

• 70% di fallimenti

• Fattori predittivi di fallimento:

• shock, acidosi metabolica, ipossiemia severa

• Nei pazienti che hanno fallito la NIV, la mortalità osservata è risultata essere > alla mortalità predetta (Apache II)

• Successo 54% dei pazienti.

• F a t t o r i p r e d i t t i v i d i fallimento:

SAPS II > 34

incapacità a migl iorare PaO2/FiO2 dopo un’ora dall’inizio della NIV

Independent risk factors for ETI

ARDS & NIV

Independent risk factors for ETI

SAPS II > 34

ARDS & NIV

Independent risk factors for ETI

SAPS II > 34

ARDS & NIV

SHOCK

Independent risk factors for ETI

SAPS II > 34

No↑PaO2/FIO2 after 1 h of NIV

ARDS & NIV

SHOCK

Independent risk factors for ETI

SAPS II > 34

No↑PaO2/FIO2 after 1 h of NIV

ARDS & NIV

Independent risk factors for mortality

SHOCK

Independent risk factors for ETI

SAPS II > 34

No↑PaO2/FIO2 after 1 h of NIV

ARDS & NIV

Independent risk factors for mortality

NIV FAILURE

SHOCK

Gruppo NIV Policlinico - MI

Gruppo NIV Policlinico - MI

Quale di questi NON vorresti incontrare?

Quale di questi NON vorresti incontrare?

Quale di questi NON vorresti incontrare?

AH

210/110 122r 36’ 85%

AH

210/110 122r 36’ 85%

RCT

Gruppo NIV Policlinico - MI

courtesy of F. Piffer

RCT

Gruppo NIV Policlinico - MI

courtesy of F. Piffer

NIV in ACPE: a meta-analysis of RCTs

Mariani et al. J Card Fail 2011

Mortality

210/110 122r 36’ 85%

VM .5

pH 7.22 pCO2 59 pO2 54

HCO3 24So2 85%

?

TNG --> 15 mcg/min

210/110 122r 36’

VM .5

pH 7.22 pCO2 59 pO2 54

HCO3 24So2 85%

210/110 122r 36’

VM .5

pH 7.22 pCO2 59 pO2 54

HCO3 24So2 85%

TNG --> 15 mcg/min

1hPEEP 10 FiO2 .5

pH 7.27 pCO2 52 pO2 89

HCO3 24So2 92%

150/90 111r 28’

210/110 122r 36’

VM .5

pH 7.22 pCO2 59 pO2 54

HCO3 24So2 85%

TNG --> 15 mcg/min

1hPEEP 10 FiO2 .5

pH 7.27 pCO2 52 pO2 89

HCO3 24So2 92%

2hPEEP 10 FiO2 .5

pH 7.27 pCO2 52 pO2 89

HCO3 24So2 92%

150/90 111r 28’ 140/90 110r 30’

210/110 122r 36’

VM .5

pH 7.22 pCO2 59 pO2 54

HCO3 24So2 85%

TNG --> 15 mcg/min

1hPEEP 10 FiO2 .5

pH 7.27 pCO2 52 pO2 89

HCO3 24So2 92%

2hPEEP 10 FiO2 .5

pH 7.27 pCO2 52 pO2 89

HCO3 24So2 92%

150/90 111r 28’ 140/90 110r 30’

?

history

DG

phys. exam.

pH 7.28

PaCO2 77

PaO2 41

HCO3- 36

SO2% 86%

lab, imaging

site of care

Tx

EPAc in stenosi mitralica misconosciuta

EPAc in stenosi mitralica misconosciuta

EPAc in stenosi mitralica misconosciuta

rythm inotropism ischemia mechanics

EPAc in stenosi mitralica misconosciuta

30

www.thennt.org ken milne

30

www.thennt.org ken milne

30

www.thennt.org ken milne

30

NNT = 8 for ETI13 for death

www.thennt.org ken milne

30

NNT = 8 for ETI13 for death

100 ACPE pts_NIV

www.thennt.org ken milne

30

NNT = 8 for ETI13 for death

100 ACPE pts_NIV

Avoid 13 ETI

www.thennt.org ken milne

30

NNT = 8 for ETI13 for death

100 ACPE pts_NIV

Avoid 13 ETIAvoid 8 deaths

www.thennt.org ken milne

vs

vs

vs

www.acpe.it

vs

www.acpe.it 1.000 ACPE patients treated w NIV

vs

www.acpe.it 1.000 ACPE patients treated w NIVMortality = 9%

S’ha da fare ...

S’ha da fare ...

Adelante Pedro... con juicio

S’ha da fare ...

Adelante Pedro... con juicio

ACPE = syndrome

S’ha da fare ...

Adelante Pedro... con juicio

ACPE = syndrome

Gruppo NIV Policlinico - MI

Gruppo NIV Policlinico - MI

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

RLL echo

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

RLL echo

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

Home or

RLL echo

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

Home or

RLL echo

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

Home or

BGA:

pH 7.48 pCO2 34 pO2 54

HCO3 25

RLL echo

SpO2 # pO2

55 ys, cough and fever, otherwise healthy120/70 84r 25’ SpO2 94%

CXR = non-diagnostic

Home or

BGA:

pH 7.48 pCO2 34 pO2 54

HCO3 25

RLL echo

110/55 114r 34’ 88% 38.9ºC

110/55 114r 34’ 88% 38.9ºC

h 8.55 M, 64 aa BPCO, fumatore

da tre giorni febbre fino a 39ºtosse, astenia GB 11.000

Hb 15.4PCR 7

crea 0.98Na 129, CK 417

h 8.55 M, 64 aa BPCO, fumatore

da tre giorni febbre fino a 39ºtosse, astenia

lucido, vigile

PA 140/70 FC 96 Sat 88% FR 40 TA 38.9º

GB 11.000Hb 15.4PCR 7

crea 0.98Na 129, CK 417

VM .5

pH 7.39pCO2 40pO2 58

HCO3 21.7 lattati 2.3sat 88%

h 8.55 M, 64 aa BPCO, fumatore

da tre giorni febbre fino a 39ºtosse, astenia

lucido, vigile

PA 140/70 FC 96 Sat 88% FR 40 TA 38.9º

GB 11.000Hb 15.4PCR 7

crea 0.98Na 129, CK 417

VM .5

pH 7.39pCO2 40pO2 58

HCO3 21.7 lattati 2.3sat 88%

NIV ?

Gruppo NIV Policlinico - MI

Gruppo NIV Policlinico - MI

Cochrane Database Syst Rev. 2012 Mar OXYGEN THERAPY FOR PNEUMONIA IN ADULTS (REVIEW)

Cochrane Database Syst Rev. 2012 Mar OXYGEN THERAPY FOR PNEUMONIA IN ADULTS (REVIEW)

Conclusioni

Intensive Care Med. 2014 Jul;40(7):942-9.

inclusion criteria

pneumoniadistress, RR> 30, PF<250

inclusion criteria

pneumoniadistress, RR> 30, PF<250

Number Needed to Treat (NNT) = 2 (CI95% = 1-3)

43

entro le 12 ore peggioramento

entro le 12 ore peggioramento

NNT = 3 for ETI criteria

NNT = 3 for ETI criteria

criteria

NNT = 3 for ETI criteria

Venturi 50% levofloxacina

FiO2 0.5FR 42

pH 7.39pCO2 38pO2 62

HCO3 23 Sat 96%

PF 124

Venturi 50% levofloxacina

FiO2 0.5FR 42

pH 7.39pCO2 38pO2 62

HCO3 23 Sat 96%

PF 124

CPAP

Venturi 50% levofloxacina

FiO2 0.5FR 42

pH 7.39pCO2 38pO2 62

HCO3 23 Sat 96%

PF 124

dopo 1 ora

CPAP

FiO2 0.5 PEEP 10FR 38

pH 7.35pCO2 44pO2 96

HCO3 24sat 99%

PF 216

Venturi 50% levofloxacina

FiO2 0.5FR 42

pH 7.39pCO2 38pO2 62

HCO3 23 Sat 96%

PF 124

dopo 1 ora

CPAP

FiO2 0.5 PEEP 10FR 38

pH 7.35pCO2 44pO2 96

HCO3 24sat 99%

PF 216

dopo 2 ore

Venturi 50% levofloxacina

FiO2 0.5FR 42

pH 7.39pCO2 38pO2 62

HCO3 23 Sat 96%

PF 124

dopo 1 ora

CPAP

FiO2 0.5 PEEP 10FR 38

pH 7.35pCO2 44pO2 96

HCO3 24sat 99%

PF 216

dopo 2 ore

FiO2 0.5 PEEP 10FR 36

pH 7.25pCO2 55pO2 95

HCO3 24sat 99%

PF 216

Is something wrong?

Is something wrong?

modified from Aliberti

FiO2 + NIV

modified from Aliberti

Transfusion Fluids Vasopressors

FiO2 + NIV

modified from Aliberti

Transfusion Fluids Vasopressors

FiO2 + NIV

ABX

modified from Aliberti

Nitrates

Transfusion Fluids Vasopressors

FiO2 + NIV

ABX

modified from Aliberti

Nitrates

Transfusion Fluids Vasopressors

FiO2 + NIV

ABX

modified from Aliberti

Nitrates

Transfusion Fluids Vasopressors

FiO2 + NIV

ABX

modified from Aliberti

Nitrates

Transfusion Fluids Vasopressors

FiO2 + NIV

ABX

modified from Aliberti

STUDIO PROSPETTICO OSSERVAZIONALE MULTICENTRICO “REAL LIFE” SULL’USO DELLA

CPAP/NIV NEL TRATTAMENTO DELLA POLMONITE

studio “3P”Pneumonia

Positive Pressure

nel 2013, 20 Centri Italiani, 342 polmoniti trattate con CPAP/NIV

protettiviobesitàBPCOr

CPAP (171) NIV (171)

Efficacia 106 (62%) 108 (63%)

Interruzione x intolleranza

10 (6%) 12 (7%)

Passaggio a NIV 33 (19%) /

IOT 11 (6.4%) 22 (12.9%)

mortalità 43 (25%) 40 (23.4%)

etàpolmonite bilateraleanemiaazotemia altaPSI alto

DNIneoplasia sepsi grave

Fattori prognostici di mortalità

pneumonia

pneumonia

± sepsis

pneumonia

± sepsis = severity

pneumonia

± sepsis = severity

= survival

pneumonia

± sepsis = severity

= survival

pneumonia

± sepsis = severity

= survival

pneumonia

± sepsis = severity

= survival

Hypercapnia

pneumonia

± sepsis = severity

= survival

Hypercapnia

HDU or ICU

history

DG

phys. exam.

pH 7.28

PaCO2 77

PaO2 41

HCO3- 36

SO2% 86%

lab, imaging

site of care

Tx

history

DG

phys. exam.

pH 7.28

PaCO2 77

PaO2 41

HCO3- 36

SO2% 86%

lab, imaging

site of care

Tx

skill

monitoring

history

DG

phys. exam.

pH 7.28

PaCO2 77

PaO2 41

HCO3- 36

SO2% 86%

lab, imaging

site of care

Tx

skill

monitoring

High mortality

10% 25% 50%

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• Fatti non foste a viver come bruti ...

• Fatti non foste a viver come bruti ...

• Fatti non foste a viver come bruti ...

• Fatti non foste a viver come bruti ...

• don’t forget the brain ...

• Fatti non foste a viver come bruti ...

• don’t forget the brain ...