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NIV: dove ventilare il paziente Dott Michele Vitacca Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)

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Presentazione sul tema: "NIV: dove ventilare il paziente Dott Michele Vitacca Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)"— Transcript della presentazione:

1 NIV: dove ventilare il paziente Dott Michele Vitacca Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)

2 NIV VS TRATTAMENTO STANDARD EI Mortality Non usare la NIV nella BPCO riacutizzata con alterazione EGA è malpractice ! New gold standard È uno strumento salvavita E’ stata rivoluzionata l’epidemiologia della BPCO

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4 IDENTIFY PATIENTS (according to location ?) 1.Clinical abnormalities - moderate to severe dyspnea - RR > 24 b/min in COPD - RR > 30 – 35 b/min in AHRF - accessory muscle use, paradoxal breathing 2. Gas exchange abnormalities - PaCO 2 > 45 mmHg, pH < PaO 2 /FiO 2 < 250 mmHg Am J Respir Crit Care M d 2001 ; 163: ; Intensive Care Medicine 2001 ; 27:

5 Difficult intubation ! Am J Respir Crit Care M d 2001 ; 163: ; Intensive Care Medicine 2001 ; 27: (according to location ?)

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7 The right location Model of health care delivery varies markedly –From country to country –Within a country –Within an institution Randomised controlled trials performed in one country may not be generalisable to another

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9 Have a plan from the outset –This may change! What is going to happen if the patient fails? –What is reversible? –Pre morbid quality of life Circumstances of failure

10 Timing is all… Start early but not too early (Barbe study) You are too late if… Pt on verge of respiratory arrest Pt severely hypoxaemic (PaO2/FiO2 < 75) Pt comatose or hugely agitated Medically unstable: acute MI, GI bleed, shock What is your unit’s ‘door to mask’ time? What are the main limitations? Simonds ERS school

11 Respiratory ward, RICU or ICU? (COPD) SITESTUDIESpHPaCO2 WARD RICU ICU

12 Location ICURICU/ HDU WARDER Staff number Safety Monitoring Equipment Familiarity with NIV The concept of the traffic light

13 Strategic use of NIV Concentrate staff expertise Training focus for NIV for medical, nursing and paramedical staff Concentrate equipment Facilitate link with ICU Audit, data collection Cost savings (?)

14 Acute NIV in exacerbations of COPD in a general respiratory ward Contraindications: pH 1 system failure, intubation likely, high dependency nursing needs – confusion, neuromuscular, monitoring requirements Simonds ERS school

15 Acute NIV in HDU/Respiratory Intermediate care units European Task Force on Respiratory Intermediate Care Survey ERJ 2002;20: Corrado et al

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17 Safety first! Patient selection Safe staffing levels Rolling programme of staff training and protocols Adequate monitoring Ability to intubate & transfer pts to ICU Suitable alarms Simonds ERS school

18 Staffing of resp int care unit ( or location with high number of NIV pts) Nurse to pt ratio 1:4 (1:6 ?) Senior Physician on call for 24 hours Training for nurses and trainee medical staff Dedicated physiotherapist Technical service Strong links with ICU Simonds ERS school

19 Nava et al.Chest 97;111:1631 HUMAN WORKLOAD in RICU

20 Teamwork Named Consultant with responsibility 24 hour service Protocols: doctors, nurses, paramedical staff can all initiate NIV if suitably trained Nurses involved in maintenance of care Rolling educational programme Regular audit Simonds ERS school

21 BTS Equipment Recommendations Staff familiarity is key to success

22 Monitoring Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance Pulse oximetry Continuous display of ECG and non-invasive BP Arterial blood gases (ABG machine easily accessed) Continuous non-invasive monitoring of CO2 helpful eg. Transcutaneous, end-tidal Duration of NIV use Ventilatory settings, FiO2, leak Severity score Side effects : skin integrity, GI, nasal symptoms CXR, screening bloods etc. Simonds ERS school

23 Protocols for acute NIV Selection of patients: suggest BTS or other national guidelines (Thorax 2002;57; ) Initiation of NIV (BTS or local guidelines) EPAP 4 + IPAP 10 increasing to IPAP 15, IPAP 20 to max tolerated over 60 mins (Plant et al Lancet 2000; 355: ) Importance of flexibility and local adaptation of protocols Choice of masks – start with full facemask Simonds ERS school

24 Problem solving in acute NIV Primary failure of NIV (poor tolerance, wrong settings, too sick) Secondary failure (progression underlying disease despite NIV) Decisions for process: who to intubate, CPR decision, liaison with ICU, Use Advance directives Simonds ERS school

25 25% of the respondents use hand restraints in >30% of the patients. Is this the way to solve the problem ? Some mild sedation may be prescribed

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27 ETMaskETMask Endotracheal Tube vs Mask Complimentary role Respiratory failure Evolving ARF Resolving ARF

28 Timing of NPPV Application 1. Early: to prevent intubation 2. Established: as alternative to intubation 3. Resolving: to wean from ventilation 4. Post-extubation: to prevent re-intubation Conventional MV with ETI Early EstablishedResolving Post-extubation

29 Pre-hospital setting to use CPAP?

30 Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim Respiratory rate + SatO2 before CPAPduring CPAP Blood pressure and heart rate before CPAPduring CPAP

31 Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim clincal situation with CPAP: much improved 51 % improved 40 % unchanged 3 % worse 3 % with the use of pre-clinical CPAP, intubation was avoided 59 % not avoided 9 % was not necessary 32 %

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33 Carlucci A. AJRCCM 2001;163:874 Considera la patologia !

34 Initial ph Answer in ph after 1-2 h Answer in RR after 1-2 h Answer of HR after 1-2 h Neurological status Improvement in neurological status 1-2 h Pmeumonia Basal FEV1 Basal ADL Apache II

35 Eur Respir J 2005; 25: – 75 % % %24 -0 % Percentage of patients who fail NIV

36 Eur Respir J 2005; 25: – 75 % % %24 -0 % Percentage of patients who fail NIV

37 Perchè fallisce la NIV ? Perchè si sbaglia paziente Perchè non si rispettono le controindicazioni Perchè si sbaglia maschera Perchè si sbaglia modalità di ventilazione Perchè si sbaglia il settaggio Perchè il paziente non supporta più la NIV Perchè non miglioranono i gas Perchè vi è cattiva interazione con il ventilatore PERCHE ‘ SI SBAGLIA LOCATION !!!!!!

38 BTS Guideline of NIMV in ARF Thorax 2002; 57: no improvement or deterioration in consciousness no improvement in ABG severe complications severe pneumonia on chest X-ray 2° intrahospital failure with necessity of NIV copiuos secretion more than 18 continous hours of NIV for more than 4 days nasal bridge erosion intolerance to ventilator Time to stop NIV for failure

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40 Pao Pes Pao Pes Pao Pes Pressure support Press/Control CPAP Assist/Control PAV AVAPS

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42 Interface: Facial Masks

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44 Prevalence of acute exacerbations: planning caseload Per population of 727,000: 983 acute COPD pts admitted /year, 20% with respiratory acidosis: corrected figure estimated 72 pts /year needing NIV per 250,000 Plant et al Thorax 2000;55: pH distribution in hypercapnic pts

45 Thorax 2011;66:43e48. doi: /thx H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later patients received NIV (11%), 55% had a pH < % patients with persisting respiratory acidosis did not receive NIV. Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis. Only 4% of patients receiving NIV who died had invasive mechanical ventilation.

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47 2008 – 2009 PAZIENTI AMMESSI NELLE TI GIVITI CON DATI VALIDI N = ; N TI = 267 PATOLOGIA ALL’AMMISSIONE: PNEUMOPATIA CRONICA RIACUTIZZATA N = 8796 (6%) COMORBIDITA’ BPCO LIEVE N= 1129 (13%) COMORBIDITA’ BPCO GRAVE N= 4471 (51%) COMORBIDITA’ BPCO MODERATA N= 3193 (36%) TI LOS < 24h N= 467 (10%) P CHIR. E TRAUM. N = 295 (6%) OUTCOMES MANCANTI N = 92 (2%) POPOLAZIONE DELLO STUDIO N = 3617 (81%) Cortesia dott. Gristina

48 POPOLAZIONE DELLO STUDIO N = 3617 (81%) VENTILAZIONE INVASIVA (IV) N= 2656 (73%) VENTILAZIONE NON INVASIVA (NIV) N= 961 (27%) NIV failure N=309 (32%) Early NIV success N=652 (68%) INTUBAZIONE SI N=309 (32%) Late NIV failure INTUBAZIONE NO N=153 (25%) DESISTENZA TERAPEUTICA (EOLC) N = 207 (6%) Cortesia dott. Gristina

49 IVNIVNIV succNIV fail N° ETA 73 ± 1073 ± ± 10 sottopeseo 7% (196)10% (91)11% (72)6% (19) SAPS II 48 ± 1540 ± 1138 ± 1144 ± 12 BMI sov+ob 61% (1611)59% (564)57% (369)64% (195) GCS 11 (37-58)15 (12-15) 14 (11-15) POLMONITE /AM 28% (748)27% (256)23% (152)34% (104) SEPSI grave 8% (208)4% (43)2% (14)10% (29) CHF 15% (435)18% (172)18% (112)19% (60) INFEZ AM 43% (1149)40% (386)39% (248)45% (138) INFEZ DEG 21% (557)11% (102)4% (26)25% (76) Dead H 34% (905)26% (252)21% (137)37% (115) Dead TI 29% (779)17% (164)9,6% (63)33% (101) LOS H 26 ± 2622 ± 2118 ± 1728 ± 27 LOS TI 14 ± 179 ± 135 ± 816 ± 16 gg VM 7 (3-14)3 (2-5)NIV 3 (2-5)2 (1-3) + 6 IV DIM PRETERM 3% (40)2% (14)2% (11)2% (3) Cortesia dott. Gristina

50 Reasons for low use of NIV in acute hospitals: US survey Physicians lack of experience Equipment not appropriate Other Poor previous experience Hospital staff inadequately trained Maheshwari v et al Chest 2006:129: No. of responses

51 Hypercapnic Respiratory Failure NPPV is the first attempt of MV in ICU in 63% of Pts Success rate is 66% Carlucci A. AJRCCM 2001;163:874 USE in the “REAL” WORLD of ICUs

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54 From 4% to 14%

55 Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 H admissions pts from NIV to EI NIV N° pts deaths

56 Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 No support NIV no EI EI NIV and EI

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58 Criteri di esclusione VMI  storia + segni RX o TC di BPCO da almeno 10 anni  O2LT > 5 anni (< 5 anni se associata a VMD)  2 ricoveri/anno negli ultimi 3 anni per BPCO riacutizzata  1 ricovero in TI con VMI per BPCO riacutizzata nell’ ultimo anno o almeno 2 ricoveri con necessità di NIV nell’ultimo anno  in fase stabile : FEV1 65  comorbilità con dimostrato danno d’organo  Età > 80 aa. Raccomandazioni S.I.A.A.R.T.I. per l’ammissione/dimissione dalla T.I. e la limitazione dei trattamenti Minerva Anestesiol 2003; 69:

59 Shared Decision Making process Proporzionalità delle Cure Proporzionalità delle Cure Evidence Based Medicine Appropriatezza Etica Volontà Appropriatezza Clinica Rappresentante V.A.L.U.E.

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61 Location summary (1) SITEPreferred diseasesCondition Respiratory WARD COPD, restrictive, Elective, semi- elective NIV, pH >7.30 Ph > 7.25 Monitoring No resp wardCOPD, CHF, PE, AgedPh > 7.30 No comatose HospiceAllPalliative, ceiling intrevention ER PE, COPD, Aged Ph > 7.20 paO2/FI02 >150 < 200 RICUAll, NM ALS, 1 system failure, first 12 hours NIV. Confusion, poor tolerance, labile bronchospasm, disability with high nursing dependency Ph > 7.20 paO2/FI02 >150 < 200 ICU Pure Ipoxemic, Sedation, Post op ARF, comorbidities, Weaning and NIV, Multi system organ failure. Haemodynamic instability. Severe confusion. Pre coma Ph <7.20 paO2/FI02<150 Pre HPEHigh expertize

62 Location summary (2) SITEadvantagesContra Respiratory WARD More enthusiasm, skills, No aggressive location, RT presence Cough assistance combination, cost effectiveness No sufficient staff Night duty ? Delay in EI Low monitoring on ventilators No adequate devices No resp wardcost effectiveness geriatric skills Beds availability No sufficient staff Night duty ? Delay in EI Low monitoring on ventilators No adequate devices Low case mix Low respiratory skills EREarly good outcome, triageLow expertize on NIV and chronic diseases HospiceAdvanced plan respect Palliative competence No adequate devices Low case mix Low respiratory skills RICUHigh enthusiasm, skills, RT presence Cough assistance combination, cost effectiveness Rapid worsening in Hypox ICUMonitoring EI availability Complexity case mix Low expertize on NIV and chronic diseases Costs Pre HEarly good outcomeHigh expertize, Delay in EI

63 NIV success: staff training and experiance are more important than location NIV success: staff training and experiance are more important than location

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