NIV in hypoxemic patients

Transcription

1 NIV in hypoxemic patients Massimo Antonelli, MD Dept. of Intensive Care & Anesthesiology Università Cattolica del Sacro Cuore Rome - Italy

2 Conflict of interest (research grants and consultations): Maquet Covidien Starmed Drager

3 Current Practice of MV in the ICU 554/13,332 (4%) patients admitted to 299 ICUs from 35 countries.

4 Does NPPV improve outcome in hypoxemic ARF? A systematic review. Keenan SP, Crit Care Med (12): RT suggest that pts. with hypoxemic ARF are less likely to require ETI... The effect on mortality is less clear and varies among different populations. As a result, the literature DOES NOT support the routine use of NPPV in all pts. with hypoxemic ARF.

5 NPPV in Acute Hypoxiemic Patients: A difficult task!! ACPE COPD ARF Antonelli M. et al ICM (11): Pelosi P. et al Eur J Emerg Med. 2003; 10(2):79-86

6 NPPV failure increases the risk of death in ALI/ARDS Demoule et al, Intensive Care Med (2006) 32:

7 Physiological Advantages

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9 Putensen, Am J Respir Crit Care Med Vol 164. pp 43 49, 2001

10 Antonelli, NEJM 1998;339: (RCT) Erwan L Her, et AL, AJRCCM 2005; 172:

11 Physiologic Effects of Noninvasive Ventilation during ALI Erwan L Her, et AL, AJRCCM 2005; 172:

12 Clinical Advantages

13 Randomized Studies: Incidence of Sepsis and Pneumonia Ferrer AJRCCM % 16%* Severe sepsis s.shock ETI-MV CT NPPV Pneumonia ETI-MV CT NPPV Brochard, NEJM % 5% 17% 5%* Wysocki, Chest 1995 NR NR NR NR Antonelli, NEJM % 19% 25% 3%* Wood, Chest 1998 NR NR 18% 0%* Confalonieri, AJRCCM1999 NR NR 7% 0%* Antonelli, JAMA % 20%* 20% 10% Martin, AJRCCM2000 0% 0% 0% 0% Hilbert, NEJM % 31%* 12% 4%* * differences statistically relevant

14 Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure: A Randomized Clinical Trial Miquel Ferrer, AJRCCM 2003;168: /51(91%) of the NIV pts had pulmonary infiltrates and 19(37%) true PN or ARDS ICU mortality 18%

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17 Patients (%) NIV in ARDS Esteban, AJRCCM 2008;15;177:

18 PaO2/FiO2 NPPV as first line intervention for ARDS 332(70%) ETI+MV PULMONARY INFILTRATES Exclusion criteria: Dyspea, RR > 30/min coma or seizures disorders PaO2/FiO2 < 200 difficult management of secretions Absence of LVF hemodynamic or EKG instability 5888 admissions 479(8.2%) ARDS Shock More than 2 organ failures Severe Trauma 147 ARDS Pts * 79(54%)successful 5(5%) ICU Deaths baseline 1 h discontinuation of NPPV * *P<0.009 Successful Failure 68(46%) Failures 36(53%) ICU Deaths Overall ARDS mortality 40 (27%) patients Antonelli, CCM 2007; 35(1):18-25

19 Is the volume the real concern? Is the pressure (transpulmoanary pressure) the real concern? Is the mortality the real concern?

20 Ventilator settings in the first week of ALI/ARDS Esteban, AJRCCM 2008;15;177:170-7 ; Antonelli, CCM 2007 Jan;35(1): Tidal volume, ml/kg ABW Higher, median (SD) (n 198) 8 (7, 10) (n 147) 9 (6.11) P Value ns Lower, median (SD) 6 (5, 8) 7 (5, 8) ns PEEP,cm H 2 O Higher, median (IQR) 10 (8, 12) 8 (8, 15) Lower, median (IQR) 5 (0, 8) 5 (4,8) ns Peak pressure, cm H 2 O Higher, median (IQR) 37 (31, 42) 23 (18,28 ) Lower, median (IQR) 22 (22, 28)

21 Outcomes in ALI/ARDS In the real life Esteban, AJRCCM 2008;15;177:170-7 ; Antonelli, CCM 2007 Jan;35(1): (n 198) (n 147/68) P Duration of MV, median (IQR), days Value 8 (5, 15) 2(1,8-2,1) 0.01 Length of stay in the ICU, median (IQR), days 12 (7, 23) 7 (3, 18) 0.01 ICU mortality, n (%) 111 (56) 36 (53) 0.76 Hospital mortality, n (%) 117/185 (63) 38/68(56) 0.36

22 Antonelli, CCM 2007;35(1);18-25

23 Patients with hematological malignancies

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27 RESULTS II NIV Standard RR Treatment p (95% CI) Intubation - no./no.total (%) 12/26 (46) 20/26 (77) ( ) Hematological malignancies 8/15 (53) 14/15 (93) ( ) Immunosuppressor 3/9 (33) 5/9 (56) ( ) AIDS 1/2 (50) 1/2 (50) 0.83 Ventilation (D) Total Ventilation (D) Survivors LoS in the ICU (D) Total LoS in the ICU (D) Survivor Complications- no. (%) 13 (50) 21 (81) 0.02 Complications death 10 (38) 18 (69) 0.03 V.A.P. and/or Sinusitis -no. (%) 3 (12) 9 (35) 0.05 G. Hilbert, N EJM 2001

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29 1302 patients with hematological Malignancies and ARF GiVITI: Italian Observatory on 300 ICUs Data from the last 2 years 274 (21%) NIV 1028 (79%) MV with ETI ICU Deaths 511(49.7%) 147(54%) Successful SAPS II 59 ±17 ICU Deaths 28(19%) 127 (46%) Failure SAPS II 60 ± 14 ICU Deaths 78 (61%) Gristina, Antonelli, et Al, CCM 2011 in press

30 Gristina, Antonelli, et Al, CCM 2011 in press

31 INV. VENT. = 295 inf. NIV SUCC. = 46 inf. NIV FAIL. = 52 inf. 147 (51%) D 123 (84%) 27(52%) D 21 (78%) 38 (13%) D 28(74%) 10 (21%) D 4(40%) 10 (19%) D 7(70%) 12 (26%) D 8 (67%) SEVERE SEPSIS SEPTIC SHOCK Frequency and outcome of severe sepsis and septic shock occurring after ICU admission in the IMV, successful NIMV, and unsuccessful NIMV groups. Gristina, Antonelli, et Al, CCM 2011 in press

32 Gristina, Antonelli, et Al, CCM 2011 in press

33 Trauma Patients

34 Postoperative and Post-trauma modifications of respiratory function Atelectasis Lung volumes reduction CV CRF VT Diaphragmatic Dysfunction Early (<24 h) Dureuil. JAP 86 Warner. Anesthesiology 2000 reversible (D3 - D7) Dureuil. BJA 87 Simonneau ARRD 83

35 Chest 2010;137:74-80 Single-center RCT in a 9 bed ICU PaO2 /FIO2 200 for 8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma.

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37 CPE (n=99) No. of patients Pulm cont (n=72) Inh PN (n=8) Atelect. (n=28) NP (n=18) ARDSp (n=27) CAP (n=38) ARDSexp (n=59) Pulm fibr/pe (n=5) percentage of failures N patients % failures l l 354 consecutive patients with hypoxemic ARF in 7 Centers (Europe and USA): l PaO2/FiO2 < 200 breathing O2 (Venturi) l l RR>30, AC accessory muscles or paradoxical abd. Mot. COPD excluded 86 ARDS (P/F <200, bil. Pulm.infiltrates, 0 0 absence of LVF) l 108 (30%) failure l 264 (70%) success. Antonelli, Intensive Care Med 2001;27:

38 NIV in ARF after surgery

39 2011

40 Prospective study : 2 years 72 patients with postop ARF after abdominal surgery NIV : PSV 14 ± 4 ; PEEP 5 ± 1 cmh20 ; FiO2 50 % Success rate: 67% (48/72) Success (n=48) Surgery time-niv (D) 9 7 Extubation-NIV (h) Mean NIV session (min) Number of sessions/day 8 5 Total NIV duration (D) 3 2 Failed (n=24) p ns ns ns ns ns Conclusion: NIV is feasible in pts with postop ARF after abdominal surgery

41 Prospective study : 2 years 72 patients with postop ARF after abdominal surgery NIV : PSV 14 ± 4 ; PEEP 5 ± 1 cmh20 ; FiO2 50 % Success rate: 67% (48/72) Success (n=48) Surgery time-niv (D) 9 7 Extubation-NIV (h) Mean NIV session (min) Number of sessions/day 8 5 Total NIV duration (D) 3 2 Failed (n=24) p ns ns ns ns ns * * LOS (Days) Succes s * * Mortality (%) Failur e Conclusion: NIV is feasible in pts with postop ARF after abdominal surgery

42 Antonelli, JAMA 2000;283: RCT (P/F < 200, RR 35b/min, Active Contraction of AM or PAM, severe dyspnea) COPD excluded NIV vs Venturi+MT to prevent ETI in 40 pts with hypoxemic ARF, after transplant (L,L,K) 20 Pts NIV, 20 Venturi NIV associated with less ETI (20% vs 70%, P=.05) and sepsis and SS (including VAP) (20% vs 50%, P=0.047) NIV N=20 Standard Treatement N=20 No. of invasive devices/patient, 5 (1) 5 (1).9 mean (sd) Length of stay in ICU in 6 (3) 9 (4).03 survivors, days, mean (sd) Severe Sepsis and septic shock after study entry 4(20%) 10(50%).05 No. of Deaths in ICU 4 (20%) 10 (50%).05 No. of Deaths in Hospital, 7 (35%) 11 (55%).17 P

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44 Conclusions: Despite these limited data and the necessity of new randomized trials, NIV could be considered as a prophylactic and therapeutic tool to improve gas exchange in postoperative patients.

45 (10%) (1%)

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48 Conclusions RCTs and Surveys suggest that NPPV can be attempted as first line intervention for early hypoxemic patients 1-5 Higher Severity score and lack of improvement predict failure 1-2,5,8-9 ALI, Trauma, hematological and post-operative patients are all eligible ARDS must be approached with great caution NPPV failure might be a risk factor for mortality Antonelli, NEJM 1998;339; Antonelli, ICM 2001;27: Hilbert, NEJM 2001; 304(7): Ferrer AJRCCM 2003;168: Antonelli CCM 2007;35(1): McIntyre, CCM 2000;28; Keenan, JAMA 2000;284; Demoule, ICM 2006;32: Demoule, ICM 2006;32:1747

49 21 bed GENERAL ICU HUB for multiple trauma serving a territory of 1,500,000 inhabitants:364 severe trauma/yr 1500 BED HOSPITAL NURSE : PATIENTS RATIO 3 senior staff during day shift, 2 senior 1:2-3 during day shift (7 a.m. to 10 p.m.) staff during night shift 1:3-4 during night shift (10 p.m. to 7 a.m.) Duties: Care of the ICU patients Severe Emergencies in the ED (1200/yr) and Consultations MET Pts ventilated outside the ICU Infec. Dis. Dept Neurology (SLA) Hematology