Nye resultater med hjemme-niv. PD Dr. med. Thomas Köhnlein Respiratory Medicine (Head of Department: Prof. Dr. Tobias Welte)

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1 Nye resultater med hjemme-niv PD Dr. med. Thomas Köhnlein Respiratory Medicine (Head of Department: Prof. Dr. Tobias Welte)

2 Physiologic targets of ventilation in COPD mechanical pressure support reduces the diaphragmatic muscle workload antagonisation of intrinsic PEEP by extrinsic PEEP

3 Clinical targets of ventilation in COPD reduction of dyspnoea improvement of oxygenation improvement of respiratory acidosis (and hypercapnia) improvement of vigilance normalization of tachypnoea normalization of tachycardia and haemodynamics

4 Long term home ventilation non-invasive in wake patients, who are not 24/24 ventilator dependent. 4 hours of continuous spontaneous breathing should be possible. invasive completely ventilator dependent patients with disturbed reflexes of the upper airways. extreme sputum production transfer possible at any time

5 Long term home ventilation Selection of ventilator type: 1. criterion: invasive or non-invasive ventilation (ventilators must be approved for invasive ventilation). 2. criterion: Availability of a certain ventilator; dependent on health insurance status of the patient. The Respiratory Unit must have experience with the selected ventilator. The patient needs to feel comfortable with the characteristics of the ventilator. Ventilators of different manufacturers may behave different, even when the parameters are set at the same levels.

6 Long term home ventilation Selection of ventilatory mode: 1. criterion: diagnosis of the patient. Pressure controlled ventilation is recommended for patients with COPD, pulmonary emphysema pulmonary fibrosis Volume controlled ventilation is recommended for patients with neuromuscular diseases severe kyphoscoliosis

7 Long-term ventilation Controlled ventilation Cycling of the ventilator is only time dependent. Assisted ventilation Cycling of the ventilator is triggered by the breathing effort of the patient.

8 Long-term ventilation Assisted/Controlled Ventilation (mode of choice for COPD) Setting of a backup frequency at the ventilator. If the patient s own breathing frequency is higher than the backup frequency, the patient is ventilated in assisted mode. If the patient s own breathing frequency drops below the backup frequency, the ventilator switches to controlled mode.

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10 NPPV in severe, stable COPD Casanova C et al. Chest 2000;118: patients with severe, stable COPD (FEV l, FVC 2.12 l, PaO mmhg, PaCO mmhg) Interventions: Controls: standard COPD treatment + LTOT Intervention group: standard COPD treatment + LTOT + NPPV (12 / 4 mbar) Outcome parameter: acute exacerbations hospital admissions endotracheal intubations mortality

11 NPPV in severe, stable COPD Casanova C et al. Chest 2000; 118: p<0.05

12 NPPV in severe, stable COPD Casanova C et al. Chest 2000; 118:

13 NPPV in severe, stable COPD Clini E et al: Eur Resp J 2002;20: multicentre, parallel group, randomized design LTOT vs. LTOT + NIV observation time: 2 years target of ventilation: Reduction of hypercapnia during NPPV by at least 5 % from baseline. 122 subjects randomized, 47 included into analysis (24 LTOT, 23 LTOT + NIV)

14 NPPV in severe, stable COPD Clini E et al: Eur Resp J 2002;20: Results: IPAP 14+3 EPAP 2+1 cmh 2 O NPPV: 9 hours per day improvements in QoL and dyspnoea scores

15 Überleben mit/ohne außerklinischer NIV McEvoy RD et al Thorax 2009;64: McEvoy RD et al Thorax 2009;64:

16 NPPV in COPD - costs Tuggey JM, et al Thorax 2003;58: Retrospective analysis of 13 patients with severe COPD Cost analysis in the year before and after initiation of home NPPV. before after hospitalizations 5 2 days hospitalized days in ICU 25 4 outpatient visits 5 4 Estimate of annual reductions of overall costs: Euro to

17 NPPV after acute on chronic respiratory failure Funk GC et al. Respir Med 2011;105:427e patients after mechanical ventilation. All received home NPPV for 6 months. NPPV was then withdraw in 13.

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19 Impact of long-term NIV on survival Budweiser et al. Int J Clin Pract 2007;61: NIV no NIV

20 Impact of long-term NIV on survival Budweiser et al. Int J Clin Pract 2007;61: NIV no NIV

21 Predictors for survival, and effect of NIV on important markers for prognosis Budweiser et al. Chest 2007;131: patients with advanced stage COPD, follow-up 32 months, all on long-term NIV Predictors for outcome (multivariate analysis): age (p < 0,05) body mass index (p < 0.05) lung overinflation (RV/TLC; p < 0.05) base excess (BE; p < 0.05)

22 Predictors for survival, and effect of NIV on important markers for prognosis Budweiser et al. Chest 2007;131: BMI > 25 BE < 9 mmol/l BMI < 25 BE > 9 mmol/l

23 Predictors for survival, and effect of NIV on important markers for prognosis Budweiser et al. Chest 2007;131: increase in BMI decrease in BMI delta BE 50 % delta BE < 50 %

24 Health related Quality of Life before/after start of long-term NIV Windisch et al. Eur Respir J 2008;32: Severe Respiratory Insufficiency (SRI) Questionnaire

25 Dreher M. et al. Thorax 2010

26 n = 231 Quality of life in hypercapnic patients with long term NIV Budweiser et al. Respiratory Research 2007,8:92

27 Windisch W et al. Pneumologie 2010;64:

28 Non-invasive ventilation in patients with severe chronic obstructive pulmonary disease and lung emphysema (COPD) ClinicalTrials.gov Identifier NCT

29 This study tested the hypothesis, that long-term use of NIV (more than one year) reduces all-cause mortality in patients with moderate or severe COPD and hypercapnia.

30 Primary outcome parameter: all-cause mortality Secondary outcome parameter: blood gases, lung function exercise capacity (6 minute walking test). Dyspnoe-Score during rest and after 6 minutes walking. Quality of life: St. George s Respiratory Questionnaire, SF-36 Questionnaire, Severe Respiratory Insufficiency Questionnaire

31 Inclusion criteria: COPD GOLD stage IV in stable state. PaCO2 above 7 kpa (51,8 mmhg), combined with a ph of 7.35 or above. These gases must be measured after 30 minutes breathing room air in sitting position.

32 group size: 150 patients + x 150 patients + x control group intervention group

33 Target of ventilatory support (intervention group) Reduction of the baseline PaO 2 by at least 20 %, or into the normal range (measured 1 hour after NIV has been stopped).

34 Start of randomization: November 2004 Participating centres: 36 in Germany and Austria Census and end of observation:

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