Wolfram Windisch Lung Center Cologne University of Witten/Herdecke, Germany

Transcription

1 Wolfram Windisch Lung Center Cologne University of Witten/Herdecke, Germany

2 Non-invasive positive pressure ventilation (NPPV) used in patients with chronic hypercapnic respiratory failure that arises from COPD is aimed at improving Hypercapnia (physiological outcome) Symptoms and quality of life (subjective outcome) Long-term survival (objective outcome)

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4 CO 2 : Extrapulmonary vasodilatation Reduction in precapillary tone Distal movement of the filtration equilibrium point in the capillaries I have morning headache I see Increased extravasation and loss of plasma volume; thus, effective circulating volume is reduced Stimulation of the sympathetic nervous system and the renin-angiotensin-aldosterone system Kidney response: sodium retention and intravascular volume restoration Maintenance of hypercapnia: Peripheral edema Leeuw PW. et al. Eur Respir J 2003; 22(suppl.) 46:33-44

5 Hypercapnic edema in COPD - Aggravation caused by diuretics - airways hypercapnia - Hypoventilation - metabolic compensation: renal bicarbonate retention limbs edema circulus vitiosus loop diuretics respiratory compensation: hypoventilation metabolic alkalosis

6 % Continuing NIPPV N = 172 Poliomyelitis Tuberculosis Neuromuscular Kyphoscoliosis COPD 0 Bronchiectasis Years Simonds AK. et al. Thorax 1995; 50:

7 Wijkstra PJ. et al. Chest 2003; 124:

8 1 year follow-up 2 years follow-up NPPV + LTOT vs. LTOT alone IPAP (cmh 2 O) EPAP (cmh 2 O) ΔPaCO 2 (mmhg) Survival Casanaova et al. Clini et al NPPV: +0.4 LTOT: NPPV: -1.0 LTOT: +0.5 No benefit (1 year) No benefit (2 years) Casanova C. et al. Chest 2000; 118: Clini E. et al. Eur Respir J 2002; 20:

9 McEvoy RD. et al. Thorax 2009; 64:

10 mean adherence to NIV: 4.5 ± 3.2 hours McEvoy RD. et al. Thorax 2009; 64:

11 McEvoy RD. et al. Thorax 2009; 64:

12 Wolfram Windisch Windisch W. Breathe 2011; 8:

13 At present, there is insufficient evidence to support the application of routine NIPPV in patients with stable COPD. However, higher IPAP levels, better compliance and higher baseline PaCO 2 seem to improve PaCO 2. Struik FM et al. Respir Med 2014; 108:

14 Wolfram Windisch Windisch W. Breathe 2011; 8:

15 Wolfram Windisch Windisch W. Breathe 2011; 8:

16 High-intensity NPPV N = 73 Windisch W. et al. Int J Med Sci 2009; 6:72-76 Improvements blood gases breathing pattern lung function anemia, polyglobulia quality of life dyspnea exercise capacity Windisch W. et al. Respir Med 2002; 96: Windisch W. et al. Respir Med 2005; 99: Windisch W. et al. Chest 2005; 128: Windisch W. et al. Respir Physiol Neurobiol 2006; 150: Windisch W. Eur Respir J 2008; 32: Windisch W. et al. Int J Med Sci 2009; 6:72-76

17 N = 34 NPPV (asspcv): IPAP 28 ±6 mbar; bf 21 ±3 /min 2-year survival: 86% Windisch W. et al. Chest 2005; 128:

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20 MRC = Medical Research Council: Oxygen 15 hours/day (MRC O 2 ) versus control (MRC controls) NOTT = Nocturnal Oxygen Therapy Trial: Continuous oxygen (COT) versus Nocturnal oxygen (NOT) Stoller JK. et al. Chest 2010; 138:

21 Mortality risk Dubois P. et al. Chest 1994; 105:

22 Lukácsovitis J. et al. Eur Respir J 2012; 39:

23 Lukácsovitis J. et al. Eur Respir J 2012; 39:

24 n = 20 mean ± standard deviation Age (years) 63.9 ± 10.2 BMI (kg/m 2 ) 28.7 ± 8.0 prior NPPV-initiation after 12 weeks of NPPV p- value HbA1c (%) 45.9 ± ± Smokers (n) 16 Pack years 37.1 ± 24.1 Trop. T (pg/ml) (0.005 / 0.027) (0.006 / 0.023) FEV 1 / FVC (%) 43.1 ± 11.7 FEV 1 (%pred.) 31.4 ± 17.1 TLC (%pred.) ± 30.0 RV (%pred.) ± 92.0 probnp (pg/ml) 91 (47 / 930) 75 (27 / 245) probnp mean (pg/ml) 865 ± ± 489 PAI-1 (ng/ml) 46.1 ± ± Triglyceride (md/dl) (84.5 / 125) 97.5 (74.5 / 127) Cholesterin (mg/dl) ± ± difference in PaCO 2 over time asspcv mean min / max IPAP (mbar) / 30 EPAP (mbar) / 11 bf (/min) / difference in BNP over time Dreher M. et al. Eur Respir J 2013; Suppl. Congress abstracts

25 Severe Respiratory Insufficiency Questionnaire SRI Respiratory Complaints RC Social Functioning SF SRI Well-Being WB German English French Spanish Dutch Swedish Norwegian Polish (Greek) Japanese Danish Physical Functioning PF Attendant Symptoms and Sleep AS Summary Scale SS Social Relationships SR Windisch W. et al. J Clin Epidemiol 2003; 56: Windisch W. et al. Intensive Care Med 2003; 29: Windisch W. et al. J Clin Epidemiol 2008; 61: Anxieties AX

26 CCQ CRQ MRF-28 SRI Struik FM. et al. J Clin Epidemiol 2013; 66:

27 N = 137 COPD Restrictive thoracic diseases Obesity- Hypoventilations-Syndrome Neuromuscular disorders Miscellaneous Windisch W. Eur Respir J 2008; 32:

28 SRI-Summary Scale (SRI-SS) IPAP/EPAP (mbar) 20/3 19/4 25/1 Changes in SRI-SS independent from the underlying disease MANOVA; F=0,62; P=0,65. P < T0 T1 T12 COPD RTD NMD P < neuromuscular P < COPD restrictive thoracic Windisch W. Eur Respir J 2008; 32:

29 high: 29 cmh 2 O; controlled ventilation low: 15 cmh 2 O; assisted ventilation Primary outcome: Nocturnal PaCO 2 Mean treatment effect: -9.2 mmhg 95%CI [-13.7, -4.6 mmhg]; P<0.001 No period effect: P=0.96 No carry over effect: P=0.87 Compliance (daily use): Mean treatment effect: 3.6 hours 95%CI [0.6, 6.7 hours]; P=0.024 Dyspnea (BDS) QoL (SRI-SS) FEV 1 (L) Lowintensity Highintensity Dreher M. et al. Thorax 2010, 65:

30 Mean IPAP: high: 29 cmh 2 O; low:14 cmh 2 O Dreher M. et al. Chest 2011; 140:

31 Is long-term NIV capable of improving long-term survival in COPD patients with chronic hypercapnic respiratory failure? NIV aimed at reducing PaCO 2 by > 20% or at achieving normocapnia 195 patients randomized Köhnlein T. et al. Lancet Respir Med 2014; 2:

32 Ventilator Setting - adherence: IPAP/EPAP: 21.6±4.7 / 4.8±1.6 mbar Respiratory rate: 16.1±3.6 (range 2 24) min patients with respiratory rate 14 min -1 Mean NPPV-usage: 5.9±3.1 hours per day Köhnlein T. et al. Lancet Respir Med 2014; 2:

33 Köhnlein T. et al. Lancet Respir Med 2014; 2:

34 1-year-mortality 33% 12% Köhnlein T. et al. Lancet Respir Med 2014; 2:

35 Windisch W. et al. Pneumologie 2010, 64:

36 5 cmh 2 O 15/5 cmh 2 O Cheung APS. et al. Int J Tuberc Lung Dis 2010; 14:

37 6-min-walking distance after 3 months 20/5 cmh 2 O N = 13 N = 13 Funk GC. et al. Respir Med 2011; 105:

38 event = readmission for respiratory cause or death = primary endpoint Struik FM et al. et al. Thorax 2014; 69:

39 Struik FM et al. et al. Thorax 2014; 69:

40 Following ARF CRF Windisch W. et al. Pneumologie 2010, 64:

41 Thank you very much!