Consigli durante la NIV

1. Consigli durante la NIV M Vitacca Divisione di Pneumologia Fondazione S.Maugeri Lumezzane (BS) Italy

2. Il momento e il paziente giusto

3. Severe ARF Severity Mild To moderate Not established TO AVOID ETI TO PREVENT ALTERNATIVE to ETI Meaning of NIV use

4. IDENTIFY PATIENTS (according to location ?) 1. Clinical abnormalities - moderate to severe dyspnea - RR > 24 b/min in COPD - RR > 30 – 35 b/min in AHRF - accessory muscle use, paradoxal breathing 2. Gas exchange abnormalities - PaCO2 > 45 mmHg, pH < 7.35 - PaO2/FiO2 < 250 mmHg Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

5. COPD CHF/CPE PNA Asthma OHS NMD UAO post-op post-extub trauma ARDS MOF IPF Tight UAO

6. the correct time to stop

7. WEAK COUGH AND HYPER-SECRETIONS • SEVERE ENCEPHALOPATHY • INTOLERANCE AND AGITATION • PATIENT-VENTILATORY ASYNCHRONIES • EXCESSIVE LEAKS • DISCOMFORT • SLEEP DISTURBANCES • HYPERGLICAEMIA • LOW ADLs • POOR RESPONSE OF ABG AND RR • HIGH SCORES OF SEVERITY OF ILLNESS NEED OF ETI: range → 5-60% Courtesy of dott Scala

8. BTS Guideline of NIMV in ARF Thorax 2002; 57: 192-211 Time to stop NIV for failure • no improvement or deterioration in consciousness • no improvement in ABG • severe complications • severe pneumonia on chest X-ray • 2° intrahospital failure with necessity of NIV • copiuos secretion • more than 18 continous hours of NIV for more than 4 days • nasal bridge erosion • intolerance to ventilator

9. Perchè fallisce la NIV ? Perchè si sbaglia paziente Perchè non si rispettono le controindicazioni Perchè si sbaglio maschera Perchè si sbaglio modalità di ventilazione Perchè si sbaglio il settaggio Perchè il paziente non supporta più la NIV Perchè non miglioranono i gas Perchè vi è cattiva interazione con il ventilatore Perchè dà un senso di falsa sicurezza

10. FATTORI PREDITTIVI PER IL FALLIMENTO DELLA NIV IN SOGGETTI CON INSUFFICIENZA RESPIRATORIA. A) Ipossiemici Ipercapnici Età Basso punteggio del livello di dipendenza misurato con scala ADL (activity daily life) Iperglicemia Presenza di polmonite come causa di insufficienza respiratoria acuta (IRA) Alto punteggio di gravità prognostica (alto APACHE II score all’ ammissione) Paziente incosciente, non collaborante Severa ipercapnia (paCO2 > 90 mmHg) Severa acidosi (pH a < 7.10) Mancanza di miglioramento (entro 1-2 h) degli scambi gassosi, frequenza cardiaca e respiratoria Paziente ipersecretivo Presenza di encefalopatia Intolleranza alla VMN Perdite di flusso dalla maschera Caduta della pressione arteriosa

11. FATTORI PREDITTIVI PER IL FALLIMENTO DELLA NIV IN SOGGETTI CON INSUFFICIENZA RESPIRATORIA. B) Ipossiemici Normocapnici Età Alto punteggio di gravità prognostica (alto SAPS II score all’ ammissione) ARDS e polmonite come causa del ricovero Edema polmonare cardiogeno senza risposta alla terapia medica Mancato miglioramento della ossigenazione dopo VMN (1-2 h) Paziente ipersecretivo Presenza di encefalopatia Intolleranza alla VMN

12. Be carefull ! NON INVASIVE RESPIRATORY SUPPORT IN HYPOXIEMIC ACUTE RESPIRATORY FAILURE ? • High percentage of failures • Late resolution • Difficult “invasive” diagnostic procedures (BAL, Brush) • Risk to delay ETI Take care of: • Accurate selection of the patients: - PaO2/FiO2 > 150 mmHg, - Lobar densities at chest X- Ray or CT - Absence of hemodynamic shock (BE > -2.5 mEq/L) • Empiric Antibiotic Treatment (Protocols !) • Non invasive fast diagnostic tests (Urinary antigens, etc.) • Hemocoltures • Don’t push to hard (stop NIV if PaO2/FiO2< 150 at 1-2 hrs)

14. La giusta location

15. BTS Equipment Recommendations Staff familiarity is key to success

16. Timing is all… • Start early but not too early (Barbe study) • You are too late if… • Pt on verge of respiratory arrest • Pt severely hypoxaemic (PaO2/FiO2 < 75) • Pt comatose or hugely agitated • Medically unstable: acute MI, GI bleed, shock • What is your unit’s ‘door to mask’ time? • What are the main limitations? Simonds ERS school

17. Location summary (1)

18. Location summary (2)

19. Il training adeguato

20. Reasons for low use of NIV in acute hospitals: US survey No. of responses 20 10 0 Poor previous experience Hospital staff inadequately trained Equipment not appropriate Physicians lack of experience Other Maheshwari v et al Chest 2006:129: 1226-33

22. Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 H admissions pts from NIV to EI N° pts NIV deaths

23. Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 NIV and EI EI NIV no EI No support

24. Monitoring: readyaccessto ETI and CPR Courtesy of dott Scala

25. Monitoraggio

26. Ventilatory Monitoring • Respiratory pattern • Pt-ventinteraction • Availabilityof ETI • in case of NIV failure Courtesy of dott Scala

27. Monitoring • Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance • Pulse oximetry • Continuous display of ECG and non-invasive BP • Arterial blood gases (ABG machine easily accessed) • Continuous non-invasive monitoring of CO2 helpful eg. Transcutaneous, end-tidal • Duration of NIV use • Ventilatory settings, FiO2, leak • Severity score • Side effects : skin integrity, GI, nasal symptoms • CXR, screening bloods etc. Simonds ERS school

28. 100 – 75 % 49 -25 % 24 -0 % 74 -50 % Percentage of patients who fail NIV Eur Respir J 2005; 25:348-355

29. Ventilatory Monitoring • Respiratory pattern • Pt-ventinteraction • Availabilityof ETI • in case of NIV failure

30. YOU HAVE……. A VENTILATOR HAS NO BRAIN, BUT NEEDS TO COUPLE TWO BRAINS !

31. Apparently there is nothing wrong on what you see on the ventilator With S. Navacourtesy

32. But if you could see the neural activity of the patient….. With S. Navacourtesy

33. 25 0 Ineffective effort Pao Pes 20 0 Sforzi inefficaci

34. Un eccesso di supporto Con la cortesia del dott. Polese

35. Totale desincronizzazione durante PSV Con la cortesia del dott. Polese

36. Totale desincronizzazione durante PSV (perdite) Con la cortesia del dott. Polese

37. Flow (l/sec) Vent. rate = 12 b/min Paw (cmH2O) Fr = 33 b/min Pes (cmH2O) 5 sec Time (sec) Triggering delay= Ineffective effort Georgopoulos et al. Intensive Care Med 2006

38. Autotriggering Paw (cmH2O) 1) Low threshold for triggering 2) Dirt circuit 3) leaks Flow (l/sec) Pes (cmH2O) Time (sec) With ERS courtesy

39. Flow Paw Pga Pes Pdi Expiratory asynchrony With ERS courtesy

40. Controlla il setting diurno e notturno

41. Bosma et al. Crit Care Med 2007;35:1048

42. A CORRECT SETTING IS IMPERATIVE !

43. Ventilatory Monitoring • Respiratory pattern • Pt-ventinteraction • Availabilityof ETI • in case of NIV failure

44. Am J RespirCrit Care Med. 2001 Feb;163(2):540-77 Almost all the side effects of NIV are due to problems with interfaces

45. 80-100% Air Leaks

46. Monitor the tightness of the mask

47. Types of Leaks Intentionalleaks Courtesy of dott Scala

48. Look for a balance betweenleaks and comfort Courtesy of dott Scala

49. Pressure sores

50. Interface rotation strategy Conti G et al. RespirMed 2007; 52:1463-71 Girault C et al. Crit Care Med 2009; 37:124-31 Courtesy of dott Scala