Concerns and Controversial Issues in NPPV. Concerns and Controversial Issues in Noninvasive Positive Pressure Ventilation

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1 : Common Therapy in Daily Practice Concerns and Controversial Issues in Noninvasive Positive Pressure Ventilation Rongchang Chen Guangzhou Institute of Respiratory Disease as the first choice of mechanical ventilation in AECOPD and CPE (Girou E et al, JAMA 3) Evidence for efficacy of for various Etiology of ARF(Crit Care Med 7) Etiology COPD Asthma Weaning(COPD) CPE Pneumonia ALI/ARDS Immunocompromized Post-operation Refused Intubation Fibro-Bronchoscopy Evidence Strength A C A A C C A B C B Recommendation Recommended Optional Guideline Recommended Optional Optional Recommended Guideline Guideline Guideline Concerns and Controversial Issues in Is there well defined criteria for? Will delay the intubation and affect overall mortality? How should be used properly in daily practice? Criteria of in AECOPD RR 3/min, PaO 5mmHg ph 7.35 ( Brochard N Engl J Med 1995 ) Tachypnea, Dyspnea respiratory acidosis with PaCO > 55 mm Hg and ph<7.35 (Nava S, RESPIR CARE ) 1

2 Moderate to severe dyspnea. Criteria of Mechanical Ventilation in AECOPD Invasive MV ph < 7.35 and PaCO > 5mm Hg) RR> 5 BPM Unable to tolerate NIV or NIV failure Severe dyspnea. RR > 35BPM PaO < mm Hg or PaO/FiO * < mm Hg ph < 7.5 and/or PaCO > mm Hg Respiratory arrest Somnolence, impaired mental status Cardiovascular complications Other complications (GOLD 7) ph (baseline) ph (1hr ) PaCO (baseline) PaCO (1hr ) Changing Criteria of in AECOPD Success 7.31±. 83±17 75± Failure 7.±.7 7.1±. 7.±.9 91±1 95±18 Success 7.1±.8 7.3±. 88±1 77± Failure 7.18± ±.8 99± 1± Carlucci A, et al, Intensive Care Med 3 Potential Roles of in Acute Respiratory Failure Intubation Question Progress Of Disease Early/Mild Respiratory Failure Recovery Severe Respiratory Failure Assisted Weaning * Is necessary in patients with mild respiratory failure due to AECOPD? Management of Underlying Disease in AECOPD Intubation Need Stratified by ph ph<7.3 ph 7.3 Control(n=171).7%(8/3) 1.8%(18/11) (n=171) 7.%(3/3) 3.9%(5/18) P value..15 Are there any criteria to select those patients who need ventilation assistance and avoid over use of in those who don t have hazard of intubation? Question * Is effective in patients with severe respiratory failure due to AECOPD? (Chin Med J, 5 )

3 Mortality of Patients met the Intubation Criteria (ph<7.) Survive (n=3) Intubation Medications (Chin Med J, 5 ) in do not intubate severe hypercapnic AECOPD 1 severe hypercapnic patients (PaCO : 1±1mmHg) Refused intubation Full face mask with bedside close monitoring Success:15/1 (Zhu GF, et al,chinese J Tuber & Respir, 3) in AECOPD Application Criteria are variable Predictors both for potential beneficial candidates and failure demand for further investigation in Weaning of Intubated AECOPD Intubated AECOPD Improved and stable? Non invasive ventilation? if deteriorated Extubation and Follow-up Extubated and Re-ntubation and Mortality Rate for Early Extubation in AECOPD (8h MV, fail T piece trial) IPPV P Weaning at days /5 17/5 N S (88%) (8%) Duration of MV (day) ±.8 ± 11.8 Time staying in ICU(day) ± 5. ± 13.7 Survival rate at days (%) ( Nava S. Ann Intern Med 1998 ) N Engl J Med 35; june1, 3

4 Patients Randomized (n=1) (n=11) Standard Therapy (n=17) Re-intubation (n=55) No intubation (n=59) Re-intubation (n=51) No intubation (n=5) (n=1) (n=7) (n=11) (n=) Question * Is indications or criteria necessary for selection of patients for assisted early extubation, even in AECOPD? Inclusion and Exclusion Criteria cited in a multiple centers study in Mainland China Inclusion 1 Ambulatory before the exacerbation Respiratory Infection as the cause of AECOPD and intubation 3 Respiratory Infection was under controlled after proper antibiotics Stable and no Dyspnea with PSV < 15 cmh O and FiO<. Exclusion Any Contra-indication with Facilitating Early Extubation 1 * 1 ** ** 1 1 * 8 Control Invasive Invasive Invasive Invasive MV MV MV MV Total Total Total Total MV MV MV MV VAP(case) VAP(case) VAP(case) VAP(case) Reintubation Reintubation Reintubation Reintubation ICU ICU ICU ICU Day Day Day Day Mortality Mortality Mortality Mortality as a method of weaning in AECOPD There are some evidence to support the application Appropriate for all patients? Further studies are necessary to elucidate the proper patients selection criteria Concerns and Controversial Issues in Is there well defined criteria for? Will delay the intubation and affect overall mortality? How should be used properly in daily practice?

5 Multivariate analyses of predictors of mortality (Lellouche F, Curr Opin Crit Care 13: ) failure and overall mortality AECOPD and CPE: No increase of mortality Hypoxemic RF Variable among different reports Difficult to determine that higher mortality is due to underlying disorder or delayed intubation by using Criteria for switching to Intubation are crucial Intensive Care Med ; Criteria for switching to Intubation Deteriorating consciousness Inability to clear secretion Intolerance to interface Unstable circulation Deteriorating oxygenation Deteriorating hypercapnia No improvement 1-h after (PaCO <1%, ph<7.3, PaO mmhg or OI<1mmHg) in Critical SARS Initial improvment: 38/39 (97%) (Criteria: SpO %, Dyspnea) Criteria for switching to intubation: OI<1mmHg Avoid Intubation and Discharge: /39(7%) Intubation: 13/39 (33%) Mortality: 3/39(8%) Overall Mortality: 3.% (Guangzhou) Respiratory Care 1997; :3-37 Concerns of in SARS Delayed intubation leading to more difficult intubation and hypoxemia Infection of medical staff Potential Benefits of Assisted Intubation Maintaining oxygen and ventilation during intubation Protecting medical staff from infection 5

6 Concerns and Controversial Issues in Is there well defined criteria for? Will delay the intubation and affect overall mortality? How should be used properly in daily practice? Practical Application of Modes Selection Interface Selection Parameters Setting (Tidal Volume, Inspiratory Pressure, etc. ) Standardized Procedure (Application procedure, time schedule etc) Physiological 1. Response to Different Modes of P A V R E S T P A V %. 8 P A V 5 % P A V % PAV.. Is patient s response to different mode the same? Volume(L) P S V R E S T P S V 1 c m H O P S V 1 c m H O P S V c m H O P e s o ( c m H O ) Esophageal Pressure º ô Î ü ö¹ volume Í ¼ curve Dyspnea Improvement Hypothesis on Mode Selection in PSV PAV 1 PAV PSV Severe Dyspnea and strong effort of breathing Less Dyspnea and mild effort of breathing? Fast increase of inspiratory pressure and flow, such as PSV Slower increase of inspiratory pressure and flow, such as PAV - Marked Deterioration Marked Improvement

7 Dose different interface have the same effect? O n e w a y m a sk C O F lo w V o lu m e Volume Flow.5. In s p ira tio n CO% R e b re a th in g v o lu m e Tim e (S ) Volume C O.5 F lo w Tw o w a y m a s k Vo lu m e. 1.5 Flow In s p ira tio n R e b re a th in g vo lu m e 58 T im e (S ) 8 CO% Re-breathing Volume (ml) 1 8 Re-breathing volume with one way and two ways mask One Way Two Way 7

8 Cross-over Study of One Way and Two Way Masks Reduction of PaCO with different mask 8 COPD with PaCO 9.98 ±. Kpa, IPAP=17. ±. EPAP= PSV=13. ±. One way or two way mask ventilation(1hr) Rest for.5hr Cross-over to another mask (1hr) PaCO Two way * One way Before After Current Parameters Setting in Proper parameters Setting? Patient s tolerance guided Subject to experience of operator and patient s co-operation Alveolar Ventilation PaCO Relation PaCO =.83 x VCO / V A Ventilatory capacity vs demand Normal V A : L/min, PaCO : mmhg Detection of Dead Space and Alveolar Ventilation P A CO NICO (RESPIRONICS,73) V A 8

9 Calculation of Tidal Volume (with target reduction of PaCO :5-1mmHg) PaCO =K VCO /VA VA=VT(1- VD/VT) f Calculated VT={(PaCO )1 (VT1- VD)/(PaCO )}+(VD+Vmask-Vmouth piece) (providing f unchanged) Calculated VT=={(PaCO )1 (VT1- VD)/(PaCO )} f1/f(vd+vmask-vmouth piece) (Modification with change of breathing frequency) The Difference between Measured and Target PaCO (Difference=PaCO (Meassured ) - PaCO (Target )) Difference (mmhg) 5 Vti-Vte<=15ml Stratified with leakage Vti-Vte>15ml Subject Measured and Target PaCO (Within ±3mmHg) Leakage Yes No Total % 15ml % >15ml % Total % Summary Is underused or overused? Strong Evidence only in some Indications, more research is demanded. Will delay the intubation and affect overall mortality? Not in AECOPD, but not clear in hypoxemic Respiratory Failure. Switching criteria from to Intubation is crucial and demands further study. How should be used properly in daily practice? Experience based rather than evidence based, demanding further well designed study. 9

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