NIV: dove ventilare il

paziente

Dott Michele Vitacca Divisione Pneumologia Riabilitativae Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)

IDENTIFY PATIENTS (according to location ?)

1. Clinical abnormalities

- moderate to severe dyspnea

- RR > 24 b/min in COPD

- RR > 30 – 35 b/min in AHRF

- accessory muscle use, paradoxal breathing

2. Gas exchange abnormalities

- PaCO2 > 45 mmHg, pH < 7.35

- PaO2/FiO2 < 250 mmHg

Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

Difficult intubation !

Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178

(according to location ?)

The right location

• Model of health care delivery varies markedly– From country to country– Within a country– Within an institution

• Randomised controlled trials performed in one country may not be generalisable to another

• Have a plan from the outset– This may change!

• What is going to happen if the patient fails?– What is reversible?

– Pre morbid quality of life

• Circumstances of failure

Timing is all…

• Start early but not too early (Barbe study)

• You are too late if…• Pt on verge of respiratory arrest• Pt severely hypoxaemic (PaO2/FiO2 < 75)• Pt comatose or hugely agitated• Medically unstable: acute MI, GI bleed, shock

• What is your unit’s ‘door to mask’ time?

• What are the main limitations?Simonds ERS school

Location

ICU RICU/

HDU

WARD ER

Staff number

Safety

Monitoring

Equipment

Familiarity with NIV

The concept of the traffic light

Strategic use of NIV

• Concentrate staff expertise• Training focus for NIV for medical,

nursing and paramedical staff• Concentrate equipment• Facilitate link with ICU• Audit, data collection• Cost savings (?)

Safety first!

• Patient selection• Safe staffing levels• Rolling programme

of staff training and protocols

• Adequate monitoring

• Ability to intubate & transfer pts to ICU

• Suitable alarms

Simonds ERS school

Staffing of resp int care unit( or location with high number of NIV pts)

• Nurse to pt ratio 1:4 (1:6 ?)• Senior Physician on call for 24 hours• Training for nurses and trainee medical

staff• Dedicated physiotherapist• Technical service• Strong links with ICU

Simonds ERS school

Nava et al.Chest 97;111:1631

HUMAN WORKLOAD in RICU

BTS Equipment Recommendations

Staff familiarity is key to success

Monitoring

• Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance

• Pulse oximetry• Continuous display of ECG and non-invasive BP• Arterial blood gases (ABG machine easily accessed)• Continuous non-invasive monitoring of CO2 helpful eg.

Transcutaneous, end-tidal• Duration of NIV use• Ventilatory settings, FiO2, leak• Severity score• Side effects : skin integrity, GI, nasal symptoms• CXR, screening bloods etc.

Simonds ERS school

25% of the respondents use hand restraints in >30% of the patients.Is this the way to solve the problem ?

Some mild sedation may be prescribed

ETMask ETMask

Endotracheal Tube vs MaskComplimentary role

Respiratory failureRespiratory failureEvolving ARFEvolving ARF Resolving Resolving ARFARF

Pre-hospital setting to use CPAP?

Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der

Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim

Respiratory rate + SatO2

before CPAP

during CPAP

Blood pressure and heart rate

before CPAP

during CPAP

Noninvasive ventilation in pre-clinical care Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der

Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim

clincal situation with CPAP:

much improved 51 %improved 40 %unchanged 3 %worse 3 %

with the use of pre-clinical CPAP, intubation was

avoided 59 %not avoided 9 %was not necessary 32 %

Carlucci A. AJRCCM 2001;163:874

Considera la patologia !

Eur Respir J 2005; 25:348-355

100 – 75 % 74 -50 % 49 -25 % 24 -0 %

Percentage of patients who fail NIV

Perchè fallisce la NIV ?

Perchè si sbaglia paziente Perchè non si rispettono le controindicazioniPerchè si sbaglia maschera Perchè si sbaglia modalità di ventilazionePerchè si sbaglia il settaggioPerchè il paziente non supporta più la NIV Perchè non miglioranono i gasPerchè vi è cattiva interazione con il ventilatore

PERCHE ‘ SI SBAGLIA LOCATION !!!!!!

Interface: Facial Masks

Thorax 2011;66:43e48. doi:10.1136/thx.2010.153114

232 H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later.

1077 patients received NIV (11%), 55% had a pH <7.26 30% patients with persisting respiratory acidosis did not receive NIV.

Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis.

Only 4% of patients receiving NIV who died had invasive mechanical ventilation.

POPOLAZIONE DELLO STUDIO

N = 3617 (81%)

VENTILAZIONE INVASIVA

(IV) N= 2656 (73%)

VENTILAZIONE NON INVASIVA

(NIV) N= 961 (27%)

NIV failure

N=309 (32%)

Early NIV success

N=652 (68%)

INTUBAZIONE SI

N=309 (32%)

Late NIV failure INTUBAZIONE NO

N=153 (25%)DESISTENZA TERAPEUTICA

(EOLC)

N = 207 (6%)Cortesia dott. Gristina

Reasons for low use of NIV in acute hospitals: US survey

Physicians lack of experience

Equipment not appropriate

Other Poor previous experience

Hospital staff inadequately trained

Maheshwari v et al Chest 2006:129: 1226-33

0

10

20

No. of responses

Hypercapnic Respiratory Failure

• NPPV is the first attempt of MV in ICU in 63% of Pts

• Success rate is 66%

Carlucci A. AJRCCM 2001;163:874

USE in the “REAL” WORLD of ICUs

From 4% to 14%

Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012

H admissions pts from NIV to EI

NIV

N° pts

deaths

Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012

No support

NIV no EI

EI

NIV and EI

Location summary (1)

SITE Preferred diseases Condition

RespiratoryWARD

COPD, restrictive, Elective, semi-elective NIV, pH >7.30

Ph > 7.25Monitoring

No resp ward COPD, CHF, PE, Aged Ph > 7.30No comatose

Hospice All Palliative, ceiling intrevention

ER PE, COPD, Aged Ph > 7.20paO2/FI02 >150 < 200

RICU All, NMALS, 1 system failure, first

12 hours NIV. Confusion, poor tolerance, labile

bronchospasm, disability with high nursing dependency

Ph > 7.20paO2/FI02 >150 < 200

ICU Pure Ipoxemic, Sedation, Post op ARF, comorbidities, Weaning and NIV, Multi system organ

failure. Haemodynamic instability. Severe confusion. Pre coma

Ph <7.20paO2/FI02<150

Pre H PE High expertize

Location summary (2)

SITE advantages Contra

RespiratoryWARD

More enthusiasm, skills,No aggressive location,

RT presence Cough assistance combination, cost

effectiveness

No sufficient staff Night duty ? Delay in EI

Low monitoring on ventilatorsNo adequate devices

No resp ward cost effectiveness geriatric skills

Beds availability

No sufficient staff Night duty ? Delay in EI

Low monitoring on ventilatorsNo adequate devices

Low case mix Low respiratory skills

ER Early good outcome , triage Low expertize on NIV and chronic diseases

Hospice Advanced plan respectPalliative competence

No adequate devices Low case mix

Low respiratory skills

RICU High enthusiasm, skills,RT presence

Cough assistance combination, cost effectiveness

Rapid worsening in Hypox

ICU Monitoring EI availability

Complexity case mix

Low expertize on NIV and chronic diseasesCosts

Pre H Early good outcome High expertize, Delay in EI

NIV success: staff training and experiance are more important than location