1 / 38

Noninvasive Mechanical Ventilation in the ICU

Noninvasive Mechanical Ventilation in the ICU. Antalya, Turkey April 2011 Nicholas Hill MD Tufts Medical Center Boston, MA USA. Disclosures. Research Grants Respironics, Inc Breathe Technologies, Inc. Outline. ICU Applications of NIV Epidemiology Main indications Patient Selection

phyre
Download Presentation

Noninvasive Mechanical Ventilation in the ICU

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Noninvasive Mechanical Ventilation in the ICU Antalya, Turkey April 2011 Nicholas Hill MD Tufts Medical Center Boston, MA USA

  2. Disclosures • Research Grants • Respironics, Inc • Breathe Technologies, Inc

  3. Outline • ICU Applications of NIV • Epidemiology • Main indications • Patient Selection • Practical Application

  4. Why Noninvasive Ventilation? • Avoids trauma of intubation • Reduces respiratory infections • More comfortable, less sedation • Less costly • Respiratory System Protective Strategy • Must be used selectively

  5. French ICU/ US NIV Utilization % of Pts Carlucci et al, AJRCCM, 2001; Demoule et al, ICM, ’06; Ozsancak et al, Chest ‘08

  6. Use of NIV for COPDMassachusetts and Rhode Island % of Vent starts for COPD exacerbations treated with NIV

  7. Main Indications for Acute Noninvasive Ventilation (NIV) Strong (Level A) Acute hypercapnic RF (COPD) Cardiogenic pulmonary edema ARF in immunocompromised

  8. Physiologic Rationale for NIV in COPD: Effect of Pressure Support plus PEEP NIV (BiPAP) – Combines expiratory (PEEP) with higher inspiratory pressure (PSV)

  9. Benefits of NIV in Acute COPDcompared to Conventional Rx* • More rapidly improves dyspnea • More rapid  RR, HR, • breathing effort • More rapid  PaCO2,  O2 • Lowers intubation rate (50%20%) • Lowers mortality, morbidity rate • Less time in hospital *Based on 7 RCTs

  10. NIV for COPD: Risk of Treatment Failure: (Death, ETT, Intolerance) Lightowler JV, et.al: BMJ 326:185, 2003

  11. NIV for COPD associated with: • Difficult weaning (to facilitate extubation) • Pneumonia • Extubation failure • Do-not-intubate status • Post-operative Respiratory Failure

  12. NIV for Acute Pulmonary Edema: Physiologic Rationale • CPAP: • Increased FRC • Re-expands flooded alveoli • Improved oxygenation • Increased compliance • Afterload reduction -  cardiac function • Pressure Support: • Further reduction in work

  13. Meta-analysis: CPAP vs NIV for ACPE “Evidence …is now robust…and use as a first line intervention is becoming mandatory.” Winck et al, Crit Care 2006 10:R69

  14. Multicenter RCT of CPE (3CPO) 26 cntrs, RR>20, pH<7.35, excl if “need for intervention” NIV(8/4) or CPAP(5) STD n 702 367 Death 7 days (%) 9.5 9.8 Intubation (%) 2.9 2.8 MI (%) 27 24.9 Dyspnea (analog) -4.6 -3.9* pH (1 hr) +0.11 +0.08* RR (1 hr) -7.2 -7.3 *P < 0.05 Gray et al, NEJM 2008

  15. Out-of-Hospital CPAP Vs Usual Care in Acute Respiratory Failure: A RCT Thompson et al,Ann Emerg Med. 2008;52:232-241 CPAP Control (10 cm H2O) n 35 34 SaO2 82% 75% RR/min 38 38 CHF/COPD/Asthma 99% 100% Intubation 7(20%) 17(50%)* Hosp Mortal (%) 4(14%) 12(35%)* *P<0.05

  16. Indications for Acute NIV Weaker (Level B) Asthma Extubation failure(COPD) Hypoxemic Respiratory Failure Postoperative Respiratory Failure Do-not-intubate pts (COPD and CHF)

  17. RCT of NPPV for Asthma Exacerbations • NPPV Sham • n 17 16 • FEV1 (%) 37.3 33.8 • 50% FEV1 (1h) 80% 20%* %  FEV1 (1h) 53.5 28.5* Hospitalized 3 (17.6%) 10 (63.5%)* Soroksky et al, Chest 2003; 123:1018.

  18. Use of NIV as Bronchodilator ∆ FEV1 % 8/6 cm H2O 6/4 cm H2O O2 by FM 44 asthmatics, FEV1 33% P 80-90, RR 20 3 Groups, “High”, “Low” and O2 ctls for 1hr Hydrocort BUT NO BDs! Soma T et al, Intern Med ‘08

  19. NIV for Asthma Used for pts with “status asthmaticus” – severe and refractory to treatment May combine with continuous neb and heliox (anecdotal evidence) Monitor very closely ? Role early for bronchodilator effect and to reduce dyspnea more rapidly?

  20. Esteban: PaCO2 > 45 MV>48h Resp muscle “fatigue” RR > 25 pH < 7.35 O2sat < 90%, PaO2 < 80 Nava PaCO2>45, MV>72h* >1 failed weaning attempt* excess secretions* upper airway disorder* • NIV for Extubation Failure • 2004 trial - no reduction in reintub- • ations and  mortality in NIV group • -Esteban et al, NEJM ’04 • Recent RCT showed  resp failure and • 90 d mortality in hypercapnics on NIV • -Ferrer et al, Lancet ‘09 • Don’t delay needed intubation! Selection Criteria in Trials to Prevent Extubation Failure Ferrer: Age > 65, CHF, APACHE score > 12

  21. Acute Hypoxemic Respiratory Failure Italian multicenter study of 354 NIV cases, 30% failures; 50% ARDS or CAP, 10% cardiogenic pulmonary edema Condition Odds Ratio ARDS or Comm Acq Pna 3.75 PaO2:FIO2  146 p 1st hr 2.51 SAPS II  35 1.81 Age > 40 1.72 PaO2/FIO2 < 200 Resp Distress, RR > 30-35 Non-COPD dx Pneumonia (incl immunosuppr) ARDS Trauma Cardiogenic Pulm Edema Antonelli et al, Int Care Med 2001 27:1718

  22. Hypoxemic Respiratory Failure:NIV as “First Line” Therapy in ARDS • 147 pts eligible of 479 (332 intubated), had dyspnea, RR > 30 and ≤ 2 new organ failures • 54% avoided intubation (15% of Total) – VAP rate 2 vs 20%, mortality 6 vs 53% • Success more likely if SAPS II ≤ 34 and PaO2/FIO2 > 175 p 1st hr of NIV therapy Antonelli et al, CCM, 2006

  23. NIV for Do-not-intubate pts • 75 and 50 % of Pulmonary Edema and COPD pts, respectively, survive hospital* • Roughly 25% of pneumonia and cancer pts survive hospital • If can awaken and cough, survival better • Two main goals – must be clear • Treat respiratory failure (CHF & COPD) • Palliate for dyspnea or transient life prolongation *Levy et al, Crit Care Med 2004; 32:2002

  24. RCTs of Noninvasive Techniques for Postoperative Patients • For Prophylaxis: • Thoracoabdominal vascular (CPAP) • Kindgren-Milles et al, Chest‘06 • Bariatric surgery (NIV) • Joris Chest ‘97 • Major abd surgery (CPAP) • Squadrone JAMA ‘05 • For Resp Failure: • Lung resection (NIV) • Auriant et al, AJRCCM ‘01

  25. Non-invasive ventilation reduces intubation in chest-trauma related hypoxemia: A RCT Hernandez et al, Chest 2010; 137:74-80 NPPV Control n 25 25 PaO2/FIO2 108 110 APACHE II 17.5 14.1* Intubation 3(12%) 10(40%)* Exhaustion 2(8%) 6(24%) VAP 2(8%) 3(12%) Hosp LOS (days) 14 21* Hosp Mortal (%) 1(4%) 1(4%) *P<0.05

  26. Use Selectively and with Caution Neuromuscular Disease Obesity Hypoventilation Upper Airway Obstruction Not to be used: ARDS with MODS Pulmonary Fibrosis

  27. NIV: Practical Application Patient Selection • Favorable Diagnosis (reversibility – COPD, CHF) • Need for ventilatory assistance • Absence of contraindications

  28. Step 1: Is there need for Ventilatory Assistance? When clinical features reveal: Dyspnea is at least moderate Respiratory rate > 24 (COPD), >30 (hypoxemic) Accessory muscle use Abdominal paradox Gas exchange abnormalities: PaCO2 > 45 mm Hg, pH < 7.35 PaO2/FIO2 < 300 Likelihood of needing intubation = 50% Window of Opportunity

  29. Step 2: Are there contraindications to NIV? The Patient is: Apneic (arresting) Medically unstable (shock, acute MI or upper GI bleed) Agitated and uncooperative (but  CO2 coma OK!) Unable to clear secretions Severely hypoxemic (PaO2/FIO2 < 75) Or has: Multiorgan failure

  30. Forehead Adjuster

  31. ORONASAL VS NASAL MASK FOR ARF (Kwok et al, Crit Care Med 2003; 31:468) Oronasal Nasal P value n 35 35 Success 23 (66%) 17 (49%) 0.15 Intolerance 4 (11%) 12 (34%) 0.02 Intubation 8 (23%) 8 (23%) 1.00 Mortality 2 (6%) 4 (11%) 0.40

  32. Newer Developments in Mask Technology

  33. Helmet Mainly for CPAP High flow to minimize rebreathing Noisy and expensive Not approved by FDA for NIV

  34. Bilevel Vents for Acute Applications (80% US) NIV modes on Critical Care Vents Leak compensation Adjustable Rise Time Inspiratory Time Limit Silence nuisance alarms Need adjustments if leaks Ferreira, Chest ‘09

  35. Ventilator – NIV or Crit Care, But Use the Right Settings! • Mode: Bilevel or NIV mode (PS+PEEP) • Settings: start low (IPAP 8-10, EPAP 4-5 cm H20), thenreadjust promptlyto achieve adequate  (PS > 8-10 cm) • IPAP titration: Relief of respiratory distress vs intolerance of higher pressures (max 20 cm H2O) • EPAP titration: counterbalance auto-PEEP, improve oxygenation (max 8-10 cm H2O) • FIO2/O2 flow adjusted to maintain O2sat>90-92%

  36. Monitoring NPPV • Assure comfort– • Minimize Dyspnea • Maximize Comfort • Optimize Synchrony • Vital signs • respiratory rate should drop • Neck muscle activity should fall • Oximetry (>90%), Tidal Vol (>6-7ml/kg) • Occasional blood gases (start & 1-2 hrs) • In ICU or step-down until stable

  37. Summary: NIV for ICU • Main Indications – COPD, CHF, Immunocompromised • Data accumulating for others – Asthma, Hypoxemic (Trauma), Extub Failure • Technological advances – New masks, ventilators • Proper application techniques, monitoring and skilled staff still important

More Related