3 Steroids Abx BDs Teophylline VE usa i farmaci e bene ! Airway narrowing &obstructionAirwayInflammationSteroids FrictionalWOBAbxShortenedmusclescurvatureAuto-PEEPBDs ElasticWOBGastrappingTeophylline VCO2 musclestrength VT VE VAPaCO2pHPaO2
4 Steroids Abx PEEP BDs Teophylline MV MV VE MV usa i farmaci e bene ! Airwaynarrowing &obstructionAirwayInflammationSteroids FrictionalWOBAbxPEEPShortenedmusclescurvatureAuto-PEEPBDs ElasticWOBGastrappingTeophyllineMVMV VCO2 musclestrength VT VEMV VAPaCO2pHPaO2
5 Non-Invasive Ventilation “a form of ventilatory support that avoids airway invasion”Hill et al Crit Care Med 2007; 35:2402-7
8 NIV - Meta-analysis (n=8) NPPV resulted indecreased mortality (RR 0.41; 95% CI 0.26, 0.64),decreased need for ETI (RR 0.42; 95%CI 0.31, 0.59)Greater improvements within 1 hour inpH (WMD 0.03; 95%CI 0.02, 0.04),PaCO2 (WMD kPa; 95%CI -0.78, -0.03),RR (WMD –3.08 bpm; 95%CI –4.26, -1.89).Complications associated with treatment (RR 0.32; 95%CI 0.18, 0.56) and length of hospital stay were also reduced with NPPV (WMD –3.24 days; 95%CI –4.42, -2.06)Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185
9 49 pazienti con IRA in BPCO dopo fallimento terapia medica, pH 7.2 Simili durata di permanenza in ICU, durata VM, complicanze generali, mortalità in ICU, e mortalità in ospedalecon NIV 48% evitano ETI, sopravvivono con permanenza in ICU inferiore vs pazienti VM invasiva (P=0.02)A 1 anno: NIV inferiore riospedalizzazione (65% vs 100% P=0.016) e minor frequenza di riutilizzo supplemento di ossigeno (0% vs 36%)
10 Studio caso-controllo: 64 paz. con IRA trattati con NIV pH = 7.18 40/64 (62%) fallimento NIV (RR con NIV - 38%)Simili mortalità in ICU, e mortalità in ospedale; durata di permanenza in ICU e post ICU, ma:Inferiori complicanze (P=0.01) e probabilità di rimanenere in VM (P=0.056)Se NIV efficace (24/64 = 38%) migliore sopravvivenza e ridotta permanenza in ICU vs pazienti VM invasiva
11 NIV: Change in practice over time (mean pH = 7.25+/-0.07) (7.20+/-0.08; P<0.001).> risk of failure pH <7.25 three fold lower than in> 1997 ARF with a pH >7.28 were treated in Medical Ward (20% vs 60%).Daily cost per patient treated with NIV (€558+/-8 vs €470+/-14,P<0.01)Carlucci et al Intensive Care Med 2003; 3:419-25
12 EpidemiologyRationale: evidence supporting use of NIV varies widely for different causes of ARF.Population: 11,659,668 cases of ARF from the Nationwide Inpatient Sample during years 2000 to 2009;Objectives: To compare utilization trends and outcomes associated with NIV in patients with and without COPD.
14 Rationale: The patterns and outcomes of NIV use in patients hospitalized for AECOPD nationwide are unknown.Population: 7,511,267 admissions for acute AE occurred from 1998 to 2008;Objectives: To determine the prevalence and trends of NIV in AECOPD.
15 Use of NIPPV or IMV as first-line respiratory support in patients hospitalized with AECOPD
16 Joint BTS/RCP London/Intensive Care Society Guidelines. NIV in COPD Joint BTS/RCP London/Intensive Care Society Guidelines. NIV in COPD. Oct 2008
20 Definition of the three levels of care European Task Force on Respiratory Intermediate Care SurveyCorrado et al, ERJ 2002;20:
21 Appropriatezza di utilizzo della Ventilazione Non-Invasiva in ambito pneumologico nell’assistenza ai pazienti con BroncoPneumopatia Cronica Ostruttiva in fase acuta.
22 Rate of NIV failure is extremely different according to study design, severity of illness and level of monitoring
23 Sixty-two RCTs including a total of 5870 patients Overall NIV failure: 16.3%
24 NIV – Real LifeEvaluation of all 449 patients receiving NPPV for a 1-yr period for acute or acute on chronic RFCPE (n=97)AECOPD (n=87)non-COPD acute hypercapnic RF (n=35)postextubation RF (n=95)acute hypoxemic RF (n=144)Intubation rate was 18%, 24%, 38%, 40%, and 60%, respectivelyHospital mortality for patients with acute hypoxemic RF who failed NPPV was 64%Schettino G. Crit Care Med 2008; 36:441-724
25 The percentage of patients transitioned from NIV to IMV ≈ 5% and did not increase from 1998 to 2008
26 Reasons for low rate of IMV use after NPPV, compared to clinical trial: End of life decision to not accept IMVPatients died before IMV could be startedGood selection of appropriate patients
27 High mortality rate (≈30%) ;↑ over time OR for death:1.63, compared to those initially on IMV↑hospital stay
28 Nearly one third of patients for whom there is the best evidence base for NIV did not receive it Admission pH < 7.26: 66% received NIV compared to 34% pH 7.26 to 7.34.Similar lowest pHSignificant proportion had a metabolic acidosisHospital mortality was 25% (270/1077) for patients receiving NIV but 39% (86/219) for those with late onset acidosis“The audit raises concerns that challenge the respiratory community to lead appropriate clinical improvements across the acute sector
29 Reasons for high mortality rate in patients transitioned to IMV Increased use of NIPPV in patients difficult to ventilate?Continuation of NIPPV despite a lack of early improvement?
30 Aetiology of NIV failure Failure to adequately ventilate/oxygenateDelayed NIV treatmentInappropriate ventilatory techniquePatient’s clinical conditionB. Dependence on non-invasive supportLack of improvement of acute illnessC. Complications
31 NIV failure is predicted by: Advanced ageHigh acuity illness on admission (i.e. SAPS-II >34)Acute respiratory distress syndromeCommunity-acquired pneumonia with or without sepsisMulti-organ system failure
33 NIV in acute COPD: correlates for success Retrospective analysis59 episodes of ARF in 47 COPD patientsNIV success: 46NIV failure: 13Predictors for NIV failure:Higher PaCO2 at admissionWorse functional conditionReduced treatment compliancePneumoniaAmbrosino N, Thorax 1995;50:755-7
34 NIV complications Complication Incidence (%) Major Minor Aspiration pneumonia<5Haemodinamyc collapseInfrequentBarotraumaRareMinorNoise50-10CO2 rebreathing50-100Discomfort30-50Claustrophobia5-20Nasal skin lesions2-50
35 Mask selection - a crucial issue! CO2 rebreathing (50-100%)Noise (50-100%)Leak/Discomfort (30-50%)Claustrophobia (5-20%)Nasal skin lesions (2-50%)
36 NIV should not be used in: Respiratory arrestInability to tolerate the device, because of claustrophobia, agitation or uncooperativenessInability to protect the airway, due to swallowing impairmentExcessive secretions not sufficiently managed by clearance techniquesRecent upper airway surgery36
37 Transition to IMV: when is in the interest of a patient? Hospital mortality: 64% (Schettino, 2008)Mortality rate: 30%; prolonged hospitalization (Chandra, 2011)Great hospital mortality (Walkey, 2013)
38 Transition to IMV (personal experience, 2011-2013) Number of subjects62Age (mean ± SD) , yrs65.4±19.3Gender (males, females)26, 36Ineffective NIV, n (%)Severe hypercapniaSevere hypoxemia52 (83.8)25 (42.4)21 (35.6)Dependence on NIV, n (%)8 (13.3)NIV complication, n (%)2 (3.4)Tracheotomy, n (%)16 (28.8)Outcome , n (%)Died during hospDischarged from hosp41 (66.1)21 (33.9)
39 Kaplan-Meier function of overall survival Median survival:46 days(95% CI, 43 to 162)Kaplan-Meier function of overall survival
40 Kaplan-Meier function of survival according to baseline condition Mean survival:NM/CW = ±36.9COPD = 53.90±7.3ILD = 31.13±7.8] p=0.0176] p<0.0001Kaplan-Meier function of survival according to baseline condition
41 Kaplan-Meier function of survival for dichotomus age (50 and >50) Median survival:50 = d (95%CI, 15.0 to n.c.)>50 = 45.0 d (95%CI,24.0 to 54.0)] p=0.0071Kaplan-Meier function of survival for dichotomus age (50 and >50)
42 RemarksMortality rate among patients transitioned to IMV is very high;The outcome of patients with ILD is extremely poor.Should IPF/COPD patients be excluded from IMV after failing a NIV trial?
43 Use of a novel veno-venous extracorporeal carbon dioxide removal system as an alternative to endotracheal intubation in a lung transplant candidate with acute respiratory failure.Submitted to Respiratory Care
45 NIV in AECOPD: conclusions Confirm and reinforce the routine use of NIV, however:Suggest caution with NIV among patients at high risk of failureThe problem of transitioning from NIV to IMV: may not be in the interest of patients!