Insufficienza
Respiratoria
Andrea Vianello
Fisiopatologia e Terapia Intensiva Respiratoria
Ospedale – Università di Padova
Airway
narrowing &
obstruction
Airway
Inflammation
Shortened
muscles
curvature
 muscle
strength
 Frictional
WOB
AutoPEEP
 Elastic
WOB
Gas
trapping
 VT
 VA
 VE
 PaCO2
pH
 PaO2
 VCO2
usa i farmaci e bene !
Airway
Inflammation
Steroids
Abx
Shortened
muscles
curvature
strength
 Frictional
WOB
AutoPEEP
BDs
 Elastic
WOB
Gas
trapping
Teophylline
 muscle
Airway
narrowing &
obstruction
 VT
 VA
 VE
 PaCO2
pH
 PaO2
 VCO2
usa i farmaci e bene !
Airway
Inflammation
Steroids
Abx
Shortened
muscles
curvature
 VT
strength
MV
PEEP
 Elastic
WOB
Gas
trapping
 VE
MV
 VA
 Frictional
WOB
AutoPEEP
BDs
Teophylline
 muscle
Airway
narrowing &
obstruction
 PaCO2
pH
 PaO2
MV
 VCO2
Non-Invasive
Ventilation
“a form of ventilatory
support that avoids
airway invasion”
Hill et al Crit Care Med 2007; 35:2402-7
NIV VS TRATTAMENTO STANDARD
Keenan S et al
NIV VS TRATTAMENTO STANDARD
Keenan S et al
NIV - Meta-analysis (n=8)
• NPPV resulted in
– decreased mortality (RR 0.41; 95% CI 0.26, 0.64),
– decreased need for ETI (RR 0.42; 95%CI 0.31, 0.59)
• Greater improvements within 1 hour in
– pH (WMD 0.03; 95%CI 0.02, 0.04),
– PaCO2 (WMD -0.40 kPa; 95%CI -0.78, -0.03),
– RR (WMD –3.08 bpm; 95%CI –4.26, -1.89).
• Complications associated with treatment (RR 0.32; 95%CI
0.18, 0.56) and length of hospital stay were also reduced with
NPPV (WMD –3.24 days; 95%CI –4.42, -2.06)
Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185
49 pazienti con IRA in BPCO dopo fallimento terapia medica, pH 7.2
• Simili durata di permanenza in ICU, durata VM, complicanze generali,
mortalità in ICU, e mortalità in ospedale
• con NIV 48% evitano ETI, sopravvivono con permanenza in ICU
inferiore vs pazienti VM invasiva (P=0.02)
• A 1 anno: NIV inferiore riospedalizzazione (65% vs 100% P=0.016) e
minor frequenza di riutilizzo supplemento di ossigeno (0% vs 36%)
Studio caso-controllo: 64 paz. con IRA trattati con NIV pH = 7.18
• 40/64 (62%) fallimento NIV (RR con NIV - 38%)
• Simili mortalità in ICU, e mortalità in ospedale; durata di permanenza in
ICU e post ICU, ma:
• Inferiori complicanze (P=0.01) e probabilità di rimanenere in VM
(P=0.056)
• Se NIV efficace (24/64 = 38%) migliore sopravvivenza e ridotta
permanenza in ICU vs pazienti VM invasiva
NIV: Change in practice over
time
• 1992-1996 (mean pH = 7.25+/-0.07)
1997-1999 (7.20+/-0.08; P<0.001).
• > 1997 - risk of failure pH <7.25 three
fold lower than in 1992-1996.
• > 1997 ARF with a pH >7.28 were
treated in Medical Ward (20% vs 60%).
• Daily cost per patient treated with NIV
(€558+/-8 vs €470+/-14,P<0.01)
Carlucci et al Intensive Care Med 2003; 3:419-25
Epidemiology
• Rationale: evidence supporting use of NIV
varies widely for different causes of ARF.
• Population: 11,659,668 cases of ARF from the
Nationwide Inpatient Sample during years 2000
to 2009;
• Objectives: To compare utilization trends and
outcomes associated with NIV in patients with
and without COPD.
• Rationale: The patterns and outcomes of NIV
use in patients hospitalized for AECOPD
nationwide are unknown.
• Population: 7,511,267 admissions for acute
AE occurred from 1998 to 2008;
• Objectives: To determine the prevalence and
trends of NIV in AECOPD.
Use of NIPPV or IMV as first-line respiratory support in
patients hospitalized with AECOPD
Joint BTS/RCP London/Intensive Care Society Guidelines. NIV in COPD. Oct 2008
When to use Non-Invasive Ventilation
Goals of NIV
can they be reached?
NIV is time consuming, needs proper equipment, enough
staff with sufficient expertise.
time
technical equipment
predict success of NIV
staff expertise
Eur Respir J 2002; 19: 1159–66
Definition of the three levels of care
European Task Force on Respiratory Intermediate Care Survey
Corrado et al, ERJ 2002;20:1343-50
Appropriatezza di utilizzo della Ventilazione Non-Invasiva in
ambito pneumologico nell’assistenza ai pazienti con
BroncoPneumopatia Cronica Ostruttiva in fase acuta.
Rate of NIV failure is extremely different
according to study design, severity of illness
and level of monitoring
Sixty-two RCTs
including a total of
5870 patients
Overall NIV failure:
16.3%
NIV – Real Life
Evaluation of all 449 patients receiving
NPPV for a 1-yr period for acute or acute
on chronic RF
– CPE (n=97)
– AECOPD (n=87)
– non-COPD acute hypercapnic RF
(n=35)
– postextubation RF (n=95)
– acute hypoxemic RF (n=144)
Intubation rate was 18%, 24%, 38%,
40%, and 60%, respectively
Hospital mortality for patients with acute
hypoxemic RF who failed NPPV was
64%
Schettino G. Crit Care Med 2008; 36:441-7
The percentage of
patients
transitioned from
NIV to IMV ≈ 5%
and did not
increase from 1998
to 2008
Reasons for low rate of IMV use after NPPV,
compared to clinical trial:
• End of life decision to not accept IMV
• Patients died before IMV could be started
• Good selection of appropriate patients
• High mortality rate
(≈30%) ;↑ over time
• OR for death:1.63,
compared to those
initially on IMV
• ↑hospital stay
• Nearly one third of patients for whom there is the best
evidence base for NIV did not receive it
– Admission pH < 7.26: 66% received NIV compared to 34%
pH 7.26 to 7.34.
– Similar lowest pH
• Significant proportion had a metabolic acidosis
• Hospital mortality was 25% (270/1077) for patients receiving
NIV but 39% (86/219) for those with late onset acidosis
• “The audit raises concerns that challenge the respiratory
community to lead appropriate clinical improvements across
the acute sector
Reasons for high mortality rate in
patients transitioned to IMV
• Increased use of
NIPPV in patients
difficult to ventilate?
• Continuation of NIPPV
despite a lack of early
improvement?
Aetiology of NIV failure
A. Failure to adequately ventilate/oxygenate
A. Delayed NIV treatment
B. Inappropriate ventilatory technique
C. Patient’s clinical condition
B. Dependence on non-invasive support
Lack of improvement of acute illness
C. Complications
NIV failure is predicted by:
-
Advanced age
High acuity illness on admission (i.e. SAPS-II >34)
Acute respiratory distress syndrome
Community-acquired pneumonia with or without
sepsis
- Multi-organ system failure
NIV in acute COPD: correlates for success
NIV failure
p=0.019
 Retrospective analysis
 59 episodes of ARF in 47 COPD
patients
• NIV success: 46
• NIV failure: 13
 Predictors for NIV failure:
• Higher PaCO2 at admission
• Worse functional condition
• Reduced treatment compliance
• Pneumonia
60
n=5
40
%
20
n=8
0
Other
Pneumonia
Ambrosino N, Thorax 1995;50:755-7
NIV complications
Complication
Incidence
(%)
Major
Aspiration pneumonia
Haemodinamyc collapse
Barotrauma
<5
Infrequent
Rare
Minor
Noise
CO2 rebreathing
50-10
50-100
Discomfort
Claustrophobia
Nasal skin lesions
30-50
5-20
2-50
Mask selection - a crucial issue!
CO2 rebreathing (50-100%)
Noise (50-100%)
Leak/Discomfort (30-50%)
Claustrophobia (5-20%)
Nasal skin lesions (2-50%)
NIV should not be used in:
• Respiratory arrest
• Inability to tolerate the device, because of
claustrophobia, agitation or uncooperativeness
• Inability to protect the airway, due to swallowing
impairment
• Excessive secretions not sufficiently managed by
clearance techniques
• Recent upper airway surgery
Transition to IMV: when is in the interest
of a patient?
• Hospital mortality: 64% (Schettino, 2008)
• Mortality rate: 30%; prolonged hospitalization
(Chandra, 2011)
• Great hospital mortality (Walkey, 2013)
Transition to IMV
(personal experience, 2011-2013)
Number of subjects
62
Age (mean ± SD) , yrs
Gender (males, females)
65.4±19.3
26, 36
Ineffective NIV, n (%)
Severe hypercapnia
Severe hypoxemia
52 (83.8)
25 (42.4)
21 (35.6)
Dependence on NIV, n (%)
NIV complication, n (%)
8 (13.3)
2 (3.4)
Tracheotomy, n (%)
Outcome , n (%)
Died during hosp
Discharged from hosp
16 (28.8)
41 (66.1)
21 (33.9)
Median survival:
46 days
(95% CI, 43 to 162)
Kaplan-Meier function of overall survival
Mean survival:
NM/CW = 305.58±36.9
COPD = 53.90±7.3
ILD = 31.13±7.8
] p=0.0176
] p<0.0001
Kaplan-Meier function of survival according to
baseline condition
Median survival:
50 = 380.0 d (95%CI, 15.0 to n.c.) ] p=0.0071
>50 = 45.0 d (95%CI,24.0 to 54.0)
Kaplan-Meier function of survival for dichotomus age
(50 and >50)
Remarks
• Mortality rate among patients transitioned to
IMV is very high;
• The outcome of patients with ILD is extremely
poor.
Should IPF/COPD patients be excluded
from IMV after failing a NIV trial?
Use of a novel veno-venous extracorporeal carbon dioxide
removal system as an alternative to endotracheal intubation in a
lung transplant candidate with acute respiratory failure.
Submitted to Respiratory Care
NIV in AECOPD: conclusions
• Confirm and reinforce the routine use of NIV,
however:
• Suggest caution with NIV among patients at high
risk of failure
• The problem of transitioning from NIV to IMV: may
not be in the interest of patients!