High Dependency Units Definitions

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Insufficienza Respiratoria
Andrea Vianello Fisiopatologia e Terapia
Intensiva Respiratoria Ospedale Università di
Padova
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Airway narrowing obstruction
Airway Inflammation
? Frictional WOB
Shortened muscles curvature
Auto- PEEP
? Elastic WOB
Gas trapping
? muscle strength
? VT
? VE

• PaCO2
• pH
• PaO2

? VA
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usa i farmaci e bene !
Airway narrowing obstruction
Airway Inflammation
Steroids
? Frictional WOB
Abx
Shortened muscles curvature
Auto- PEEP
BDs
? Elastic WOB
Gas trapping
Teophylline
? muscle strength
? VT
? VE

• PaCO2
• pH
• PaO2

? VA
4
usa i farmaci e bene !
Airway narrowing obstruction
Airway Inflammation
Steroids
? Frictional WOB
Abx
PEEP
Shortened muscles curvature
Auto- PEEP
BDs
? Elastic WOB
Gas trapping
Teophylline
MV
? muscle strength
? VT
? VE
MV

• PaCO2
• pH
• PaO2

? VA
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Non-Invasive Ventilation
a form of ventilatory support that avoids airway
invasion
Hill et al Crit Care Med 2007 352402-7
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NIV VS TRATTAMENTO STANDARD
Keenan S et al
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NIV VS TRATTAMENTO STANDARD
Keenan S et al
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NIV - Meta-analysis (n8)

• NPPV resulted in
• decreased mortality (RR 0.41 95 CI 0.26,
  0.64),
• decreased need for ETI (RR 0.42 95CI 0.31,
  0.59)
• Greater improvements within 1 hour in
• pH (WMD 0.03 95CI 0.02, 0.04),
• PaCO2 (WMD -0.40 kPa 95CI -0.78, -0.03),
• RR (WMD 3.08 bpm 95CI 4.26, -1.89).
• Complications associated with treatment (RR 0.32
  95CI 0.18, 0.56) and length of hospital stay
  were also reduced with NPPV (WMD 3.24 days
  95CI 4.42, -2.06)

Lightowler, Elliott, Wedzicha Ram BMJ 2003
326185
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• 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 ospedale
• con NIV 48 evitano ETI, sopravvivono con
  permanenza in ICU inferiore vs pazienti VM
  invasiva (P0.02)
• A 1 anno NIV inferiore riospedalizzazione (65
  vs 100 P0.016) e minor frequenza di riutilizzo
  supplemento di ossigeno (0 vs 36)

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• 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 (P0.01) e probabilità di
  rimanenere in VM (P0.056)
• Se NIV efficace (24/64 38) migliore
  sopravvivenza e ridotta permanenza in ICU vs
  pazienti VM invasiva

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NIV Change in practice over time

• 1992-1996 (mean pH 7.25/-0.07) 1997-1999
  (7.20/-0.08 Plt0.001).
• gt 1997 - risk of failure pH lt7.25 three fold
  lower than in 1992-1996.
• gt 1997 ARF with a pH gt7.28 were treated in
  Medical Ward (20 vs 60).
• Daily cost per patient treated with NIV (558/-8
  vs 470/-14,Plt0.01)

Carlucci et al Intensive Care Med 2003 3419-25
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Epidemiology

• Rationale 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.

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• 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.

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Use of NIPPV or IMV as first-line respiratory
support in patients hospitalized with AECOPD
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Joint BTS/RCP London/Intensive Care Society
Guidelines. NIV in COPD. Oct 2008
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When to use Non-Invasive Ventilation
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Goals of NIV can they be reached?
NIV is time consuming, needs proper equipment,
enough staff with sufficient expertise.
time
technical equipment
staff expertise
predict success of NIV
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Eur Respir J 2002 19 115966
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Definition of the three levels of care
European Task Force on Respiratory Intermediate
Care Survey Corrado et al, ERJ 2002201343-50
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Appropriatezza di utilizzo della Ventilazione
Non-Invasiva in ambito pneumologico
nellassistenza ai pazienti con BroncoPneumopatia
Cronica Ostruttiva in fase acuta.
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• Rate of NIV failure is extremely different
  according to study design, severity of illness
  and level of monitoring

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Sixty-two RCTs including a total of 5870 patients
Overall NIV failure 16.3
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NIV Real Life

• Evaluation of all 449 patients receiving NPPV for
  a 1-yr period for acute or acute on chronic RF
• CPE (n97)
• AECOPD (n87)
• non-COPD acute hypercapnic RF (n35)
• postextubation RF (n95)
• acute hypoxemic RF (n144)
• Intubation rate was 18, 24, 38, 40, and 60,
  respectively
• Hospital mortality for patients with acute
  hypoxemic RF who failed NPPV was 64

Schettino G. Crit Care Med 2008 36441-7
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• The percentage of patients transitioned from NIV
  to IMV 5 and did not increase from 1998 to 2008

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Reasons for low rate of IMV use after NPPV,
compared to clinical trial

• End of life decision to not accept IMV
• Patients died before IMV could be started
• Good selection of appropriate patients

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• High mortality rate (30) ? over time
• OR for death1.63, compared to those initially on
  IMV
• ?hospital stay

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• Nearly one third of patients for whom there is
  the best evidence base for NIV did not receive it
• Admission pH lt 7.26 66 received NIV compared to
  34 pH 7.26 to 7.34.
• Similar lowest pH
• Significant proportion had a metabolic acidosis
• Hospital 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

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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?

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Aetiology of NIV failure

• Failure to adequately ventilate/oxygenate
• Delayed NIV treatment
• Inappropriate ventilatory technique
• Patients clinical condition
• B. Dependence on non-invasive support
• Lack of improvement of acute illness
• C. Complications

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• NIV failure is predicted by
• Advanced age
• High acuity illness on admission (i.e. SAPS-II
  gt34)
• Acute respiratory distress syndrome
• Community-acquired pneumonia with or without
  sepsis
• Multi-organ system failure

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NIV in acute COPD correlates for success

• Retrospective analysis
• 59 episodes of ARF in 47 COPD patients
• NIV success 46
• NIV failure 13
• Predictors for NIV failure
• Higher PaCO2 at admission
• Worse functional condition
• Reduced treatment compliance
• Pneumonia

Ambrosino N, Thorax 199550755-7
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NIV complications
Complication Incidence ()
Major
Aspiration pneumonia lt5
Haemodinamyc collapse Infrequent
Barotrauma Rare
Minor
Noise 50-10
CO2 rebreathing 50-100
Discomfort 30-50
Claustrophobia 5-20
Nasal skin lesions 2-50
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Mask selection - a crucial issue!
CO2 rebreathing (50-100)
Noise (50-100)
Leak/Discomfort (30-50)
Claustrophobia (5-20)
Nasal skin lesions (2-50)
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NIV should not be used in

• Respiratory arrest
• Inability to tolerate the device, because of
  claustrophobia, agitation or uncooperativeness
• Inability to protect the airway, due to
  swallowing impairment
• Excessive secretions not sufficiently managed by
  clearance techniques
• Recent upper airway surgery

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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)

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Transition to IMV(personal experience, 2011-2013)
Number of subjects 62
Age (mean SD) , yrs 65.419.3
Gender (males, females) 26, 36
Ineffective NIV, n () Severe hypercapnia Severe hypoxemia 52 (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 hosp Discharged from hosp 41 (66.1) 21 (33.9)
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Kaplan-Meier function of overall survival
Median survival 46 days (95 CI, 43 to 162)
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Kaplan-Meier function of survival according to
baseline condition
Mean survival NM/CW 305.5836.9 COPD
53.907.3 ILD 31.137.8
p0.0176
plt0.0001
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Kaplan-Meier function of survival for dichotomus
age (?50 and gt50)
Median survival ?50 380.0 d (95CI, 15.0 to
n.c.) gt50 45.0 d (95CI,24.0 to 54.0)
p0.0071
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Remarks

• Mortality 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?

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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
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NIV in AECOPD conclusions

• Confirm and reinforce the routine use of NIV,
  however

• Suggest caution with NIV among patients at high
  risk of failure

• The problem of transitioning from NIV to IMV may
  not be in the interest of patients!