NIV in the ICU: Lessons learnt in the last 20 years

1. NIV in the ICU: Lessons learnt in the last 20 years Laurent Brochard

3. Ventilatoryproblems in thoracic anesthesia; VO Björk, CG Engström et al J Thoracic Surg. 1956; 31:117 The Engström ventilator (1951)

4. Sadoul, Bull.physio-pathol.Resp. 1965

5. NIV and 2y mortality Traitement par ventilation instrumentale de 100 cas d'insuffisance respiratoire aigue severe (pACO2> 70) chez des pulmonaires chroniques Sadoul, Bull.physio-pathol.Resp. 1965

6. Mask ventilation difficult • Need for respiratory stimulant • Tracheal ventilation considered • much easier 1960. Pr A.B. Tonnel

7. Chest 1990 Chest 1994

8. Brochard L ARRD 1987

9. Brochard L et al. ARRD 1989; 139:513-521

13. NIV and exacerbations of COPD Effects on arterial blood gases Brochard et al NEJM 1990, 323, 1523

15. Brochard et al. 1995 NIV and exacerbations of COPD

16. NIV and exacerbations of COPD Intubation Hosp Stay Mortality O2( n=42 ) 74 % 35 ± 33 j 29 % NIV - PS 20 ( n=43 ) 26 % 23 ± 17 j 9 % Brochard et al NEJM 1995; 333, 817-22

17. Endotracheal Intubation Respiratory Rate Mortality Rate

19. CPAP vs BIPAP in CPE: Overall

20. No central line No urinary catheter No sedation No endotracheal tube

21. NIV & Nosocomial infections p<0.001 p<0.0001 p=0.02 Girou et al. JAMA 2000

22. n = 51 n = 54 Ferrer et al. AJRCCM 2003; 168: 1438

23. CCM 2007

25. NIV in hypoxemic or hypercapnic patients:Is there a different impact?

26. Mortality Demoule A et al ICM 2006

27. Postextubation ARF Reintubation 48% Reintubation 72%

28. Prevention of postextubation ARF Reintubation 11% Reintubation 8%

29. Use of Mechanical ventilation 1998 Incidence study 361 ICU 20 countries Esteban et al, JAMA 2002 2004 Incidence study 353 ICU 26 countries Esteban et al, AJRCCM 2008 2010 Incidence study 553 ICU 39 countries Esteban et al

30. 1st, 2d, 3rd International Studies of Mechanical Ventilation Countries 37 ICUs 1,267 Patients 18,321

31. Baseline Demographics

32. NIV as first attempt

33. Use of NIV 1998 - 2010

34. SRLF - 2012Results of the 3rd NIV incidence study (France and Belgium) A Demoule, S Jaber, A Kouatchet, J Lambert, F Meziani, S Perbet, L Camous, R Janssen-Langenstein, M Alves, B Zuber, F Collet, J Messika, X Favre, O Guisset, B Misset, A Lafabrie, L Brochard, E Azoulay For the oVNI group

35. Methods Survey 2010 - 2011 • Prospective longitudinal study • 54 ICUs • 2 months (Nov 2010- April 2011) • 2653 patients included • 2445 invasive ventilatory assistance or NIV

36. Results 1 Incidence NIV 23 vs.31% - pre 23% - post-extub 8% * *

37. Results 2 Indications CPE: 53 vs.37% - « de novo » : 16 vs. 22% * * * $

38. Results 3 success overall success rate : 68 vs. 56% $

39. The global NIV rate is stable Increase for post-extubation Variations across indications Increase for CPE Stable in exacerbations of CRF Decrease in « de novo » ARF Success rate isincreasing Summary Compared to 2002

40. Crit Care Med 2007;35:932–939

41. Azoulay E et al ICM 2012

42. Azoulay E et al ICM 2012

43. Azoulay E et al ICM 2012

44. Azoulay E et al ICM 2012

45. Patients Azoulay E et al ICM 2012

46. Relatives Azoulay E et al ICM 2012

47. Non invasive ventilation for acute respiratory failure • Reduces the complications associated with mechanical ventilation • Improves the outcome of COPD exacerbations and cardiogenic pulmonary edema • A careful use in hypoxemic respiratory failure may be interesting • NIV represents an interesting therapy when intensity of therapy is limited

48. Merci! Thank you! Blog • http://mechanicalventilation.wordpress.com

49. Non-Invasive Ventilation