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NIPPV for cardiogenic pulmonary edema. Dr Romain Pirracchio, MD Anesthesiology & Critical Care Lariboisière University Hospital University Paris 7 Diderot romain.pirracchio@lrb.aphp.fr. ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416. European guidelines.
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NIPPV for cardiogenic pulmonary edema Dr Romain Pirracchio, MD Anesthesiology & Critical Care Lariboisière University Hospital University Paris 7 Diderot romain.pirracchio@lrb.aphp.fr
ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416 European guidelines
LV Dysfonction VICIOUS CIRCLE Impairment in alveolar gas exchanges Impairment in ventilatory mechanic shunt Pleural Pressure WOB Hypoxemia preload afterload VO2 DO2 MvO2
LV Dysfonction Nitrates diuretics Inotropes Vasodilators O2 Impairment in alveolar gas exchanges Impairment in ventilatory mechanic shunt Pleural Pressure WOB Hypoxemia ? précharge preload afterload VO2 DO2 MvO2
Alveolar recrutment WOB pressure • Inspiratory drops in pleural pressure • Afterload cardiac output preload PPV effects on heart-lung interaction
CPAP • Effects on cardiac failure Naughton, Circulation 1995 Lin, Chest 1995 • Effects on respiratory failure : WOB, pulm compliance, FRC, intubations Lenique, AJRCCM 1997 Bersten, NEJM 1991 Rasanen, Am J Cardiol 1985 • Non invasive vs Invasive PPV: pulmonary infections Girou, JAMA 2000 Antonelli, N Eng J Med 1998
CPAP & Cardiac output ZEEP PEEP7.5 ZEEP PEEP10
CPAP & central venous saturation 100 90 80 70 50 40 30 SV (ml) 70 - 50 - 30 - CPAP 1 4 2 3 15 20 SvO2 PCWP (mmHg) 1: dobu 2: dobu + IAoCPB 3: dobu + IAoCPB + Enoximone 4: dobu + IAoCPB + CPAP Pery N, Chest 1991
CPAP & WOB Lenique, AJRCCM 1997
A randomised study of Out-of-Hospital CPAP for Acute Cardiogenic Pulmonary Oedema: physiological and clinical effects. 3 questions : • Benefit of CPAP applied early and alone ? • Benefit of adding medical treatment to CPAP ? • Effects of an early CPAP withdrawal ? Pirracchio et al. Eur Heart J, in press
Patients • Pre-hospital, prospective, randomised study • Inclusion : • Severe cardiogenic pulmonary edema (SpO2 90% with O2 15 L/mn) • Non inclusion : • History of COPD, asthma • Coma • Cardiogenic shock • Valvular stenosis Pirracchio et al. Eur Heart J, in press
Venturi CPAP device Vital Signs (Gamida) PEEP valve Venturi flux generator FiO2 monitor
Protocol « Early CPAP » T0 T15’ T30’ T45’ O2 + MT OUTCOME CPAP 7.5 cmH2O CPAP 7.5 cmH2O + MT DCS, HR, RR, BP, SpO2, blood gases « Late CPAP » T15’ T30’ T45’ T0 O2 + MT O2 + MT CPAP 7.5 cmH2O + MT Pirracchio et al. Eur Heart J, in press
Early CPAP Late CPAP * p<0.05 early CPAP vs late $ p<0.05 early CPAP T15 vs T0 Evolution of Dyspnea Clinical Score 10 9 * 8 7 6 DCS 5 4 3 $ 2 1 T45 T0 T15 T30 Pirracchio et al. Eur Heart J, in press
Early CPAP Late CPAP * p<0.05 CPAP early vs late $p<0.05 CPAP early T15 vs T0 Arterial blood gases 130 * 55 * $ * 110 50 (mmHg) (mmHg) 90 45 70 40 PaCO2 PaO2 50 35 $ 30 30 T0 T15 T30 T45 T0 T15 T30 T45
Outcome • Intubation : (p=0.01) • « early CPAP » : n=6 • « late CPAP » : n=16 • Inotropes : (p=0.02) • « early CPAP » : n=0 • « late CPAP » : n=5 • In hospital mortality : (p=0.05) • « early CPAP » : n=2 • « late CPAP » : n=8 Pirracchio et al. Eur Heart J, in press
CPAP vs BiPAP ? • CPAP > BiPAP ? • Metha, Crit Care Med 1997 : • BiPAP associated with more AMI ++ • BiPAP > CPAP ? • Chadda, Crit Care Med 2002 : BiPAP>CPAP • CPAP = BiPAP +++ • Bellone, Crit Care Med 2005 • Moritz, Ann Emerg Med 2007 • Ferrari, Chest 2007 in press (No difference in AMI +++)
Metaanalyses BiPAP et VNI Massip, JAMA 2005
Metaanalyses BiPAP vs VNI Massip, JAMA 2005
CPAP or BiPAP • On scene or in the ER: • CPAP for CPE (G1+) • BiPAP can be used : • For CPE or COPD , • ONLY by trained teams and with ventilators allowing NIPPV (G2+) Consensus SFAR, SPLF, SRLF 2006 • CPE even with hypercarbia => CPAP COPD => BiPAP Consensus ATS-ESICM-SRLF-ERS 2000
Conclusion • PPV is the only way to break the vicious circle due to deleterious heart-lung interactions • PPV improves the outcome • CPAP and BiPAP have similar results • As more simple, CPAP might be used as first line ventilatory therapy for CPE out of the ICU
Respiratoy muscles consumption 20 - 15 - 10 - 5 - 0 - rest Respiratory failure Blood flow dedicated to respiratory muscles (mL/100 gr/Lof cardiac output)
EFFETS CARDIOVASCULAIRES DE LA VENTILATION MÉCANIQUE "Pompe dans la pompe" POMPE RESPIRATOIRE PRESSION ALVEOLAIRE POSTCHARGE VD: RVP PRECHARGE VG: VES VD Cap. Pulm. PRESSION THORACIQUE (Ppl) POMPE CARDIAQUE VD VG PVC POSTCHARGE VG: PtmVG elastance Ao gradient PIT-PIA PRECHARGE VD: Résistances veineuses gradient par POD PRESSION ATMOSPHERIQUE TISSUS PMS
Metaanalyses BiPAP vs VNI Ho KM, Crit Care, 2006