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

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

the correct time to start

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 - PaCO2 > 45 mmHg, pH < 7.35 - PaO2/FiO2 < 250 mmHg Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

Difficult intubation ! (according to location ?) Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

the correct setting

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

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

Timing is all… What is your unit’s ‘door to mask’ time? 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

Respiratory ward, RICU or ICU? (COPD) SITE STUDIES pH PaCO2 WARD 8 7.31 62 RICU 5 7.24 75 ICU 7.25 72

Location The concept of the traffic light ICU RICU/ HDU WARD ER Staff number Safety Monitoring Equipment Familiarity with NIV

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 (?)

Acute NIV in exacerbations of COPD in a general respiratory ward Contraindications: pH< 7.30, > 1 system failure, intubation likely, high dependency nursing needs – confusion, neuromuscular, monitoring requirements Simonds ERS school

Acute NIV in HDU/Respiratory Intermediate care units European Task Force on Respiratory Intermediate Care Survey ERJ 2002;20:1343-50 Corrado et al

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

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

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

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

BTS Equipment Recommendations Staff familiarity is key to success

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

Protocols for acute NIV Selection of patients: suggest BTS or other national guidelines (Thorax 2002;57;192-211) 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: 1931-35) Importance of flexibility and local adaptation of protocols Choice of masks – start with full facemask Simonds ERS school

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

Some mild sedation may be prescribed 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

the correct condition

Endotracheal Tube vs Mask Complimentary role ET Mask ET Respiratory failure Evolving ARF Resolving ARF

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 1 2 3 4 Conventional MV with ETI Early Established Resolving Post-extubation

Pre-hospital setting to use CPAP?

Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C 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 Blood pressure and heart rate Respiratory rate + SatO2 before CPAP during CPAP before CPAP during CPAP

Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C 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 %

the correct time to stop

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

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

Percentage of patients who fail NIV Eur Respir J 2005; 25:348-355 100 – 75 % 74 -50 % 49 -25 % 24 -0 % Percentage of patients who fail NIV

Percentage of patients who fail NIV Eur Respir J 2005; 25:348-355 100 – 75 % 74 -50 % 49 -25 % 24 -0 % Percentage of patients who fail NIV

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 !!!!!!

Time to stop NIV for failure BTS Guideline of NIMV in ARF Thorax 2002; 57: 192-211 Time to stop NIV for failure 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

Technical note

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

Interface: Facial Masks

the real life

Prevalence of acute exacerbations: planning caseload pH distribution in hypercapnic pts 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;55:550-54

1678 (20%) on admission were acidotic and 6% became acidotic later. Thorax 2011;66:43e48. doi:10.1136/thx.2010.153114 232 H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later. 1077 patients received NIV (11%), 55% had a pH <7.26 30% 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.

2008 – 2009 PAZIENTI AMMESSI NELLE TI GIVITI CON DATI VALIDI N = 154698 ; 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

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

Cortesia dott. Gristina IV NIV NIV succ NIV fail N° 2656 961 652 309 ETA 73 ± 10 73 ± 11 sottopeseo 7% (196) 10% (91) 11% (72) 6% (19) SAPS II 48 ± 15 40 ± 11 38 ± 11 44 ± 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 ± 26 22 ± 21 18 ± 17 28 ± 27 LOS TI 14 ± 17 9 ± 13 5 ± 8 16 ± 16 gg VM 7 (3-14) 3 (2-5) NIV 3 (2-5) 2 (1-3) + 6 IV DIM PRETERM 3% (40) 2% (11) 2% (3) Cortesia dott. Gristina

Reasons for low use of NIV in acute hospitals: US survey No. of responses 20 10 Equipment not appropriate Poor previous experience Hospital staff inadequately trained Physicians lack of experience Other Maheshwari v et al Chest 2006:129: 1226-33

Hypercapnic Respiratory Failure USE in the “REAL” WORLD of ICUs 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

From 4% to 14%

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

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

Ethical problems

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< 30% teorico + PaCO2 > 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; 69:101-118

Shared Decision Making process

Conclusion

Palliative, ceiling intrevention Location summary (1) SITE Preferred diseases Condition Respiratory WARD COPD, restrictive, Elective, semi-elective NIV, pH >7.30 Ph > 7.25 Monitoring No resp ward COPD, CHF, PE, Aged Ph > 7.30 No comatose Hospice All Palliative, ceiling intrevention ER PE, COPD, Aged Ph > 7.20 paO2/FI02 >150 < 200 RICU All, NM ALS, 1 system failure, first 12 hours NIV. Confusion, poor tolerance, labile bronchospasm, disability with high nursing dependency 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 H PE High expertize

Location summary (2) SITE advantages Contra 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 ward cost effectiveness geriatric skills Beds availability Low case mix Low respiratory skills ER Early good outcome , triage Low expertize on NIV and chronic diseases Hospice Advanced plan respect Palliative competence RICU High enthusiasm, skills, Cough assistance combination, Rapid worsening in Hypox ICU Monitoring EI availability Complexity case mix Costs Pre H Early good outcome High expertize, Delay in EI

NIV success: staff training and experiance Correct pt interface nurses monitoring Location MT NIV success: staff training and experiance are more important than location

Grazie per l’attenzione By evaluating the TA service after five years from the beginning of the service we found that the steady state of activity may be reached after 4 years of work with increasing nurse workload and decreasing specialist’s time dedicated.