OSSIGENO TERAPIA E IPOSSIEMIA: STRUMENTI E

METODICHE DI TRATTAMENTO

Antonio Corrado

UNITA’ DI TERAPIA INTENSIVA PNEUMOLOGICA E FISIOPATOLOGIA

TORACICA AOU CAREGGI –FIRENZE

Milano, 25.05.2015

INSUFFICIENZA RESPIRATORIA

Turba del metabolismo cellulare secondaria a ridotto apporto di ossigeno ai tessuti per alterazione di una o più tappe del processo della respirazione

SISTEMA RESPIRATORIO

• Polmoni organo deputato allo scambio dei gas • Pompa ventilatoria (parete toracica, muscoli

respiratori, centri nervosi della respirazione) sistema deputato ad assicurare il periodico

apporto di aria (ventilazione) ai polmoni

PACO2 = (VCO2 / VA) . K PAO2= PIO2 - (PACO2 / R)

Differenza Alveolo-arteriosa di O2 %O2 inspirato = 0.21 piO2 = (760-45) x . 0.21 = 150 mmHg

O2 CO2

palvO2 = piO2 – pCO2 / RQ = 150 – 40 / 0.8 = 150 – 50 = 100 mm Hg

PaO2 = 90 mmHg

palvO2 – partO2 = 10 mmHg

Il gradiente A-a O2

• In termini generali il A-a O2 è una misura di come efficacemente l’O2 si sposta dagli alveoli ai capillari polmonari

• Δ A-a O2 = PAO2 – PaO2 • Valore normale ≈ (age + 10) / 4

INSUFFICIENZA RESPIRATORIA

Incapacità del Sistema Respiratorio ad assicurare un adeguato scambio gassoso intrapolmonare e/o a rimuovere nell’ambiente esterno la CO2 prodotta dal metabolismo tissutale

• PaO2 = 103.5 - (0.42 • Età) mm Hg (95 mm Hg - 20 anni / 70 mm Hg - 80 anni)

• Pa CO2 = 37 - 43 mm Hg

Valori normali dei gas arteriosi

INSUFFICIENZA RESPIRATORIA

PaO2 < 60 mmHg

INSUFFICIENZA RESPIRATORIA

PaO2 < 60 mmHg

PARZIALE

PaO2 < 60 mmHg +

PaCO2 > 45 mmHg

GLOBALE

Insufficienza Respiratoria ACUTA (IRA), quando insorge rapidamente su un

apparato respiratorio integro CRONICA (IRC): quando si instaura in modo

progressivo e nella fase tardiva della storia naturale della patologia respiratoria

Ossigeno-terapia

Somministrazione di O2 in concentrazione maggiore di quella presente nell’aria ambiente allo scopo di trattare o prevenire i sintomi e le manifestazioni dell’ipossiemia arteriosa

Correggere l’ipossiemia arteriosa. Prevenire contemporaneamente il danno ipossico tessutale.

OSSIGENOTERAPIA SCOPO:

situazione di acuzie per il periodo necessario a

superare l’evento acuto

Ossigeno-terapia

a lungo termine se esiste una grave ipossiemia

cronica stabilizzata

L’Ossigenoterapia nel paziente acuto

Neuromuscular Transmission

Airway Resistance (R)

CENTRAL DRIVE

Ppl

Pab

Lung and Chest wall Elastance (E)

Diaphragm

(LOAD) N-M COMPETENCE ( )

(ΔV x E) + (V x R) = ΔP

ΔV ΔV

V .

.

CARICO

Depressione del Drive Respiratorio Agenti sedativi

Grave Alcalosi Metabolica Lesioni del midollo spinale

Aumentato Carico Resistivo •Broncospasmo acuto •Aumento delle secrezioni •Ostruzione delle vie aeree superiori

Riduzione della forza dei muscoli respiratori

•Malnutrizione •Iperinsufflazione Polmonare

•Miastenia Gravis •Fattori metabolici

CAPACITA’

DRIVE

INSUFFICIENZA RESPIRATORIA ACUTA

Aumento della VE •Dolore, Ansietà •Sepsi •Aumento VD/VT

Aumentato Carico Elastico •Bassa Compliance polmonare •Bassa Compliance toracica •PEEP intrinseca

Anomalie della parete toracica

•Volee costale •Dolore post-toracotomia

Malattie Neurologiche Periferiche

•Danno spina cervicale •Lesione del nervo frenico

•Disfunzione del diaframma post-Intervento sull’addome

•Polineuropatia da critical illness •Sindrome di Guillain-Barrè

Acute Respiratory Failure

Definition: The loss of the ability to ventilate adequately or

to provide sufficient oxygen to the blood and systemic organs. The pulmonary system is no longer able to meet the metabolic demands of the body with respect to oxygenation of the blood and/or CO2 elimination

LUNG FAILURE PUMP FAILURE

GAS EXCHANGE FAILURE

VENTILATORY FAILURE

CENTRAL DEPRESSION

FATIGUE

MECHANICAL DEFECT

RESPIRATORY FAILURE

HYPOXEMIA

HYPERCAPNIA

Type I or Acute Hypoxemic Respiratory Failure

Type II or Hypercapnic Respiratory Failure

Type III Perioperative Respiratory Failure

Type IV Respiratory Failure

Often secondary to pulmonary edema and susequent intrapulmonary shunting

Secondary to alveolar hypoventilation resulting in the ina-bility to effectively eliminate CO2

Secondary to lung atelectasis

Secondary to hypoperfusion of respiratory muscles in patients in shock

LUNG FAILURE PUMP FAILURE

GAS EXCHANGE FAILURE

VENTILATORY FAILURE

CENTRAL DEPRESSION

FATIGUE

MECHANICAL DEFECT

RESPIRATORY FAILURE

HYPOXEMIA

HYPERCAPNIA

Hypoxemic Respiratory Failure (Type 1)

Physiologic Causes of Hypoxemia • Low FiO2 (high altitude) • Hypoventilation • V/Q mismatch (low V/Q) • Shunt (Qs/Qt) • Diffusion abnormality • Venous admixture ( low mixed venous oxygen)

I

VA/Q . .

PaO2

The 3 major determinants of hypoxemia 1st: the composition of Inspired air (gas): ⇒Low FiO2

3rd: the composition of Mixed venous blood: ⇒LowPvO2

2nd: quality and capacity of the gasexchanger: ⇒ V/Q mismatching

PAO2= (Pb-PH2O=)x0.21-PACO2/R

v

the two most common causes of hypoxemic respiratory failure in the ICU

• V/Q mismatch • Shunt. These can be distinguished from each other by

their response to oxygen. V/Q mismatch responds very readily to oxygen whereas shunt is very oxygen insensitive

SHUNT DESTRO-SINISTRO

Common Causes of Hypoxemic Respiratory Failure

• Pneumonia • Cardiogenic pulmonary edema • Acute respiratory distress syndrome • Aspiration of gastric contents • Multiple trauma • Immunocompromised host with pulmonary infiltrates • Pulmonary embolism

LUNG FAILURE (alveolar filling, consolidation, atelectasis)

PUMP FAILURE

Gas exchange failure (shunt, mismatch V/Q, ↓ diffusion)

HYPOXEMIA

↓ Compliance of the lung

↑ Minute ventilation

↑ Work of breathing (25-50% total O2 consumption)

↓OXYGEN DELIVERY

PaO2 80*, PaCO2 27, pH 7.49

PaO2 = PaCO2 * 1.66 + [ PaO2] - [66.4]

*PaO2 standardizzata= 58.4 mmHg

Oxygen therapy remains the first line intervention in acute hypoxemic respiratory failure.

Is integral to the treatment of patients admitted to ICU. It

is administered to hypoxemic patients to: decrease the effort of breathing, increase alveolar tension, prevent tissue hypoxia.

Therapy should be guided by goal directed outcomes to

maximise its efficient use but also to minimise the complications associated with its administration.

OXYGEN DELIVERY SYSTEMS

LOW FLOW SYSTEMS

Nasal cannula Nasal catheters Simple Oxygen mask Trans-tracheal catheter

HIGH FLOW SYSTEMS

Venturi mask Reservoir mask Trach Mask Humidified High flow nasal systems

Nasal cannulae at 1–4 l/min can have effects on oxygen saturation approximately equivalent to those seen with 24–40% oxygen from Venturi masks. The oxygen dose continues to rise up to flows above 6 l/min, but some patients may experience discomfort and nasal dryness at flows above 4 l/min, especially if maintained for several hours.

The oxygen supplied to the patient will be of variable concentration depending on the flow of oxygen and the patient’s breathing pattern. Flows between 5 and 10 l/min.

Flows of <5 l/min can cause increased resistance to breathing, and there is a possibility of a build-up of carbon dioxide within the mask and rebreathing may occur.

This type of mask delivers oxygen at concentrations between 60% and 90% when used at a flow rate of 10–15 l/min. The concentration is not accurate and will depend on the flow of oxygen and the patient’s breathing pattern.

Simple Oxygen mask

High concentration Reservoir mask Non-rebreathing

Venturi Mask

FiO2: 24%-60%

Face Tent

RESERVOIR MASKS

MASCHERA DI VENTURI (I)

Permette di realizzare FiO2 precise a concentrazioni progressivamente più alte (24%, 28%, 31%, 35%, 40%,50%, 60%), senza provocare rirespirazione (rebreathing) della CO2 espirata dal paziente Permette l’applicazione del principio di Venturi

La maschera facciale in dotazione presenta dei fori di

grosso calibro

MASCHERA DI VENTURI (II) Vantaggi: concentrazione precisa della FiO2 scelta efficace anche in corso di respirazione prevalente per via

orale disponibile anche per tracheotomizzati possibile umidificare la miscela inspirata e somministrare

l’aerosolterapia (raccordo apposito) Svantaggi: impedisce varie attività fisiologiche (espettorare) richiede impiego e consumo di maggiori quantità di O2

in corso di pronunciata iperventilazione (fibrosi polmonare con VE > 10 L/min) la FiO2 risulta inferiore alla prefissata

30 L/min VE (40 cpm x 750 ml)

12 L/min

12 L/min of 100% of O2 + 18 L/min of air drawn into the mask (21% O2) = 30 L/min VE FiO2= (1.0 x 12) + (0.21 x 18)

30

(52,6%)

33.75 L/min VE (45 cpm x 750 ml)

12 L/min

12 L/min of 100% of O2 + 21.75 L/min of air drawn into the mask (21% O2) = 33.75 L/min VE FiO2= (1.0 x 12) + (0.21 x 21,75)

33,75

(49,0%)

Maschera reservoir (FiO2 80%)

MASCHERA per O2 Viasys HI-OX80

MASCHERA FiO2 100% Sono le comuni maschere da resuscitazione post-chirurgica,con connessione del raccordo di O2 diversa, prive di Venturi e di grossi fori. Quindi non sono dotate di sistema anti-rebreathing. Indicazioni: ipossiemia refrattaria solo se associata ad ipocapnia ipossiemia in corso di interstiziopatia associata ad ipocapnia broncopolmonite associata ad ipocapnia embolia polmonare associata ad ipocapnia Controindicazioni: ipercapnia dei soggetti con patologia respiratoria cronica

“Pending the results of clinical trials, it is reasonable to use humidified oxygen for patients who require high-flow oxygen

systems for more than 24 h or who report upper airway discomfort due to dryness.” [Grade B]

Guidelines recommend humidification of the delivered gas to homeostatic levels to preserve nasal mucosal function, minimise viscosity of tracheobronchial secretions and prevent disruption of the mucociliary transport mechanisms which predisposes patients to infection. This becomes increasingly important in the ICU setting where oxygen concentration and required flow rates increase to meet metabolic demand

Historically, high flow therapy has been used with face masks, where the high flows flush the mask volume to facilitate high inspiratory oxygen fractions. While effective in supporting oxygenation, mask therapy can be limited by factors including ability to eat/drink and communicate, as well as feelings of claustrophobia, leading to poor patient compliance.

HIGH FLOW SYSTEMS

Recently, a new therapy which provides heated humidified high flow oxygen via nasal cannula

(HHFNC) has been introduced as an alternative for the treatment of spontaneously ventilating patients

with high oxygen requirements

VAPOTHERM MR850: FISHER & PAYKEL

HEALTHCARE

High flow oxygen administration devices provide sufficient flow to meet the patient’s minute ventilation requirements.

air oxygen blender

I. OXYGEN II. COMPRESSED AIR

HIGH FLOW DEVICE

Precision Flow (Vapotherm Inc. USA)

Struttura del Circuito Paziente del Precision Flow™ tubo coassiale Cartuccia Umidificatrice –fa parte

del Circuito Paziente

I. FiO2 II. Temperature III. Flow

HIGH FLOW DEVICE MR850 FISHER & PAYKEL HEALTHCARE

humidifier systems

high-flow oxygen flow meters

FISHER & PAYKEL HEALTHCARE VAPOTHERM

Humidity, temperature and FiO2 can be controlled with minimal effect from the patient’s respiratory effort or PIFR

VE: 40 L/min

VE: 60 L/min

Objective: To measure 1) the discomfort in non-intubated patients under high-flow oxygen therapy (HFOT ) humidified with bubble (BH) or heated humidifiers (HH), and 2) the hygrometric properties of oxygen with a BH and an HH.

Design and setting: This was a randomized cross-over study in critically ill patients during a 3-day period. The humidification device used at days 1 and 3 was changed for the other at day 2.

Methods: Discomfort, particularly dryness of the mouth and throat, was measured, in 30 patients, for two humidification conditions (BH and HH in a double-blinded condition.

Intensive Care Med (2009) 35:996–1003

Oxygen Flow at inclusion time l/min: 8 (5-11)

(MR850; Fisher & Paykel Healthcare, Panmure, New Zealand)

Intensity of each discomfort symptom evaluated for each of the two humidification devices

The intensity of all dryness discomfort symptoms. A decreased with heated umidification compared to the bubble humidifier. The difference was significant only for mouth and throat dryness and trended towards significance for the others (P values B 0.12). The facial heat sensation (b) was not significantly greater with the heated humidifier (P = 0.20). Medians are expressed as horizontal bars, 25–75 percentiles as boxes and maximal–minimal values as verticalbars. ***P\0.001; **P\0.01

How is High Flow Oxygen Delivered?

Physiological effects and key therapeutic advantages of HFNC

Delivers a high FIO2 accurately

Meets the patient’s ventilatory demands

Pharyngeal dead space washout

Reduction of nasopharyngeal resistance

Provides a modest amount of positive airway pressure

(PEEP effect)

increase EELV and tidal volume

Optimizes mucociliary clearance

Provides patient comfort

Reduction of inspiratory resistence (WOB) by providing adequate flow

Washout of nasopharyngeal dead space: improving fraction of alveolar gas

Reduction in the metabolic cost of gas conditioning

IMPROVE THE EFFICIENCY OF THE VENTILATION

Where does the Clinician Intervene with HFNC?

Non-invasive ventilation

Invasive ventilation

High concentration reservoire mask

Nasal cannula

HFNC Venturi mask

In patients who require an escalation in respiratory support, should NHF be seen as a logical step between traditional oxygen therapy and CPAP/NIV?

High-O2

Low-O2

Possible clinical application of HFT

Acute hypoxemic respiratory failure

Post-extubation period

Postoperative ARF

Emergency department

Acute heart failure

SARI, severe acute respiratory infection

Palliative care

Bronchoscopy and others invasive procedures

Chronic airway disease (Fibrosis, ….)

Modified by Gotera C et al. Rev Port Pneumol 2013; 19(5):217-227

There is limited experience of HFNC in adults.

There are no established guidelines or decision-making

pathways to guide use of the HFNC therapy for adults.

Author (year)

Type of study and HFNC

device

n° pts and setting

Etiology of ARF

Duration of oxygen

administration by HFNC

HFNC treatment outcomes

Comments

Roca et al. 2010

Prospective sequential intervention Conventional oxygen face mask and Optiflow HFNC

20 ICU patients with SpO2<96% with O2 face mask with FiO2≥50% ARF: 65% Pneumonia

30 min

PaO2 ↑ SpO2 ↑ RR ↓ Comfort ↑

No randomized design Delivered FiO2 were based on manufacter specification

Sztrymf et al. 2012

Prospective Observational Optiflow HFNC

20 ICU Patients with persistent ARF despite oxygen with conventional facemask were treated with HFNC oxygen. ARF: 65% Pneumonia

26,5 h (17-21)

SpO2 ↑ RR ↓ Intubation 30% Gen. Ward 47% Death 15%

No randomized design Delivered FiO2 were based on manufacter specification

Purpose To evaluate the efficiency, safety and outcome of high flow nasal cannula oxygen (HFNC) in ICU patients with ARF

Methods Pilot prospective monocentric study. 38 patients were included. Arterial blood gases were measured before and after the use of HFNC. Noise and discomfort were monitored along with outcome and need for invasive mechanical ventilation

INCLUSION CRITERIA All patients exhibiting ARF requiring more than 9 l/min of oxygen output to achieve a SpO2 of more than 92% or persistent signs of respiratory distress (defined when one or more of the following criteria were present: respiratory rate equal to or greater than 25 bpm, thoraco-abdominal asynchrony and supraclavicular retraction) despite oxygen administration were eligible. EXCLUSION CRITERIA Patients requiring immediate endotracheal intubation were excluded, as were those with hypercapnic respiratory failure (defined as a known history of COPD and hypercapnia on arterial blood gases).

Differences between patients that eventually required mechanical ventilation (black bars) and the patients that did not (white bars)

Early lack of decrease in respiratory rate and persistence of thoraco-abdominal asynchrony

represent early and simple indicators of HFNC failure

NHF therapy generates a PEEP with

potential reduction on the work of breathing and improvement of the oxygenation

METHODS 15 pats scheduled for elective cardiac surgery participated . Nasopharyngeal pressure measurements were performed using NHF with gas flows of 30, 40, and 50 L/min. All measurements were performed in random order, with the subject breathing with mouth closed. RESULTS At flows of 30–50 L/min the HFNC system provided a PEEP of 3–5 cm H2O. …..the pressure is higher during the expiratory phase.

It has been reported that postoperative hypoxemia and complication increase morbidity and mortality and prolonged ICU/hospital length of stay. After extubation and with spontaneous breathing at ambient air, derecruitment of lung areas and loss of functional alveolar units may rapidly occur leading to hypoxemia. Respiratory support is of major importance following extubation to avoid respiratory failure and reintubation.

Methods. 20 patients prescribed HFNC post-cardiac surgery were investigated. Impedance measures, Paw, Pao2/FIo2 ratio, respiratory rate, and modified Borg scores were recorded first on low-flow oxygen and then on HFNC.

Results. A strong and significant correlation existed between Paw and end-expiratory lung impedance (EELI) (P,0.001). Compared with low-flow oxygen, HFNC significantly increased EELI and Paw. RR reduced with HFNC use, Pao2/FIo2 ratio improved. A trend towards HFNC improving subjective dyspnoea scoring was found. Increases in EELI were significantly influenced by BMI.

This increase in EELV may be explained by the recruitment of alveoli, and prevention of further alveolar collapse, as a result of the low-level positive Paw generated by HFNC.

Conclusions. This study suggests that HFNCs reduce respiratory rate and improve oxygenation by increasing both EELV and tidal volume and are most beneficial in patients with higher BMIs.

Patients at the end of life and with do-not-intubate (DNI) orders often receive NIV to improve comfort and reduce breathlessness. NIV can reverse hypoxemic respiratory distress in some do not resuscitate/DNI subjects, especially those with COPD and cardiogenic pulmonary edema Many patients have difficulty tolerating a tight-fitting mask, and it has been urged that informed consent and the goals of therapy be clearly identified in this population

METHODS: 50 DNI patients with hypoxemic respiratory distress who were admitted to a medical ICU and who received HFNC. Pts with PaCO2 > 65 mm Hg and pH < 7.28 were excluded. The primary end point was the need for escalation to NIV, as determined by the primary service. Secondary end points included clinical parameters of ventilation and gas exchange, patient tolerance of HFNC.

• 41/50 (82%) were maintained on high-flow nasal cannula (HFNC). • 9/50 (18%) escalated to noninvasive ventilation. • Overall hospital mortality was 60%. • The mean HFNC FIO2 was 0.67 (range 0.3–1.0). • The mean HFNC flow was 42.6 L/min (range 30–60 L/min). • The median duration of HFNC was 30 hours (range 2–144 h).

CONCLUSIONS HFNC can provide adequate oxygenation for many patients with hypoxemic respiratory failure and may be an alternative to NIV for DNI patients. HFNC requires less training than NIV and may be more acceptable to hospital staff.

HEATED HUMIDIFIED HIGH FLOW NASAL CANNULAE OXYGEN THERAPY (HHHFNC) IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: A PHYSIOLOGICAL STUDY

Respiratory Intensive Care Unit Azienda Ospedaliera-Universitaria Careggi - Firenze

AIM: To compare the efficacy of Heated Humidified High Flow Nasal Cannulae (HHHFNC) versus High Concentration Reservoir Mask (HCRM) and CPAP in adult patients with severe acute hypoxemic respiratory failure.

METHODS • 20 patients admitted to RICU, mean age (SD): 66 (13) years, M/F: 16/4 • severe acute hypoxemic respiratory failure defined as Pa02<60 mm Hg with Fi02=

60% (PaO2/FiO2 ratio < 100). • No criteria for endotracheal intubation or immediate noninvasive CPAP on the

judgment of physician in charge

Pts were treated in random order with: • CPAP (10 cmH2O, FiO2=100) using a high flow generator and helmet or mask • high concentration reservoir mask (HCRM) with flow rate of 30 L/min • HHHFNC provided by precision flow (Vapotherm inc. Maryland, USA) set with

flow rate= 35 L/min, FiO2=100% and temperature= 37 degree

At the end of 60 min period trials we evaluated: • arterial blood gases and pH • respiratory frequency • heart rate • systolic pressure • Dyspnea • overall comfort of patients using a scale of 1 (lowest) to 3 (highest)

RESULTS

* ° ^

*° p= 0.0006 *^ p= 0.02 °^ p= 0.21

CPAP HCRM HHHFNC

p < 0.05

RESPIRATORY RATE

RESULTS

P<0.02

CPAP HCRM HHHFNC

DYSPNEA

P<0.02 OVERALL COMFORT

All but one patients continued oxygen therapy with

HHHFNC (mean duration 4 days) No nosocomial pneumonia occurred with HHHFNC All but two patients required noninvasive CPAP or

noninvasive mechanical ventilation One patients required endotracheal intubation

OUTCOMES

CONCLUSIONS

The emerging preliminary evidence suggests that HHFNC is effective in improving oxygenation in patients with ARF, compared to standard oxygen therapy.

HHFNC may reduce the work of breathing and improve the efficiency of ventilation.

It may provide a bridge from NIPPV to conventional oxygen delivery devices and also may give some patients NIPPV free hours.

Further research is required to determine the long-term effect and how this treatment can be introduced in the daily clinical practice

L’Ossigenoterapia nel paziente cronico

High

Low

Func

tion

Time

Death

COPD

CRF*

END-STAGE

Long Term Oxygen Therapy

Long Term Ventilation

Transplantation

?

*CRF: Chronic Respiratory Failure

There will be an increasing proportion of end-

stage patients who can live longer through long-term oxygen therapy and assisted

ventilation, but with elevated suffering and huge costs.

High

Low

Func

tion

Mostly heart and lung failure

Begins to use hospital often; self-care becomes difficult

Time 2-5 years, but death usually seems sudden

Death

Organ system failure trajectory Field MJ 1997

Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and

emphysema

Lancet 1981;1:681-5

Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med 1980;93:391-8

• 87 patients • Age < 70 yr (range 42-69) •FEV1 <1.2 L • PaO2 between 40 and 60 mmHg breathing air at rest (two repeated measures 3 weeks apart)

• 203 patients • Age >35 yr • PaO2 < 55 mmHg or ≤ 59 plus one of the following: oedema, Hct ≥ 55%, cor pulmonale on ECG • FEV1/FVC < 70% TLC ≥ 80% predicted

MRC

NOTT PaO2 < 55mmHg

Corrado A et al. Monaldi Arch Chest Dis, 2010

These studies are not fully comparable

Long Term Oxygen Therapy is effetive in treating

severe stable hypoxemic COPD

L’Ossigenoterapia nel paziente cronico:

sistemi e modalità di somministrazione

OSSIGENOTERAPIA

MODALITA’ di SOMMINISTRAZIONE:

Ossigeno gassoso: per urgenze e nel caso di malati terminali Ossigeno liquido: per OTLT ed in ambito ospedaliero Concentratore è un compressore che, aspirando l’aria dall’ambiente, separa l’azoto dall’ossigeno presente nella percentuale del 21% nell’aria

OSSIGENO GASSOSO Il sistema è composto da: Bombola per O2 medicinale ad alta pressione, generalmente

avente capacità geometriche fra i 7 e i 14 litri. Sviluppa una quantità di O2 che varia da 1200 a i 3000 litri di gas, a seconda della capacità geometrica

Riduttore di pressione con selettore di flusso

Umidificatore

Accessorio per erogazione

OSSIGENO LIQUIDO Il sistema è composto da: Contenitore criogenico base per ossigeno liquido medicale,

avente capacità geometrica fra i 20 e i 45 litri. Sviluppa una quantità di O2 che varia da 15.000 a 40.000 litri di gas, a seconda della capacità geometrica.

Contenitore criogenico portatile di volume compreso tra 0,5 e 1,2 litri di capacità geometrica in grado di sviluppare dai 500 ai 1000 litri di ossigeno gassoso. Lo stesso, con una semplice manovra, può essere riempito dal contenitore di base. Il peso dei contenitori portatili è di circa 2/3 kg

Umidificatore Accessorio per erogazione

CONCENTRATORE

Il sistema è composto da: Apparecchiatura elettromedicale da collegarsi alla rete

elettrica domestica

Umidificatore

Accessorio per l’erogazione

OSSIGENOTERAPIA

TECNICHE di SOMMINISTRAZIONE nel paziente cronico stabile:

Sondino naso-faringeo (SNF) Occhiali o cannule nasali (lunette o prongs) Cannula transtracheale

SONDINO NASO-FARINGEO Vantaggi: può essere ben fissato anche durante il sonno permette l’O2-terapia durante varie attività riduce la dispersione dell’O2

può essere impiegato anche insieme alla Ventimask

Svantaggi: richiede frequenti controlli di pervietà dell’estremo distale esteticamente meno valido non è in grado di erogare FiO2 prestabilite

OCCHIALI O CANNULE NASALI Vantaggi: permettono l’attuazione dell’O2-terapia durante varie attività possono essere più facilmente nascosti Svantaggi: possono essere malposti durante il sonno possono essere inefficienti (respirazione per via orale,

ostruzioni nasali) la concentrazione dell’O2 inalato (FiO2) è molto

approssimativa È possibile l’inalazione di FiO2 elevate, specialmente nei

soggetti con patologia restrittiva, ma anche in soggetti con BPCO

Nasal cannulae at 1–4 l/min can have effects on oxygen saturation approximately equivalent to those seen with 24–40% oxygen from Venturi masks.

la somministrazione di O2 con ON e SNF non permette di conoscere il flusso esatto somministrato; in tal caso ricorrere alla formula che ci permette di ottenere un calcolo

approssimativo della FiO2

CATETERI TRANS-TRACHEALI PERMANENTI Sono sonde siliconate introdotte in trachea attraverso un foro molto piccolo (1.7,5-3 mm il diametro interno ed esterno) con lunghezza regolabile. Vantaggi: Risparmio di O2 erogato La dispersione nelle vie aeree superiori è minima Svantaggi: Tecnica invasiva Richiede sorveglianza Possibili emoftoe Possibili sovrainfezioni Possibile ostruzione del lume distale

Transtracheal catheter (Transtracheal oxygen therapy-TTO)

Transtracheal catheter delivers oxygen directly into the trachea through a small opening between the first and second tracheal ring. TTOT improves the efficiency of oxygen delivery by creating an oxygen reservoir in the trachea and larynx. Consequently, mean oxygen savings amount to 50% at rest and 30% during exercise

In the USA close to 800,000 patients receive LTOT at a cost of approximately $1.8 billion annually In Italy about 50- 60,000 of patients receive LTOT with a global burden for the national health system (SSN) amounting to about Euro 250,000,000/year. Worldwide, several hundred thousands of patients receive LTOT, following the recommendation of international documents.

Long Term Oxygen Therapy:

the cost of treatment

This large number of patients receiving supplemental oxygen as treatment and the high costs incurred in providing oxygen therapy is a crucial problem for the National Health Systems worldwide obliging the scientific community to carry out a critical revision of the actual indications for LTOT

2010; 73:1,34-43

It is generally accepted without solid evidence that LTOT in clinical practice is warranted in

other forms of chronic respiratory failure such as pulmonary fibrosis, cyphoscoliosis, cystic fibrosis when arterial blood gas criteria are

similar to those established for COPD patients.

This aspect may contribute, albeit marginally, to the increasing use and cost of oxygen. !

Current guidelines criteria for LTOT prescription

HYPOXEMIA ATS-ERS

ERJ 2004

GOLD

AJRCCM 2007

NCCC-NICE

Thorax 2004

Thoracic Society of

Australia and New Zeland

MJA 2005

AIPO

Rass.Pat.App. Resp. 2004

Severe PaO2<55 mmHg or SpO2≤88%

PaO2≤55 mmHg or SpO2≤88%

PaO2<55 mmHg PaO2≤55 mmHg PaO2<55 mmHg

Moderate PaO2 of 55 to 59 mmHg or SpO2 of 89% and at least one of the following criteria: Cor pulmonale, peripheral edema, hematocrit>55%

PaO2 of 55 to 59 mmHg or SpO2 of 89% and at least one of the following criteria: pulmonary hypertension, peripheral edema, hematocrit>55%

PaO2 of 55 to 59 mmHg or SpO2 of 89% and at least one of the following criteria: pulmonary hypertension, peripheral edema, secondary polycythemia, nocturnal desaturation >30% of sleep ♣

PaO2 of 56 mmHg to 59 and there is evidence of hypoxic organ damage (right hearth failure, pulmonary hypertension, peripheral edema, secondary polycythaemia)

PaO2 of 55 mmHg to 60 and at least one of the following criteria: hematocrit>55% signs of pulmonary hypertension, signs of hypoxia (peripheral edema of right heart failure, mental decline) ischemic heart failure ♣

None ♣ PaO2 ≥60 mmHg or SpO2 >90% with severe nocturnal desaturation and lung-related dyspnea responsive to oxygen

No raccomandation

No raccomandation

♣ Nocturnal oxygen may be indicate: desaturation (SpO2≤88%) >30% of sleep or in presence of hypoxia-related sequelae.

♣ Intermittent oxygen may be indicate : desaturation (SpO2<90%) >30% of sleep or in presence of exercise-related desaturation.

♣ This recommendation are not evidence based. Corrado A et al. Monaldi Arch Chest Dis, 2010

1. Few studies have evaluated continuous oxygen therapy in COPD patients with mild-to-moderate degree of hypoxemia.

2. Perhaps in a sub group of mild-moderate hypoxemic COPD patients with other conditions such as pulmonary hypertension, low body mass index, poor exercise capability, frequent exacerbations, or comorbid cardiac disease, LTOT could be advantageous in term of survival but no evidence has yet been reported

Role of oxygen in COPD patients who do not fulfil the criteria for continuous therapy is controversial

Long Term Oxygen Therapy In COPD with

MODERATE HYPOXAEMIA

• Randomised controlled study

• 135 patients with COPD and moderate hypoxemia (56-65 mmHg) were enrolled from 1987 to 1992 and followed up to 1994

• 68 patients received LTOT + Medical Treatment (LTOT group); 67 patients received medical treatment alone (Control group)

• Medical treatment: bronchodilators; antibiotics, diuretics and gluco-cortico-steroids as needed

• Oxygen was administered by concentrators

• Hours/day prescribed: 17 hrs

Effect of long term oxygen therapy on survival in patients with chronic obstructive pulmonary disease with moderate hypoxaemia D. Gorecka, K. Gorzelak, P. Sliwinski, M Tobiasz, J. Zielinski

Thorax 1997;52:674

Table 1 Mean (SD) clinical characteristics of 135 patients with COPD at entry to the study

* p<0.05

Age (years) 62.4 (8.2) 60.1 (8.8) M/F 52/15 51/17 BMI (Kg/m2) 23.3 (4.0) 23.8 (5.1) PaO2 (kPa/mmHg) 8.2 (0.4)/61.3(2.7) 7.9 (0.4)/59.5 (2.7)* PaCO2 (kPa/mmHg) 5.7 (0.9)/42.8(6.6) 6.0(0.9)/45.3(6.7) FEV1% pred 29.8 (10.3) 29.7 (9.4) FEV1/VC (%) 40.8 (12.1) 45.1 (13.4) Haematocrit (%) 46.4 (5.3) 47.9 (5.7) Steroids (no of pts) 20 19 O2 use (hours) 13.5 (4.4)

Variable Control group LTOT group (n = 67) (n = 68)

Thorax 1997;52:674

Cumulative survival rate in LTOT group and controls

0

0,2

0,4

0,6

0,8

1

1,2

Cu

mu

lati

ve S

urv

ival

Rat

e

LTOT Controls

0 12 24 36 48 60 72 84

Survival Time (months)

P = 0.892

Thorax 1997 52:674

CONCLUSIONS • In COPD patients with moderate hypoxaemia

there is no difference in survival rates between patients treated and not treated with domiciliary oxygen

• Oxygen use for longer periods did not improve the survival rate

• Prescription of LTOT in this specific group of COPD pats should be done more cautiously, reserving this expensive treatment for patients for severe hypoxaemia

Long Term Oxygen Therapy in

normoxic patients with exercise desaturation

CHEST 2008; 134:497–506

Multivariate 8-year survival* analysis in normoxic participants randomized to medical therapy, stratified by oxygen use; p values adjusted for BMI, age, FEV1 (% of predicted), and exercise desaturation.

* Not include patients randomized to surgical therapy in NETT when evaluating survival.

CONCLUSION

1. In the NETT, the use of continuous oxygen in resting nonhypoxemic emphysema patients was associated with worse disease severity and survival.

2. The differential survival observed could be accounted for by the higher prevalence of exercise desaturation in those using continuous oxygen, suggesting that it is not a harmful effect of oxygen therapy contributing to mortality.

3. These data suggest that exercise desaturation is a predictor of mortality inpatients with severe emphysema and resting normoxia.

4. It remains unclear whether continuous oxygen therapy improves survival in normoxic patients with exercise desaturation.

REG.I.RE Registro Italiano Insufficienza Respiratoria

Corrado Antonio Renda Teresa

REGIRE: un nuovo modello di gestione della sanità italiana

REG.I.RE Registro Italiano Insufficienza Respiratoria

Non è ancora presente in tutte le Regioni una regolamentazione regionale per l’OTLT (Ossigenoterapia a Lungo Termine) e la Ventilazione Meccanica Domiciliare (VMD)

Nella maggior parte delle Regioni non esiste un Registro per l’OTLT e la VMD

Si stima attualmente che in Italia ci siano 62500 pazienti in ossigenoterapia e che il costo del trattamento sia pari a 250000000 Є/anno.

La realtà Italiana

Corrado A, Renda T, Bertini S. Long-Term Oxygen Therapy in COPD: evidences and open questions of current indications Monaldi Arch Chest Dis, 2010; 73: 1, 34-43

Survey promossa dall’Agenzia di Coordinamento delle regioni dell’AIPO (Associazione Italiana Pneumologi Ospedalieri), 2006

Adesioni al Registro al 30/09/2011 Distribuzione regionale

DISTRIBUZIONE REGIONALE N° Centri

Piemonte-Valle d’A. 16

Lombardia 22

Veneto 11 Emilia Romagna 3

Lazio 25

Marche 3 Abruzzo-Molise 5

Sardegna 13 Campania-Basilicata 27

Puglia 18

Calabria 14 Sicilia 17

Liguria 8

Friuli V.G. 8

Toscana 22 Umbria 8

TOTALE 220

8

8

13 18

16

17

11

8

27

3

25

22

22

14

5

3

Adesione al Registro REGIRE al 30/09/2013 Distribuzione regionale

OTLT: 6760 VMD: 2192

0102030405060708090

100

BPCO NON BPCO

74,3

25,7

%

BPCO Non BPCO

OTLT. 6764 casi M/F: 4005/2759 (59.2 % vs 40.8 %) Età: 76 (17-103) Fumo: Si : 8,2%, No: 45.9%, Ex: 45.9%

MALATTIA CRONICA DI BASE

VMD. 2190 casi M/F: 1331/859 (60.8% vs 39.2%) Età: 62 (6-96) Fumo: Si : 7 %, No: 57.9%, Ex: 35.1%

BPCO Non BPCO

MALATTIA CRONICA DI BASE

Dall’avvio del REGIRE risulta: SISTEMA DI

EROGAZIONE Ore die prescritte OTLT

Modalità di Ventilazione

VMD Ore die prescritte Uso contemporaneo di ossigeno

La prescrizione dell’ossigeno liquido in Italia è in controtendenza alla pratica prescrittiva degli altri paesi europei dove al contrario

che da noi la forma più diffusa di erogazione di ossigeno è quella tramite concentratore.

Altitude Adventure, August 26th 2006, photo courtesy of John Goodman, RRT

MA, QUANTI SONO????

Chest 1994; 105:1061-65

Ten COPD pats who were already receiving TTO were recruited. STUDY DESIGN: Each subject underwent a total of four modified progressive treadmill tests in a single blind randomized fashion on two separate days. TTO was compared to both high and low flow nasal cannula oxygen (NP). The flows were adjusted to provide equivalent oxygen saturations at rest for respective groups. Results: use of high-flow oxygen via both transtracheal catheter and NP significantly increased exercise tolerance in COPD patients when compared to low-flow oxygen. There was no significant difference in exercise distance and dyspnea scores with HF-TTO as compared with HF-NP and LF-TTO versus LF-NP.

Design: Prospective, nonrandomized, nonblinded study. Patients: Ten COPD patients, stable with no exacerbation, and advanced airflow obstruction (age:54±6 years; FEV1:23±6% pred ). Interventions

Warm humidificated oxygen VAPOTHERM HFO

CHEST 2004; 126:1108–1115

150

Conclusion High flows of humidified oxygen improved exercise performance in patients with COPD and severe oxygen dependency, in part by enhancing oxygenation.

Under normal breathing conditions, approximately 30% of an inspired tidal volume represents anatomical dead space. At the start of an inspiration, this dead space is filled end-expiratory gas remaining from the previous expiration. This anatomical dead space volume is essential to 1) inspiratory gas warming and humidifying 2) conducting gas to the thorax and dispersing to lung regions The contribution of dead-space (end-expiratory gas) to a new breath does impact breathing efficiency.

CHEST 2005; 127:98–104

** CRF was due to COPD in 10 patients (10/14)

**

Figure 3. Individual and mean changes in end-expiratory lung volume with transtracheal high-flow insufflation. The baseline indicates end-expiratory lung volume during low-flow insufflation. During high-flow insufflation, end-expiratory lung volume decreased in 8 of 10 patients with , and in all 4 patients with non-obstructive lung diseases (o).

LowF: 1,5 L/min HighF: 15 L/min

End-expiratory lung volume decreased during high-flow insufflation, possibly due to the reversal of dynamic hyperinflation secondary to lower ŮE e and longer TE.

High-flow transtracheal insufflation of oxygen-enriched air assists ventilation by reducing VE without compromising gas exchange and by reducing end-expiratory lung volume, possibly through the reversal of dynamic hyperinflation.

CONCLUSIONS