Barcelona Devices for severe heart failure NON-INVASIVE VENTILATION Josep Masip MD, PhD, FESC Intensive Care Medicine Department H. Moisès Broggi - Sant Joan Despí. Barcelona Consorci Sanitari Integral Associated Professor of Cardiology University of Barcelona SPAIN NO CONFLICT OF INTEREST
Barcelona Noninvasive ventilation (NIV) Noninvasive refers to the ventilation delivery (NIV) of refers mechanical to the delivery ventilation of positive to the lungs using techniques that do intrathoracic pressure without not require an endotracheal endotracheal airway. intubation. Hillberg RE, Johnson DC. N Engl J Med 1997 Mehta S, Hill NS. Am J Resp Crit Care Med 2001
Barcelona TWO COMPONENTS for NON INVASIVE VENTILATION SOURCE OF AIR - OXYGEN (VENTILATOR) INTERFACE (MASK)
Portable NIV ICU Ventilators Alarms Modalities Displays Leakage compensation Flow regulation
INTERFACES A B C D E F
TOTAL FACE MASKS Barcelona
Barcelona MODALITIES OF NONINVASIVE VENTILATION IN APE Continuous positive airway pressure (CPAP) Pressure support ventilation (NIPSV) Bilevel (BIPAP)
CONTINUOUS POSITIVE AIRWAY PRESSURE CPAP Pressure (cm H 2 O) 20 10 normal CPAP Boussignac PEEP = 10 cm H 2 O 0 Time
PRESSURE SUPPORT VENTILATION NIPSV Pressure (cm H 2 O) 20 10 0 normal PSV Tidal 370 ml Bilevel - BIPAP Tidal 540 ml Tidal 630 ml PEEP = 5 cm H2O Time
Barcelona THE EVIDENCE FOR NIV IN ACUTE PULMONARY EDEMA
CPAP Conventional CPAP
NIPSV ICU No AMI IPAP 20 EPAP 5 V T : 543 ml J. Masip. Lancet 2000
NEED FOR INTUBATION CPAP 1997 NIPSV RR = 0.40 95% CI 0.27-0.58 P<0.0001 RR = 0.48 95% CI 0.30-0.76 P=0.002 RR = 0.43 95% CI 0.32-0.57 P<0.0001 Masip J et al. JAMA. 2005;294:3124-3130
MORTALITY CPAP 1997 NIPSV RR = 0.53 95% CI 0.35-0.81 P=0.003 RR = 0.60 95% CI 0.34-1.05 P=0.07 RR = 0.55 95% CI 0.40-0.78 P=0.0006 Masip J et al. JAMA. 2005;294:3124-3130
CPAP vs NIPSV Death RR = 0.90 95% CI 0.38-2.16 P=0.82 Need to intubate RR = 1.45 95% CI 0.62-3.38 P=0.39 Masip J et al. JAMA. 2005;294:3124-3130
The 3CPO N=1069 distributed in 3 groups : 367 ST, 346 CPAP, 356 NIPPV ph < 7.35
Gray A, NEJM 2008
The 3CPO Gray A, NEJM 2008
The 3CPO Gray A, NEJM 2008
Masip J, Mebazaa A, Filippatos G. N Engl J Med 2008; 359: 2068-9 Different intubation threshold Different populations
The 3CPO 5/15 (33%) studies were performed in ICU Masip J et al. JAMA. 2005;294:3124-3130
The 3CPO BASELINE ph 7.22 PaO2 100 mmhg Pa CO2 57 mmhg Gray A, NEJM 2008
Author ph PaO2 Bersten 7.17 67 mmhg Lin 7.38 70 mmhg Levitt 7.29 100 mmhg Rasanen 7.36 52 mmhg Kelly 89 mmhg Crane 7.19 99 mmhg Park 7.33 49 mmhg Masip 7.25 67 mmhg Some delay in starting the protocol? Pre-hospital treatment?
European Journal of Emergency Medicine 2007, 14:276 279
Acid lactic (mg/dl) Arterial ph Changes in pha, phv and Lactacidemia 30 pha phv Acid lactic 7.5 7.45 25 20 15 7.4 7.35 7.3 7.25 7.2 7.15 7.1 0 60 120 180 240 600 Time after inclusion (min) Masip J. Unpublished data
Gray A, NEJM 2008
INTUBATION CPAP 56% Reduction Bilevel 44% Reduction Cui-Lian Weng. Ann Intern Med. 2010;152:590-600;
MORTALITY CPAP 36% Reduction Bilevel n.s. Cui-Lian Weng. Ann Intern Med. 2010;152:590-600;
CPAP Cui-Lian Weng. Ann Intern Med. 2010;152:590-600;
Barcelona NIV in APE in CLINICAL PRACTICE
Esteban A, et al Evaluation in the use of non-invasive ventilation in the ICU. Proceedings of the American Thoracic Society 2006;3: A472 100 90 80 70 60 50 40 30 20 10 0 Hypercapnic Asthma de novo CPE 1998 2004
EUROPEAN HEART FAILURE SURVEY Adherence to ESC guidelines for AHF in Europe. EHFS-II 410 Patients with Acute Pulmonary Edema Therapy Indication Class EHFS CPAP / NIPPV Acute Pulmonary Edema IIa B 22.4% & Hypoxemia Mechanical - No response to medical IIa C 11.5% Ventilation treatment & CPAP With Intubation - Post cardiac arrest 32
ADHERE Registry Tallman T. Academic Emergency Med 2008; 15: 1 8
Crit Care Med 2005;33:1477-1480
Pre-hospital setting
Number of patients INTUBATION RATE 16 14 12 10 8 6 * * p<0.05 Early CPAP Late CPAP 4 2 0 * Pre-hospital Hospital OVERALL Plaisance et al. Eur Heart J 2007
Number of patients HOSPITAL MORTALITY 8 7 6 5 4 3 2 1 0 * * p=0.05 Early CPAP Late CPAP Plaisance et al. Eur Heart J 2007
CONCLUSIONS in patients with ACPE The use of NIV has increased in the last 20 years and ACPE is currently the second indication for this technique. CPAP and NIPSV are safe techniques that improve the acute respiratory failure faster than conventional oxygen therapy. CPAP is simpler and does not require special equipment or experience. Both techniques reduce the intubation rate, whereas CPAP may reduce hospital mortality, particularly in high-risk ischemic patients. NIV, primarily CPAP, should be used early, on arrival or preferably, in the pre-hospital setting (ambulance).