VAP in COPD patients. Ignacio Martin-Loeches. St James s University Hospital. Trinity Centre for Health Sciences. Dublin Ireland.

Transcription

1 VAP in COPD patients Ignacio Martin-Loeches St James s University Hospital. Trinity Centre for Health Sciences. Dublin Ireland.

2 Outline Pathophysiology Is enough information? COPD trends in ICU How do we manage MV in COPD VAP in COPD vs. COPD in VAP Aetiology Summary

3 Risk factors for VAP in COPD patients. Rouzé et al Curr Opin Crit Care 2014

4 Risk factors for VAP in COPD patients. Gursel et al Respiration 2005 Hadda V et al Lung India 2014 Rouzé et al Curr Opin Crit Care 2014

5 Risk factors for VAP in COPD patients. Liang BM et al Lung Rouzé et al Curr Opin Crit Care 2014

6 Risk factors for VAP in COPD patients. Herzog R et al. Curr Drug Targets 2011 Rouzé et al Curr Opin Crit Care 2014

7 How important is COPD as a risk factor?

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9 Mortality trends in chronic obstructive pulmonary disease in Europe, : a joinpoint regression analysis López Campos et al Lancet Respir Med

10 Trends in hospital admissions for acute exacerbation of COPD Miguel Dıez et al. Respiratory Medicine 2013

11 Trends in hospital admissions for acute exacerbation of COPD Lykkegaard et al. Respiratory Medicine (2012)

12 Trends in hospital admissions for acute exacerbation of COPD Lykkegaard et al. Respiratory Medicine (2012)

13 Trends in use and impact on outcome of empiric antibiotic therapy and non invasive ventilation in COPD patients with acute exacerbation Ouanes et al. Ann. Intensive Care 2015

14 Trends in use and impact on outcome of empiric antibiotic therapy and non invasive ventilation in COPD patients with acute exacerbation NIMV MV MV NIMV Ouanes et al. Ann. Intensive Care 2015

15 In weaning of COPD patients from ventilation, we suggest using non invasive ventilation to reduce length of invasive mechanical ventilation, incidence of HAP, morbidity and mortality. GRADE 2+, STRONG AGREEMENT Effect of NIMV weaning on VAP Leone et al. Anaesthesia Critical Care & Pain Medicine 2017 Peng et al. Medicine 2016

16 In weaning of COPD patients from ventilation, we suggest using non invasive ventilation to reduce length of invasive mechanical ventilation, incidence of HAP, morbidity and mortality. GRADE 2+, STRONG AGREEMENT Leone et al. Anaesthesia Critical Care & Pain Medicine 2017 Peng et al. Medicine(Baltimore) 2016

17 In weaning of COPD patients from ventilation, we suggest using non invasive ventilation to reduce length of invasive mechanical ventilation, incidence of HAP, morbidity and mortality. GRADE 2+, STRONG AGREEMENT Peng et al. Medicine(Baltimore) 2016

18 Prospective observational study Mixed ICU 3 year period. Mechanical ventilation for >48 Microbiologically confirmed VAP.

19 Nseir et al. Respiratory Medicine 2011

20 Nseir et al. Respiratory Medicine 2011

21 The end of the spectrum of the disease

22 Limitation ICU Lobo et al. Chest 2017

23 Insult/ Infection Pathogen Susceptibility Site/ Time Sistemic Predisposition Age Sex Genetics Comorbidities Response Biomarkers SIRS Shock Hypoxemia Organ Disfunction ARDS ARF Cardiovascular SOFA

24 Approach to Ventilator associated Pneumonia Based on the PIRO System Martin Loeches I et al. Annual Update in Intensive Care and Emergency Medicine 2011

25 HOW TO ASSESS SEVERITY OF VAP EPISODE? APACHE 24 Comorbidities Shock Bacteremia Organ Dysfunction All above

26 VAP PIRO PIRO Score P COPD 1 point I Bacteremia 1 point R Systolic BP<90mmHg* 1 point O ARDS 1 point Comorbidities: COPD, Immunocompromise, CHF, Chronic Renal Failure, Chronic Hepatopathy * Or need of vasopressor drugs to maintain blood pressure Total Score 2 points Interpretation 0 1 point Low risk (1 in 8) ICU mortality 2 points High risk (1 in 2) ICU mortality 3 4 points Very high risk (4 in 5) ICU mortality

27 VAP PIRO PREDICTED MORTALITY p<0.001 Mortality (%) Lisboa T et al, Chest 2008

28 20% of MV > COPD VAP INCIDECE 20% in COPD & NON COPD Early VAP 30% in COPD & NON COPD

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32 Pathogens by country Koulenti,Martin Loeches,Rello,CCM.2009

33 Aetiology ICU AP Rinaudo et al. Chest 2016

34 Nseir et al. Respiratory Medicine 2011

35 Aetiology Europe Koulenti et al. EJCIMD 2017

36 Pacientes % Ufc > 10 4 Ufc <

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39 Type III cytotoxin secretions (ExoU and ExoS) and type III secretion facilitator protein (PcrV) Zhuo et al. Crit Care Med 2008

40 McDunn et al. Plos 2008

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42 Nseir et al. Respiratory Medicine 2011

43 * P = * P = * * P = P = * P = * * P = P < Martin Loeches et al. Submitted.

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45 Martin loeches et al. LRM 2016 Dallas et al. 2011

46 SUMMARY COPD is decreasing but coming worse to Hospital and ICU COPD poor characterized when admitted to ICU GOLD IV makes a true difference Should they be admitted? Similar VAP incidence to general population Unique aetiology P aeruginosa and NFGNB more common in EO VAP Aspergillus sp role? COPD (If VAP) is a risk factor for mortality

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