La Ventilazione non-invasiva: questioni aperte... Andrea Bellone UOC di Pronto Soccorso-OBI-Medicina per Acuti Azienda Ospedaliera Sant'Anna Como

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1 La Ventilazione non-invasiva: questioni aperte... Andrea Bellone UOC di Pronto Soccorso-OBI-Medicina per Acuti Azienda Ospedaliera Sant'Anna Como

2 Ruolo del medico di PS 1) Diagnostica differenziale 2) Stratificazione del rischio 3) Trattamento precoce

3 Trattamento precoce... In PS la VNI è mandatoria in pazienti affetti da BPCO riac e EPAC

4 Carlucci et al ICM 2003 : pts treated with NIV over 8 yrs

5 CPAP/Bilevel-PAP Acute Cardiogeni c Pulmonary Edema

6 Non-invasive ventilation: four unanswered questions 1. Bilevel-PAP and AMI 2. CPAP versus Bilevel-PAP in hypercapnic ACPE 3. Non-invasive ventilation in DNI and palliative therapy 4. The inhomogeneity of patients according to the pathophysiology of ACPE

7 Question (1) Question (1) Is there a risk of an increased incidence of myocardial infarction during bilevel PAP?

8 Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Critical Care Medicine. 25(4): , April Mehta, Sangeeta MD; Jay, Gregory D. MD, PhD; Woolard, Robert H. et al Conclusions: Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema. The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings.

9 BiPAP and AMI A Bellone, A Monari, F Cortellaro et al, 2004,Critical Care Medicine Conclusions: BiPAP proved to be equally effective in improving vital signs and ventilation without increasing acute myocardial infarction rate

10 Trial profile (Bellone et al CCM 2004)

11 BiPAP and AMI Ferrari G, Olliveri F, De Filippi G et al, 2007,CHEST Conclusions: the acute myocardial infarction rate was not different with CPAP and IPPV

12 Question 2 CPAP versus Bilevel PAP in pazients with Hypercapnic ACPE?

13 Chadda et al. CCM 2002 Bilevel PAP is more effective than CPAP in unloading respiratory muscle activity

14 Noninvasive Ventilation in Cardiogenic Pulmonary Edema A multicentric Randomized trial (AJRCCM 2003) Stefano Nava, Giorgio Carbone, Nicola DiBattista, Andrea Bellone, Paola Baiardi, Roberto Cosentini, Mauro Marenco, Fabrizio Giostra, Guido Borasi and Paolo Groff In the subgroup of hypercapnic patients noninvasive pressure support ventilation improved PaCO2 significantly faster and reduced the intubation rate compared with medical therapy (p= 0.05).

15 Noninvasive pressure support ventilation vs. continuous positive airway pressure in acute hypercapnic pulmonary edema Intensive Care Medicine 2004; 31: A Bellone, M Vettorello, A Monari, et al Conclusions: NIPSV proved as effective as CPAP in the treatment of patients with acute pulmonary edema and hypercapnia but did not improve resolution time.

16 ACPE ACPE Aumento domanda energetica iperventilazione Aumento del carico elastico Aumento carico imposto ai m. ispiratori congestione polmonare Ipercapnia Ridotta Compliance Aumento carico imposto ai m. ispiratori Ipercapnia

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18 Non-invasive ventilation as a palliative treatment (3) Palliative NIV can either be administered to offer a chance for survival or to alleviate the symptoms of respiratory distress in dying patients (Intens Care Medic 2011)

19 NIV of patients with do-notintubate orders DNI patients with diagnoses such as congestive heart failure or COPD have better prognosis (CCM 2004)

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22 Patients with heart failure and preserved ejection fraction without valvular disease are considered to have DIASTOLIC HEART FAILURE

23 Bathia RS. et al NEJM 2006 Among patients presenting with new-onset heart failure, a substantial proportion had an ejection fraction of more than 50%. The survival of patients with heart failure with preserved ejection fraction was similar to that of patients with reduced ejection fraction.

24 Question What is the role of NIV in patients with ACPE due to left ventricular diastolic dysfunction?

25 Left Ventricular Pressure-Volume Loops in Systolic and Diastolic Dysfunction Aurigemma, G. P. et al. N Engl J Med 2004;351:

26 What is the role of noninvasive ventilation in diastolic heart failure? Intensive Care Medicine R Agarwal, D Gupta Caution must be used with CPAP because patients with DHF are sensitive to the right and left ventricular preload reduction and may develop hypotension or several prerenal azotemia

27 The role of CPAP in ACPE with preserved LVSF (Bellone A, Vettorello M, Etteri M et al, Am J Emerg Medic 2009) Patients: 36 patients were included in the study (18 affected by DHF and 18 by SHF) Interventions: All patients underwent a morphologic echocardiographic investigation shortly before CPAP

28 Patients Group A (n=18) Group B (n=18) Ph 7,26±0,13 7,27±0,09 PaCO 2 51±12,5 51,7±10,2 PaO2/FiO 2 182,2±34,9 177,9±39,9 SpO 2 76±11,4 80,9±9,3 HCO3 21,8±4,1 21,8±3,5 Heart rate 111±15 106±19 Respiratory 44±4 41±6 frequency Systolic pressure 195±22 157±38* Diastolic pressure 102±15 86±18*

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30 Conclusion The result of the present preliminary study shows that CPAP is equally safe and effective in patients with CPE due to diastolic and systolic heart failure

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32 CONCLUSIONE LA VENTILAZIONE NON INVASIVA NEL TRATTAMENTO DELL EDEMA POLMONARE ACUTO CARDIOGENO SECONDARIO A DISFUNZIONE DIASTOLICA è SICURA ed EFFICACE

33 Frequency of the most important reasons for low utilization rates of NPPV (Chest 2006)

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