Mitteinvasiivne ventilatsioon kiirabi ja EMO praktikas, ehk morfiinivaba kopsuturse ravi
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1 Mitteinvasiivne ventilatsioon kiirabi ja EMO praktikas, ehk morfiinivaba kopsuturse ravi Arkadi Popov Põhja-Eesti Regionaalhaigla reanimobiil
2 A. Bobrov ja tema aparaat
3 Morfiin ja kopsutuse: kas vennad igaveseks? 1. Southern Medical Journal: July Volume 4 - Issue 6 - ppg The Movie: Love & Doves
4 Ägeda südamepuudulikkuse diagnoosimise ja ravi Eesti juhend (2007) morfiinist: Morfiin on näidustatud raske SP-ga hospitaliseeritud patsientidel varajases staadiumis, eriti rahutu ja hingeldava patsiendi korral (näidustus IIb, B) Morfiin põhjustab venodilatatsiooni ja on nõrgatoimeline arteriaalne vasodilataator, samuti langetab ta südame löögisagedust Enamikes uurimustes on morfiini manustatud intravenoosselt boolusena 3 mg kohe peale veenikanüüli paigaldamist Vajadusel manustatakse morfiini korduvalt
5 Morfiin + Kopsuturse = X Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Emerg Med J Apr;25(4): pt. ägeda dekompenseeritud südamepuudulikkuse diagnoosiga Morfiini said (14.1%) Morfiini ei ole saanud (85.9%)
6 Morfiin + Kopsuturse = IRO + SURM? Kopsuturse ravi + Morfiin Kopsuturse ravi - Morfiin P Mehhaaniline ventilatsioon Keskmine aeg (p) haiglas Hospitaliseerimine IROsse SUREMUS
7 Kokkuvõtte: Emerg Med J Apr;25(4):
8 Morfiini kasutamine patsientidel hingamispuudulikkusega EMO-intensiivravisaalis (PERH, 2010) 100; 78% Kopsuturse ilma morfiinita Kopsuturse morfiiniga 9; 7% 12; 9% Pneumoonia ilma morfiinita Pneumoonia morfiiniga 1; 1% 5; 4% 1; 1% KOKH ilma morfiinita KOK morfiiniga
9 Kopsuturse ja morfiin EMOs (NPPV saanud patsiendid, PERH, 2010) Kopsuturse + Morfiin Kopsuturse - Morfiin Muu HP + Morfiin Hospitaliseerimine KIO / IROsse Intubatsiooni vajadus 10/12 (83,3%) 26/69 (37,7%) 2/5 (40%) 0/12 (0%) 5/69 (7,3%) 2/5 (40%) Suremus 4/12 (33,3%) 11/69 (15,9%) 2/5 (40%) Hingamissageduse langus 32,5 21,5 (31,7%) 27,3 23,0 (15,8%) 38,6 29,6 (25,3%) SpO2 tõus 92,6 97,7 (5,2%) 91,4 96,4 (5,2%) 91,2 91,0 (0,2%)
10 ALTERNATIIV?!
11 CPAP põhimõtte
12 Mis on NIV, ehk MITTEINVASIIVNE VENTILATSIOON? Kunstliku ventilatsiooni meetodid, mille teostamisel ei rakendata invasiivseid võtteid hingamisteedes (intubatsioon; trahheostoomia) Mitteinvasiivse ventilatsiooni läbiviimiseks ÄSP korral on kasutusel kaks peamist meetodit: CPAP (continuous positive airway pressure) NIPPV (noninvasive positive pressure ventilation)
13 NIV ajalugu Esimene mitteinvasiivne tank tüüpi ventilaator oli konstrueeritud šoti arsti John Dalziel poolt 1838 aastal Dalziel J. On sleep and apparatus for promoting artificial respiration. Br Assoc Adv Sci 1838; 1: 127 Iron Lung : negatiivse ventilatsiooni põhimõttel töötav agregaat Robert Gregory Henderson, October 12, 1928 at Children's Hospital, Boston
14 Mis on NIV, ehk MITTEINVASIIVNE VENTILATSIOON? CPAP-maski eesmärgiks on püsiva positiivse rõhu tekitamine hingamisteedes, mille tulemusena paraneb funktsionaalne residuaalkapatsiteet ja oksügenisatsioon ning väheneb hingamiseks kulutatav energia NIPPV on keerukam ventilatsiooni metoodika, mille korral lisaks hermeetilisele maskile kasutatakse ventilaatorit inspiiriumi ja ekspiiriumi kontrolliks ning abistamiseks Ägeda südamepuudulikkuse diagnoosimise ja ravi Eesti juhend
15 CPAP vs BiPAP
16 NIV näidustused erakorralises meditsiinis CPAP Äge südamepuudulikkus (kopsuturse) CPAP-PS Kopsuturse KOKH Bronhiaalastma BiPAP KOKHi ägenemine hüperkapniaga Kopsuturse hüperkapniaga Äge ja krooniline hüperkapniline HP rindkere deformatsioonide ja neuromuskulaarsete haiguste korral
17 NPPV (NIV) vastunäidustused Sügav teadvusehäire (GCS < 10) Neurotrauma kõrge ICP ja koljuvigastusega Seisund peale op. GI trakti ülaosal Näopõletus või muu näotrauma Oksendamine või soolesulgus Väljendunud motoorne rahutus Madal köharefleks ja röga retentsioon Lahendamata pneumotooraks
18 Aparatuur CPAP NPPV
19 NIV eelised Vähendab intubatsiooni sagedust Vähendab hingamistööd Hoiab ära alveoolide kollapsi Vähendab lähiperioodi suremust Cohrane Database Syst. Rev 2008
20 ESC 2008: Ägeda ja kroonilise südamepuudulikkuse diagnoosimise ja ravi juhend ESC Guidlines, European Heart Journal (2008) 29,
21 NIV with positive end-expiratory pressure (PEEP) should be considered as early as possible in every patient with acute cardiogenic pulmonary oedema and hypertensive AHF ESC Guidlines, European Heart Journal (2008) 29,
22 Ägeda südamepuudulikkuse käsitluse algoritm haiglaeelses etapis ja EMOs Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Mebazaa A, & al., Crit Care Med Jan;36(1 Suppl):S129-39
23 Uuring 3CPO: NPPV ja suremus CPAP NIPPV Odds Ratio 95% Confidence Intervals P Value 7-Day Mortality 9.6% 9.4% to Day Mortality /Intubati on 11.7% 11.1% to Day Mortality 15.4% 15.4% to
24 Uuring 3CPO: Standardne kopsuturse ravi vs. NPPV Cumulative Survival Non-invasive Ventilation Standard Oxygen Therapy P= Days
25 Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema (Systematic Review and Meta-analysis) Josep Masip, MD and all. JWatch Emergency Med ;2006(314):1.
26 Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema (Systematic Review and Meta-analysis) Josep Masip, MD and all. JWatch Emergency Med ;2006(314):1.
27 Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema (Systematic Review and Meta-analysis) Josep Masip, MD and all. JWatch Emergency Med ;2006(314):1.
28 Patsiendid hingamispuudulikkusega EMO-intensiivravisaalis (PERH, 2010) KOKH; 24; 13% Kopsuturse; 103; 55% Pneumonia; 45; 24% Asthma; 3; 2% Ca pulm; 8; 4% Muu; 3; 2%
29 NPPV rakendamine patsientidel hingamispuudulikkusega EMOs (PERH, 2010) Kopsuturse; 81; 44% Pneumoonia; 21; 11% Ilma NPPV-ta; 72; 39% KOKH; 10; 5% Ca; 1; 0% Trauma; 1; 1%
30 Kopsuturse ja NPPV EMOs (PERH, 2010) Ilma NPPV-ta; 22; 21% Hingamissageduse langus NPPV foonil NPPV; 81; 79% 28,1 SpO2 tõus NPPV foonil 22, ,6 SpO2 enne NPPV Hingamissagedus enne NPPV 96,6 Hingamissagedus pärast NPPV SpO2 pärast NPPV
31 NIVi PLUSSID ja MIINUSED PLUSSID: Kiire ja efektiivne hüpoksia kõrvaldamine Prognoosi parandamine Komfortne transport MIINUSED: Aparatuur Hind? Portatiivsus? Lihtne kasutuses? Personali ettevalmistus Koolitus? Praktika? Kogemus?
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