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Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο

ΜΕΜΑ σε οξύ πνευμονικό οίδημα. Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο. Acute Cardiogenic Pulmonary Oedema. Acute pulmonary edema represents nearly 20% of acute heart failure cases.

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Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο

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  1. ΜΕΜΑ σε οξύ πνευμονικό οίδημα Ηρακλής Τσαγκάρης 2η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο

  2. Acute Cardiogenic Pulmonary Oedema • Acute pulmonary edema represents nearly 20% of acute heart failure cases. • The diagnostic criteria of this syndrome have not been universally established. • Sudden onset of severe dyspnoea /the presence of typical signs on physical examination /alveolar oedema on chest radiograph / and acute respiratory failure • Common - 15-20,000 hospital admissions per annum in UK • Deadly - 15-20% in-hospital mortality • Costly - 6.5 million hospital days per annum in USA Eur Heart J. 2008;29:2388-442

  3. Differences and similarities of acute pulmonary edema (APE) and acutely decompensated chronic heart failure (ADHF) Parissis, Eur J Heart F, 2010

  4. Standard CPE therapy • Loop Diuretic Therapy • Nitrate Therapy • Oxygen Therapy • (Opiates) • Treat Underlying Cause

  5. Οξύ καρδιογενές πνευμονικό οίδημα • ελαστικού φορτίου •  φορτίου αντιστάσεων (Noble, JAP 1975) • Οι αν. μύες παράγουν  πίεση για ικανοποιητική ροή και VT •  αρνητικής ενδοθωρακικής πίεσης   προφορτίου και μεταφορτίου των κοιλιών (Hall, JAP 1998) •  ενεργειακού κόστους αναπνοής   μεταφοράς Ο2 στο μυοκάρδιο

  6. Targets of ventilation incardiogenic pulmonary oedema • improvement of oxygenation • improvement of respiratory acidosis • reduction of work of breathing • improvement of cardiac performance • reduction of patient’s distress

  7. Physiological Improvement with CPAP in Pts with CardPE Kelly et al. Eur Heart J 2002;23:1379-1386

  8. Non-invasive Ventilation In Acute Cardiogenic Pulmonary Oedema “When the household vacuum cleaner is employed, the machine should be run for some minutes first of all to get rid of dust” Poulton EP, Oxon DM: Left-sided heart failure with pulmonary oedema: Its treatment with the "pulmonary plus pressure machine." Lancet (1936);231:981-983.

  9. 354 consecutive pts 7 centers EUR+USA

  10. When to start NIV in CPE • Patients with pH <7.25 or • systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for NIV. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation. Masip J, et al. Riskfactorsforintubationas a guidefornoninvasiveventilationinpatientswithsevereacutecardiogenicpulmonaryedema. IntensiveCareMed 2003;29:1921-1928

  11. NIV failure in CPE: decide early • Worsening encephalopathy/agitation • Inability to clear secretion • Inability to accept any interface • Hemodynamic instability • Worsening oxygenation • Progressive respiratory acidosis (pH<7.2) • Persistent tachypnea-tachycardia

  12. Effects of Noninvasive Ventilation on Mortality Masip et al, JAMA 2005;294:3124-3130

  13. Mortality reduced from 22% to 11% RR 0.53 (95% CI 0.35-0.81) (Individual Group Sizes of n = 9 to 46) Masip et al. JAMA 2005;294:3124-3130

  14. Effects of Noninvasive Ventilation on Need to Intubate Masip et al, JAMA 2005;294:3124-3130

  15. Effects of Continuous Positive Airway Pressure vs Noninvasive Pressure Support Ventilation Masip et al, JAMA 2005;294:3124-3130

  16. NIV for CPE (Cochrane Review): MortalityVital FMR. et al., 2008

  17. NIV for CPE (Cochrane Review): Intubation rateVital FMR. et al., 2008

  18. 3-CPO In patients with acute cardiogenic pulmonary oedema: Aims • Clinical effectiveness of non-invasive ventilation • Comparative effectiveness of CPAP and NIPPV • Safety of non-invasive ventilation Hypothesis: • Non-invasive ventilation reduces mortality Gray et al NEJM 2008; 359:142-51

  19. CPOE3:Standard vs CPAP vs NIPPV • 26 hospitals in the UK, open, randomized, controlled, multicentre trial, in the ED • Designed to • evaluate the effect of NIV on Pulmonary Edema mortality compared with standard therapy • to compare the effectiveness of CPAP vs. NIPPV • 1069 patients, hospitalized with pulmonary edema, tachypnea (>20 breaths/min) and acidosis • Randomized to at least 2 h of 60% O2 delivered either by standard face mask (n=367), CPAP (n=346) or NIPPV (n=356) Gray et al NEJM 2008; 359:142-51

  20. 3-CPO:baseline characteristics Gray et al NEJM 2008; 359:142-51

  21. 3-CPO:Immediate therapeutic interventions

  22. CPOE3:Standard vs CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

  23. 3-CPO Physiological Response to Intervention:One Hour Physiology Gray et al NEJM 2008; 359:142-51

  24. CPOE3:Standard vs CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

  25. CPOE3: CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

  26. CPOE3:CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

  27. 3-CPO In patients with acute cardiogenic pulmonary oedema, non-invasive ventilation: • Produces more rapid resolution of metabolic abnormalities and respiratory distress • Has no major effect on 7-day or 30-day mortality • Is beneficial irrespective of the mode (CPAP or NIPPV) of delivery Gray et al NEJM 2008; 359:142-51

  28. Masip, Mebazaa, NEJM 2008, 359:2068

  29. CPAP vs NIPSV: Intubation rate Argawal, Singapore Med 2009 P=0.97 P0.46 P=0.49

  30. Early vs late CPAP in the out-of-hospital environment Plaisance P et al. Eur. Heart J. 2007; 28:2895

  31. Early vs late CPAP *p < 0,05 Plaisance P et al. Eur. Heart J. 2007; 28:2895

  32. Early vs late CPAP Plaisance P et al. Eur. Heart J. 2007; 28:2895

  33. Early vs late CPAP in the out-of-hospital environment • Conclusion:When compared to usual medical care, immediate application of CPAP alone in out-of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality. Plaisance P et al. Eur. Heart J. 2007; 28:2895

  34. Boussignac CPAP CPAP device: • Vygon Boussignac CPAP • maximum pressure: 8 mbar Cigada M et al. Novel indications for the Boussignac CPAP valve. Intensive Care Med 2007;33:374-375.

  35. Πνευμονικό οίδημα και NIV • To οξύ πνευμονικό οίδημα αποτελεί προνομιακό πεδίο εφαρμογής του ΝΙV • Τόσο η CPAP όσο και ο NIPPV μειώνουν στον ίδιο βαθμό την ανάγκη για διασωλήνωση και βελτιώνουν τη δύσπνοια και τις φυσιολογικές παραμέτρους • Ο ΝΙV δεν φαίνεται να επηρεάζει τη θνητότητα

  36. Πνευμονικό οίδημα και NIV • Αποτελεσματικότερος στους ασθενείς με υπερκαπνία- Ο NIPPV δεν φαίνεται να υπερτερείτης CPAP • Δεν φαίνεται να σχετίζεται με επιπλοκές όπως το OEM • H προνοσοκομειακή χρήση του συνδυάζεται με θετικά αποτελέσματα.

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