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

1. Μη επεμβατικός μηχανικός αερισμός στην οξεία υποξαιμική αναπνευστική ανεπάρκεια(ALI/ARDS) Γεώργιος Νάκος Πανεπιστήμιο Ιωαννίνων

2. 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

3. NIMV in ALI/ARDS • NIMV vs Standard treatment • NIMV first line treatment (vs IMV?)

4. 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.

5. Incidence of Nosocomial Pneumonia

6. Indication & recommendations

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

8. Lancet 2009; 374: 250–59

9. H1N1?

11. 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

12. 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;

13. RCTs focused on ALI/ARDS exclusively do not exist

14. Hypoxic Respiratory Failure inImmunocompromisedPatients.

15. 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

16. NIMV vs Standard treatment Hilbert G, et al: N Engl J Med 2001; 344:481

22. NIV is recommended as first choice treatment

24. 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.

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

27. Antonelli M, et al. Intensive Care Med 2001; 27:1718–1728.

28. Intensive Care Med (2006) 32:1756–1765

29. Am J Respir Crit Care Med Vol 168. pp 1438–1444, 2003

30. 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

31. Crit Care Med2007; 35:2402–2407

32. 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.

33. Antonelli M, et al. Intensive Care Med 2001; 27:1718–1728.

34. Πολύ προσεκτική επιλογή περιστατικών ! Intensive Care Med (2006) 32:1756–1765

35. 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)

36. 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.

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

40. 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.

41. 70,3 %

43. 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.

44. Crit Care Med 2007; 35:18–25 ARDS: PO2/FiO2 <200

45. 479 ARDS/332 already intubated 147 eligible for NPPV 79 avoided intubation 68 required intubation

46. 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

47. NIV βοηθά το weaning ασθενώνμε ALI/ARDS;

48. 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.

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