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Ο ΜΕΜΑ στην Οξεία Αναπνευστική Ανεπάρκεια. Πρινιανάκης Γεώργιος ΕΑ’ ΜΕΘ ΠΑΓΝΗ ΚΡΗΤΗΣ. NIMV may be used . To prevent respiratory failure . Exacerbation of COPD and Hypercapnic respiratory failure. To prevent the need for endotracheal intubation. Alternative to invasive ventilation.

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slide1

Ο ΜΕΜΑ στην Οξεία Αναπνευστική Ανεπάρκεια

Πρινιανάκης Γεώργιος

ΕΑ’ ΜΕΘ

ΠΑΓΝΗ ΚΡΗΤΗΣ

slide2

NIMV may be used

To prevent respiratory failure

Exacerbation of COPD and Hypercapnic respiratory failure

To prevent the need for endotracheal intubation

Alternative to invasive ventilation

Cardiogenic pulmonary oedema

To prevent the development of respiratory failure once extubated

De novo Hypoxic respiratory failure

To treat post-extubation respiratory failure

To facilitate weaning from mechanical ventilation

slide4

Mild exacerbation of COPD

No reduction in mortality

No reduction on intubation rate

No reduction in hospital stay

30 patients with pH> 7.35, randomized to early NIMV or medical therapy alone

Bardi et al. ERJ 2000

No reduction in any clinical outcome

reduction in dyspnoea

52 patients with a prior history of COPD who presented with a recent onset of shortness of breath and a pH of > 7.30

Keenan et al Respiratory Care 2005

Faster improvement in arterial gases

Shorter Length of stay in hospital

42 COPD patients with chronic hypercapnic respiratory failure admitted to the hospital with acute exacerbations and an arterial pH > 7.35

Pastaka et al. Eur J Int Med 2007

slide5

CARDIOGENIC PULMONARY OEDEMA

IN EMERGENCY DEPARTMENT

Intubation Rate

Hospital Mortality

p<0.05

p>0.05

Park et al CCM 2005

Crane et al. Emerg Med J 2004

NIMV was effective in preventing endotracheal intubation, improving hospital mortality in patients with respiratory distress of cardiac origin.

NIMV must be seen as a nonpharmacologic form of treatment of acute pulmonary edema rather than a supportive measure.

slide7

COPD patients

Risk for Mortality

Risk for endotracheal intubation

Lightowler et al. BMJ 2003

slide8

Acute Cardiogenic Pulmonary Edema

MORTALITY

Masip et al. JAMA 2005

slide9

NEED FOR INTUBATION

Masip et al. JAMA 2005

slide10

Masip et al. JAMA 2005

MORTALITY

NEED FOR INTUBATION

slide14

PATIENTS WITH SEVERE CAP

p=0.005

p=0.73

NIMV

NIMV

COPD without COPD

Confalonieri et al. AM J RESPIR CRIT CARE MED 1999

cpap in 123 hypoxemic patients
CPAP in 123 Hypoxemic patients

RCT

p=0.53

p=0.89

p=0.01

4 cardiac arrest

% patients

STANDAR

CPAP

CPAP

STANDAR

CPAP

Intubation Rate Hospital mortality Adverse events

Delcloux et al. JAMA 2000

slide16

RCTs

Hilbert et al. NEJM 2001

Antonelli et al. JAMA 2000

% patients

Intubation Rate ICU Mortality Intubation Rate ICU Mortality

slide17

NIMV v.s standard therapyMetanalysis

INTUBATION RATE

RCTs

Sean P. Keenan et al. Crit Care Med 2004

slide19

HYPOXEMIC RESPIRATORY FAILURE

Antonelli et al. Intensive Care Medicine 2001

slide21

Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial

Noninvasive ventilation group (n=23) Conventional ventilation group (n=26) p

pH 7.2±0.05 7.2±0.05 0.91

PaCO2 85±16 (mmHg) 87±14 (mmHg) 0.38

p>0.05

No patients

Patients in the NIMV group had a lower rate of sepsis and septic shock

Conti et al. ICM 2002

slide24

NIV to prevent post-extubation failure

  • Prospective, randomized, controlled
  • 97 consecutive patients at risk of post-extubation failure:
  • PaCO2 > 45 mmHg
  • CHF
  • >1 comorbidities
  • > 1 failed weaning attempt
  • excessive secretion
  • upper airways disorders
  • Randomized to:

sequential NIV

(first 48 hrs)

standard

medical therapy

Nava et al CCM 2005;332:465-470

slide25
Criteria of enrolment:
  • Age > 65 yrs
  • CHF as a cause of intubation
  • APACHE II >12
slide28

NIMV vs standard therapy to prevent respiratory failure after extubation

p=0.001

p=0.02

p=0.3

p=0.7

Ferrer et al Lancet 2009

slide30

Keenan S. et al

39 patients in NIMV group vs 42 patients in standard therapy group

After one year of study, COPD patients were excluded

p=n.s

ημέρες

p=n.s

% of the patients

reintubation ICU survival Hospital survival

MV duration ICU stay Hospital stay

NIMV

standard therapy

slide32

Mortality

Reintubation

Time delay

12 hrs

Non-Invasive Ventilation

(n.114)

25%

49%

49%

2 hrs

14%

Conventional Therapy

(n.107)

0

Absolute Risk Difference

11.4%

Relative Risk (95% CI)

1.75

0.99

P value 0.05 NS 0.02

time to reintubation
TIME to REINTUBATION

%

Epstein and Ciubotaru AJRCCM 1998;158:489-93

slide35

Nava et al. Ann Intern Med 1998

50 COPD patients- 48h in MV

Weaning failure (t-piece trial)

Am J RespirCritCareMed 2003

Σε 43 ασθενείς της ΜΕΘ (50% COPD)οι οποίοι είχαν αποτύχει 3 δοκιμασίες αυτόματης αναπνοής

Am J RespirCritCareMed1999

Σε 33 ασθενείς της ΜΕΘ (50% COPD)οι οποίοι είχαν αποτύχει σε t-piece trial

icu stay
ICU stay

P<0.05

P<0.05

Days

p=NS

NIMV

control

Girault Ferrer Nava

  • WMD -6.88 (-12.60, -1.15)p= 0.02

ΜΕΙΩΣΗ ΤΗΣ ΠΑΡΑΜΟΝΗΣ ΣΤΗ ΜΕΘ ΚΑΤΑ 6.88 ΗΜΕΡΕΣ

days on etmv
Days on ETMV

p<0.05

p<0.05

NIMV

p<0.05

control

Girault Ferrer Nava

WMD -7.33 (-11.45, -3.22) P = 0.0005

ΜΕΙΩΣΗ ΤΗΣ ΔΙΑΡΚΕΙΑΣ ΤΟΥ ΜΗΧΑΝΙΚΟΥ ΑΕΡΙΣΜΟΥ ΚΑΤΑ 7.33 ΗΜΕΡΕΣ

slide38

Effect of non-invasive and invasive weaning on mortality in critically ill adults on invasive ventilation

Burns et al. BMJ 2009

9%

24%

0.001 0.01 0.11 10 100 1000

slide39

Ventilator Associated Pneumonia

36%

8%

Burns et al. BMJ 2009

slide41

ΜΕΘ - ΠΑΓΝΗ

Ποσοστό διασωλήνωσης-θνητότητα

1 θάνατος στην ΜΕΘ

slide43

First

Author

Conclusion/Recommendation

Application

Nava

Girault

Ferrer

Chen

Hill

NIV reduces the need for mechanical ventilation in selected patients with acute-on chronic respiratory failure (eg, COPD).

Facilitate

weaning

NIV is not effective when used routinely after extubation in unselected patients.

NIV is effective when used immediately after extubation in patients at high risk for extubation

Failure (COPD) .

Jiang

El-Solh

Nava

Ferrer

Prevent

extubation

failure

NIV probably is effective in established post-extubation respiratory failure in patients with

COPD.

Treat

extubation

failure

Hilbert

Keenan

Esteban

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