NIV: dove ventilare il paziente

1. NIV: dove ventilareilpaziente Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS) Dott Michele Vitacca

2. the correct time to start

3. IDENTIFY PATIENTS (according to location ?) 1. Clinical abnormalities - moderate to severe dyspnea - RR > 24 b/min in COPD - RR > 30 – 35 b/min in AHRF - accessory muscle use, paradoxal breathing 2. Gas exchange abnormalities - PaCO2 > 45 mmHg, pH < 7.35 - PaO2/FiO2 < 250 mmHg Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

4. Difficult intubation ! (according to location ?) Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

5. the correct setting

6. The right location • Model of health care delivery varies markedly • From country to country • Within a country • Within an institution • Randomised controlled trials performed in one country may not be generalisable to another

8. Have a plan from the outset • This may change! • What is going to happen if the patient fails? • What is reversible? • Pre morbid quality of life • Circumstances of failure

9. Timing is all… • Start early but not too early (Barbe study) • You are too late if… • Pt on verge of respiratory arrest • Pt severely hypoxaemic (PaO2/FiO2 < 75) • Pt comatose or hugely agitated • Medically unstable: acute MI, GI bleed, shock • What is your unit’s ‘door to mask’ time? • What are the main limitations? Simonds ERS school

10. Location The concept of the traffic light

11. Strategic use of NIV • Concentrate staff expertise • Training focus for NIV for medical, nursing and paramedical staff • Concentrate equipment • Facilitate link with ICU • Audit, data collection • Cost savings (?)

12. Safety first! • Patient selection • Safe staffing levels • Rolling programme of staff training and protocols • Adequate monitoring • Ability to intubate & transfer pts to ICU • Suitable alarms Simonds ERS school

13. Staffing of resp int care unit( or location with high number of NIV pts) • Nurse to pt ratio 1:4 (1:6 ?) • Senior Physician on call for 24 hours • Training for nurses and trainee medical staff • Dedicated physiotherapist • Technical service • Strong links with ICU Simonds ERS school

14. HUMAN WORKLOAD in RICU Nava et al.Chest 97;111:1631

15. BTS Equipment Recommendations Staff familiarity is key to success

16. Monitoring • Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance • Pulse oximetry • Continuous display of ECG and non-invasive BP • Arterial blood gases (ABG machine easily accessed) • Continuous non-invasive monitoring of CO2 helpful eg. Transcutaneous, end-tidal • Duration of NIV use • Ventilatory settings, FiO2, leak • Severity score • Side effects : skin integrity, GI, nasal symptoms • CXR, screening bloods etc. Simonds ERS school

17. 25% of the respondents use hand restraints in >30% of the patients. Is this the way to solve the problem ? Some mild sedation may be prescribed

18. the correct condition

19. Evolving ARF Respiratory failure Resolving ARF Endotracheal Tube vs MaskComplimentary role Mask ET Mask ET

20. Pre-hospital setting to use CPAP?

21. Noninvasive ventilation in pre-clinical careJerrentrup A, Kill C. et al. Vortrag auf demKongressderDeutschenGesellschaftfürPneumologie und Beatmungsmedizine.V. 2007, Mannheim Blood pressure and heart rate Respiratory rate + SatO2 before CPAP during CPAP before CPAP during CPAP

22. Noninvasive ventilation in pre-clinical careJerrentrup A, Kill C. et al. Vortrag auf demKongress der DeutschenGesellschaftfürPneumologie und Beatmungsmedizine.V. 2007, Mannheim clincal situation with CPAP: much improved 51 % improved 40 % unchanged 3 % worse 3 % with the use of pre-clinical CPAP, intubation was avoided 59 % not avoided 9 % was not necessary 32 %

23. the correct time to stop

24. Considera la patologia ! Carlucci A. AJRCCM 2001;163:874

25. 100 – 75 % 49 -25 % 24 -0 % 74 -50 % Percentage of patients who fail NIV Eur Respir J 2005; 25:348-355

26. Perchè fallisce la NIV ? Perchè si sbaglia paziente Perchè non si rispettono le controindicazioni Perchè si sbaglia maschera Perchè si sbaglia modalità di ventilazione Perchè si sbaglia il settaggio Perchè il paziente non supporta più la NIV Perchè non miglioranono i gas Perchè vi è cattiva interazione con il ventilatore PERCHE ‘ SI SBAGLIA LOCATION !!!!!!

27. Technical note

29. Interface: Facial Masks

30. the real life

31. Thorax 2011;66:43e48. doi:10.1136/thx.2010.153114 232 H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later. 1077 patients received NIV (11%), 55% had a pH <7.26 30% patients with persisting respiratory acidosis did not receive NIV. Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis. Only 4% of patients receiving NIV who died had invasive mechanical ventilation.

33. POPOLAZIONE DELLO STUDIO N = 3617 (81%) VENTILAZIONE INVASIVA (IV) N= 2656 (73%) VENTILAZIONE NON INVASIVA (NIV) N= 961 (27%) Early NIV success N=652 (68%) NIV failure N=309 (32%) Late NIV failure INTUBAZIONE NO N=153 (25%) INTUBAZIONE SI N=309 (32%) DESISTENZA TERAPEUTICA (EOLC) N = 207 (6%) Cortesia dott. Gristina

34. Reasons for low use of NIV in acute hospitals: US survey No. of responses 20 10 0 Poor previous experience Hospital staff inadequately trained Equipment not appropriate Physicians lack of experience Other Maheshwari v et al Chest 2006:129: 1226-33

35. USE in the “REAL” WORLD of ICUs Hypercapnic Respiratory Failure • NPPV is the first attempt of MV in ICU in 63% of Pts • Success rate is 66% Carlucci A. AJRCCM 2001;163:874

38. From 4% to 14%

39. Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 H admissions pts from NIV to EI N° pts NIV deaths

40. Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012 NIV and EI EI NIV no EI No support

41. Conclusion

42. Location summary (1)

43. Location summary (2)

44. NIV success: staff training and experiance are more importantthan location

45. Grazie per l’attenzione