agenda ddefinition & mechanism of action iindications wwhen, who, where, what & how ?...
TRANSCRIPT
Non-Invasive Ventilation
Arjun Srinivasan, Mahadevan & PattabhiramanPulmonology Associates
KMCH
Agenda
Definition & mechanism of action
Indications
When, who, where, what & how ?
Technical aspects
Weaning off NIV
Complications
NONINVASIVE VENTILATION
Non-invasive ventilation (NIV) refers to a form of assisted ventilation that involves provision of ventilatory support without endotracheal intubation (ETI)
CPAP vs. NIV
CPAP
Pressure greater than atm applied to proximal airway throughout resp cycle Splints airway Increases lung
volume Raises intrathoracic
pressures Does not offload resp
muscles
NIV
Greater pressure applied during inspiration over and above the baseline CPAP Unloads resp muscles Can provide complete
resp support
NIV – how it works
Decreasing work of breathing
Off loading of resp muscles & decreasing fatigue
Preventing wide swings in intrathoracic pressure
Decreasing afterload to heart
Preventing complications of IMV Intubation & MV Loss of airway defenses Post extubation issues
NIV
Whom to initiate ?
Acute COPD Pulmonary edema Immunocompromised patients Weaning from mechanical Neuromuscular weakness Bronchial asthma ARDS Do not intubate – pts Other indications
Chronic
What is expected of NIV ?
NIV in COPD exacerbation
COPD exacerbation is a perfect indication for NIV use Excellent candidates for partial respiratory
support Offloads respiratory muscles & prevents
dynamic hyperinflation Gives time for the bronchodilators & steroids to
take effect Supports till balance of respiratory system is
restored
First study on COPD exacerbation
Pressure support ventilation by face mask leads to:
Reduced need for intubation
Duration of mechanical ventilation
Duration of ICU stay
LIMITATIONS OF STUDY
Used historical controls
Not randomized controlled trial
Bochard et al., 1990 NEJM
First RCT
Compared NIV (n =30)with conventional therapy (n = 30):Equal number received bronchodilators, corticosteroids and antibiotics therapy
Within first hour
NIV patients had greater improvement in pCO2 and dyspnea scoreMortality of 10% in NIV group as compare to 30 % in control groupBott et al, Lancet 1993
Risk of treatment failure in seven studies of NPPV as an adjunct to usual medical
care
0
0.5
1
1.5
2
2.5
3A
vd
eev e
t
al 1998
Barb
e e
t al
1996
Bott
et
al
1993
Bro
ch
ard
et
al 1995
Celikel et
al 1998
Dik
en
soy
et
al 2002
Pla
nt
et
al
2000
Tota
l
(95%
CI)
NPPVUsual Medical Care
0.58
6.60
0.38
0.36
0.17
0.51
0.63 0.51
BMJ 2003;;326:1-5
Risk of treatment failure in seven studies of NPPV as an adjunct to usual medical care
0.63 (0.39 to 1.00)
35/11822/118Plant et al 2000
0.51 (0.38 to 0.67)
106/26155/268Total (95% CI)
0.51 (0.18 to 1.45)
7/174/19Dikensoy et al 2002
0.17 (0.02 to 1.22)
6/151/15Celikel et al 1998
0.36 (0.21 to 0.59)
33/4212/43Brochard et al 1995
0.38 (0.16 to 0.94)
13/305/30Bott et al 1993
6.60 (0.39 to 110.32)
0/104/14Barbe et al 1996
0.58 (0.27 to 1.27)
12/297/29Avdeev et al 1998
Risk ratio (fixed 95%
CI)Risk ratio (fixed 95% CI)
Usual medical
careNPPVStudy
0.63 (0.39 to 1.00)
35/11822/118Plant et al 2000
0.51 (0.38 to 0.67)
106/26155/268Total (95% CI)
0.51 (0.18 to 1.45)
7/174/19Dikensoy et al 2002
0.17 (0.02 to 1.22)
6/151/15Celikel et al 1998
0.36 (0.21 to 0.59)
33/4212/43Brochard et al 1995
0.38 (0.16 to 0.94)
13/305/30Bott et al 1993
6.60 (0.39 to 110.32)
0/104/14Barbe et al 1996
0.58 (0.27 to 1.27)
12/297/29Avdeev et al 1998
Risk ratio (fixed 95%
CI)Risk ratio (fixed 95% CI)
Usual medical
careNPPVStudy
BMJ 2003;;326:1-5
0
1
2
3
4
5
6A
vd
eev e
t al 1998
Barb
e e
t al 1996
Bott
et
al 1993
Bro
ch
ard
et
al 1995
Celikel et
al 1998
Dik
en
soy e
t al 2002
Kra
mer
et
al 1995
Pla
nt
et
al 2000
Tota
l (9
5%
CI)
NPPVUsual medical Care
Risk of endotracheal intubation in eight trials of NPPV as an adjunct to
usual medical care
0.620.20
0.35
0.50
0.29
0.14
0.56
0.42
Risk of endotracheal intubation in eight trials of NPPV as an adjunct to usual medical care
0.56 (0.34 to 0.94)32/11818/118Plant et al 2000
0.14 (0.02 to 0.92)8/121/11Kramer et al 1995
0.42 (0.31 to 0.59)90/27338/273Total (95% CI)
0.29 (0.07 to 1.18)7/172/17Dikensoy et al 2002
0.50 (0.05 to 4.94)2/151/15Celikel et al 1998
0.35 (0.20 to 0.60)31/4211/43Brochard et al 1995
0.20 (0.01 to 4.0)2/300/30Bott et al 1993
Not estimable0/100/10Barbe et al 1996
0.62 (0.23 to 1.68)8/295/29Avdeev et al 1998
Risk ratio (fixed 95% CI)
Risk ratio (fixed 95% CI)Usual
medical care
NPPVStudy
0.56 (0.34 to 0.94)32/11818/118Plant et al 2000
0.14 (0.02 to 0.92)8/121/11Kramer et al 1995
0.42 (0.31 to 0.59)90/27338/273Total (95% CI)
0.29 (0.07 to 1.18)7/172/17Dikensoy et al 2002
0.50 (0.05 to 4.94)2/151/15Celikel et al 1998
0.35 (0.20 to 0.60)31/4211/43Brochard et al 1995
0.20 (0.01 to 4.0)2/300/30Bott et al 1993
Not estimable0/100/10Barbe et al 1996
0.62 (0.23 to 1.68)8/295/29Avdeev et al 1998
Risk ratio (fixed 95% CI)
Risk ratio (fixed 95% CI)Usual
medical care
NPPVStudy
BMJ 2003;;326:1-5
Mortality in seven studies of NPPV as an adjunct to usual medical care
0123456789
10
Avd
eev e
t al 19
98
Barb
e e
t al 19
96
Bott
et
al
1993
Bro
ch
ard
et
al 199
5
Celikel et
al 19
98
Dik
en
soy e
t al 20
02
Pla
nt
et
al 20
00
Tota
l (9
5%
CI)
NPPVUsual medical care0.33 0
0.33 0.33 0.33
0.50
0.50
0.41
Mortality in seven studies of NPPV as an adjunct to usual medical care
0.50 (0.26 to 0.95)
24/11812/118Plant et al 2000
0.41 (0.26 to 0.64)
57/26123/62Total (95% CI)
0.50 (0.05 to 5.01)
2/171/17Dikensoy et al 2002
0.33 (0.01 to 7.58)
1/150/15Celikel et al 1998
0.33 (0.11 to 0.93)
12/424/43Brochard et al 1995
0.33 (0.10 to 1.11)
9/303/30Bott et al 1993
Not estimable0/100/10Barbe et al 1996
0.33 (0.10 to 1.11)
9/293/29Avdeev et al 1998
Risk ratio (fixed 95% CI)
Risk ratio (fixed 95% CI)Usual
medical care
NPPVStudy
0.50 (0.26 to 0.95)
24/11812/118Plant et al 2000
0.41 (0.26 to 0.64)
57/26123/62Total (95% CI)
0.50 (0.05 to 5.01)
2/171/17Dikensoy et al 2002
0.33 (0.01 to 7.58)
1/150/15Celikel et al 1998
0.33 (0.11 to 0.93)
12/424/43Brochard et al 1995
0.33 (0.10 to 1.11)
9/303/30Bott et al 1993
Not estimable0/100/10Barbe et al 1996
0.33 (0.10 to 1.11)
9/293/29Avdeev et al 1998
Risk ratio (fixed 95% CI)
Risk ratio (fixed 95% CI)Usual
medical care
NPPVStudy
BMJ 2003;;326:1-5
Role of NIV in COPD exacerbation
Established beyond doubt that NIV decreases Failure Intubation (NNT 4) Mortality (NNT 10)
Chandra et al. analyzed healthcare utilization between 1998 -2008 and concluded that patients who get intubated after failed NIV had higher mortality Increasing use of NIV in difficult to ventilate patients Continuation of NIV despite lack of early improvement
NIV in cardiogenic pulmonary edema
Robust data supporting use of NIV in CPE
Cochrane review of 21 trials and 1071 subjects showed NIV Decreases intubation (NNT 8) Decreases in hospital mortality (NNT 13) Does not increase risk of MI
Winck et al, reviewed 7 studies comparing NIV vs. CPAP and showed both were equally efficient even in patients with hypercapnea
NIV in extubation
NIV as a tool for facilitating extubation and weaning off ventilator
NIV post extubation for preventing respiratory failure for patients at risk
NIV as a treatment for established extubation failure
NIV in weaning
Latest review included 16 trials involving 994 patients with COPD & mixed populations
They analysed effect on Weaning failure VAP Mortality
Effect on weaning failure
Effect on VAP
Effect on mortality
NIV for preventing weaning failure in at
risk group Patients of hypercapneic respiratory failure
including COPD, neuromuscular dis orders
NIV post extubation as per protocol to prevent weaning failure
Studies have shown significant benefit with NIV in these sub- groups
NIV in established extubation failure
2 trials till date have looked at NIV in established extubation failure
Both have not shown any benefit in Re intubation rate ICU mortality
NIV in post operative patients
Main aim in post operative patients is Prevent acute respiratory failure Treat acute respiratory failure and prevent intubation
29 studies identified in a recent review
Significant heterogeneity in the type of surgery, patient co morbidities & outcome measurements
Take home point is despite lack of RCT NIV improved blood gas & prevents hypoxemia in most cases
Summarizing role in weaning
Definite role in weaning COPD patients
Preventing re-intubation in high risk group
No evidence to support its use in established weaning failure
Should be considered in post operative period for preventing & treating respiratory failure
Immunocompromised patients
NIV plays a vital role in management of these patients
Intubation is associated with significant morbidity & mortality
2 RCTs & several observational studies have been consistent in demonstrating NIV Improves oxygenation Reduces intubation Reduces mortality
NIV in ARDS
Area of intense debate & no consensus
Studies & systematic reviews have shown May decrease intubation rates, ICU stay in select
sub-groups who show early response High rates of failure Disturbingly patients who get intubated after failed
NIV have higher mortality
Use with caution / not at all
When in doubt, intubate
NIV in asthma
Data is scarce in Asthma
Early studies showed no clear benefit
Recent study from PGI showed better lung function with lower bronchodilator requirements with NIV
Likely to remain this way as with modern therapy established respiratory failure requiring ventilatory support is very rare
NIV in do not intubate
NIV is being increasingly used in these patients especially in wards
Recent studies have shown Up to 43 % of these patients survive to discharge Depends on primary etiology
COPD & CCF fare better Better sensorium / ability to clear secretions have
better outcome Post exubation failure, hypoxemic respiratory failure
& end stage cancers patients fare poorly
NIV in DNI- guidelines
Goals NIV in patients without any restrictions to other life
supporting treatments NIV in patients refusing endotracheal intubation NIV as the only support (TLC group)
Need to discuss goals clearly & get consent from relatives
Unclear issues Whether actually provides comfort ?
Or Just prolongs the dying process ?
NIV in chest trauma
Recent systematic review of 9 studies showed in In blunt trauma chest without ALI, NIV
Reduces intubation Hypoxemia ICU stay Mortality
With established ALI Controversial with no good data
NIV for pre-oxygenation
2 RCTs have evaluated 3-5 mins of NIV as compared to routine preoxygenation before intubation
NIV associated with Higher SpO2 immediately after & at 5 mins Higher lung volumes Especially in morbidly obese patients
NIV in OHS
Acute exacerbation patients fare similarly if not better than COPD patients with hypercapneic respiratory failure
They they get intubated, will need NIV immediately post extubation
These patients need continuance of care with home NIV
Can have late NIV failures because of non compliance
NIV facilitated FOB
Patient receives NIV (10/5) by full face mask @ 100% FiO2 for 5 minutes preceding procedure
Patient’s vitals & SpO2 are continuously monitored
NIV facilitated FOB
Bronchoscope is introduced through“dual axis swivel” adapter of a catheter mount
This is done after patient is adequately oxygenated
NIV facilitated FOB
2 % lidocaine gel for lubrication & local anesthesia
Mask is replaced after nasal entry of bronchoscope
Tight apposition to ensure no leak
Vitals are continuously monitored
NIV facilitated FOB
BAL - wedging scope against approprite segment (3-5 alliquots of ~ 50 ml NS)
TBLB – after decreasing CPAP to 0 & PS = 10 cms
NIV continued for 30 mins post procedure
Mechanism of action of NIV
• Splinting of upper airway & increasing cross sectional area
• Counteracting the PEEPi created due to obstruction caused by bronchoscope
• Ability to provide FiO2 of 1
• Recruitment of collapsed alveoli- thereby reducing shunt fraction & increasing FRC
• Decreases WOB
Evidence…
Author (Year)
Study No. of patients
Age ± SD
GenderM:F
NIV setting NIV duration Bronchoscopic procedure
Complications
Antonelli et al(3) (1996)
Prospective observational
8 40 ± 14 years
CPAP-4PSV-17FiO2-1
10 minutes before FOB and 90 minutes after the procedure
BAL Two patients died after 5 & 7 days of FOB due to underlying disease
Maitre et al (2002)
Randomized controlled study
30With CPAP-15Without CPAP-15
58 (35-78) 57 (26-83)
15:415:5
CPAP titrated in incremental steps of 2.5 cm H2O up to
7.5 cm
5 minutes before FOB and 30 minutes after the procedure
BAL Bronchial biopsy
Eight patients required intubation, 7 in the O2 group
and 1 in CPAP group
Antonelli et al (2002)
Randomized controlled study
2613-NIV 13-O2
supplement by venturi mask
NIV - 52 ± 20 years O2 - 57
± 10 years
8:8 in both groups
CPAP-4PSV-15 to 17FiO2-0.9
10 minutes before FOB and 30 minutes after the procedure
BAL 4 in NIV 7 in O2 died of underlying illnessNo procedural complications
Antonelli et al (2003)
Prospective observational
4 60.25 years
PSV-10 to 20PEEP- 8 to 14FiO2-0.7to 0.9
Before and during FOB and 30 minute after procedure
BAL One patient died after 48 hours due to underlying disease
Heunks et al (2010)
Prospective observational
12 64.25 years
6:6 PSV-10 PEEP- 6 FiO2-1
20 minutes before FOB until SpO2 > 92% @
FiO2 0.4
BAL Worsening hypoxemia during procedure in 1 patient requiring temporary withdrawal of FOB
Scala et al (2010)
Prospective case-control study
NIV-15CMV-15
NIV-80 ± 5CMV-80 ± 5
12:39:6
PSV-10 to 25 PEEP- 5 FiO2-1
Before FOB until clinical improvement with gradual reduction of PSV
BAL None related to the procedure
Respir Care. 2012 Mar 13. [Epub ahead of print]
Bronchoscopic Lung Biopsy Using Noninvasive Ventilatory Support: Case Series and Review of Literature of NIV-assisted Bronchoscopy.Agarwal R, Khan A, Aggarwal AN, Gupta D.
AbstractRESULTS: Six patients with a mean (SD) age of 44.5 (11.6) years were included in the study. The median (IQR) PaO₂/FiO₂ ratio prior to lung biopsy was 164.5 (146.3-176.3) and the median (IQR) IPAP/EPAP used was 14 (12-15)/5 cm H₂O. FOB was well tolerated and all patients maintained SpO₂ >92% during the procedure. One patient required endotracheal intubation due to hemoptysis. A definite diagnosis was obtained in five of the six patients. A repeat procedure was performed in one patient, which again yielded no diagnosis. No other periprocedural complications were encountered.
CONCLUSIONS: NIV-assisted BLB is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.
Monitoring during NIV
Subjective and objective parameters First 2hrs - intense monitoring Next 8hrs - close monitoring �
There after - routine monitoring
Even if parameters were borderline at start of NIV, early change / improvement predicts success of NIV
This is the most important aspect of NIV
First few hours predict the outcome of the patient
Monitoring during NIV
� Look at patient, ventilator, interface, bed side monitor, ABG
� Patient - Comfort, conscious level
Chest expansion
Accessory muscles
Synchrony
� Interfaces - leak, tightness
� Trigger, volume delivered, cycling
� HR, RR, SpO2, BP
� ABG - pCO2, pH, pO2
at base line, 1-2hrs after, then based on response
Trouble shooting
Potential issues
1. Leak
2. Agitation / asynchrony
3. Hypoxia
4. Hypercarbia
Solutions
1. Check mask fit/ strap position/ tubings / ? Chin strap
2. Talk to patient / adjust settings / sedation /analgesia
3. Adjust ventilator / FiO2/ intubate
4. Adjust ventilator / FiO2/ intubate
Potential indicators of success in NIV
� Younger age
� Lower acuity of illness� Able to cooperate� Better neurologic score� Less air leak
� PaCO2 45 - 60 mmHg
� pH 7.10 - 7.35
� Synchronous breathing� Intact dentition� Less secretions� Better compliance� Improvements in gasexchange and heartrespiratory rates withinfirst 2 hours
Situations where NIV is likely to fail
Hypercapnic failure
GCS < 11
RR > 35/min
PH < 7.25
APACHE > 29
Asynchrony
Agitation / intolerance
Edentulous / excessive leak
No initial improvement
Hypoxemic failure
Diagnosis of ARDS / pneumonia
Age > 40
SBP < 90
Metabolic acidosis PH < 7.25
Low PO2/ FiO2
Simplified APS II > 34
Failure of PO2 / FiO2 to improve above 175 by 1st hour
Weaning patients from NIV
No specific protocol
Pts of COPD would require at least 24 hours to stabilise
NIV is usually removed as per patient’s request for feeding/facial hygiene
Re – attached as deemed necessary
Attempt gradual decrease in IPAP / EPAP & discontinue when patient tolerates
Complications of NIV
Failure is the most serious complication
Most dreaded complication is failure to recognize NIV failure early leading to delay in intubation
Studies have shown that this can lead to increased mortality especially when used in situations where NIV is used without strong evidence
Complications of NIV
Principles of mechanical ventilation. 3e
Summary & conclusions
NIV is an important tool in the hands of RT & intensivist
Provides a level of respiratory support in emergency / wards unimaginable otherwise
Has changed the way we manage COPD exacerbations
Needs careful monitoring during initial hours
A tool which needs to be used wisely for us to reap the benefits
Thank you
Questions ?