M Vitacca Divisione di Pneumologia Fondazione S.Maugeri Lumezzane (BS) Italy

Il momento e il paziente giusto

Severe Mild To moderate Not established COPD exacerbation Post-extubation COPD exacerbation Hypoxemic Post-extubation COPD Exacerbation Hypoxemic Weaning DNI order Meaning of NIV use ARF Severity TO PREVENT TO AVOID ETI ALTERNATIVE to ETI

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:

COPD CHF/CPE PNA Asthma OHS NMD UAO post-op post-extub trauma ARDS MOF IPF Tight UAO

NEED OF ETI: range → 5-60% WEAK COUGH AND HYPER-SECRETIONS SEVERE ENCEPHALOPATHY INTOLERANCE AND AGITATION PATIENT-VENTILATORY ASYNCHRONIES EXCESSIVE LEAKS POOR RESPONSE OF ABG AND RR HIGH SCORES OF SEVERITY OF ILLNESS DISCOMFORT SLEEP DISTURBANCES HYPERGLICAEMIA LOW ADLs Courtesy of dott Scala

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

Perchè fallisce la NIV ? Perchè si sbaglia paziente Perchè non si rispettono le controindicazioni Perchè si sbaglio maschera Perchè si sbaglio modalità di ventilazione Perchè si sbaglio il settaggio Perchè il paziente non supporta più la NIV Perchè non miglioranono i gas Perchè vi è cattiva interazione con il ventilatore Perchè dà un senso di falsa sicurezza

FATTORI PREDITTIVI PER IL FALLIMENTO DELLA NIV IN SOGGETTI CON INSUFFICIENZA RESPIRATORIA. A) Ipossiemici Ipercapnici Età Basso punteggio del livello di dipendenza misurato con scala ADL (activity daily life) Iperglicemia Presenza di polmonite come causa di insufficienza respiratoria acuta (IRA) Alto punteggio di gravità prognostica (alto APACHE II score all’ ammissione) Paziente incosciente, non collaborante Severa ipercapnia (paCO2 > 90 mmHg) Severa acidosi (pH a < 7.10) Mancanza di miglioramento (entro 1-2 h) degli scambi gassosi, frequenza cardiaca e respiratoria Paziente ipersecretivo Presenza di encefalopatia Intolleranza alla VMN Perdite di flusso dalla maschera Caduta della pressione arteriosa

FATTORI PREDITTIVI PER IL FALLIMENTO DELLA NIV IN SOGGETTI CON INSUFFICIENZA RESPIRATORIA. B) Ipossiemici Normocapnici Età Alto punteggio di gravità prognostica (alto SAPS II score all’ ammissione) ARDS e polmonite come causa del ricovero Edema polmonare cardiogeno senza risposta alla terapia medica Mancato miglioramento della ossigenazione dopo VMN (1-2 h) Paziente ipersecretivo Presenza di encefalopatia Intolleranza alla VMN

Be carefull ! NON INVASIVE RESPIRATORY SUPPORT IN HYPOXIEMIC ACUTE RESPIRATORY FAILURE ? High percentage of failures Late resolution Difficult “invasive” diagnostic procedures (BAL, Brush) Risk to delay ETI Take care of: Accurate selection of the patients: - PaO 2 /FiO 2 > 150 mmHg, - Lobar densities at chest X- Ray or CT - Absence of hemodynamic shock (BE > -2.5 mEq/L) Empiric Antibiotic Treatment (Protocols !) Non invasive fast diagnostic tests (Urinary antigens, etc.) Hemocoltures Don’t push to hard (stop NIV if PaO 2 /FiO 2 < 150 at 1-2 hrs)

La giusta location

BTS Equipment Recommendations Staff familiarity is key to success

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

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

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

Il training adeguato

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

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

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

Monitoring: ready access to ETI and CPR Courtesy of dott Scala

Monitoraggio

Availability of ETI in case of NIV failure Ventilatory Monitoring Respiratory pattern Pt-vent interaction Courtesy of dott Scala

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

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

Availability of ETI in case of NIV failure Ventilatory Monitoring Respiratory pattern Pt-vent interaction

YOU HAVE……. A VENTILATOR HAS NO BRAIN, BUT NEEDS TO COUPLE TWO BRAINS !

Apparently there is nothing wrong on what you see on the ventilator With S. Nava courtesy

But if you could see the neural activity of the patient….. With S. Nava courtesy

Pao Pes Ineffective effort Sforzi inefficaci

Un eccesso di supporto Con la cortesia del dott. Polese

Totale desincronizzazione durante PSV Con la cortesia del dott. Polese

Totale desincronizzazione durante PSV (perdite)

Time (sec) Flow (l/sec) Paw (cmH 2 O) Pes (cmH 2 O) 5 sec Fr = 33 b/min Georgopoulos et al. Intensive Care Med 2006 Vent. rate = 12 b/min Triggering delay= Ineffective effort

Flow (l/sec) Paw (cmH 2 O) Pes (cmH 2 O) Time (sec) 1) Low threshold for triggering 2) Dirt circuit 3) leaks Autotriggering With ERS courtesy

Flow Paw Pga Pes Pdi Expiratory asynchrony With ERS courtesy

Controlla il setting diurno e notturno

Bosma et al. Crit Care Med 2007;35:1048

A CORRECT SETTING IS IMPERATIVE !

Availability of ETI in case of NIV failure Ventilatory Monitoring Respiratory pattern Pt-vent interaction

Am J Respir Crit Care Med Feb;163(2): Almost all the side effects of NIV are due to problems with interfaces

80-100% Air Leaks

Monitor the tightness of the mask

Types of Leaks Intentional leaks Courtesy of dott Scala

Look for a balance between leaks and comfort Courtesy of dott Scala

Interface rotation strategy Conti G et al. Respir Med 2007; 52: Girault C et al. Crit Care Med 2009; 37: Courtesy of dott Scala

Ventilator monitoring: numeric data and curves Courtesy of dott Scala

Berg KM et al., Respir Care 2012;57: Respiratory pattern and NIV Failure INTUBATION aRSBI= RR/exp- TV during NIV Exp TV = pt TV HOW COULD WE MONITOR exp-TV and RR DURING NIV?

Insp-TV To the patient From the patient Exp-TV TV monitoring Ventilator with Dual-Limb Circuit Exp-TV = Insp-TV – Non Intentional-Leaks NI-Leaks vent-V Courtesy of dott Scala

TV monitoring Ventilator with Single-Limb “vented” circuit vent-V Insp-TV NI-Leaks Exp-TV = Insp-TV - Intentional Leaks Intentional leaks Estimated Exp-TV? Courtesy of dott Scala

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:

Conclusion 1 1.Caution to use NIV in patients with «de novo» ARF 2.NIV in patients with ARF and COPD even in case of hypercapnic coma 3.I intubate my patient without delay when he meets criteria for intubation (RR > 40 under NIV, hemodynamic instability…) 4. In patients with chronic lung disease and with persistent respiratory failure (RR >30 and pH < 7.30), I don’t extend NIV beyond 3-12 h (?)

1. on ventilators: Good screen with clear traces Algorythm able to depict the presence of asynchrony and warn the clinicians 2. Non-invasive monitoring of gas exchange during NIV 3. sleep architecture monitoring Conclusion 2

Knowledge, skills, technical competence and experience in NIV is important Training must be multidisciplinary and on going: train the team and “measure the treasure” Provide opportunity for deliberate practice: consider the use of simulation-based education Teach about patients, not diseases Conclusion 3

NIV success