NIV in non CPE, non-copd, non-neuromuscular patients

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1 NIV in non CPE, non-copd, non-neuromuscular patients Giorgio Iotti Anestesia e Rianimazione 2 Pavia Italia

2 Missioni ECMOteam Pavia 2009/ Trasporto con ECMO senza ECMO

10 ALI/ARDS

11 Immunocompetent patients Community Acquired Pneumonia

Hypox.ARF Level of evidence No. of patients Physiological improvement Mortality ETI or failure criteria Complications Wysocki et al., Chest Antonelli et al., NEJM Confalonieri et al.

12 Hypox.ARF Level of evidence No. of patients Physiological improvement Mortality ETI or failure criteria Complications Wysocki et al., Chest Antonelli et al., NEJM Confalonieri et al.,ajrrccm Antonelli et al., JAMA Martin et al., AJRCCM Hilbert et al., NEJM Auriant et Al CCM Antonelli et Al CCM Antonelli et Al Int Care Med Carlucci et Al AJRCCM Girault et Al CCM I I I I I I I II II II II Only if 21 vs. 20 PaCO2 > vs. 32 Yes 28 vs. 28 Yes 20 vs. 20 Yes 14 vs. 11 Yes 26 vs. 26 Yes 24 vs 24 Yes 99 Yes na 354 Yes na 15 of 108 Yes 37 of 124 Yes na na na na

, NEJM Auriant et Al CCM Antonelli et Al CCM Antonelli et Al Int Care Med Carlucci et Al AJRCCM Girault et Al CCM I I I I I I I II II II II

13 Randomized Studies Incidence of Sepsis and Pneumonia Severe sepsis s.shock Pneumonia ETI-MV CT NPPV ETI-MV CT NPPV Brochard, NEJM % 5% 17% 5%* Wysocki, Chest 1995 NR NR NR NR Antonelli, NEJM % 19% 25% 3%* Wood, Chest 1998 NR NR 18% 0%* Confalonieri, AJRCCM1999 NR NR 7% 0%* Antonelli, JAMA % 20%* 20% 10% * differences statistically relevant Martin, AJRCCM2000 0% 0% 0% 0% Hilbert, NEJM % 31%* 12% 4%* Ferrer AJRCCM % 16%* 19 15

Antonelli, NEJM 1998 34% 19% 25% 3%* Wood, Chest 1998 NR NR 18% 0%* Confalonieri, AJRCCM1999 NR NR 7% 0%*

14 ARF in Immunocompromized patients

15 When does NIV fail? When does NIV work better?

16 CPE (n=99) Pulm cont (n=72) Inh PN (n=8) Atelect. (n=28) NP (n=18) ARDSp (n=27) CAP (n=38) ARDSexp (n=59) Pulm fibr/pe (n=5) No. of patients percentage of failures N patients % failures 354 consecutive 100 patients with hypoxemic ARF 90 in 7 Centers 80 (Europe and USA): PaO2/FiO2 < 200 breathing O2 (Venturi) RR>30, AC accessory muscles or paradoxical abd. Mot. COPD excluded 86 ARDS (P/F < 200, bil. Pulm.infiltrates, absence of LVF) 108 (30%) failure 264 (70%) success. Antonelli et Al. Intensive Care Med 2001;27:

80 (Europe and USA): 70 60 50 40 30 20 10 0 PaO2/FiO2 < 200 breathing O2 (Venturi) RR>30, AC accessory muscles or paradoxical abd. Mot.

354 consecutive patients with hypoxemic ARF in 7 Centers (Europe and USA): PaO2/FiO2 < 200 breathing O2 (Venturi) RR>30, AC accessory muscles or paradoxical abd.

17 354 consecutive patients with hypoxemic ARF in 7 Centers (Europe and USA): PaO2/FiO2 < 200 breathing O2 (Venturi) RR>30, AC accessory muscles or paradoxical abd. Mot. COPD excluded 86 ARDS (P/F < 200, bil. Pulm.infiltrates, absence of LVF) 108 (30%) failure 264 (70%) success. Antonelli et Al. Intensive Care Med 2001;27:

abd. Mot. COPD excluded 86 ARDS (P/F < 200, bil. Pulm.

18 Rana, Critical Care 2006, 10:R79 (doi: /cc4923)

19 Rana, Critical Care 2006, 10:R79 (doi: /cc4923)

20 NPPV as first line intervention for ARDS PULMONARY INFILTRATES Dyspea, RR > 30/min PaO2/FiO2 < 200 Absence of LVF Survey in 3 European University Hospitals (2 in Italy and 1 in Spain) between March 2002 and April admissions 479(8.2%) ARDS 332(70%) ETI+MV 147(30%) NPPV Exclusion criteria: coma or seizures disorders difficult management of secretions hemodynamic or EKG instability Shock More than 2 organ failures Severe Trauma Antonelli, CCM 2007;35:18-25

21 NPPV as first line intervention for ARDS 147 ARDS Pts 79(54%)successful 74(95%) ICU Survivors 68(46%) Failures 36(52%)Survivors Overall ARDS mortality 40 (27%) patients Antonelli, CCM 2007; 35:18-25

22 PaO2/FiO2 NPPV as first line intervention for ARDS * baseline 1 h discontinuation of NPPV * *P<0.009 Successful Failure Overall ARDS mortality 40 (27%) patients Antonelli, CCM 2007; 35:18-25

23 Time (hours)

24 Antonelli, CCM 2007;35;18-25

25 Timing of NPPV application to treat ARF 1. Early: to prevent intubation 2. Established: as alternative to intubation 3. Resolving: to wean from ventilation 4. Post-extubation: to prevent re-intubation WHEN? Early Established Resolving Post-Extubation

27 1170 screened 855 Ventilated>48hrs Nava S,Gregoretti C et al CCM Considered at risk 25 excluded 97 randomised exclusion criteria (n.16) not randomised (n.6) Refusal (n.2) 48 NIV 49 Standard medical therapy 4 Reintubated 3 deaths 12 Reintubated 2 deaths 3 Deaths 7 Deaths

28 NIV in ARF Several successes, several failures Frequent need for: Nearly continuous application Prolonged application Face mask, the typical interface, frequently is not well tolerated when application is Continuous Prolonged Is face mask a key reason for failures?

30 Failure = Intubation Mask failure: 14/33 Helmet failure: 10/33

31 NIV by helmet (1) Antonelli M Critical Care Med 2002; 30: 602 COPD e ARF ipossiemica, vs maschera Fattibilità, efficacia, miglior tolleranza, applicazione più prolungata, meno complicanze Chiumello D Intensive Care Med 2003; 29: 1671 Simulatore e volontari, vs maschera Minor efficienza meccanica rispetto alla maschera Pelosi P Eur J Emerg Med 2003; 10: 77 ARF ipossiemica Fattibilità, efficacia, meno complicanze

32 NIV by helmet (2) Antonelli M Anesthesiology 2004; 100: 16 COPD scompensata, vs maschera Fattibilità, miglior tolleranza, minor efficienza (CO2) Rocco M Chest 2004; 126: 1508 ARF ipossiemica in immunocompromessi, vs maschera Fattibilità, efficacia, miglior tolleranza, applicazione più prolungata, meno complicanze Piastra M Intensive Care Med 2004; 30: 472 ARF ipossiemica in bambini leucemici (senza controllo) Fattibilità, buona tolleranza, non complicanze

33 NIV by helmet (3) Racca F J Appl Physiol 2005; 99: 1262 Volontari, vs maschera Minore efficienza meccanica Moerer O Chest 2006; 129: 1424 Simulatore attivo, vs maschera, vs PSV invasiva Effetti meccanici complessi, possibilità di sforzi inefficaci Navalesi P Intensive care Med 2007; 33: 74 COPD scompensata, vs maschera Efficacia (scambi gassosi) e buona tolleranza, minor efficienza meccanica e dissincronismi

34 NIV by helmet (4) Conti G Respir Care 2007; 52: 1463 ARF after abdominal surgery, vs. Mask NIV (historical control) Good efficacy, better tolerance, less complications Carron M J Clin Anesth 2007; 19: 632 Case report PNX Patroniti N Intensive Care Med 2007; 33: 153 Healthy volunteers, physiological study Dangers from disconnection Mojoli F Intensive Care Med 2008; 34: 1454 Bench study + patient How to manage CO2 rebreathing

35 NIV by helmet (5) Moerer O Intensive Care Med 2008; 34: 1615 Neural vs. pneumatic trigger & cycling off during helmet NIV in healthy volunteers Better synchrony with neural trigger and cycling off Racca F Anesth Analg 2009; 109: 164 Helmet in 2 patients with neuromuscular disease (Duchenne) and nasal skin breakdown Good efficacy, good tolerance, special settings required (biphasic ventilation needed) Vargas F Crit Care Med 2009; 37: 1921 Mask vs. helmet vs. helmet + special settings Special settings required for helmet Feltracco P Transplant Proc 2009; 41: 1339 Postoperative NIV of lung transplant recipients The preferred interface, also in prone position

36 NIV by helmet (6) Moerer O Critical Care 2009; 13: R85 Helmet with high-flow BiPAP tested on in-vitro model Reduced CO2 rebreathing with high flow Piastra M Intensive Care Med 2009; 35: 1420 Helmet in immunocompromised children with ARDS Feasibility Costa R Intensive Care Med 2010; 36: 1363 Helmet vs. face mak vs. ET-tube in active mannequin and healthy volunteers Helmet was the worst for synchrony; special settings required Isgrò S Intensive Care Medicine 2010; 36: 1688 Helmet BIPAP vs helmet Sigh vs helmet CPAP in acute hypoxemic respiratory failure PaO2 was better with Sigh or BIPAP

37 NIV by helmet The helmet is probably the best interface for patient tolerance and hence for extensive use of NIV in the acute setting The problem is how to make the helmet as efficient as a face mask (see my next lecture)

38 Thank you for your attention and many thanks to my good friends Massimo Antonelli Giorgio Conti Cesare Gregoretti Stefano Nava Paolo Navalesi Francesco Mojoli for discussions, advices and many of the slides I have shown

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