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Nichtinvasive Beatmung bei COPD

Nichtinvasive Beatmung bei COPD. Wolfram Windisch. Lungenklinik Merheim. Verkürzung der Insp.-Zeit Atemwegsobstruktion Dynamische Überblähung Intrinsic PEEP Thorakale Vordehnung Erhöter ventilatorsicher Bedarf Oxygenierungsstörung Anämie Herzinsuffizienz.

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Nichtinvasive Beatmung bei COPD

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  1. Nichtinvasive Beatmung bei COPD Wolfram Windisch Lungenklinik Merheim

  2. Verkürzung der Insp.-Zeit • Atemwegsobstruktion • Dynamische Überblähung • Intrinsic PEEP • Thorakale Vordehnung • Erhöter ventilatorsicher • Bedarf • Oxygenierungsstörung • Anämie • Herzinsuffizienz • Diaphragmale Abflachung • Vordehnung der M.-Fasern • Systemmanifestation • Inflammation • Steroide • VIDD • Co-Morbiditäten • Herzinsuffizienz • Pulmonale Hypertonie • Diabetes mellitus Jolley CJ and Moxham J. Eur Respir Rev 2009; 18:112,1-14

  3. Evans TW. Intensive Care Med 2001; 27:166-178

  4. NPPV: Conclusions NPPV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients. NPPV should be tried early in the course of respiratory failure and before severe acidosis, to reduce mortality, avoid endotracheal intubation, and decrease treatment failure. first line pH: 7.20–7,35 Improves outcome Lightowler JV. et al. BMJ 2003; 326:185-189 NPPV = noninvasive positive pressure ventilation

  5. NIV verhindert Intubation • (NNT = 5) • NIV reduziert die Mortalität • (NNT = 8) Lightowler JV. et al. BMJ 2003; 326:185-189 NNT = number needed to treat

  6. 80% 70% 35% Chu CM. et al. Thorax 2004; 59:1020-1025

  7. 5 cmH2O 15/5 cmH2O Cheung APS. et al. Int J Tuberc Lung Dis 2010; 14:642–649

  8. 6-min-Gehstrecke nach 3 Monaten 20/5 cmH2O N = 13 N = 13 Funk GC. et al. Respir Med 20011; 105:427-434

  9. Wijkstra PJ. et al. Chest 2003; 124:337-343

  10. 2 years follow-up 1 year follow-up NPPV + LTOT vs. LTOT alone Clini E. et al. Eur Respir J 2002; 20:529-538 Casanova C. et al. Chest 2000; 118:1582-1590

  11. McEvoy RD. et al. Thorax 2009; 64:561-566

  12. mean adherence to NIV: 4.5 ± 3.2 hours McEvoy RD. et al. Thorax 2009; 64:561-566

  13. McEvoy RD. et al. Thorax 2009; 64:561-566

  14. Wolfram Windisch Windisch W. Breathe 2011; 8:114-123

  15. If the targeted physiological parameter (PaCO2) remains unaffected by the specific treatment modality (long-term NPPV)… If artificial ventilation does not improve alveolar ventilation … How can we expect an improved outcome?

  16. mmHg NPPV (assPCV) - mean IPAP30 ±4 mbar - mean bf23 ±2 /min Days Windisch W. et al. Respir Med 2002; 96:572-579

  17. NPPV (assPCV): IPAP28 ±6 mbar; bf 21 ±3 /min N = 34 2-year survival: 86% Windisch W. et al. Chest 2005; 128:657-662

  18. N = 141 NPPV (assPCV) - mean IPAP20 ±4 mbar - mean bf20 ±4 /min BMI <20kg/m2 = 21% Budweiser S. et al. Respir Care 2006; 51:126-132

  19. Social Functioning SF Respiratory Complaints RC SRI Summary Scale SS Well-Being WB • German • English • French • Spanish • Dutch • Swedish • Norwegian • Polish • Greek • Hebrew • Japanese Physical Functioning PF Anxieties AX Attendant Symptoms and Sleep AS Social Relationships SR Severe Respiratory Insufficiency Questionnaire SRI Windisch W. et al. J Clin Epidemiol 2003; 56:752-759 Windisch W. et al. Intensive Care Med 2003; 29:615-621 Windisch W. et al. J Clin Epidemiol 2008; 61:848-853 ATS homepage: http://www.atsqol.org/sections/instruments/pt/pages/sri.html

  20. N = 137 • COPD • Restrictive thoracic diseases • Obesity- • Hypoventilations-Syndrome • Neuromuscular disorders • Miscellaneous Windisch W. Eur Respir J 2008; 32:1328-1336

  21. IPAP/EPAP (mbar) 20/3 19/4 25/1 P < 0.001 restrictive thoracic P < 0.001 neuromuscular P < 0.001 COPD SRI-Summary Scale (SRI-SS) Changes in SRI-SS independent from the underlying disease MANOVA; F=0,62; P=0,65. Windisch W. Eur Respir J 2008; 32:1328-1336

  22. N = 73 5-year survival: 58% Windisch W. et al. Int J Med Sci 2009; 6:72-76

  23. Low-intensity 14.6 ± 0.8 4.0 ± 0 8.0 ± 0 2.2 ± 0.8 High-intensity 28.6 ± 1.9 4.5 ± 0.7 17.5 ± 2.1 2.2 ± 0.8 IPAP [cmH20] EPAP [cmH20] Breathing frequ. [min-1] Oxygen [L* min-1] Insp. volume(pneumotachygraph): Mean treatment effect: 325 mL 95%CI [159 , 492 mL]; P=0.002 Exp. volume(pneumotachygraph): Mean treatment effect: 96 mL 95%CI [23 , 169 mL]; P=0.015 Leak volume(pneumotachygraph): Mean treatment effect: 226 mL 95%CI [28 , 425 mL]; P=0.030 Dreher M. et al. Thorax 2010, 65:303-308

  24. Primary outcome:Nocturnal PaCO2 Mean treatment effect: -9.2 mmHg 95%CI [-13.7 , -4.6 mmHg]; P<0.001 No period effect: P=0.96 No carry over effect: P=0.87 high: 29 cmH2O; controlled ventilation low: 15 cmH2O; assisted ventilation Compliance (daily use): Mean treatment effect: 3.6 hours 95%CI [0.6 , 6.7 hours]; P=0.024 Low- intensity High- intensity Dyspnea (BDS) QoL (SRI-SS) FEV1(L) + + + + 110 ml Dreher M. et al. Thorax 2010, 65:303-308

  25. Mean IPAP: high: 29 cmH2O; low:14 cmH2O Dreher M. et al. Chest 2011, 140:939-945

  26. 50 209 6 P<0.001 53 Borg Dyspnea Scale P<0.001 Walking distance [m] P<0.05 PaCO2 [mmHg] 50 252 4 n.s. 51 Dreher M. et al. Eur Respir J 2007; 29:930-936

  27. Rehab [20/6 cmH20; 18 breaths/min] Rehab + NPPV Rehab alone Rehab + NPPV baseline baseline 3 months 3 months Duiverman ML. et al. Thorax 2008; 63:1052-1057

  28. Windisch W. et al. Pneumologie 2010, 64:207-240

  29. Windisch W. et al. Pneumologie 2010, 64:207-240

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