INDICAZIONI ALLA
VENTILAZIONE MECCANICA NON
INVASIVA A LUNGO TERMINE
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INDICAZIONI ALLA VMD
La ventilazione meccanica (VM) è
indicata quando gli sforzi respiratori
spontanei del paziente non sono in
grado di sostenere un’adeguata
ventilazione alveolare.
Selection Guidelines for NIMV in
CRF
Slowly progressive respiratory failure due to:
-NEUROMUSULAR DISEASE
Muscular dystrophies
Postpolio syndrome
Multiple sclerosis
ALS
- THORACIC WALL DEFORMITIES
Kyphoscoliosis
Post-thoracoplasty
- OBSTRUCTIVE SLEEP APNEA
- IDIOPATHIC HYPOVENTILATION
- COPD (efficacy not established)
Meyer and Hill Ann.Intern.Med. 120;1994
THE MAIN OBJECTIVES OF LT-MV ARE:
IMPROVE SURVIVAL
IMPROVE QUALITY OF LIFE
REDUCE THE IMPACT OF DISEASE
(POTENTIALLY) REDUCE COSTS
VMD NON INVASIVA:
applicazione mediante interfaccia
nasale o oro-nasale
VMD INVASIVA:
applicazione mediante interfaccia
tracheostomico
LIFE SUSTAINING:
for ventilator dependent patients
(respiratory autonomy < 8 hrs/day).
Needs back-up ventilation
LIFE SUPPORT:
for partially ventilator dependent
patients (respiratory autonomy > 8 hrs/
day).
Does not need back-up ventilation.
Draft Reviewer Guidance For
Ventilators, July, 1995.
LONG-TERM MECHANICAL VENTILATION
Indications for IMV beyond the ICU
• Uncontrollable airway secretions
• Impaired swallowing
• Persistent symtomatic RF despite NIMV
• Need for >20 hours ventilatory support
• Patient’s willingness
(from ACCP Consensus 1998. Chest 1998;113:289-321S)
Pao
VT
Pes
MODES OF POSITIVE PRESSURE MV
VOLUME-CYCLED MECHANICAL VENTILATION
PRESSURE-CYCLED MECHANICAL VENTILATION
BILEVEL POSITIVE AIRWAY PRESSURE
VENTILATORE
TRIGGER
QUANTITA’ E
TIPOLOGIA DI
FLUSSO
CICLAGGIO
INSP/ESP
PAZIENTE
DRIVE DEL
PAZIENTE
RICHIESTA
VENTILATORIA
CICLO
RESPIRATORIO
ReCV
Onyx
PV102
Harmony
Helià
n° pts
RCWD
best
n° pts
COPD
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Harmony
% OC
worse
10
50
13
12
11
10
9
8
7
6
5
4
3
2
1
0
100
Onyx
% OC
10
50
n° pts
n° pts
n° pts
13
12
11
10
9
8
7
6
5
4
3
2
1
0
13
12
11
10
9
8
7
6
5
4
3
2
1
0
13
12
11
10
9
8
7
6
5
4
3
2
1
0
PV 102
10
50
% OC
100 10
@
Helià
50
% OC
100 10
100
Re CV
50
% OC
100
1. MALATTIE RESTRITTIVE DEL
TORACE
• Patologie neuromuscolari
• Cifoscoliosi
• Postumi di malattie neurologiche e della
gabbia [polio-toracoplastica]
NPPV and Restrictive Thoracic Disorders
Clinical indicators
1. Disease documentation
i. hystory, physical examination, diagnostic tests
ii. appropiate diagnosis
2. Indications for usage
i. symptoms
ii. physiologic criteria
(PaCO2 >45, SatO2 <88% for 5 consecutive min,
MIP <60 cmH2O or FVC <50% prd.)
(ACCP Conference Report. Chest 1999;116:521-534)
Symptoms
Assessment annually
Ambulatory
NO
VC < 1.5 L.
YES
Abnormal diurnal ABG
YES
Assessment 3-6 months
NO
Abnormal nocturnal gas exchange
NO
YES
H.M.V.
LTMV in hypoventilation from RTD
(Metanalysis based on 4 RCTs)
RESULTS
• Reversal of day-time related symptoms
Risk of no improvement -0.417 in favor of LTMV
• Reversal of day-time hypercapnia
Risk of no improvement -0.635 in favor of LTMV
• One-year mortality
Risk of no improvement -0.259 in favor of LTMV
(from Annane D. et al. The Cochrane Library Issue 2. 2000; Oxford)
Thorax 1998
2. MALATTIE DELLE VIE AEREE E
DEL POLMONE
• BPCO
• Fibrosi Cistica
• Bronchiectasie
OLT rappresenta il gold-standard
per il trattamento della BPCO
con IR stabile
NPPV and COPD
Clinical indicators
1. Disease documentation
i. hystory, physical examination, diagnostic tests
ii. appropiate diagnosis (COPD, BK, CF)
2. Indications for usage
i. symptoms
ii. physiologic criteria
(PaCO2 >55, PaCO2 54<50 + SatO2 <88% for 5
consecutive min while on oxygen >2 L/min,
PaCO2 54<50 + recurrent hypercapnic ARFs
(ACCP Conference Report. Chest 1999;116:521-534)
(from Aida A. et al. AJRCCM 1998; 158: 188-193)
Eur Respir J 2002
9
8
*
6
4
Symptoms
Impacts
*
PaCO2 on oxygen
M0
M12
0
-10
M24
-20
20
5
LTOT
NPPV
10
4
3
*
2
1
Activity
Total
10
7
5
Score change from baseline
20
MRC dyspnea
M0
M12
*
NPPV
Cognitive behaviour
Activity
Disability
Others
Total
0
-10
-20
M24
LTOT
LTOT
NPPV
UTILIZZO DELLA VNI A DOMICILIO
La ventilazione meccanica notturna non invasiva con pressione
positiva (NPPV) aggiunta al regime corrente di OLT in pazienti
ipercapnici puo’ determinare:
- stabilizazione della capnia (B)
- riduzione della sintomatologia (B)
- miglioramento della Qualita’ di Vita e dell’outcome clinico (ma
non della sopravvivenza) (B)
TUTTAVIA NON VI E’ EVIDENZA ATTUALE
PER UNA PRESCRIZIONE GENERALIZZATA
HOSPITAL ADMISSIONS
Total hospital admissions
(nr/pt/year)
4
3,5
ICU admissions (nr/pt/year)
2
Follow-back
3
Follow-up
2,5
1,5
1
2
1,5
0,5
1
0,5
0
0
LTOT
NPPV
LTOT
NPPV
DIAGNOSI E PROBABILITA’ DI
SOPRAVVIVENZA
• VMD non INVASIVA
• VMD INVASIVA
from Leger et al. Chest 1994;105:100
probability to continue
NIMV (%)
100
75
50
Kyphoscoliosis
TB sequelae
COPD
Bronchiectasis
Duchenne
25
0
0
6
12
18
months
24
30
36
HOME MECHANICAL VENTILATION (HMTV)
% survival
100
90
80
70
60
50
40
30
20
10
0
Polio (41)
MP (13)
KP (53)
TB (55)
COPD (50)
BR (10)
0
1
2
3
4
5
6
7
8
9
years
From Robert 1983
RACCOMANDAZIONI PER LA VENTILAZIONE
MECCANICA DOMICILIARE
Position paper joitly by AIPO and SIMRI
(Rassegna Patologia Apparato Respiratorio 2003; 18: parte 1 e parte 2)