Ο ΜΕΜΑ στην Οξεία Αναπνευστική Ανεπάρκεια

1. Ο ΜΕΜΑ στην Οξεία Αναπνευστική Ανεπάρκεια Πρινιανάκης Γεώργιος ΕΑ’ ΜΕΘ ΠΑΓΝΗ ΚΡΗΤΗΣ

2. 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

3. To prevent respiratory failure

4. 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

5. 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.

6. To prevent the need for endotracheal intubation

7. COPD patients Risk for Mortality Risk for endotracheal intubation Lightowler et al. BMJ 2003

8. Acute Cardiogenic Pulmonary Edema MORTALITY Masip et al. JAMA 2005

9. NEED FOR INTUBATION Masip et al. JAMA 2005

10. Masip et al. JAMA 2005 MORTALITY NEED FOR INTUBATION

11. N engl j med 2008

12. META-ANALYSIS

13. De novo hypoxic respiratory failure

14. 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

15. 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

16. RCTs Hilbert et al. NEJM 2001 Antonelli et al. JAMA 2000 % patients Intubation Rate ICU Mortality Intubation Rate ICU Mortality

17. NIMV v.s standard therapyMetanalysis INTUBATION RATE RCTs Sean P. Keenan et al. Crit Care Med 2004

18. MORTALITY(trials without COPD and CPE)

19. HYPOXEMIC RESPIRATORY FAILURE Antonelli et al. Intensive Care Medicine 2001

20. Alternative to invasive ventilation

21. 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

22. Cardiogenic Pulmonary Oedema no studies

23. To prevent the development of respiratory failure once extubated

24. 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

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

26. Agarwalet al. Respiratory care 2007-Meta-analysis

27. Lancet 2009

28. 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

29. To treat post-extubation respiratory failure

30. 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

32. 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

33. TIME to REINTUBATION % Epstein and Ciubotaru AJRCCM 1998;158:489-93

34. To facilitate weaning from mechanical ventilation

35. 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

36. 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

37. 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

38. 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

39. Ventilator Associated Pneumonia 36% 8% Burns et al. BMJ 2009

40. Intubation rate during NIMV in ICU of the University Hospital of Heraklion

41. ΜΕΘ - ΠΑΓΝΗ Ποσοστό διασωλήνωσης-θνητότητα 1 θάνατος στην ΜΕΘ

42. ΣΥΜΠΕΡΑΣΜΑΤΑ

43. 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