Learning Objectives 1. Indications versus contra-indications 2. CPAP versus NiVS 3. Clinical evidence
Pre-hospital Non-invasive vventilatory support Marc Gillis, MD Imelda Bonheiden
Our goal out there 1. Identify the environment 2. Identify the patients distress state 3. Can you buy some therapeutic time? 4. Play & stay versus play & run? 5. Do we have the skills to go all the way? 6. Can we avoid a ETT? 7. Do nt get messy! 8. Threat or comfort?
Respiratory failure? Type Problem pathology I O 2 ARDS Pneumonia CHF II CO 2 COPD Asthma
First things first O 2? FiO 2 :0,3>>1,0%? Is there a response? Oxygenation Index.
Ventilation perfusion mismatch (V/Q) Ex.: Pulmonary embolus Other Causes of V/Q problems?
The physiologic effects of keeping the lung open 1.Work of breathing (WOB) 2. Breathing pattern Dyspnoe Respiratory rate Inspiratory effort (60%) & off loading the diaphragm 3. Respiratory system Mechanics Dynamic lung compliance 4. Cardio vascular function Left venticular afterload 5. Pulmonary gas exchange PaO 2 & PaCO 2
High-flow Oxygen systems: a.the NASAL CANULA
Physiological effects Cause Effect 1. Wash out of anatomical dead space 1. RR but PCO 2 Vt remain constant 2. MV 2. PEEP effect 1. Paw 2. Closed mouth: 1 cm H 2 O every 10l/ 3. Lungvolume & Alveolar recruitment 3. FiO 2 delivery constant SPO 2 4. Humidification 1. Less mucociliary damage 2. Better comfort
Practical? YES 1. Initially: neonatal medicine- NARDS 2. Recently: better oxygenation in adults 3. Heated & humidified gas at flows up to 60l/ NO Pre-hospital (complex) In Acute hypoxaemic Failure 1. Not beneficial 2. Delaying ETT 3. Unnessesary work load for nurses
b. Continuous Positive Airway Pressure (CPAP)
It s all about
What happens in CPAP: One Pressure(c) >> High flow up to 250l/ FRC Alveolar recruitment PaO 2 WOB ITP Preload Alveolar splinting
Practical?
Alternative?
When to use Acute heart failure Left cor decompensation Acute cardiogenic lungedema Asthma Cardiale *Near drowning * Acute hypoxia
When to hold back Severe pneumonia with thick sputa Non-cooperative/ anxious Semi-conscious state COPD excacerbation Children.?
Pressure support systems: Bi level Positive Airway Pressure (BPAP)
What happens in BPAP? Two pressures Pressure support! IPAP & EPAP S/T mode: + back up rate (timed) S mode: only spontaneous PaO 2 PaCO 2
CPAP versus BPAP (1)
CPAP versus BPAP (2) CPAP High flow +PEEP Alveolar recruitment Corrects V/Q Ex: CHF : CPAP > BPAP > Standard care BPAP I push behind breath + PEEP Tv & CO 2 Augments spontaneous breath Ex: COPD: BPAP > standard care
ARDS,CHF COPD,Asthma
My ex favorite: The Boussignac Vylife: 3 in 1 CPAP/NIV2P/AV)
Non-invasive ventilation in a pre- and in-hospital setting J. Van der Mullen 1 - M. Gillis 2 BESEDIM JAN 2017 Materials and methods In this prospective observational study Vylife Boussignac was evaluated in pre- and inhospital setting between November 2013 and May 2016. Strict in- and exclusion criteria were put in place. The primary outcome was the combination of increased of peripheral O2 saturation to 92% or more, hemodynamic stability (minimal mean arterial pressure of 60 mm Hg) and an improved arterial blood gas (po2 min 65 mm Hg without further increase of pco2 and lactate concentration). Secondary outcome was defined as no need for further sedation, intubation and mechanical ventilation. Discussion & Conclusion Our study results correspond with those of previous studies. With this NIV-system, 52 patients (80%) were spared of further sedation, intubation and mechanical ventilation. For those patients who needed further treatment, the apnea-mode of the NIV-system allowed easy conversion to mechanical ventilation. The tested NIV-system was very efficient and allowed to obtain good results similar to the bigger, closed circuit systems.
What about NP?
And in case of Cardiac Arrest? What if. You keep the lung open? You don t ventilate Applying O 2 by mask supraglottic device ETT Sufficient CO 2 elimination
Known devices The Boussignac CPR tube revisited?
Scientifical recognition: An integration in the 2015 international recommendations Adult Advanced Life Support Section 42
The use of the LUCAS and the Boussignac tube in the pre-hospital setting Clinical observational study 48 patients in CA Applying BLS-AED ERC and after the LUCAS device and in most cases (n=38) the Boussignac tube Patients is transported to the ED and to the cathlab if necessary Gillis et al, ERC Congress 2008, Poster 219
The Bcard cpr device
CPAP b-card 45
Same concept than Boussignac CPR Tube Virtual valve 15 L/min
COMPRESSION BREATHING OUT 47 RELAXATION BREATHING IN
b-card Functionning First point: 15 L/min 6 cm H2O static P in Upper Airways Second point: Chest Compressions Intra-thoracic Δ P - 7 à + 20 cm H2O Improve venous return Improve heamodynamic No alveolar collapsus improve gas exchange
BLS CIO 1 - Connect the B-CARD to the face mask, the O2 and the manometer 2- Put the B-CARD mask on the face in impermeable manner with 2 hands. Put 2 knees on the ground and maintain the head in extension position - Observe the oscillations of the pressures on the manometer, to check the airflow during CPR Initial pressure in static (without CC) Maximal pressure in compression Minimal pressure in relaxation
The main objective of this study was to compare the volume of gas insufflated in the stomach with continuous external chest compressions versus standard-cpr. The secondary objective was to compare upper airway pressures (intra-tracheal and intramask) generated during continuous oxygen insufflation. Results: Standard CPR during 6 min. induces average of 5400 ml gas insufflated in stomach versus 221 ml with continuous insufflation device. ml with Pressure in upper airway with b-card is measured less than 10 cm H2O. 50
51
Don t stop the flow! Continuous Chest Compressions 100/ min
All thank s to