Assist. Prof. Dr. Gazi Gülbaş Inonu University, Department of Pulmonary Medicine, Malatya

1. CONTRIBUTION OF NONINVASIVE MECHANICAL VENTILATION TO EXTUBATION SUCCESS IN PATIENTS WITH OBSTRUCTIVE LUNG DISEASE Assist. Prof. Dr. Gazi Gülbaş Inonu University, Department of Pulmonary Medicine, Malatya

2. Introduction-1 • Invasive mechanical ventilation is asociated with an increased risk of nosocomial pneumonia and mortality. • Prolonged mechanical ventilation, may be a consequence of persistent weaning failure, and is associated with an increased morality and morbidity , especially in patients with chronic respiratory failure. Ferrer M,Am J Respir Crit Care 2003 (168):70-6.

3. Introduction-2 • Patients who require reintubation (extubation failure) have a poor prognosis, with hospital mortality rates exceeding 30 to 40 % (1). • A series of investigations have identified various factors predisposing for extubation failure. • These factors included; - age above 70 years - higher severity of illness at weaning onset, - anemia - possibly a longer duration of mechanical ventilation prior to extubation (2). 1)Epstein SK, Am J Respir Crit Care 1998 (158):489-93. 2)El Solh AA, Respir Med 2004 (98):661-8.

4. Introduction-3 • Noninvasive mechanical ventilation (NIMV) facilitates early extubation and improves the outcomes of selected patients with an exacerbation of obstructive lung disease and weaning failure. Nava S, Ann Intern Med 1998 (128); 721-8

5. Introduction-4 : This study was planned to evaluate the contributionof noninvasive mechanical ventilation (NIMV) to extubation success in patients withobstructive lung diseases.

6. Material and Methods-1: • Inonu University, Department of Pulmonary Medicine, Intensive Care Unite • Forty patients with obstructive lung disease intubated due to respiratory failure were evaluated between December 2007 and May 2008.

7. Patients with Mechanical Ventilator 40 21 group 1(n:12)group 2(n:9) Group 1: Patients with NIMV following extubation Group 2: Patients without NIMV following extubation

8. Material and Methods-3: Classification of patients according to diagnosis

9. Material and Methods-4: Weaning Criteria: *Objective measurements: Adequate oxygenation (PaO2 ≥ 60 mm Hg on FiO2≤0.40 PEEP≤5-8 cm H2O; PO2/FiO2≥ 150-300) Stable cardiovascular system (HR≤140, stable BP; minimal (or no) Vazopressör ) Temperature<38ºC No significant respiratuar acidosis Adequate Hgb values ( Hgb ≥8-10 g/dL) Adequate mentation (arousable, GCS≥13, no continuous sedative infusion) Stable metabolic status (acceptable electrolites) *Subjective clinical assessments: Resolution of disease acute phase; physician believes discontinuation possible; adequate cough

10. Material and Methods-5: • Reentubation : -request to intubation within 48 h • Criteria for extubation failure: -RR>25 /dk (for 2 h) -HR>140 /min or sustained increase or decraese of >20% -Clinical signs of respiratory muscle fatigue or increased work of breathing SaO2 < 90% PaO2 <80 mmHg (FiO2≥0.50) -Hypercapnia (PaO2 >80 mmHg or >%20 from pre-extubation), pH<7.33 RR:respiratory rate, HR:Heart Rate,SaO2:arteriel oxygen saturation, PaO2:ateriel O2 tension, FiO2:inspiratory O2 fraction, PaCO2:arteriel carbon dioxide tension

11. Material and Methods-6: NIMV Protocol : -Oronasal mask used. -Standart pressure values performed to group 1 patients following extubation were Pins:10 cmH2O, PEEP:5cm H2O. Then the pressures were adjusted according to arterial blood gases, monitorisation and vital signs. -First arterial blood gase measurement was done at the end of first hour. Then measurements were repeated in 6.,12. and 24. hour -NIMV was performed 30 min to 2 hours in every 4 hours depending on patients toleration.

12. Results-1: Group 1 Group 2 p value Age 72.7±11 73.5 ±13 NS Sex(F/M) 6/6 3/6 <0.05 Hgb 13.9 ±2.5 13.0±3.2 NS Hct 43.4 ±6.9 39.7±10.0 NS WBCadm 9.7 ±3.6 18.5±9.6 0.015 WBCextb 13.9 ±7.8 18.6 ±9.6 NS Dur of hsp 18.6 ±9.7 15.1 ±9.7 NS F/M:Female/Male, Hgb:Hemoglobin, Hct:Hemotocrit, WBC:white Blood cell, NS:Not Significant, adm:admission, extb:extubation Dur of hsp:duration of hospitalization.

13. Results-2: Group 1 Group 2 p value pH adm 7.28±0.10 7.27±0.15 NS pH extb 7.41±0.02 7.41±0.06 NS PCO2 adm 69±15.5 70.5±33.3 NS PCO2 extb 57.5±16.1 50.6±13.3 NS PO2 adm 59.0±29.8 42.4±18.3 NS PO2 extb 79.0±42.2 72.0±41.9 NS SO2 adm(%) 77.2±17.0 61.5±27.0 NS SO2 extb(%) 85.8±14.0 85.6±14.1 NS HCO3 adm 28.0±5.0 24.2±6.2 NS HCO3 extb 34.0±8.7 31.0±9.3 NS NS:Not Significant, adm:admission, extb:extubationHCO3:Bicarbonat.

14. Results-3: Patients (n:20)group 1(n:12) group 2 (n:9) Reintubation n,(%)4(% 33.3)4 (%44.4) Mortality n,(%) 4 (%33.3)4 (%44.4) NS NS NS:Not Significant.

15. Results-4:

16. Conclusion-1: • Although it was found in our study that the use of NIMV following extubation from mechanical ventilation decreased the rates of mortality and reintubation in patients with obstructive lung diseases, • the difference was not statistically significant. This may be due to the limited number of the patients.

17. Conclusion-2:

18. Conclusion-3: We think that, • In patients with obstructive lung disease, intubated due to respiratory failure, application of NIMV following extubation; - increases success of extubation, - reduces treatment costs by decreasing hospitalization period.

19. THANK YOU!