Workshop: Pulmonary rehabilitation and NIV

Transcription

1 Workshop: Pulmonary rehabilitation and NIV Jean-Christian Borel INSERM U 1042, HP2 Laboratory, University Joseph Fourier, Grenoble, France, AGIRadom, Research and Development department, Meylan, France j.borel@agiradom.com Eric Derom Ghent University Hospital Department of Respiratpory Medicine De Pintelaan Gent eric.derom@ugent.be

2 NIV as an adjuvant in rehabilitation Two different contexts NIV during exercise NIV outside exercise (recovery of exercise) Dizzy Gillepsie Le souffle magnifié, IMOTHEP

3 NIV as an adjuvant in rehabilitation Two different contexts NIV during exercise Dizzy Gillepsie

4 Using NIV during Exercise in order to improve rehabilitation outcomes Severity of respiratory disability may affect the outcome of pulmonary rehabilitation. This outcome is associated with the intensity of this training. However, only few severe patients can tolerate sufficient workload. Patients were stratified for disability (dyspnoea) There was no improvement in exercise performance in the severely dyspnoeic patients receiving exercise J. Wedzicha, Eur Resp J :

5 Clinical case: - A 68 year old man, with obesity (BMI = 36.9 kg/m²) was addressed for a rapid progressive respiratory failure with orthopnea. - never smoke - a type 2 diabetes > 30 years (insulino-dependant for 10years) (HbA1C 8.5%); dyslipidemia; hypertension, ischemic cardiomyopathy since At admission (2012), - because of severe orthopnea, supine VC measurement was impossible and sitting VC was declined (VC=1.64L, 49% pred), with a chronic alveolar hypoventilation (PaO2 = 8.8kPa, PaCO2 = 6.5kPa, ph=7.43, HCO3-34 mmol/l). - Sleep oxymetry recording confirmed severe sleep breathing disorders. - Ten years earlier, because of an elevated left diaphragm on the thorax X-ray, a phrenic neuropathy was diagnosed - Vital Capacity of 2.4L (70%pred), worsening in supine position (2.17L; - 10% of prone position), - Maximal static inspiratory pressure (MSIP) = -62cmH 2 O (57%pred) and Twich-Pdi at 62cmH2O. - history of surgery nor trauma existed, a neuromuscular disease was excluded by a referent neurologist, and cerebral, cervical and thoracic MRI excluded abnormality of the phrenic path and confirmed diaphragm integrity.

6 - Although, daytime breath discomfort decreased and blood gases were normalized (PaO2 = 10.23kPa, PaCO2=5.73kPa, ph=7.41, HCO3-26 mmol/l) the patient was still highly limited to exercise, quite housebound March 2013 Pmax= 40W VO2 max= 15mL/min/kg Ve max= 40 L/min Very severe dyspnea (Borg scale), decision of rehabilitation under NIV

7 What s the appropriate mode of NIV during Exercise? What are the appropriate settings? Endurance time under NIV (min) Pressure support 02 April 2013

8 In thoraco-restrictive patients, high level of pressure support (20 cmh 2 O) increases endurance time, compared with unassisted, sham NIV or low pressure support (10 cmh 2 O) Meanadue C et al. Eur Respir J. 2010;36:370-8

9 Endurance time under NIV (min) 09 April 2013 Pressure support Pressure support 02 May 2013

10 In COPD patients, higher pressure support (10 vs 5 cmh2o) increases training intensity and rehabilitation outcomes Van t Hul A. Eur Respir J. 2006;27:65-72

11 IPAP= 22 ± 3 cmh2o EPAP= 3 ± 1cmH2O RR = 19.8 ± 1.7 Ti= 1.1s Dreher M et al. Eur Respir J 2007; 29:

12 Respiratory rate during exercise under NIV 45 FR VL VNI studies (n) RR under NIV (b/ min) Inspiratory time under NIV (sec) min Vant Hull, 2004 BPCO 23 ± 5 0,89 50 Bianchi, 1998 BPCO 30 ± 7 0,83 40 FR, /min VL VNI Highcock, 2003 BPCO 28 ± 6 0,79 Highcock, 2002 CS 33 ± 5 0, Borel, 2008 CS 31 ± 7 min Inspiratory time of less than 1sec!!! (or around) A high speed of «rise time» is needed

13 Set a high speed of «rise time» 20 R=20ml/cmH2O/s C=20ml/cmH2O 20 R=5ml/cmH2O/s C=20ml/cmH2O cmh2o 12 8 cmh2o 10 PTP500: 1.6 cmh2o*s 4 sec PTP500: 3.99 cmh20*s sec Unpublished data JC Borel,

14 How does NIV work during exercice? Decrease in work of breathing could improve peripheral muscle oxygenation during exercise: «Stealing hypothesis» No hemodynamical modification PAV versus Sham (PEP 2 cm H20-AI 5 cm H20) Borghi-Silva A et al. Thorax 2008;63;

15 Decrease in work of breathing could improve peripheral muscle oxygenation during exercise: «Stealing hypothesis» Borghi-Silva A. Respirology , rest 30 rest Local exercise +NIV Local exercise +NIV

16 Decrease in work of breathing could improve peripheral muscle oxygenation during exercise: «Stealing hypothesis» Borghi-Silva A. Respiratory Care (2010) 55,

17 Borel JC et al. Resp Physiol Neurobiol 2009 Variation in Fatigue score (CRDQ) when restrictive patients were trained (10-12 weeks) with or without NIV during exercise 10 * Δ Fatigue after - before(points) With NIV Without NIV With NIV Without NIV Reduced fatigue after rehabilitation program Increased fatigue after rehabilitation program All patients «more severe»

18 Fatigue is a determinant factor in reducing time spent outdoor Baghai-Ravary, R resp med 2009

19 NIV as an adjuvant in rehabilitation Two different contexts NIV outside exercise (recovery from exercise) Le souffle magnifié, IMOTHEP

20 Non-Invasive Ventilation Applied for Recovery from Exercise-Induced Diaphragmatic Fatigue Hypothesis: NIV applied during recovery from exercise should be capable of accelerating recovery from respiratory muscles fatigue and prolonging exercise time during a subsequent exercise compared to recovery during spontaneous breathing.tested in highly-trained subjects Diaphrgam strenght assessed by Twitch Pdi Spontaneous breathing during recovery (30 ) NIV during recovery (30 ) 531±48 sec 514±49 sec 524±96 sec 511±92 sec Kabitz HJ et al. The Open Respiratory Medicine Journal, 2008, 2, 16-21

21 Nocturnal NIV + Diurnal exercise training R Garrod, AJRCCM 2000; 162:

22 Nocturnal NIV + Diurnal exercise training R Carrod, AJRCCM 2000; 162:

23 Nocturnal NIV + Diurnal exercise training R Garrod, AJRCCM 2000; 162:

24 Nocturnal NIV + Diurnal exercise training COPD FEV1 =0.9 L 50% LT-Oxygen Without OSAS Duiverman ML et al. Thorax 2008; 63:

25 Nocturnal NIV + Diurnal exercise training M L Duiverman, P J Wijkstra, Thorax 2009

26 Long term follow-up of patients with nocturnal NIV associated with long term exercise training (2 years) M L Duiverman, et al Respir research 2011

27 Can NIV be used as an adjuvant in rehabilitation? Menadue C. et al, Cochrane Review 2014:Authors conclusions: The small number of included studies with small numbers of participants, as well as the high risk of bias within some of the included studies, limited our ability to draw strong evidence-based conclusions. It is currently unknown whether the demonstrated benefits of NIV during exercise training are clinically worthwhile or cost-effective. NIV usefull during exercise in more severe patients: Weakness of respiratory muscles In patients who benefit from NIV during exercise testing «responders» Patients with fatigue Nocturnal NIV associated with diurnal rehabilitation Two concordant RCTs: Mechanisms unknown but the decrease in fatigue may be a key issue. Intersesting strategy in highly selected patients Try it if you think it may help!