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CASO CLINICO I

CASO CLINICO I. Uomo 64 anni Forte fumatore Nessuna terapia specifica Dispnea da sforzo moderato Tosse e catarro nei mesi invernali Mai eseguito alcun accertamento. Giorno I ore 22,15 P.S. Tachipnea = 26 a/m Dispnea a riposo = 6 Borg Edemi declivi

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CASO CLINICO I

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  1. CASO CLINICO I Uomo 64 anni Forte fumatore Nessuna terapia specifica Dispnea da sforzo moderato Tosse e catarro nei mesi invernali Mai eseguito alcun accertamento

  2. Giorno I ore 22,15 P.S. Tachipnea = 26 a/m Dispnea a riposo = 6 Borg Edemi declivi MV molto ridotto con qualche fischio e sibilo PA= 170/95 FC= 94 b/m TC= 36.4°

  3. ACCERTAMENTI Rx-torace= ipertrasparenza, ombra cardiaca leggermente ingrandita. Non lesioni p.p. ECG= P-polmonari in ritmo sinusale EGA in aria ambiente: pH=7.32 PaCO2= 62.1 mmHg PaO2= 55.5 mmHg EGA in ossigeno (Venturi 30%) pH=7.32 PaCO2= 64.1 mmHg PaO2= 67.2 mmHg

  4. h. 23,50 Paziente trasferito in Medicina. Terapia impostata: Teofillina 1 fiala ev 02 terapia 3 L/m Nebulizzazione con salbutamolo x 2/die NAC 1 bustina /die

  5. GIORNO II Dal diario clinico: “ Condizioni generali stazionarie, prosegue terapia in atto” Si prescrive ossigenoterapia al bisogno

  6. GIORNO III h.13,15 Dispnea importante post-prandiale Borg 6 Cianosi (messo 02 terapia= AL BISOGNO) Frequenza Respiratoria= 28 Fischi e sibili diffusi + segni di ipersecrezione bronchiale. Emogasanalisi in 02 (4 L/m) pH=7.28 PaCO2= 66.1 mmHg PaO2= 59.2 mmHg

  7. h. 14,30 • Terapia impostata: • Teofillina 1 fiala ev x 3/die • 02 terapia 3 L/m CONTINUA • Nebulizzazione con salbutamolo x 3/die • Metilprednisolone 40 mg ev • NAC 1 bustina /die • Amoxicillina + ac.Clavulanico • Furosemide 1 fiala ev

  8. GIORNO IV Dal diario clinico: “ Condizioni generali stazionarie, prosegue terapia in atto”

  9. GIORNO IVh. 18,20 Paziente estremamente dispnoico ed agitato Sensorio leggermente obnubilato Frequenza respiratoria > 35 Respiro alternante Emogasanalisi arteriosa in O2 (4 L/m) pH=7.18 PaCO2= 96.1 mmHg PaO2= 60.2 mmHg

  10. PROVVEDIMENTO TERAPEUTICO Chiamato l’Anestesista Rianimatore

  11. UN PASSO INDIETRO GIORNO I pH=7.32 PaCO2= 64.1 mmHg PaO2= 67.2 mmHg QUALCHE ALTRA POSSIBILITA’ in REPARTO ?

  12. YONIV Study - pH Difference at 1 & 4hrs p <0.001 for both groups NIV v conventional - difference p=0.02 at 1 hr

  13. NIMV in the MEDICAL WARD Plant PK

  14. UN ALTRO PASSO INDIETRO GIORNO III pH=7.28 PaCO2= 66.1 mmHg PaO2= 59.2 mmHg QUALCHE ALTRA POSSIBILITA’ ?

  15. Authors pH PaC02 Meduri,1989 7.23 82.5 Elliott, 1990 7.32 65,0 Brochard,1990 7.31 68,0 Meduri,1991 7.27 75.3 Pennock,1991 7.38 49.2 Foglio,1992 7.33 73.5 Benhamou,1992 7.28 69.5 Bott,1993 7.35 61.5 Fernandez,1993 7.27 68.0 Wysocki,1993 7.28 69.2 Vitacca,1993 7.27 83.0 Confalonieri,1994 7.30 66.9 Servera,1995 7.30 75.0 Brochard,1995 7.28 67.0 Kramer,1995 7.27 80.9 Meduri,1996 7.28 70.5 Confalonieri,1996 7.29 72.3 Vitacca,1996 7.28 83.0 Nava,1997 7.21 88.2 Hilbert,1997 7.29 74.5 mean7.28 72.3

  16. WARD, ICU or RICU ? • ICU( 8 studies) • pH=7.25 PaC02=72.5 mmHg • RICU (5 studies) • pH=7.24 PaC02=75.5 mmHg • WARD (8 studies) • pH=7.31 PaC02=62.5 mmHg

  17. SMT NIMV RATE OF DEATH 50 40 * * 30 Rate of of Death (%) * 20 10 0 Bott Brochard Kramer Barbè Plant

  18. Multicenter Survey on NIV 42 ICUs 1337 pts admitted to ICU 689 pts on mechanical ventilation 581 ETI (84%) 108 NIV (16%) 56 success (53%) 52 premature stop (47%) 43 ETI (39%) Carlucci A. AJRCCM 2001;163:874

  19. 36% SAMU 28% ER 36% Other Hypercapnic Respiratory Failure(n=100) • NIV is the first attempt of MV in ICU in 63% of Pts • Success rate is 64% Carlucci A. AJRCCM 2001;163:874

  20. INCIDENCE OF NOSOCOMIAL PNEUMONIA * * Patients (%)

  21. Ventilated patients deceased in the ICU NIV patients Trends for mortality in an ICU for COPD and CPE 100 p<0.0001 90 80 70 60 % 50 40 30 20 24% p=0.028 7% 10 0 1994 1995 1996 1997 1998 1999 (n=41) (n=54) (n=66) (n=62) (n=69) (n=56) Year Girou et al. 2002

  22. Where NIMV in COPD ? • Medical Ward: • To prevent “overt” ARF (pH>7.30<7.35) • RICU: • To treat severe ARF (pH<7.30) if: • - hemodynamic stability • - PaO2/FiO2 > 1.5 • - no sepsis • - Minimal spontaneous capacity • - Normal sensorium • ICU: • - PaO2/FiO2< 1.5 • - > 1 organ failure

  23. DUE PASSI INDIETRO GIORNO IV pH=7.18 PaCO2= 96.1 mmHg PaO2= 60.2 mmHg E’ PROPRIO NECESSARIO INTUBARE QUESTO PAZIENTE ?

  24. Navalesi et al. ERJ 2001

  25. HOW to SET NIMV 1.Explain the technique to the patient 2.Choose the mask 3.Set Pressures (i.e PS ~8 cmH2O and CPAP 2) 4.Hold the mask manually 5.Start gentle mask fitting 6.Avoid excessive tight fit 7.Set FiO2 8.Set alarms 9.Ask the patients about his/her feelings 10.Re-set Pressures (PS to achieve Vtexp>6ml/Kg)

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