Acute NIV in COPD and what happens next. Dr Rachael Evans PhD Associate Professor, Respiratory Medicine, Glenfield Hospital

Transcription

1 Acute NIV in COPD and what happens next Dr Rachael Evans PhD Associate Professor, Respiratory Medicine, Glenfield Hospital

2 Content Scenarios Evidence based medicine for the first 24 hrs Who should we refer to ICU? NIV guidelines refresh (Type II RF BTS 2016) Discharge Home ventilation

3 Why is this group of patients important? Not uncommon Inpatient mortality consistently around 30% (one of the highest mortality figures in acute medicine) Good care can lower mortality (trial evidence) Co-existing pneumonia very common NCEPOD report awaited due this year Shameless Plug: If anyone wants a project 3 years of data showing a reduction in our mortality - improvements to NIV and the pneumonia service please contact me!! re66@le.ac.uk

4 Patient scenario 66 yr old lady known smoker retired receptionist Possible history of COPD has a Ventolin inhaler Unwell for a couple of weeks with SOB and cough Much more SOB last 24 hrs Deteriorated in the ambulance despite nebulisers GCS 8/15, EWS 8 ph 7.11, CO , O 2 10, HCO 3 28, BE 5 on FiO2 35% What will you do next?

5 Next steps Needs ICU assessment assuming no serious co-morbidity and prior good functional assessment CAOS study

6 Need for ICU How good are we at estimating prognosis for patients with COPD requiring ICU care? CAOS study BMJ 2007 Admitting doctor estimated survival on ICU, to hospital discharge and at 180 days

7 ICU Further data from CAOS

8 Severity scoring system

9 Patient scenario 76 yr old lady known smoker retired receptionist Known severe COPD (hospital letter on ICE) Unwell for a couple of weeks with SOB and cough Much more SOB last 24 hrs attends with son 4 admissions in 3 months Previous DNAR palliative care discussions about hospital care patient not keen on further NIV GCS 7/15, EWS 4, agitated ph 7.15, CO , O 2 8, HCO 3 28, BE 5 on FiO What will you do next?

10 Discuss with relatives What if patient preference unknown? NIV might help? For what gain? Maybe prolonging the inevitable No prolonged period at home In this case clear prior directive from patient Not for NIV Palliative Sounds easy but always remember just because you can do something doesn t mean you should

11 Patient scenario 66 yr old lady known smoker retired receptionist Unwell for a couple of weeks with SOB and cough Much more SOB last 24 hrs Deteriorated in the ambulance GCS 15/15, EWS 4 ph 7.30, CO 2 7.5, O 2 9, HCO 3 28, BE 5 on FiO What will you do next?

12 Next steps Medical management for an hour (controlled oxygen) IV aminophylline?

13 Evidence Meta-analysis negative BMJ RCT pragmatic study in Liverpool (non-acidaemic patients) No difference between groups in inpatient mortality, need for ICU, LOS However, treatment group had increased rates of nausea, vomiting and arrhythmias Thorax Sep;60(9):713-7

14 Same scenario after 1 hr of medical management Feels worse, looks worse EWS 6 ph 7.25, CO 2 8.5, O 2 8.0, HCO 3 30, BE 7 What to do next?

15 Starting NIV What do you do?

16 Starting NIV What do you do? What must you remember?

17 NICE COPD guidelines recommend that NIV should be available in all hospitals that admit COPD Bilevel Positive Airway Pressure (BiPAP) most commonly used

18 When is acute NIV indicated? Acute Exacerbation of COPD Respiratory Acidosis (ph < 7.35, PaCO 2 >6 kpa) Despite full medical treatment Controlled oxygen therapy for an hour

19 NIV Increased Tidal Volumes Decreased Work of Breathing Decreased Respiratory Rate

20 Benefit of NIV NIV reduced LOS by 3 days NNT 8 for mortality 5 for intubation Cochrane Review BMJ Jan 25; 326:185.

21 NIV will typically avoid 6 deaths and 3-9 ICU admissions per year associated cost reduction of per year

22 Escalation Decisions Ideally made at the time of NIV set up Discussed with patient and/or family

23 Set up

24 Complications Rabec et al Thorax 2010

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26 Monitoring physiological and clinical parameters continuous pulse oximetry cardiac monitor if HR >120 frequent monitoring (hourly for the first 12 hrs) ABG at 1 hr (and 1 hr after any subsequent change in settings) then 4 hrs (unless sooner) decision re ITU within 4 hrs (Consultant) patient comfort and compliance is key mask fit skin condition, leak

27 Duration first 24 hrs if working to wear it as much as possible until acute cause resolves (2-3 days) if successful in first 24 hrs (symptoms improved, ph>7.35 and RR normalised) then start weaning

28 Weaning

29 Patient weaned What next?

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31 What happens next?

32 Why might home NIV be beneficial Mechanical Respiratory muscle weakness x Hyperinflation/Increased work of breathing Sleep disordered breathing Obesity Outcomes maybe different? Symptoms/HRQOL Cardiac Improve fluid balance/rostral shift/cardiac status? Survival But might reduce preload, increase tachycardia etc. Infection Alter airway microbiome? Airway inflammation? Exacerbations

33 Home NIV in stable Type II RF RCT ITT n=74 Home NIV +LTOT vs LTOT Excluded AHI>10/hr Primary outcome CO2 2 year follow up pco 2 Breathing Oxygen Mean IPAP 14 (3) No change in survival

34 RCT LTOT vs LTOT + Domiciliary NIV Australian multicentre study COPD Stable hypercapnia Patients with OSA AHI > 20/hr or BMI > 40 were excluded N=142 randomised All on LTOT Primary endpoint - survival Underpowered Health-related quality of life was worse with NIV Mean IPAP 13 (12.5 to 13.4) cmh 2 0

35 Stable disease Primary outcome all cause mortality Recruitment started 2004 N=195 Randomised to NIV or UC PCO 2 >7kPA 4/52 stable disease BMI<35 NIV targeted to reduce PCO 2 by 20% or <6.5 kpa HR 0.24 Mean IPAP 25 cmh2o

36 What about home NIV after an acute episode of NIV

37 What are the challenges? Extremely heterogeneous group Type II RF corrects in some Frequent exacerbators (i.e intermittent type IIRF) Diagnosis can be a challenge: obese,?sdb,?copd, pneumonia (47%), CCF, Cor Pulmonale (the nebs/pred/diuretic/abx group ) Different causes of exacerbation Different co-morbid diseases

38 Last decade of studies. N=75??????????????

39 Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study. 201 COPD patients admitted to hospital with ARF and prolonged hypercapnia >48 h after termination of ventilatory support were randomised to NIV or standard treatment. 1 year after discharge, 65% versus 64% of patients (NIV vs UC) were readmitted to hospital for respiratory causes or had died; time to event was not different (p=0.85). Daytime PaCO 2 was significantly improved in NIV versus standard treatment (PaCO2 0.5 kpa (95% CI 0.04 to 0.90, p=0.03)) HRQL showed a trend p=0.054, in favour of NIV. Number of exacerbations, lung function, mood state, daily activity levels or dyspnoea was not significantly different. Struik Thorax Sep;69(9):826-34

40 Research next steps Treatable traits ERJ 2016 Characterise patients with acute type II RF and COPD Obesity, SDB, fluid retention, heart failure, cardiac disease, exacerbations Understand the potential mechanisms of benefit/harm Role of fluid retention/rostral shift, impaired pre-load, microbiome Understand timing of decision (discharge vs 48hrs vs 2-6 weeks) Large multicentre/multinational studies with carefully characterised participants Explore patient view (compliance etc) Use of Pulmonary Rehabilitation as a facilitator

41 Summary Remember indications when and how for acute NIV New guidelines 2016 Consider ICU referral more often Local protocol/guidance/on going audit/educated team Once the patient is going home remember check list Unwell group high rate of admissions what do they want in future? Ensure respiratory follow up (locally please refer to me in the advanced COPD clinic) After 3 admissions with acute NIV for home NIV refer to home ventilation team (locally Prof Morgan and Prof Steiner)