CASO CLINICO I

• Uomo 64 anni• Forte fumatore• Nessuna terapia specifica• Dispnea da sforzo moderato• Tosse e catarro nei mesi invernali• Mai eseguito alcun accertamento

Giorno I ore 22,15 P.S.

• Tachipnea = 26 a/m

• Dispnea a riposo = 6 Borg

• Edemi declivi

• MV molto ridotto con qualche fischio e sibilo

• PA= 170/95

• FC= 94 b/m

• TC= 36.4°

ACCERTAMENTI

• Rx-torace= ipertrasparenza, ombra cardiaca leggermente ingrandita. Non lesioni p.p.• ECG= P-polmonari in ritmo sinusale• EGA in aria ambiente: pH=7.32 PaCO2= 62.1 mmHg PaO2= 55.5 mmHg• EGA in ossigeno (Venturi 30%) pH=7.32 PaCO2= 64.1 mmHg PaO2= 67.2 mmHg

h. 23,50

Paziente trasferito in Medicina.

Terapia impostata:

• Teofillina 1 fiala ev

• 02 terapia 3 L/m

• Nebulizzazione con salbutamolo x 2/die

• NAC 1 bustina /die

GIORNO II

Dal diario clinico:

“ Condizioni generali stazionarie, prosegue terapia in atto”

Si prescrive ossigenoterapia al bisogno

GIORNO III h.13,15

• Dispnea importante post-prandiale Borg 6

• Cianosi (messo 02 terapia= AL BISOGNO)

• Frequenza Respiratoria= 28

• Fischi e sibili diffusi + segni di ipersecrezione bronchiale.

• Emogasanalisi in 02 (4 L/m)

pH=7.28

PaCO2= 66.1 mmHg

PaO2= 59.2 mmHg

h. 14,30

Terapia impostata:

• Teofillina 1 fiala ev x 3/die

• 02 terapia 3 L/m CONTINUA

• Nebulizzazione con salbutamolo x 3/die

• Metilprednisolone 40 mg ev

• NAC 1 bustina /die

• Amoxicillina + ac.Clavulanico

• Furosemide 1 fiala ev

GIORNO IV

Dal diario clinico:

“ Condizioni generali stazionarie, prosegue terapia in atto”

GIORNO IVh. 18,20

• Paziente estremamente dispnoico ed agitato• Sensorio leggermente obnubilato• Frequenza respiratoria > 35• Respiro alternante• Emogasanalisi arteriosa in O2 (4 L/m) pH=7.18 PaCO2= 96.1 mmHg PaO2= 60.2 mmHg

PROVVEDIMENTO TERAPEUTICO

Chiamato l’Anestesista Rianimatore

UN PASSO INDIETRO

GIORNO I

pH=7.32 PaCO2= 64.1 mmHg PaO2= 67.2 mmHg

QUALCHE ALTRA POSSIBILITA’ in REPARTO ?

YONIV Study - pH

7.29

7.3

7.31

7.32

7.33

7.34

7.35

0 1hr 4hr

ConventionalNIV

Difference at 1 & 4hrs p <0.001 for both groupsNIV v conventional - difference p=0.02 at 1 hr

NIMV in the MEDICAL WARD

Plant PK

UN ALTRO PASSO INDIETRO

GIORNO III

pH=7.28

PaCO2= 66.1 mmHg

PaO2= 59.2 mmHg

QUALCHE ALTRA POSSIBILITA’ ?

Authors pH PaC02

Meduri,1989 7.2382.5

Elliott, 1990 7.32 65,0

Brochard,1990 7.3168,0

Meduri,1991 7.2775.3

Pennock,1991 7.3849.2

Foglio,1992 7.3373.5

Benhamou,1992 7.2869.5

Bott,1993 7.3561.5

Fernandez,1993 7.2768.0

Wysocki,1993 7.2869.2

Vitacca,1993 7.2783.0

Confalonieri,1994 7.3066.9

Servera,1995 7.3075.0

Brochard,1995 7.2867.0

Kramer,1995 7.2780.9

Meduri,1996 7.2870.5

Confalonieri,1996 7.2972.3

Vitacca,1996 7.2883.0

Nava,1997 7.2188.2

Hilbert,1997 7.2974.5

mean 7.2872.3

WARD, ICU or RICU ?WARD, ICU or RICU ?

ICU ( 8 studies)

pH=7.25 PaC02=72.5 mmHg

RICU (5 studies)

pH=7.24 PaC02=75.5 mmHg

WARD (8 studies)

pH=7.31 PaC02=62.5 mmHg

0

10

20

30

40

50

Rat

e o

f o

f D

eath

(%

)

Bott Brochard Kramer Barbè Plant

* **

RATE OF DEATH

SMT

NIMV

Multicenter Survey on NIV

42 ICUs

1337 pts admitted to ICU

689 pts on mechanical ventilation

108 NIV(16%)

581 ETI(84%)

56 success(53%)

52 premature stop(47%)

43 ETI(39%) Carlucci A. AJRCCM 2001;163:874

Hypercapnic Respiratory Failure(n=100)

29%21%

50%ETI outside

ETI in ICU

NIV in ICU

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

• Success rate is 64%

36% SAMU

28% ER

36% Other

Carlucci A. AJRCCM 2001;163:874

0

10

20

30

Total HypercapnicRF

HypoxemicRF

Pulmonaryedema

ETI

NIV

INCIDENCE OF NOSOCOMIAL INCIDENCE OF NOSOCOMIAL PNEUMONIAPNEUMONIA

Pat

ien

ts (

%)

*

*

Trends for mortality in an ICU Trends for mortality in an ICU for COPD and CPEfor COPD and CPE

Ventilated patients deceased in the ICUVentilated patients deceased in the ICU

NIV patientsNIV patients

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

19941994 (n=41)(n=41)

19951995 (n=54)(n=54)

19961996 (n=66)(n=66)

19971997 (n=62)(n=62)

19981998 (n=69)(n=69)

19991999 (n=56)(n=56)

YearYear

%%

p<0.0001p<0.0001

p=0.028p=0.02824%24% 7%7%

Girou et al. 2002Girou et al. 2002

Where NIMV in COPD ?Medical Ward:

• To prevent “overt” ARF (pH>7.30<7.35)

RICU:• To treat severe ARF (pH<7.30) if:

- hemodynamic stability - PaO2/FiO2 > 1.5 - no sepsis - Minimal spontaneous capacity - Normal sensorium ICU: - PaO2/FiO2< 1.5 - > 1 organ failure

DUE PASSI INDIETRO

GIORNO IV

pH=7.18

PaCO2= 96.1 mmHg

PaO2= 60.2 mmHg

E’ PROPRIO NECESSARIO

INTUBARE QUESTO PAZIENTE ?

NIV(n=64)

ETI+MV(n=64)

p Value

Matching Criteria

Age, mean, yr 69 (6) 70 (5) .51

FEV 1% of predicted 35 (7) 34 (6) .62

SAPS II, score 35 (7) 35 (6) .95

pH before ventilation7.18

(0.05)7.18

(0.06).91

Characteristics

PaCO2 before ventilation, mmHg 104 (14)

100 (13) .06

HCO3 before ventilation 39 (4) 38 (4) .07

Outcomes

ICU mortality, no. (%) 5 (8) 11 (17) .14

Post-ICU hospital mortality, no. (%) 6 (9) 5 (8) .74

Duration of ventilation, mean (SD), days

10 (8) 12 (3) .39

ICU stay, mean (SD), days 13 (8) 15 (3) .43

Patients with serious complications, no.(%)

24 (37) 40 (62) .012Navalesi et al. ERJ 2001

HOW to SET NIMV 1. Explain the technique to the patient 2. Choose the mask

3. Set Pressures (i.e PS ~8 cmH2O and CPAP 2) 4. Hold the mask manually 5. Start gentle mask fitting 6. Avoid excessive tight fit

7. Set FiO2

8. Set alarms 9. Ask the patients about his/her feelings 10.Re-set Pressures (PS to achieve Vtexp>6ml/Kg)