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NIV: ipossiemico

NIV: ipossiemico. Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS). Dott Michele Vitacca. DAY I 4.45 pm Emergency Room. 49 year old woman, professional vocalist at the Scala; BMI=21

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NIV: ipossiemico

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

  2. DAY I 4.45 pmEmergency Room 49 year old woman, professional vocalist at the Scala; BMI=21 Emergency Room for dyspnea (onset 24 hr before), thoracic pain and Fever Previous history: Known to have “mild” emphysema treated with LABA and ICS. No major complains when she sings. No PFTs available

  3. DAY I 4.55 pm Emergency Room Kelly 1 (normal sensorium) Some bilateral crackles 24 breaths/min. No recruitment accessory muscles SaO2 94% with FiO2 50% (Venturi mask) BP= 90/45 mmHg HR= 124 b/m Body T.= 38.8° Waiting for chemical examinations, Chest X-ray, Urinary culture

  4. ABG with a FiO2 of 50%: pH 7.37 PaCO2 48 mmHg PaO2 75 mmHg PaO2/FiO2= 150 DAY I 5.15 pm Emergency Room Hb 12.5 g/dl Ht 43% WBC 27.000 Albumin 3gr % Cl- 110 Na+ 144 K+ 3.1 Creat 1.2

  5. Chest X-ray

  6. What would you do? • Perform a CPAP trial in the ER • Transfer the patient to a “protected” environment • Perform a NIV trial (by Bilevel mode) in the ER

  7. What would you do? • Perform a CPAP trial in the ER • Transfer the patient to a “protected” environment • Perform a NIV trial (by Bilevel mode) in the ER

  8. Definition ofACUTE RESPIRATORY FAILURE PaO2/FiO2 < 300 PaO2/FiO2 ratio of 150 is a sign of SEVERE hypoxia necessitating Intensive monitoring and treatment

  9. DAY I 6.30 pm High-Dependency Respiratory Unit Started therapy with: • Ciprofloxacin 500 mg x 2/die • Clarytromycicn 500 mg x 2/die • Methilpredisolone 40 mg/die • Aspirin 500 mg ev

  10. DAY I 8.30 am Kelly 1 Body T= 37.9° Respiratory rate= 28 breaths/min Minimal recruitment of accessory muscles

  11. ABG on Venturi mask 50% pH 7.33 PaCO2 51 mmHg PaO2 65 mmHG with FiO2 Venturi 50% PaO2/FiO2= 105 mmHg Bic 28.4 BE 4.3

  12. NIV should be started! She has become more hypoxic and hypercapnic

  13. Which mode? • CPAP • PSV + extPEEP • PSV without extPEEP

  14. Which mode? • CPAP • PSV + extPEEP • PSV without extPEEP

  15. USE PSV + CPAP or extPEEP! • Greater improvement of hypoxia • Greater reduction of diaphragmatic effort • Greater reduction of dyspnea -

  16. Which interface? • Nasal Mask • Full Face Mask • Helmet

  17. Which interface? • Nasal Mask • Full Face Mask • Helmet

  18. DAY II 10.30 am • NIV is started: PSV + CPAP ICU ventilator with leak compensation Full face mask Following settings: FiO2= 21% PS= 18 cmH20 CPAP= 8 cmH20 to get a SaO2>88%, then increase FiO2 to get a SaO2 > 93% “Final” FiO2= 45%

  19. ABG 1hr after NIV pH 7.39 PaCO2 31 mmHg PaO2 71 mmHG Bic 3 BE 26.2 SaO2 92% PaO2/FiO2= 157

  20. Are we happy? • Yes because ABG 1 hr after NIV predict a good prognosis • No because a PaO2/FiO2 < 200 after 1 hr of NIV is associated with a higher NIV failure in ARF • Yes, but caution should be excercised because the diagnosis of CAP is independently associated with a higher risk of NIV failure

  21. Are we happy? • Yes because ABG 1 hr after NIV predict a good prognosis • No because a PaO2/FiO2 < 200 after 1 hr of NIV is associated with a higher NIV failure in ARF • Yes, but caution should be excercised because the diagnosis of CAP is independently associated with a higher risk of NIV failure

  22. Antonelli et al. 27;2001 pag.1718-28 This observational study shows that the outcomes of NIV during hypoxic RF may differ according to the underlying pathologies. The likelihood of failure is very low in patients affected by Cardiogenic Pulmonary Edema but it is very high in patients with CAP.

  23. DAY III…. continuing story • The patient was continuously monitored • ABG were taken after 1hr and then every 3 hrs for the following 12 hrs • She tolerated NIV well and the last ABG during spontaneous breathing showed: • pH= 7.39 • PaCO2 37 mmHg • PaO2 82 mmHG (with a FiO2= 35%) • PaO2/FiO2=235 • Respiratory rate= 16 breaths/min

  24. Remember:she was also a COPD patient

  25. Intubation 2-months mortality %

  26. The message to take home NIV used in a protected environment may PREVENT endotracheal intubation in HYPOXIC patients with pneumonia, but ONLY in those patients with pre-existing COPD

  27. IN THE FOLLOWING DAYS…. • She improved daily and NIV was stopped on day 4, after having progressively reduced the duration of its application

  28. . . VA/Q v The 3 major determinants of hypoxemia 1st: the composition of Inspired air (gas): Low FiO2 I 2nd: quality and capacity of the gasexchanger:  V/Q mismatching PAO2= (Pb-PH2O=) x 0.21-PACO2/R PaO2 3rd: the composition of Mixed venous blood:  LowPvO2

  29. Common Causes of Hypoxemic Respiratory Failure • Pneumonia • Cardiogenic pulmonary edema • Acute respiratory distress syndrome • Aspiration of gastric contents • Multiple trauma • Immunocompromised host with pulmonary infiltrates • Pulmonary embolism

  30. Neurological Signs and Symptoms of Hypoxia F. Laghi and M. Tobin 2013

  31. Ma funziona sul serio la NIV ?

  32. CPAP : Respiratory Effects CPAP intrathoracic alveolar PEEPi pressure pressure compensation Shunt FRC work of breathing Improve gas atelectasis Exchange hypoxemia Pelosi Chest 1996 Pelosi Anesthesiology 1999

  33. CPAP: Cardiovascular Effects Positive Pressure  ITP  FRC  WOB  LVafterload PTM  PaO2 • Pre-load  Venous return  Cardiac performance  pulmonary congestion

  34. Non invasive CPAP to treat PE or CHF

  35. Metanalisi

  36. Non-invasive positive pressureventilation (CPAP orbilevel NPPV) forcardiogenicpulmonaryedema (Cochrane Review) Vital FMR. et al., 2008 hospital mortality NIV/CPAP vs 02

  37. Non-invasive positive pressureventilation (CPAP orbilevel NPPV) forcardiogenicpulmonaryedema (Cochrane Review) Vital FMR. et al., 2008 endotracheal intubation rate NIV/CPAP vs 02

  38. The best candidate

  39. New Variable: HYPERCAPNIA

  40. CPE – RiskFactorsfor NIV Failure Arterial pressure and hypercapnia Masip J. ICM 2003; 29: 1921-8

  41. CPE – Risk Factors for NIV Failure Masip J. ICM 2003; 29: 1921-8

  42. New Variable: ACIDOSIS

  43. Endotracheal intubation or Non invasive CPAP/PPV to treat Postoperative Hypoxiemic Respiratory Failure ?

  44. Patients scheduled for elective major abdominal surgery (§) and general anesthesia who met a PaO2/FiO2 < 300 after 1 h at 30% (Venturi mask ) in the recovery room. • (§) Opening abdominal wall and viscera exposition > 90 minutes with laparotomic or subcostal incision . Helmet CPAP 10 cmH2O (104 pts) Venturi Mask (105 pts)

  45. Endotracheal intubation or Non invasive CPAP/PPV to treat Hypoxiemic Respiratory Failure (Pneumonia or ARDS) ?

  46. Predictorsoffailureofnoninvasiveventilation in acute hypoxiemicpatients 100 NIV Efficiency (%) 50 0 ACPE COPD ARF Pelosi Eur Emerg J 2000 Antonelli ICM 2001

  47. HYPOXEMIC ARF (ARDS) IMMUNOCOMPETENT PATIENTS STUDIES [*= RCT ] n Particularities Mask Mode SUCCESS MeduriChest 1996 41 PaO2/FiO2 =110F PS/PEEP 66 % WysockiChest 1995 *42 F PS/PEEP 38 % Patrick AJRCCM 1996 11 Intubation C NPAV 73 % AntonelliNEJM 1998 *64 Intubation CF PS/PEEP 69 % Rocker Chest 1999 12 ALI / ARDS F PS/PEEP 50 % PaO2/FiO2 = 102 Confalonieri1999 *56 Comm. PN F PS/PEEP 79 vs 50% DelclauxJAMA 2000* 123 PaO2/FiO2  300 F CPAP 66 vs 61 % FerrerAJRCCM 2003 * 105 PaO2/FiO2 =102F PS/PEEP 75 vs 48%

  48. Acute RespiratoryFailure in Patients withSevereCommunity-acquiredPneumonia Confalonieri M., et al. 1999; 160:1585-1591 COPDNon COPD NIV Standard p NIV Standard p (n = 12) (n = 11) (n = 16) (n = 17) SUCCESS100 % 45 % 0.005 63 % 53 % 0.73 ICU Stay (days) 0.25 ± 2.1 7.6 ± 2.2 0.02 2.9 ± 1.8 4.8 ± 1.7 0.44 Hospital Stay 14.9 ± 3.4 22.5 ± 3.5 0.13 17.9 ± 2.9 15.1 ± 2.8 0.48 Hospital Death 1 (8.3%) 2 (18.2%) 0.59 6 (37.5%) 4 (23.5%) 0.47

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