Differences and similarities of acute pulmonary oedema (APE) and acutely decompensated chronic heart failure (ADHF)

1
???? se ??? p?e?µ????? ??d?µa
??a???? ?sa?????? 2? ?a?ep?st?µ?a?? ???????
??tat???? Te?ape?a? ?tt??? ??s???µe??
2
Acute Cardiogenic Pulmonary Oedema

• Common - 15-20,000 hospital admissions per annum
  in UK
• Deadly - 15-20 in-hospital mortality
• Costly - 6.5 million hospital days per annum in
  USA

• Acute pulmonary edema represents nearly 20 of
  acute heart failure cases.
• The diagnostic criteria of this syndrome have not
  been universally established.
• Sudden onset of severe dyspnoea /the presence of
  typical signs on physical examination /alveolar
  oedema on chest radiograph / and acute
  respiratory failure

Eur Heart J. 2008292388-442
3
Differences and similarities of acute pulmonary
edema (APE) and acutely decompensated chronic
heart failure (ADHF)
Parissis, Eur J Heart F, 2010
4
Standard CPE therapy

• Loop Diuretic Therapy
• Nitrate Therapy
• Oxygen Therapy
• (Opiates)
• Treat Underlying Cause

5
??? ?a?d???e??? p?e?µ????? ??d?µa

• ?e?ast???? f??t???
• ? f??t??? a?t?st?se?? (Noble, JAP 1975)
• ?? a?. µ?e? pa?????? ? p?es? ??a ??a??p???t???
  ??? ?a? VT
• ? a???t???? e?d????a????? p?es?? ?
• ? p??f??t??? ?a? µetaf??t??? t?? ??????? (Hall,
  JAP 1998)
• ? e?e??e?a??? ??st??? a?ap???? ? ? µetaf???? ?2
  st? µ?????d??

6
Targets of ventilation incardiogenic pulmonary
oedema

• improvement of oxygenation
• improvement of respiratory acidosis
• reduction of work of breathing
• improvement of cardiac performance
• reduction of patients distress

7
Physiological Improvement with CPAP in Pts with
CardPE
Kelly et al. Eur Heart J 2002231379-1386
8
Non-invasive Ventilation In Acute Cardiogenic
Pulmonary Oedema
When the household vacuum cleaner is employed,
the machine should be run for some minutes first
of all to get rid of dust
Poulton EP, Oxon DM Left-sided heart failure
with pulmonary oedema Its treatment with the
"pulmonary plus pressure machine." Lancet
(1936)231981-983.
9
354 consecutive pts 7 centers EURUSA
10
(No Transcript)
11
(No Transcript)
12
When to start NIV in CPE

• Patients with pH lt7.25 or
• systolic blood pressure less than 180 mmHg
  associated with hypercapnia
• should be promptly considered for NIV. With
  this strategy about 40 of the patients would be
  initially treated with this technique, which
  would involve nearly 90 of the patients that
  require intubation.

Masip J, et al. Risk factors for intubation as a
guide for noninvasive ventilation in patients
with severe acute cardiogenic pulmonary edema.
Intensive Care Med 2003291921-1928
13
NIV failure in CPE decide early

• Worsening encephalopathy/agitation
• Inability to clear secretion
• Inability to accept any interface
• Hemodynamic instability
• Worsening oxygenation
• Progressive respiratory acidosis (pHlt7.2)
• Persistent tachypnea-tachycardia

14
Effects of Noninvasive Ventilation on Mortality
Masip et al, JAMA 20052943124-3130
15
Mortality reduced from 22 to 11 RR 0.53 (95
CI 0.35-0.81) (Individual Group Sizes of n 9
to 46)
Masip et al. JAMA 20052943124-3130
16
Effects of Noninvasive Ventilation on Need to
Intubate
Masip et al, JAMA 20052943124-3130
17
Effects of Continuous Positive Airway Pressure vs
Noninvasive Pressure Support Ventilation
Masip et al, JAMA 20052943124-3130
18
NIV for CPE (Cochrane Review) MortalityVital
FMR. et al., 2008
19
NIV for CPE (Cochrane Review) Intubation
rateVital FMR. et al., 2008
20
3-CPO

• In patients with acute cardiogenic pulmonary
  oedema
• Aims
• Clinical effectiveness of non-invasive
  ventilation
• Comparative effectiveness of CPAP and NIPPV
• Safety of non-invasive ventilation
• Hypothesis
• Non-invasive ventilation reduces mortality

Gray et al NEJM 2008 359142-51
21
CPOE3Standard vs CPAP vs NIPPV

• 26 hospitals in the UK, open, randomized,
  controlled, multicentre trial, in the ED
• Designed to
• evaluate the effect of NIV on Pulmonary Edema
  mortality compared with standard therapy
• to compare the effectiveness of CPAP vs. NIPPV
• 1069 patients, hospitalized with pulmonary edema,
  tachypnea (gt20 breaths/min) and acidosis
• Randomized to at least 2 h of 60 O2 delivered
  either by standard face mask (n367), CPAP
  (n346) or NIPPV (n356)

Gray et al NEJM 2008 359142-51
22
3-CPObaseline characteristics
Standard CPAP NIPPV All
Number 367 346 356 1069
Age (years) 78.7 77.6 77.2 77.8
Sex (male) 42 45 43 43
Sx of MI at Presentation 22 22 22 22
Ischemic heart disease 63 65 60 63
Congestive heart failure 45 42 47 44
Valvular heart disease 12 11 9 11
COPD 19 15 21 18
Hypertension 56 55 57 56
Diabetes Mellitus 30 30 33 31
Hypercholesterolemia 30 33 31 32
Current Smoker 16 19 19 18
PVD 10 11 10 10
Cerebrovascular disease 18 17 16 17
Gray et al NEJM 2008 359142-51
23
3-CPOImmediate therapeutic interventions
Standard CPAP NIPPV All
Nitrate Therapy 93 88 91 90
Diuretic Therapy 90 89 89 89
Opiate Therapy 3 5 4 4
Inspired Oxygen (L/min) 124 134 124 124
Ventilation Pressure (cmH2O) - 104 145/72 -
24
CPOE3Standard vs CPAP vs NIPPV
Standard CPAP NIPPV P-value
Treatment allocated 365 342 351
Started allocated treatment 365 (100) 336 (98.2) 341 (97.2) 0.07
Completed allocated treatment 298 (83.2) 284 (84.5) 265 (77.7) 0.016
Not tolerated 1 (0.3) 18 (5.4) 30 (8.8) lt0.001
Worsening ABGs 26 (7.1) 10 (3.0) 15 (4.4) 0.027
Respiratory distress 31 (8.5) 5 (1.5) 12 (3.5) lt0.001
Other reason 17 (4.6) 24 (7.1) 25 (7.3) 0.152
Changed to standard 3 (0.8) 32 (9.5) 51 (15.0)
Changed to CPAP 43 (11.8) 1 (0.3) 12 (3.5)
Gray et al NEJM 2008 359142-51
25
3-CPO Physiological Response to InterventionOne
Hour Physiology
Standard CPAP or NIPPV P Value (t-test)
Pulse rate (/min) 10223 9622 lt0.001
Systolic BP (mmHg) 12830 12427 0.073
Diastolic BP (mmHg) 6520 6618 0.390
Respiratory Rate (/min) 266 256 0.023
Oxygen Saturation () 946 936 0.044
Arterial pH 7.300.08 7.320.08 lt0.001
Arterial pO2 (kPa) 14.18.5 13.0 9.0 0.074
Arterial pCO2 (kPa) 6.72.5 6.21.9 lt0.001
Bicarbonate (mmol/L) 228 226 0.934
Gray et al NEJM 2008 359142-51
26
CPOE3Standard vs CPAP vs NIPPV
Gray et al NEJM 2008 359142-51
27
CPOE3 CPAP vs NIPPV
Gray et al NEJM 2008 359142-51
28
CPOE3CPAP vs NIPPV
CPAP NIPPV OR 95 CI P Value
7-Day Mortality 9.6 9.4 0.97 0.59 to 1.61 0.912
7-Day Mortality/ Intubation 11.7 11.1 0.94 0.59 to 1.51 0.806
30-Day Mortality 15.4 15.4 0.99 0.65 to 1.51 0.976
Gray et al NEJM 2008 359142-51
29
3-CPO

• In patients with acute cardiogenic pulmonary
  oedema, non-invasive ventilation
• Produces more rapid resolution of metabolic
  abnormalities and respiratory distress
• Has no major effect on 7-day or 30-day mortality
• Is beneficial irrespective of the mode (CPAP or
  NIPPV) of delivery

Gray et al NEJM 2008 359142-51
30
Masip, Mebazaa, NEJM 2008, 3592068
31
CPAP vs NIPSV Intubation rate
Argawal, Singapore Med 2009
P0.97
P0.46
P0.49
32
Early vs late CPAP in the out-of-hospital
environment
Plaisance P et al. Eur. Heart J. 2007 282895
33
Early vs late CPAP
p lt 0,05
Plaisance P et al. Eur. Heart J. 2007 282895
34
Early vs late CPAP
Early CPAP Late CPAP p-value
Intubation Rate 6 16 0,01
Intubation between T0 and T15 1 8
Need for Dobutamine 0 5 0,02
In-hospital Mortality 2 8 0,05
Plaisance P et al. Eur. Heart J. 2007 282895
35
Early vs late CPAP in the out-of-hospital
environment

• Conclusion When compared to usual medical care,
  immediate application of CPAP alone in
  out-of-hospital treatment of ACPO is
  significantly better improving physiological
  variables and symptoms and significantly reduces
  tracheal intubation incidence and in-hospital
  mortality.

Plaisance P et al. Eur. Heart J. 2007 282895
36
Boussignac CPAP

• CPAP device
• Vygon Boussignac CPAP
• maximum pressure 8 mbar
• Cigada M et al.
• Novel indications for the Boussignac CPAP
  valve. Intensive Care Med 200733374-375.

37
??e?µ????? ??d?µa ?a? NIV

• To ??? p?e?µ????? ??d?µa ap?te?e? p????µ?a??
  ped?? efa?µ???? t?? ??V
• ??s? ? CPAP ?s? ?a? ? NIPPV µe?????? st?? ?d??
  ßa?µ? t?? a????? ??a d?as?????s? ?a? ße?t??????
  t? d?sp???a ?a? t?? f?s????????? pa?aµ?t????
• ? ??V de? fa??eta? ?a ep??e??e? t? ???t?t?ta

38
??e?µ????? ??d?µa ?a? NIV

• ?p?te?esµat???te??? st??? as?e?e?? µe ?pe??ap??a-
  ? NIPPV de? fa??eta? ?a ?pe?te?e? t?? CPAP
• ?e? fa??eta? ?a s?et??eta? µe ep?p????? ?p?? t?
  OEM
• H p????s???µe?a?? ???s? t?? s??d???eta? µe ?et???
  ap?te??sµata.