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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


NIV αερισμός στην usually 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


NIMV in ALI/ARDS αερισμός στην

  • NIMV vs Standard treatment

  • NIMV first line treatment (vs IMV?)


NIMV αερισμός στην 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.


Incidence of Nosocomial Pneumonia αερισμός στην


Indication & recommendations αερισμός στην


Review: NIV in acute respiratory failure, The αερισμός στην Lancet 2009; 374: 250–59


Lancet αερισμός στην 2009; 374: 250–59


H1N1? αερισμός στην


a αερισμός στην A, 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


ΕΡΩΤΗΜΑ αερισμός στην

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;


RCTs focused on ALI/ARDS exclusively αερισμός στην do not exist


Hypoxic αερισμός στην Respiratory Failure

inImmunocompromisedPatients.


Respiratory Failure in αερισμός στην ImmunocompromisedPatients.

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


NIMV vs Standard treatment αερισμός στην

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



Pneumonia. αερισμός στην

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.


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


Antonelli M, et al. Intensive Care Med 2001; 27:1718–1728. intubation in severe ARF with the possible exception of pneumonia.


Intensive Care Med (2006) 32:1756–1765 intubation in severe ARF with the possible exception of pneumonia.


Am J Respir Crit Care Med Vol 168. pp 1438–1444, 2003 intubation in severe ARF with the possible exception of pneumonia.


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


Crit Care Med inconsistency of those studies’ results 2007; 35:2402–2407


Acute Lung Injury/Acute Respiratory Distress Syndrome. inconsistency of those studies’ results

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.


Antonelli M, et al. Intensive Care Med 2001; 27:1718–1728. inconsistency of those studies’ results


Πολύ προσεκτική επιλογή περιστατικών !

Intensive Care Med (2006) 32:1756–1765


Variants of pulmonary edema
Variants of Pulmonary Edema περιστατικών !

  • 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)


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.


In conclusion, VOL 168 2003except in patients with ARDS, the use of NIV is effective to reduce intubation in patients with severe AHRF.


Critical Care VOL 168 2003Vol 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.


70,3 % VOL 168 2003


Key messages VOL 168 2003

• 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.


Crit Care Med 2007; 35:18–25 VOL 168 2003

ARDS: PO2/FiO2 <200


479 ARDS/332 already intubated VOL 168 2003

147 eligible for NPPV

79 avoided intubation

68 required intubation


In conclusion it is VOL 168 2003 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


NIV VOL 168 2003βοηθά το weaning ασθενώνμε ALI/ARDS;


Noninvasive Ventilation during Persistent VOL 168 2003Weaning 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.


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


Methods VOL 168 2003

  • CPAP vs Bilevel ventilation :

    • Bilevel except CPO

  • PC vs PS

    • PS ?

  • PC or PS vs PAV

    • PAV?


Staffing VOL 168 2003

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?


Helmet and mask VOL 168 2003


Helmet vs mask VOL 168 2003

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

Intensive Care Med (2004) 30:147–150


A VOL 168 2003practical 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.


Classify ARDS Type, Severity, & Co-Morbidities VOL 168 2003

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?


High Severity ALI/ARDS VOL 168 2003

  • 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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