L’organizzazione di una UTIR oggi
Andrea Vianello
S.C. Fisiopatologia Respiratoria
Ospedale-Università di Padova
Non-Invasive
Ventilation
“a form of
ventilatory support
that avoids airway
invasion”
Hill et al Crit Care Med 2007; 35:2402-7
Tipi di IRA trattabili mediante NIV
Diagnosi di IRA
Ostruttiva
Restrittiva
Parenchimale
Cardiogenica
BPCO
Asma
Fibrosi cistica
Ostruzione delle vie aeree superiori
Cifoscoliosi
Malattie neuro-muscolari
Sdr obesità-ipoventilazione
Polmonite
ARDS
Infezioni polmonari
Edema polmonare acuto
Metha & Hill, AJRCCM 2001
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 Intens Care Med 2003; 3:419-25
NIV VS TRATTAMENTO STANDARD
Keenan S et al
NIV VS TRATTAMENTO STANDARD
Keenan S et al
Paziente con riacutizzazione acidotica di BPCO
Terapia medica + O2 q.b. per SpO2 89-92%
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
Paziente con riacutizzazione acidotica di BPCO
Terapia medica + O2 q.b. per SpO2 89-92%
Ripetizione di EGA
pH > 7.35
NIV non indicata
>7.30 pH < 7.35
pH < 7.30
pH < 7.20
NIV consigliata
l’80% dei pazienti migliora comunque con
terapia standard
Ogni 10 pazienti trattati con NIV si evita 1 ETI;
NIV migliora la dispnea
NIV altamente consigliata
Senza NIV 1 paziente su 2 necessita di ETI
NIV migliora la sopravvivenza
NIV altamente consigliata
1 paziente su 2 fallisce NIV
Tuttavia con NIV migliora outcome ospedaliero e
sopravvivenza a 1 anno
Keenan S et al
Keenan S et al
Definition of the three levels of care
European Task Force on Respiratory Intermediate Care Survey
Corrado et al, ERJ 2002;20:1343-50
Flow chart of the management of acute
exacerbations of COPD
Ambrosino et al, ERJ 2008; 31: 874–886
Respiratory
Intensive
Care Unit
 Patients who require, or may soon
require ETI
 More than one organ/system
failure
 Haemodynamic instability
 Patients needing invasive
monitoring
 Severe acidosis
Respiratory
Intermediate
Care Unit
 Patients with life threatening
 High level monitoring
respiratory illness but not likely to
 Patients with a tracheostomy
need ETI in the near future
 Require mask CPAP for RF
 One organ/system system failure
General Ward
 Intubation unlikely, not indicated
 Elective, semi-elective NIV
 pH > 7,30
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
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
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
NIV NELL’IRA IN BPCO
• EBM dell’efficacia della NIV vs il
trattamento standard e vs VM invasiva
• A quale paziente, in quale ambiente, con
che strumenti?
• Fallimento della NIV
Portable ventilator
ICU ventilator
ICU ventilator
Portable
ICU
Mode availability
limited
maximal
Monitoring
limited
expanded
Alarm function
limited
expanded
Handling
simple
complex
Trigger problems
rarely
possible
Oxygen blender
depending
always
CO2 re-breathing
potentially
no
Weight
light
heavy
Costs
less expensive
expensive
Staff
familiarity
is key
Leak
compensation
frequently
to success!
limited
BTS Equipment Recommendations
Staff familiarity is key to success
Interfaces
ATS-ERS position paper:
Standards for COPD. ERJ 2004; 23:932
Punto chiave
Flow-chart for the
use of noninvasive
positive pressure
ventilation (NPPV)
during exacerbation
of COPD
complicated by
acute respiratory
failure.
Management of tracheal intubation in the respiratory
intensive care unit by pulmonary physicians.
A.VIANELLO, G. ARCARO, F. BRACCIONI, F. GALLAN, C. GREGGIO,
A. MARANGONI, C. ORI, M. MINUZZO
Attento monitoraggio e rapido accesso ad ETI in
caso di mancata risposta!
Respir Care 2007; 52:26-30
Problemi legati
all’uso di NIV in acuto
• Fallimento primario:
legato all’operatore
• Fallimento secondario:
legato all’affezione sottostante
Fallimento primario di NIV
• Selezione del paziente
• Scelta della maschera e
settaggio del ventilatore
• Ambiente inadeguato
Totale desincronizzazione durante PSV
cortesia del dott.G. Polese
Un eccesso di supporto
cortesia del dott.G. Polese
Totale desincronizzazione durante PSV (perdite)
cortesia del dott.G. Polese
Fallimento secondario di NIV in acuto
dopo successo iniziale nella COPD
• Fallimento complessivo di NIV 10-20%
• Fallimento tardivo (>48 ore) 5-40%
• Fattori di rischio: basso ADL, comorbidità
mediche, basso pH
• Trattamento con ETI+MV (mortalità
52.6%) o NIV più agggressiva (mortalità
91.6%)
• Complessiva mortalità ospedaliera 67.7%
Moretti at al Thorax 2000;55:819-25
After two hours
Location summary
SITE
Respiratory
WARD
No resp ward
RICU
ICU
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
High enthusiasm, skills,
RT presence
Cough assistance combination,
cost effectiveness
Rapid worsening in Hypox
Monitoring
EI availability
Complexity case mix
Low expertize on NIV and chronic diseases
Costs