1. Insufficienza Respiratoria
Andrea Vianello
Fisiopatologia e Terapia Intensiva Respiratoria
Ospedale – Università di Padova 1

2.  VE Airway narrowing & obstruction Airway Inflammation  Frictional
WOB
Shortened
muscles
curvature
Auto-
PEEP
 Elastic
WOB
Gas
trapping
 VCO2
 muscle
strength
 VT
 VE
 VA
PaCO2 pH
PaO2

3. Steroids Abx BDs Teophylline  VE 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
 VCO2
 muscle
strength
 VT
 VE
 VA
PaCO2 pH
PaO2

4. Steroids Abx PEEP BDs Teophylline MV MV  VE MV 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 MV
 VCO2
 muscle
strength
 VT
 VE MV
 VA
PaCO2 pH
PaO2

5. Non-Invasive Ventilation
“a form of ventilatory support that avoids airway invasion”
Hill et al Crit Care Med 2007; 35:2402-7

6. NIV VS TRATTAMENTO STANDARD
Keenan S et al

7. NIV VS TRATTAMENTO STANDARD
Keenan S et al

8. NIV - Meta-analysis (n=8)
NPPV resulted in
decreased 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 in
pH (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 ospedale
con 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. 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.

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

17. When to use Non-Invasive Ventilation

18. 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

19. Eur Respir J 2002; 19: 1159–66

20. Definition of the three levels of care
European Task Force on Respiratory Intermediate Care Survey
Corrado 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 Life
Evaluation of all 449 patients receiving NPPV for a 1-yr period for acute or acute on chronic RF
CPE (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%, respectively
Hospital mortality for patients with acute hypoxemic RF who failed NPPV was 64%
Schettino G. Crit Care Med 2008; 36:441-7 24

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 IMV
Patients died before IMV could be started
Good 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 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

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/oxygenate
Delayed NIV treatment
Inappropriate ventilatory technique
Patient’s clinical condition
B. Dependence on non-invasive support
Lack of improvement of acute illness
C. Complications

31. NIV failure is predicted by:
Advanced age
High acuity illness on admission (i.e. SAPS-II >34)
Acute respiratory distress syndrome
Community-acquired pneumonia with or without sepsis
Multi-organ system failure

33. 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 1995;50:755-7

34. NIV complications Complication Incidence (%) Major Minor
Aspiration pneumonia
<5
Haemodinamyc collapse
Infrequent
Barotrauma
Rare
Minor
Noise
50-10
CO2 rebreathing
50-100
Discomfort
30-50
Claustrophobia
5-20
Nasal skin lesions
2-50

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 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 36

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 subjects 62
Age (mean ± SD) , yrs
65.4±19.3
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)

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 = ±36.9
COPD = 53.90±7.3
ILD = 31.13±7.8
] p=0.0176
] p<0.0001
Kaplan-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=0.0071
Kaplan-Meier function of survival for dichotomus age (50 and >50)

42. 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?

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