Insufficienza Respiratoria Andrea Vianello Fisiopatologia e Terapia Intensiva Respiratoria Ospedale – Università di Padova.

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 VS TRATTAMENTO STANDARD

Keenan S et al

NIV VS TRATTAMENTO STANDARD

Keenan S et al

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

Joint BTS/RCP London/Intensive Care Society Guidelines. NIV in COPD. Oct 2008

When to use Non-Invasive VentilationWhen to use Non-Invasive Ventilation

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

Eur Respir J 2002; 19: 1159–66

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

Overall NIV failure: 16.3%

Sixty-two RCTs including a total of 5870 patients

• 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

The percentage of patients transitioned from NIV to IMV ≈ 5% and did not increase from 1998 to 2008

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 overall survival

Median survival:46 days

(95% CI, 43 to 162)

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

NIV in AECOPD: conclusions• Confirm and reinforce the routine use

of NIV, however:

• The problem of transitioning from NIV to IMV: may not be in the interest of patients!

• Suggest caution with NIV among patients at high risk of failure