NIV: dove ventilare il paziente
Dott Michele Vitacca
Divisione Pneumologia Riabilitativa
e Centro svezzamento Fondazione S.
Maugeri IRCCS Lumezzane (BS)
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
Difficult
intubation !
(according to location ?)
Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178
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
• 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
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
Location
The concept of the traffic light
ICU
Staff number
Safety
Monitoring
Equipment
Familiarity with NIV
RICU/ WARD ER
HDU
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 (?)
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
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
HUMAN WORKLOAD in RICU
Nava et al.Chest 97;111:1631
BTS Equipment Recommendations
Staff familiarity is key to success
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
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
Endotracheal Tube vs Mask
Complimentary role
Mask
ET
Evolving ARF
Mask
Respiratory failure
ET
Resolving ARF
Pre-hospital setting to use CPAP?
Noninvasive ventilation in pre-clinical
care
Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für
Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim
Respiratory rate +
SatO2
before CPAP
during CPAP
Blood pressure and
heart rate
before CPAP
during CPAP
Noninvasive ventilation in pre-clinical
care
Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für
Pneumologie und Beatmungsmedizin e.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
not avoided
was not necessary
59 %
9%
32 %
Considera la patologia !
Carlucci A. AJRCCM 2001;163:874
Eur Respir J 2005; 25:348-355
100 – 75 %
74 -50 %
49 -25 %
Percentage of patients who fail NIV
24 -0 %
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 !!!!!!
Interface: Facial Masks
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.
POPOLAZIONE DELLO STUDIO
N = 3617 (81%)
VENTILAZIONE INVASIVA
VENTILAZIONE NON INVASIVA
(IV) N= 2656 (73%)
(NIV) N= 961 (27%)
DESISTENZA
TERAPEUTICA (EOLC)
Early NIV success
NIV failure
N=652 (68%)
N=309 (32%)
Late NIV failure
INTUBAZIONE NO
INTUBAZIONE SI
N=153 (25%)
N=309 (32%)
N = 207 (6%)
Cortesia dott. Gristina
Reasons for low use of NIV in
acute hospitals: US survey
No. of
responses
20
10
0
Physicians lack of
experience
Equipment not
appropriate
Other
Poor
previous
experience
Hospital staff
inadequately
trained
Maheshwari v et al Chest 2006:129: 1226-33
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
From 4% to 14%
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
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
Location summary (1)
SITE
Respiratory
WARD
No resp ward
Hospice
ER
RICU
ICU
Pre H
Preferred diseases
Condition
COPD, restrictive, Elective, semielective NIV, pH >7.30
Ph > 7.25
Monitoring
COPD, CHF, PE, Aged
Ph > 7.30
No comatose
All
Palliative, ceiling
intrevention
PE, COPD, Aged
Ph > 7.20
paO2/FI02 >150 < 200
All, NM
ALS, 1 system failure, first
12 hours NIV. Confusion,
poor tolerance, labile
bronchospasm, disability with high
nursing dependency
Ph > 7.20
paO2/FI02 >150 < 200
Pure Ipoxemic,
Sedation, Post op ARF, comorbidities,
Weaning and NIV, Multi system organ
failure. Haemodynamic instability. Severe
confusion. Pre coma
Ph <7.20
paO2/FI02<150
PE
High expertize
Location summary (2)
SITE
advantages
Contra
More enthusiasm, skills,
No aggressive location,
RT presence
Cough assistance combination, cost
effectiveness
No sufficient staff
Night duty ?
Delay in EI
Low monitoring on ventilators
No adequate devices
cost effectiveness
geriatric skills
Beds availability
No sufficient staff
Night duty ?
Delay in EI
Low monitoring on ventilators
No adequate devices
Low case mix
Low respiratory skills
Early good outcome , triage
Low expertize on NIV and chronic diseases
Advanced plan respect
Palliative competence
No adequate devices
Low case mix
Low respiratory skills
High enthusiasm, skills,
RT presence
Cough assistance combination,
cost effectiveness
Rapid worsening in Hypox
ICU
Monitoring
EI availability
Complexity case mix
Low expertize on NIV and chronic diseases
Costs
Pre H
Early good outcome
High expertize, Delay in EI
Respiratory
WARD
No resp ward
ER
Hospice
RICU
NIV success: staff training and experiance
are more important than location