Congresso Nazionale Interdisciplinare "B ti li i i i tifi ll' ""Buona pratica clinica e ricerca scientifica nell'urgenza-emergenza"

Roma, 2 - 4 Novembre 2011

Il trattamento non invasivoIl trattamento non invasivo dell’insufficienza respiratoria acuta

dal “domicilio al domicilio”: dalla pratica clinica alle evidenze scientifichedalla pratica clinica alle evidenze scientifiche

Quali pazienti ventilare nelle divisioni internistiche e con quale monitoraggio ?

Il ruolo delle Medicine InterneIl ruolo delle Medicine InterneFederico Lari – UO Medicina Interna AUSL BolognaFederico Lari UO Medicina Interna AUSL Bologna

Ospedale di San Giovanni in Persiceto

BACKGROUNDNIMV in ARF

’80 ICUs Avoid ETI

general, respiratory

’90 ED “First Line”

2000 General Respiratory Wards

General Medical Wards

BACKGROUNDNIMV in ARF in general medical wards…

1 - knowledge in the experience2 - in elderly patients with comorbidities that need to be treated2 - in elderly patients with comorbidities that need to be treated

outside the intensive care units3 – COPD Pts3 COPD Pts4 - presence of clinical conditions in which conventional mechanical

ventilation (with oro-tracheal intubation) will lead to frequent complications - worsening of prognosis: cancer patients, immunocompromised ...

5 - ethical issues: DNI patient (do not intubate)

6 - lack of available beds in intensive care units

7 - technological evolution with devices more and more manageable

BACKGROUNDNIMV in ARF: “safe” in the wards!

•Correct selection of Pts: COPD, ACPE

•It’s not an alternative to ETI

•Early application

Staff training: technical motivational•Staff training: technical, motivational

•MonitoringMonitoring

•Organization / LogisticsATS 2000ATS 2000

g gATS 2000ATS 2000

BTS 2002BTS 2002

NIMV in ARF NIMV in ARF in Italian general medical wards…in Italian general medical wards…

NIMV in ARFNIMV in ARF in general medical wards…Which Patients?

H t F ilH t F il 429429Heart Failure, Heart Failure, acute and chronicacute and chronic 429429

COPDCOPD 491491COPD COPD 491491

Cerebrovascular DiseaseCerebrovascular Disease 430430 438438Cerebrovascular Disease Cerebrovascular Disease 430430--438438

PneumoniaPneumonia 482482 485485Pneumonia Pneumonia 482482--485485

ICDICD--99--CMCM

COPD: NPPV vs usual medical care:

2009ETI

Mortality

L ht f h it l tLenght of hospital stay

Lenght of ICU stay

Complication of treatmentComplication of treatment

pH, PaO2

PaCO2 RRPaCO2, RR

symptom

RiacutizzazioniTrattamento delle riacutizzazioni

del paziente ospedalizzato

Valutare la gravità dei sintomi ed i valori di PaO2 e PaCO2, Rx torace, ECGPaCO2, Rx torace, ECG

Somministrare O2 terapia fino a raggiungere SaO2>90% e <96% (pulsossimetria) ed eseguire EGA dopo 30 min

Broncodilatatori:Corticosteroidi orali o e.v.Antibioticoterapia NIMV (PSV+CPAP)

In ogni caso: - valutare nutrizione e bilancio idrico

considerare l’utilizzo di eparina a basso peso molecolare- considerare l utilizzo di eparina a basso peso molecolare- identificare e trattare le possibili comorbidità

(insufficienza di altri organi, aritmie)- monitorare lo stato del paziente

Considerare intervento riabilitativo post acutoConsiderare intervento riabilitativo post-acuto precoce (Evidenza B)

S.Nava 2008

Dec 2009A VAnno VVol 5pp 6-17

(30%)( )(49%)

(7%) (7%)

6 (8%)

10

73

(14%) 4 (5.5%)3 IOT/ICU, 1 +

40%

15 (20 5%)73 15 (20.5%)

Dec 2009A VAnno VVol 5pp 6-17

NIMV and pneumonia

exudate difficult recruitment shock sepsis exudate, difficult recruitment, shock, sepsis…

120 100

N° patients % failures

100

120

8090100

80at

ient

s6070

ailu

res

40

60

No.

of p

a

304050

ntag

e of

fa

20102030

perc

en

0

(n=9

9)

t (n=

72)

N (n

=8)

(n=2

8)

(n=1

8)

p (n

=27)

P (n

=38)

p (n

=59)

E (n

=5) 0

CPE

Pulm

con

t

Inh

PN

Ate

lect

.

NP

AR

DSp

CA

P

AR

DSe

xp

Pulm

fibr

/PE

Antonelli M, et al. Int Care Med 2001

Boussignac CPAP in CAPBoussignac CPAP in CAP

20 Pz consecutivi

IRAPaO2 < 60mmHg, Ventimask FiO2 40PaO2 < 60mmHg, Ventimask FiO2 40--50%50%

P/F<200P/F<200P/F<200P/F<200

FR>25/min, distress respiratorio, p

CAP severa (no BPCO) ATS – BTSCAP severa (no BPCO) ATS BTS

PSI – CURB 65 - SCAPPSI CURB 65 SCAP

Boussignac CPAP in CAPBoussignac CPAP in CAPFallimento CPAP IOT, VM, UTI

6 (33%) 3 (16 5 % 50%)6 (33%), 3 (16.5 % - 50%)

P i t d l i (K ll > 4)•Peggioramento del sensorio (Kelly > 4): 1 Pz

•incapacità di correggereincapacità di correggere il distress respiratorio ( i di f ti ) 4 P(segni di fatica): 4 Pz

P O < 65 FiO ≥ 70% 1 P•PaO2 < 65 mmHg con FiO2 ≥ 70%: 1 Pz

Sleep Disorders (OSAS – CSA)…cause and effect…

COPDCOPD

StrokeStroke

Heart FailureHeart Failure

Myocardial InfarctionMyocardial InfarctionMyocardial InfarctionMyocardial Infarction

High Blood PressureHigh Blood Pressure

Pulmonary HypertensionPulmonary Hypertension

ArrhythmiasArrhythmiasArrhythmiasArrhythmias

Obesity Diabetes Metabolic SyndromeObesity Diabetes Metabolic Syndrome

Chronic Renal FailureChronic Renal Failure

A multidisciplinary strategymultidisciplinary strategy is critical toappropriate evaluation of sleep-related disease and

heightened interaction between specialists in cardiovascular and sleep medicine hold promise for future improved and

integrated patient careintegrated patient care.Because of the emerging evidence of associations between

untreated SDB and cardiovascular disease, the Nationaluntreated SDB and cardiovascular disease, the National Center on Sleep Disorders Research was established…

Sleep Disorders High prevalence in acute stroke

>80 90% OSAS 30 40% CSA CSR>80-90% OSAS – 30-40% CSA-CSR

CPAP Sleep Apneas NIHSSp p

The importance of CHF

•• High social economical and High social economical and High social, economical and High social, economical and epidemiolocial impactepidemiolocial impact

•• Increasing prevalenceIncreasing prevalence•• New New nonnon--pharmacological approach pharmacological approach

non easly availablenon easly availablenon easly availablenon easly available•• MortalityMortalityMortalityMortality•• Quality of lifeQuality of life

F.Lari, Azienda USL di Bologna, Italy

Q yQ y1734 The project for the “SS Salvatore” Building, the first public Hospital in Persiceto

The The importance of Respiratory importance of Respiratory Sl Di d i CHFSl Di d i CHF

UNSleep Disorders in CHFSleep Disorders in CHF ND

1.1. prevalenceprevalence:: 4040--60%60%O CO C C R CHFC R CHF

DE

OSA, CSAOSA, CSA--CSR in CHFCSR in CHFOSA in Healthy Subject 4OSA in Healthy Subject 4--9%9%

RVy jy j

Lofaso Chest 1994, Krachman Chest 1999, Sin AmJRespCritCareMed 1999, Lofaso Chest 1994, Krachman Chest 1999, Sin AmJRespCritCareMed 1999, Escourrou Rev Mal Resp 2000, Rev Neurol 2001, Escourrou Rev Mal Resp 2000, Rev Neurol 2001,

l d b dl d b d

VA

2.2. mortality and morbiditymortality and morbidityOSA CSAOSA CSA CSR in CHFCSR in CHF

LUOSA, CSAOSA, CSA--CSR in CHFCSR in CHF

Greenberg et al J Sleep Res 1995, Hanly AmJRespCritCareMed 1996, Greenberg et al J Sleep Res 1995, Hanly AmJRespCritCareMed 1996, Burgess Respirology 1997, Lanfranchi Circulation 1999, Leite JACC 2003Burgess Respirology 1997, Lanfranchi Circulation 1999, Leite JACC 2003

UE

F.Lari, Azienda USL di Bologna, Italy

ED1920 the surgeon and his co-workers

The “route” of Pt with Heart Failurein Internal Medicine: the role of NIMV

ACPE NIMV in the ward

Sleep Disorders? Sleep Study in the wardS eep so de s Sleep Study in the ward

CHF with OSAS/CSA Discharge with NIMV

Home Treatment NIMV at home

Follow upFollow up

NIMV in general medical ward: gorganization / logistic

i t i li i …sistemi semplici e monitoraggio “povero”…m gg p

Monitoraggio del Pz in NIMVMonitoraggio del Pz in NIMVMonitoraggio del Pz in NIMVMonitoraggio del Pz in NIMV

1 Es m Obi tti : 1. Esame Obiettivo: Score Neurologico (Kelly)

Pattern Respirat ri (FR se ni di fatica)Pattern Respiratorio (FR, segni di fatica)

2 Parametri Clinici Monitor! (SpO2)2. Parametri Clinici Monitor! (SpO2)

3 EGA: 3. EGA: di base, a Pz adattato, a ogni modifica

4. Parametri del ventilatore

…new skills… bedside…

eco

…innovation…

CONCLUSIONNIMV in ARF in general medical wards…

• It’s essential to disseminate knowledge aboutNIMV also in medical departmentsNIMV also in medical departments

• Forms of ARF in patients with particular clinicalfeatures can and should be treated in theseareas home treatment !!!

• It is therefore essential to develop sharedt l ithi h lth i tiprotocols within healthcare organizations,

involving the various professionals in themanagement of these issuesmanagement of these issues

• A multidisciplinary “NIMV-team” is desiderable sothat every patient receives the best treatment iny pthe most appropriate setting

Thanks !!!

The “old” SS Salvatore Hospital in Persiceto