2.Nakos - NivARF Athens,Larissa

8/3/2019 2.Nakos - NivARF Athens,Larissa

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(ALI/ARDS)


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NIV usually refers to the provision ofinspiratorypressure support + PEEP via a mask or helmet

(without intubation)

Although CPAP does not actively assist inspirationand is not a ventilatory support mode, it is considered

a form ofNIV


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1. NIMV vs Standard treatment

2. NIMV first line treatment (vs IMV?)

NIMV in ALI/ARDS


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NIMV vs Oxygen Mask (standard approach)

RationalWork of

breathing

reduced ~60%,

The settings that minimize WOB

are not the setting that maximize

patient comfort

Breathing

pattern

Increase VT , decrease frequency

Mechanics Increase lung compliance

Decrease intrinsic PEEP

Cardiovascular

function

In healthy and COPD, reduced CO

In ARDS no effect on CO

In heart failure, increase CO

Gas exchange Increase PaO2 , decrease PCO2

LHer E, et al. Physiologic effects of

noninvasive ventilation during ALI.

Am J Respir Crit Care Med 2005;172:1112-8.


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19

10

24

8

0

10

20

30

IncidenceofPneumonia(%)

All Hypercapnic RF

ETI

NIV

Incidence ofNosocomial Pneumonia


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Indication &recommendations


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Review: NIV in acute respiratory failure, The Lancet2009;374:25059


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Lancet2009;374:25059


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H1N1?


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Concise Definitive Review- Crit Care Med 2007; 35:2402

aA, multiple RCTs and meta-analyses; B, more than one RCT, case control series, or cohort studies; C, case

series or conflicting data; b recommended,first choice for ventilatory support in selected patients; Guideline,

can be used in appropriate patients but careful monitoring advised; Option, suitable for a very carefully

selected and monitored minority of patients.


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N

IMV

ALI/ARDS ;

O

;

:

NIMV

ALI/ARDS; ;


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RCTs focused on ALI/ARDS exclusivelydo not exist


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Hypoxic Respiratory Failure

in Immunocompromised Patients.


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Respiratory Failure in Immunocompromised Patients.

RCTs in recipients of solid-organ, bone-marrowtransplants and AIDS who developed hypoxemicrespiratory failure have found

decreased intubation

shorter ICU lengths of stay andDecreased ICU mortality rates with NIV

The reduced mortality is likely related to reduced

infectious complications associated with NIV usecompared with endotracheal intubation, includingVAP, other nosocomial infections, and septic shock

Antonelli et al JAMA 2000; 283:235

Hilbert G, et al:N Engl J Med2001; 344: 481


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NIMV vs Standard treatment

Hilbert G, et al:N Engl J Med2001; 344: 481


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NIV is recommended as first choice treatment


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Pneumonia.

Pneumonia has been a challenge to treat non invasively and has been

identified as a risk factor for NIV failure.

An RCT on patients with severe community-acquired pneumonia

showed that NIV reduced intubation rates, ICU length of stay, and 2-

month mortality rate,but only in the subgroup with underlying

COPD.

Two thirds of patients with severe community-acquired pneumonia

required intubation after being started on NIV in one cohort study.


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In conclusion, we found that NIMV reduces the need for intubation in

severe ARF with the possible exception of pneumonia.


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Antonelli M, et al. Intensive Care Med 2001; 27:17181728.


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Intensive Care Med (2006) 32:17561765


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Am J Respir Crit Care Med Vol 168. pp 14381444, 2003


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The small number of studies and patients, and the inconsistency of

those studies results preclude a recommendation for NIV in

immunocompetent patients with severe community-acquired

pneumonia


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Crit Care Med 2007;35:24022407


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Acute Lung Injury/Acute Respiratory Distress Syndrome.

Studies on NIV to treat ALI /ARDS have reported

failure rates ranging from 50% to 80% , but no

RCTs have focused on ALI/ARDS exclusively.


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Antonelli M, et al. Intensive Care Med 2001; 27:17181728.


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!


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Variants of Pulmonary Edema

Hydrostatic PE :

(Cardiogenic, Flash)

High Permeability PE:

(ARDS)

Non edematus RDS Unclear or Mixed cause PE:

(Pulmonary embolism, High altitude PE, Re-expantion, Neurological, Postical, Tocolysis )

Rapid resolving non-HPE:(Neurogenic PE, Heroin-induced PE, Metabolicacidosis, CPR, Inhalational injury)


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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 168 2003

Patients with severe AHRF, defined as PaO2persistently less than 60 mm

Hg while breathing conventional Venturi oxygen at a maximal

concentration (50%), were considered eligible for the study

Patients were randomly allocated either to the NIV or the control group:

In the noninvasive ventilation group, patients were ventilated using the

bilevel positive airway pressure mode. FiO2 was set to achieve a PaO2 ofmore than 65 mm Hg.

In the control group, patients received oxygen using high concentration

sources. The FiO2 was set to achieve PaO2 of more than 65 mm Hg.


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In conclusion, except in patients with ARDS, the use of

NIV is effective to reduce intubation in patients with severe

AHRF.


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Critical Care Vol 10 No 3

Observational cohort study at the two intensive

care units of a tertiary center,

Consecutive patients with ALI were initially

treated with NIPPV.

ALI:PO2/FiO2


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70,3 %


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Key messages

Hemodynamic instability and shock are majorcontraindications to non-invasive ventilation in

patients with ALI.

Metabolic acidosis and severe hypoxemia are

associated with failure of non-invasive ventilationin patients with ALI.

Carefully selected patients with ALI are successfully

treated with non-invasive ventilation and their

outcome isbetter than predicted

by initial severityof illness.


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Crit Care Med 2007; 35:1825

ARDS: PO2/FiO2


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479 ARDS/332 already intubated

147 eligible forNPPV

79 avoided intubation68 required intubation


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In conclusion it is suggested avoiding NPPV inARDS patients with SAPS II > 34 because of the

high mortality observed in those who were

eventually intubated (56%).

In patients with SAPS < 34, those with a PaO2/FIO2

> 175 after 1 hr ofNPPV will likely benefit from

continuation ofNPPV

Irrespective of SAPS II or PaO2/FIO2 after 1 hr of

NPPV, avoidance of intubation was associated with

significant reduction in mortality


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NIV weaning

ALI/ARDS;


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Noninvasive Ventilation during Persistent Weaning Failure

A Randomized Controlled TrialMiquel Ferrer at al Am J Respir Crit Care Med Vol 168. pp 14381444, 2003

To assess the efficacy of noninvasive ventilation (NIV) inpatients with persistent weaning failure, we conducted aprospective, randomized, controlled trial in 43 mechanicallyventilated patients who had failed a weaning trial for 3

consecutive days. This trial was stopped after a planned interim analysis.

The conventional weaning approach was an independent riskfactor of decreased ICU and 90-day survival

0.


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Noninvasive Ventilation during Persistent Weaning Failure

A Randomized Controlled TrialMiquel Ferrer at al Am J Respir Crit Care Med Vol 168. pp 14381444, 2003


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Methods

CPAP vs Bilevel ventilation :

Bilevel except CPO

PC vs PS

PS ?

PC or PS vs PAV

PAV?


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Chevrolet and co-workers characterised non-invasive

ventilation as excessively demanding on personnel time.

Chest1991; 100:77582.

Staffing

Keenan and colleagues evaluated the health economics for severe

acute exacerbations of COPD with a theoretical model that used a

decision-tree analysis constructed from a meta-analysis ofrandomised trials. They concluded that non-invasive ventilation was

very cost-eff ective.

Cost

Crit Care Med2000; 28:2094

102.

ALI/ARDS ?


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Helmet and mask


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Noninvasive continuous positive airway pressure delivered by helmet in

hematological malignancy patients with hypoxemic acute respiratory failure


Helmet vs mask


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A practical clinical message is that the

physician should set higher levels of PEEP

and pressure support to reduce inspiratory

muscle effort closer to that with the face

mask.

Although the patient tolerates the helmetbetter, it needs careful clinical monitoring and

setting.

Classify ARDS Type, Severity, & Co-Morbidities


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Classify ARDS Type, Severity, & Co Morbidities

Adequate ABGs & Tolerance?

Stable and Alert

Continue Non-Invasive

Ventilation

Yes

Extubate and/orDiscontinue Ventilation

Yes

Continue Supine 45-900Reposition Frequently

NoReady for Ventilator

Discontinuation?

High Severity or Obtunded?

Non-Invasive Ventilation No

No

Intubate and Minimize EffortYes

Estimate Intravascular

Volume Status

Repair Volume Deficit or Excess

Establish Adequate BP

Determine Recruitment Potential WithRecruiting Maneuver & PEEP Trial

Adjust PEEP and Tidal Volume

Adequate Improvement?

Proning Contraindicated?

NoYes

Yes

INO,TGI,Flo-Lan, ILA

Significant Clinical Improvement?

No

YesProne Positioning for

12-20 Hours/Day

No


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Multi-organ dysfunction, more than 2 organs,SAPs II>34

Inability to cooperate or to protect the airway

Shock, severe hypoxemia or acidosis.

High Severity ALI/ARDS

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2.Nakos - NivARF Athens,Larissa