Acute cardiac decompensation: the role of MV Massimo Antonelli, MD Dept. of Intensive Care & Anesthesiology Università Cattolica del Sacro Cuore, Rome-Italy

Effects of different ventilatory mode on cardiopulmonary performance SPONT. PARTIAL ASSIST. TOTAL ASSIST. Mofied from Synder 1984

Effects PEEP on venous return Fessler 1992 PEEP Basal condition

Interrelationship between the venous return and cardiac function Pinsky R 1987

HEART ITP ITP and BLOOD FLOW  effort =  - ITP and  VR and  RV blood volume  LV afterload and  LV blood volume  chest blood volume ITP and BLOOD FLOW  effort =  - ITP and  VR and  RV blood volume  LV afterload and  LV blood volume  chest blood volume THORAX VCVC ITP and LV function  effort =  - ITP =  Ptm(trans. Pressure)=  LV afterload ITP and LV function  effort =  - ITP =  Ptm(trans. Pressure)=  LV afterload ITP and RV function  + ITP=  Pra  Pms (upstream pressure)]  VR and RVEDV ITP and RV function  + ITP=  Pra  Pms (upstream pressure)]  VR and RVEDV AO RVLV

CARDIOVASCULAR EFFECTS of MV  ITP during CHF  pre-load due to the decrease of the venous returrn  Ptransm LV e  afterload of LV  CI,  SVi when PCWP > 12 mm Hg Buda AJ NEJM 1979; Farden F NEJM 1981; T.D.Bradley et al. Am.Rev.Respir.Dis. 1992; 145: 377 M.T.Naughton e al. Circulation 1995; 91: 1725 F. Lenique 1994

Effect of  ITP on CO in CHF patients Pinsky 1987

EFFECTS on the RESPIRATORY System  VA/Q  elastic workload  resistive workload  treshold workload due to Peepi ? Gherini S Chest 1979; Perel A Intensive Care Med1983; KatzJA Anesthesiology 1985; Gattinoni L. Am Resp Dis 1987; Naughton M.T. Circulation 1995; Lenique F. 1994

 Vt and  (Vd/Vt)   Va  inspiratory effort  load imposed by spontaneous ventilation  VCO 2    PaC0 2  Vt   Va/Q  inspiratory effort  V0 2    Pa0 2 PaC0 2 K VCO 2 Va PaC0 2 K VCO 2 Va How does ABG improve ?

Effects of MV during CPE

TRATTAMENTO CPAP/IPPV Net filtration =LpS x [(Pcap - Pif) - s(cap - if)]

LV failure Pulmonary edema Pulmonary edema  Pulmonary compliance  Pulmonary compliance  Airway resistance  Airway resistance  Negative Intrathoracic Pressure Swing  Negative Intrathoracic Pressure Swing  Work of breathing  Work of breathing  CO  PaO 2 Respiratory muscle fatigue  DaO 2

LV failure Pulmonary edema Pulmonary edema  Pulmonary compliance  Pulmonary compliance  Airway resistance  Airway resistance  Negative Intrathoracic Pressure Swing  Negative Intrathoracic Pressure Swing  LV transmural pressure  O2 Cost of breathing  O2 Cost of breathing  LV afterload

  ITP    WOB    Negative Pleural Pressure  RV pre-load  LV after-load   Resp. muscles O2 demand  Cardiac O2 demand

P<0.037 Masip, Lancet, 2000;356: patients with CPE 3 patients withdrawn P<0.002 *Time needed for SAT >96% and RR<30b/min

NPPV plus SMT One randomized controlled trials Case Series and Case Reports ( ) 22 patients. 8 (36.3%) required intubation

NPPV plus SMT vs SMT Hoffmann B* 1999 (29 pts) vs. Rusterholtz T °1999 study (26 pts) *PSV 12 to 24 (mean 16,6)* plus Peep 2 to 8 (mean 5.5) cmH 2 0 vs. °PSV 20.5  4.7° cmH 2 0 plus Peep 3.5  2.3 cmH 2 0 Sa  11* vs 84  12°; PaC  18.5* vs 54.2  15°; pH 7.22  0.1° vs 7.25  0.11* 1 pts reqired intubation ( 3.4%)* 5 pts required intubation (19.2%)°

NIPPV vs SMT compared to NIPPV vs CPAP Hoffmann and Rusterholtz studies (55pts)* vs Metha study (27 pts)° 6 pts were intubated (11%)* 2 pts were intubated (7%)°

NIPPV plus SMT vs CPAP and SMT Mehta SJ, Gregory D, Woolard RH, et al. Randomized prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit.Care Med.1997; 25(4): Pang D Chest 1998

NPPV plus SMT vs CPAP plus SMT Mehta S et al. Crit. Care Med no differences between CPAP and NPPV in the need for intubation and mortality MI 71% (NIPPV) vs il 31% (CPAP)

CPAP plus SMT vs NIPPV plus SMT Mehta S et al. Crit. Care Med no differences between CPAP and NIPPV in the need for intubation and mortality MI occurred in 71% (NIPPV) vs il 31% (CPAP) even though baseline differences showed a trend toward more patients with chest pain in the NIPPV group vs CPAP group. Pang Chest 1998

Randomized Studies: Hypoxiemic ARF timing Early=to prevent (1) and established=to treat (2)

Studies: Hypoxiemic ARF a total of 176 pts randomized to NIV

Noninvasive vs Conv. Mechanical Ventilation: an epidemiologic survey: hypoxemic, hypercapnic ARF and CPE Carlucci at al. (SRLF collaborative group), AJRCCM 2001;163: (prospective survey 3 wk, 42 ICU) Mortality 22% NP 11(10%) LoS in ICU 5.1(5.7) days Duration of MV 8(6.3) days NIV N=108 (16%) Mortality 41% NP 72(19%) LoS in ICU 7.8(9.8) days Duration of MV 13.9(14.5) days ETI N=581 P<0.002 P= 0.03 P<0.001 P<0.04 SAPSII 36(20) SAPSII 47(21)* *P< pts MV NIV 14% pts Hypoxemic ARF 27% pts CPE 50% Pts HypercapnicARF

354 consecutive patients with hypoxemic ARF in 7 Centers (Europe and USA): PaO2/FiO2 < 200 breathing O2 (Venturi) RR>30, AC accessory muscles or paradoxical abd. Mot. COPD excluded 86 ARDS ( P/F < 200, bil. Pulm.infiltrates, absence of LVF) 108 (30%) failure 264 (70%) success. Antonelli et Al. Intensive Care Med 2001;27: