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Μη επεμβατικός μηχανικός αερισμός στην οξεία υποξαιμική αναπνευστική ανεπάρκεια ( ALI/ARDS)

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Μη επεμβατικός μηχανικός αερισμός στην οξεία υποξαιμική αναπνευστική ανεπάρκεια ( ALI/ARDS) - PowerPoint PPT Presentation


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Μη επεμβατικός μηχανικός αερισμός στην οξεία υποξαιμική αναπνευστική ανεπάρκεια ( ALI/ARDS). Γεώργιος Νάκος Πανεπιστήμιο Ιωαννίνων. NIV usually refers to the provision of inspiratory pressure support + PEEP via a mask or helmet (without intubation)

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ali ards

Μη επεμβατικός μηχανικός αερισμός στην οξεία υποξαιμική αναπνευστική ανεπάρκεια(ALI/ARDS)

Γεώργιος Νάκος

Πανεπιστήμιο Ιωαννίνων

slide2

NIVusually refers to the provision of inspiratorypressure support + PEEP via a mask or helmet (without intubation)

Although CPAP does not activelyassist inspiration and is not a ventilatorysupport mode, it is considered a form ofNIV

slide3

NIMV in ALI/ARDS

  • NIMV vs Standard treatment
  • NIMV first line treatment (vs IMV?)
slide4

NIMV vs Oxygen Mask (standard approach)

Rational

L’Her E, et al. Physiologic effects of noninvasive ventilation during ALI.

Am J Respir Crit Care Med 2005;172:1112-8.

slide11

aA, multiple RCTs and meta-analyses; B, more than one RCT, case control series, or cohort studies; C, case series or conflicting data; b recommended,first choice for ventilatory support in selected patients; Guideline, can be used inappropriatepatients but careful monitoring advised; Option, suitable for a very carefully selected and monitoredminority of patients.

Concise Definitive Review- Crit Care Med2007; 35:2402

slide12

ΕΡΩΤΗΜΑ

ΠΡΕΠΕΙ ΝΑ ΧΡΗΣΙΜΟΠΟΙΤΑΙ NIMVΣΕ ALI/ARDS ;

ΑΠΑΝΤΗΣΗ

ΑΠΟ ΤΑ ΜΕΧΡΙ ΤΩΡΑ ΔΕΔΟΜΕΝΑ OΧΙ

ΣΩΣΤΗ ΕΡΩΤΗΣΗ;

ΟΧΙ

Η ΣΩΣΤΗ ΕΡΩΤΗΣΗ ΕΙΝΑΙ:

ΠΟΤΕ ΠΡΕΠΕΙ ΝΑ ΧΟΡΗΓΗΤΑΙ NIMV ΣΤΟ ALI/ARDS;ΠΟΙΑΣ ΒΑΡΥΤΗΤΑΣ;

slide14

Hypoxic Respiratory Failure

inImmunocompromisedPatients.

slide15
Respiratory Failure inImmunocompromisedPatients.

RCTs in recipients ofsolid-organ, bone-marrow transplants and AIDS who developed hypoxemic respiratoryfailure have found

  • decreased intubation
  • shorter ICUlengths of stay and
  • Decreased ICU mortality rates withNIV

The reduced mortality is likelyrelated to reduced infectious complicationsassociated with NIV use comparedwith endotracheal intubation, includingVAP, othernosocomial infections, and septic shock

Antonelli et al JAMA 2000; 283:235

Hilbert G, et al: N Engl J Med 2001; 344:481

slide16

NIMV vs Standard treatment

Hilbert G, et al: N Engl J Med 2001; 344:481

slide24

Pneumonia.

Pneumonia has been achallenge to treat noninvasively and hasbeen identified as a risk factor for NIVfailure.

An RCT on patientswith severe community-acquired pneumoniashowed that NIV reduced intubationrates, ICU length of stay, and2-month mortality rate, but only in thesubgroup with underlying COPD.

Two thirds of patients withsevere community-acquired pneumoniarequired intubation after being started onNIV in one cohort study.

slide26

In conclusion, we found that NIMV reduces the need for intubation in severe ARF with the possible exception of pneumonia.

slide30

The small number of studies and patients, and the inconsistency of those studies’ results preclude a recommendation for NIV in immunocompetent patients with severe community-acquired pneumonia

slide32

Acute Lung Injury/Acute Respiratory Distress Syndrome.

Studies on NIV to treat ALI /ARDS have reported failure rates ranging from 50% to 80% , but no RCTs have focused on ALI/ARDS exclusively.

slide34

Πολύ προσεκτική επιλογή περιστατικών !

Intensive Care Med (2006) 32:1756–1765

variants of pulmonary edema
Variants of Pulmonary Edema
  • Hydrostatic PE :

(Cardiogenic, Flash)

  • High Permeability PE:

(ARDS)

  • Non edematus RDS
  • Unclear or Mixed cause PE:

(Pulmonary embolism, High altitude PE, Re-expantion, Neurological, Postical, Tocolysis )

  • Rapid resolving non-HPE:

(Neurogenic PE, Heroin-induced PE, Metabolic acidosis, CPR, Inhalational injury)

slide36

AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 168 2003

Patients with severe AHRF, defined as PaO2 persistently less than 60 mm Hg while breathing conventional Venturi oxygen at a maximal concentration (50%), were considered eligible for the study

Patients were randomly allocated either to the NIV or the control group:

In the noninvasive ventilation group, patients were ventilated using the bilevel positive airway pressure mode. FiO2 was set to achieve a PaO2 of more than 65 mm Hg.

In the control group, patients received oxygen using high concentration sources. The FiO2 was set to achieve PaO2 of more than 65 mm Hg.

slide39

In conclusion, except in patients with ARDS, the use of NIV is effective to reduce intubation in patients with severe AHRF.

slide40

Critical Care Vol 10 No 3

ALI:PO2/FiO2 <300

Observational cohort study at the two intensivecare units of a tertiary center,

Consecutive patientswith ALI were initially treated with NIPPV.

slide43

Key messages

• Hemodynamic instability and shock are major contraindicationsto non-invasive ventilation in patients with ALI.

• Metabolic acidosis and severe hypoxemia are associatedwith failure of non-invasive ventilation in patientswith ALI.

• Carefully selected patients with ALI are successfullytreated with non-invasive ventilation andtheir outcome isbetter than predicted by initial severity of illness.

slide45

479 ARDS/332 already intubated

147 eligible for NPPV

79 avoided intubation

68 required intubation

slide46

In conclusion it is suggested avoidingNPPV in ARDS patients with SAPS II > 34because of the high mortality observed inthose who were eventually intubated(56%).

In patients with SAPS < 34, thosewith a PaO2/FIO2 > 175 after 1 hr of NPPVwill likely benefit from continuation ofNPPV

Irrespective of SAPS II or PaO2/FIO2 after 1 hr of NPPV, avoidance of intubation wasassociated with significant reduction in mortality

slide48

Noninvasive Ventilation during PersistentWeaning FailureA Randomized Controlled TrialMiquel Ferrer at al Am J Respir Crit Care Med Vol 168. pp 1438–1444, 2003

  • To assess the efficacy of noninvasive ventilation (NIV) in patientswith persistent weaning failure, we conducted a prospective, randomized,controlled trial in 43 mechanically ventilated patients whohad failed a weaning trial for 3 consecutive days.
  • This trial wasstopped after a planned interim analysis.
  • The conventional weaningapproach was an independent risk factor of decreased ICUand 90-day survival
  • 0.
slide50

Noninvasive Ventilation during PersistentWeaning FailureA Randomized Controlled TrialMiquel Ferrer at al Am J Respir Crit Care Med Vol 168. pp 1438–1444, 2003

slide54

Methods

  • CPAP vs Bilevel ventilation :
    • Bilevel except CPO
  • PC vs PS
    • PS ?
  • PC or PS vs PAV
    • PAV?
slide55

Staffing

Chevrolet and co-workerscharacterised non-invasive ventilation as excessivelydemanding on personnel time.

Chest 1991; 100: 775–82.

Cost

Keenan and colleaguesevaluated the health economics for severe acuteexacerbations of COPD with a theoretical model thatused a decision-tree analysis constructed from ameta-analysis of randomised trials. They concluded thatnon-invasive ventilation was very cost-eff ective.

Crit Care Med 2000; 28: 2094–102.

ALI/ARDS?

slide57

Helmet vs mask

Noninvasive continuous positive airwaypressure delivered by helmet in hematologicalmalignancy patients with hypoxemic acuterespiratory failure

Intensive Care Med (2004) 30:147–150

slide58

A practical clinical message is that the physician should sethigher levels of PEEP and pressure support to reduceinspiratory muscle effort closer to that with the facemask.

Although the patient tolerates the helmet better,it needs careful clinical monitoring and setting.

slide59

Classify ARDS Type, Severity, & Co-Morbidities

High Severity or Obtunded?

Non-Invasive Ventilation

No

Yes

Intubate and Minimize Effort

No

Estimate Intravascular

Volume Status

Adequate ABGs & Tolerance?

Stable and Alert

Repair Volume Deficit or Excess

Establish Adequate BP

Yes

Continue Non-Invasive

Ventilation

Determine Recruitment Potential With

Recruiting Maneuver & PEEP Trial

Yes

No

Ready for Ventilator

Discontinuation?

Adjust PEEP and Tidal Volume

Adequate Improvement?

Yes

No

Extubate and/or

Discontinue Ventilation

Continue Supine 45-900

Reposition Frequently

Yes

Proning Contraindicated?

INO,TGI,Flo-Lan, ILA

No

Prone Positioning for

12-20 Hours/Day

Yes

No

Significant Clinical Improvement?

slide60

High Severity ALI/ARDS

  • Multi-organ dysfunction, more than 2 organs, SAPs II>34
  • Inability tocooperate or to protect the airway
  • Shock, severe hypoxemia or acidosis.
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