La Ventilazione non-invasiva: questioni aperte.......................

Andrea BelloneUOC di Pronto Soccorso-OBI-Medicina per

AcutiAzienda Ospedaliera Sant'Anna

Como

Ruolo del medico di PS

• 1) Diagnostica differenziale

• 2) Stratificazione del rischio

• 3) Trattamento precoce

Trattamento precoce.......

In PS la VNI è mandatoria in pazienti affetti da BPCO riac e EPAC

Carlucci et al ICM 2003 : pts treated with NIV over 8 yrs

CPAP/Bilevel-PAP

Acute Cardiogeni c Pulmonary Edema

Non-invasive ventilation: four unanswered questions

Non-invasive ventilation: four unanswered questions

1. Bilevel-PAP and AMI2. CPAP versus Bilevel-PAP in

hypercapnic ACPE3. Non-invasive ventilation in DNI and

palliative therapy4. The inhomogeneity of patients according

to the pathophysiology of ACPE

Question (1)Question (1)

Is there a risk of an increased incidence of myocardial infarction during bilevel

PAP?

Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute

pulmonary edema. Critical Care Medicine. 25(4):620-628, April 1997.

Mehta, Sangeeta MD; Jay, Gregory D. MD, PhD; Woolard, Robert H. et al

Conclusions: Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema. The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings.

BiPAP and AMI

A Bellone, A Monari, F Cortellaro et al, 2004,Critical Care Medicine

Conclusions: BiPAP proved to be equally effective in improving vital signs and ventilation without increasing acute myocardial infarction rate

Trial profile (Bellone et al CCM 2004)

BiPAP and AMI

Ferrari G, Olliveri F, De Filippi G et al, 2007,CHEST

Conclusions: the acute myocardial infarction rate was not different with CPAP and IPPV

Question 2

CPAP versus Bilevel PAP in pazients with Hypercapnic

ACPE?

Chadda et al. CCM 2002

Bilevel PAP is more effective than CPAP in unloading respiratory muscle activity

Noninvasive Ventilation in Cardiogenic Pulmonary EdemaA multicentric Randomized trial (AJRCCM 2003)

Stefano Nava, Giorgio Carbone, Nicola DiBattista, Andrea Bellone, Paola Baiardi, Roberto Cosentini, Mauro Marenco,

Fabrizio Giostra, Guido Borasi and Paolo Groff In the subgroup of hypercapnic patients noninvasive pressure support ventilation improved PaCO2 significantly faster and

reduced the intubation rate compared with medical therapy (p= 0.05).

Noninvasive pressure support ventilation vs. continuous positive airway pressure in acute

hypercapnic pulmonary edema Intensive Care Medicine 2004; 31: 807-11

A Bellone, M Vettorello, A Monari, et al

Conclusions: NIPSV proved as effective as CPAP in the treatment of patients with acute pulmonary edema and hypercapnia but did not improve resolution time.

ACPEACPE

Ipercapnia

Aumento carico imposto ai m. ispiratori

iperventilazione

Ipercapnia

Aumento carico imposto ai m. ispiratori

Ridotta Compliance

congestione polmonare

Aumento del carico elastico

Aumento domanda energetica

Non-invasive ventilation as a palliative treatment

(3)Palliative NIV can either be

administered to offer a chance for survival or to alleviate the

symptoms of respiratory distress in dying patients

(Intens Care Medic 2011)

NIV of patients with do-not-intubate orders

DNI patients with diagnoses such as congestive heart failure or COPD have

better prognosis (CCM 2004)

Patients with heart failure and preserved Patients with heart failure and preserved

ejection fraction without valvular disease are ejection fraction without valvular disease are

considered to have considered to have

DIASTOLIC HEART FAILUREDIASTOLIC HEART FAILURE

Patients with heart failure and preserved Patients with heart failure and preserved

ejection fraction without valvular disease are ejection fraction without valvular disease are

considered to have considered to have

DIASTOLIC HEART FAILUREDIASTOLIC HEART FAILURE

Bathia RS. et al NEJM 2006

Among patients presenting with new-onset heart failure, a substantial proportion had an ejection fraction of more than 50%.

The survival of patients with heart failure with preserved ejection fraction was similar to that of patients with reduced ejection fraction.

What is the role of NIV in patients with ACPE due to left ventricular

diastolic dysfunction?

What is the role of NIV in patients with ACPE due to left ventricular

diastolic dysfunction?

QuestionQuestion

Aurigemma, G. P. et al. N Engl J Med 2004;351:1097-1105

Left Ventricular Pressure-Volume Loops in Systolic and Diastolic Dysfunction

What is the role of noninvasive ventilation in diastolic heart

failure? Intensive Care Medicine 2005. R Agarwal, D Gupta

“Caution must be used with CPAP because patients with DHF are sensitive to the right and left ventricular preload reduction and

may develop hypotension or several prerenal azotemia”

The role of CPAP in ACPE with preserved LVSF

(Bellone A, Vettorello M, Etteri M et al, Am J Emerg Medic 2009)

Patients: 36 patients were included in the study (18 affected by DHF and 18 by SHF)

Interventions: All patients underwent a morphologic echocardiographic investigation shortly before CPAP

PatientsPatients

Group A (n=18) Group B (n=18)

Ph 7,26±0,13 7,27±0,09

PaCO2 51±12,5 51,7±10,2

PaO2/FiO2 182,2±34,9 177,9±39,9

SpO2 76±11,4 80,9±9,3

HCO3 21,8±4,1 21,8±3,5

Heart rate 111±15 106±19Respiratory frequency

44±4 41±6

Systolic pressure 195±22 157±38*

Diastolic pressure 102±15 86±18*

The result of the present preliminary study shows that CPAP is equally safe

and effective in patients with CPE due to diastolic and systolic heart

failure

The result of the present preliminary study shows that CPAP is equally safe

and effective in patients with CPE due to diastolic and systolic heart

failure

ConclusionConclusion

CONCLUSIONECONCLUSIONE

LA VENTILAZIONE NON INVASIVA LA VENTILAZIONE NON INVASIVA NEL TRATTAMENTO DELL’EDEMA NEL TRATTAMENTO DELL’EDEMA

POLMONARE ACUTO CARDIOGENO POLMONARE ACUTO CARDIOGENO SECONDARIO A DISFUNZIONE SECONDARIO A DISFUNZIONE

DIASTOLICA è SICURA ed DIASTOLICA è SICURA ed EFFICACEEFFICACE

Frequency of the most important reasons for low utilization rates of NPPV (Chest 2006)