THE PATIENT WITH ACUTE HEART FAILURE ON THE ICU

RESPIRATORY SUPPORT Josep Masip, MD, PhD, FESC

Associate Professor of CardiologyUniversity of Barcelona

ICU DepartmentH. Sant Joan Despí Moisès Broggi

Consorci Sanitari Integral

Cardiology Department Hospital Sanitas CIMA Barcelona

HOSPITALCIMA

NO CONFLICT OF INTEREST

ALARM Trial

Follath et al. Intensive Care Med 2011

4.953 Patients 2.247 ICU 1.475 CCU 1.231 wards

75%

Esteban A, et al. JAMA 2004

INTERNATIONAL ICU SURVEY

5.183/ 15.757 33%Mechanical Ventilation

539 (10.4%) Cardiac Failure100 (1.9 %) Cardiac Arrest

12 % Cardiac reasons

Diagnosis on admission n= 6415ACS 69 %Acute Heart Failure 11 % Other* 20 %

Reasons for Invasive MV n=633 Complicated ACS 35 %AHF 25 %Cardiac Arrest 17 %Arrhythmia 11 %Other: 12 %

Reasons for NIV n=194Complicated ACS 34 %AHF 55 %Other: 11 %

Catalunya Survey on Ventilatory Support in the CICU

(*) Acute aortic syndromes, Arrhythmia-AV block, Post Cardiac Arrest; CICU: Cardiovascular Intensive Care Unit; ACS: Acute coronary syndromes; IMV: Invasive mechanical ventilation; NIV: Noninvasive mechanical ventilation; AHF: Acute heart failure

12%

Intensive Care Units• Acute respiratory failure (65%)

• Pneumonia• Sepsis • Trauma

• Surgical complications• Heart failure• ARDS

• Coma • COPD• Neuromuscular disorders• Postoperative high risk interventions

MAIN DISEASES TREATED WITH MV ACCORDING TO THE TYPE OF ICU

Masip J. Mechanical ventilation in AHF. In A. Maisel book 2013

Cardiovascular Intensive Care Unit• Cardiogenic shock (ACS or myocarditis)• Acute pulmonary edema• Cardiorespiratory arrest• Postoperative cardiac surgery

10-20%

30-40%

AHF population managed in the CICU

• Acute Pulmonary Edema

• Acute Coronary Syndrome complicated with AHF

• Cardiogenic Shock

• Cardiac Arrest

• AHF during weaning

• AHF with unstable arrhythmia

• Acute right ventricular failure

• AHF in sepsis and ARDS

• AHF Post Cardiac Surgery

IN THE ICU THESE PATIENTS

SHOULD BE TREATED WITH NONINVASIVE VENTILATION

• Continuous positive airway pressure (CPAP)

• Pressure support ventilation (NIPSV)

Bilevel (BIPAP)

ACUTE PULMONARY EDEMA

Cui-Lian Weng. Ann Intern Med. 2010;152:590-600;

CPAP

Bilevel

56% Reduction

44% Reduction

INTUBATION

Cui-Lian Weng. Ann Intern Med. 2010;152:590-600;

CPAP

Bilevel

36% Reduction

n.s.

MORTALITY

High-flow oxygen administered via nasal cannula connected to heated humidifiers

Carratala JM et al. Rev Esp Cardiol 2011

Flow : up to 60 l/min.

Patients with PaO2/FiO2 < 200mmHg

OverallPopulation

High-Flow Oxygen through Nasal Cannulain Acute HypoxemicRespiratory Failure

Frat J.P et al. NEJM 2015

High-Flow Oxygen through Nasal Cannulain Acute Hypoxemic Respiratory Failure

Frat J.P et al. NEJM 2015

Adaptative Servo-Ventilation (ASV)

Hypopnea

Pressure

Flow

Nakano S, et al. Eur Heart J Acute Cardiovasc Care 2014

58 patients APE were succesfully treated with ASV

CPAP

Oxygen Therapy in AHF

PS-PEEPInitial signs of fatigue

↑CO2 ↓pHSigns of CPAP failure

Upright positionPre-Hospital

orEmergency Room

SpO2<90%RR>25

↑ Work of breathingOrthopnea YesNo

RESPIRATORY DISTRESS (▲) ?

After blood gasesNo

Room air

After 60-90 min

Conventionaloxygen therapy

FAILURESUCCESSWeaning

(▲)

Intolerance

Yes

SIGNIFICANT HYPERCAPNIA AND ACIDOSIS

CPAP

In hospitalRESPIRATORY DISTRESS () ?

Blood gases

Conventionaloxygen therapy

Intubation

Intubation

() Same criteria than initially, although SpO2 may be >90% if FiO2 is high

Masip J. Eur Heart J: Acute Cardiovasc Care 2012

Venous blood gases in patients with APE

Masip J et al. Eur Heart J: Acute Cardiovasc Care 2012

Venous vs Arterial gas samples

AHF in ACS

18-30% of the patients show some degree of AHF

Masip J et al. Rev Esp Cardiol 2012

SpO2 and Killip Classification

Masip J et al. Rev Esp Cardiol 2012

SpO2 and Radiology Score

RR=19RR=20

RR=21

RR=24

RR=26

SpO2 ≤ 92 %

AVOID Trial

Individual Data for CBF and CVR in Subjects During Sequential Room Air and 100% Oxygen Breathing

McNulty et al. Am J Physiol Heart Circ Physiol 2005

Hyperoxia

Pulsed Doppler Recording of LAD in Healthy Subjects and Cardiac Transplant Patients

Coronary blood flow

Wanga Ch.H et al Ressuscitation 2014

20.223 participants

SHOCK Trial

Hochman J et al. NEJM 1999

Mechanical ventilation (78 %)

Mechanical ventilation (88 %)

83%

CARDIOGENIC SHOCK

CARDIOGENICSHOCK

INOTROPIC and VENTILATORYSUPPORT

ECMO

IABP

Ventricular Assist Devices

Recovery Trasplant Destination

Revascularization

Hongisto M (1), Lassus J (2), Tarvasmäki T (3), Tolppanen H (2), Sionis A 

(4), Köber L (5), Parissis J (6), Spinar J (7), Banaszewski M (8), Cardoso JS (9), Metra M (10), DiSomma S (11), Tolonen J (3), Masip J (12), Harjola V-P 

(1)for the CardShock study investigators

Invasive vs. non-invasive ventilation in cardiogenic shock

(1) Helsinki University Central Hospital, Division of emergency care, Department of medicine, Helsinki, Finland; (2) Helsinki University Central Hospital, Heart and Lung Center, Division of Cardiology, Helsinki, Finland; (3) Helsinki University Central Hospital, Department of medicine, Helsinki, Finland; (4) Hospital de la Santa Creu i Sant Pau, Department of Cardiology, Barcelona, Spain; (5) Rigshospitalet - Copenhagen 

University Hospital, Division of Heart Failure, Pulmonary Hypertension and Heart Transplantation, Copenhagen, Denmark; (6) Attikon University Hospital, Heart Failure Clinic and Secondary Cardiology Department, Athens, Greece; (7) University Hospital Brno, Department of Internal Medicine and 

Cardiology, Brno, Czech Republic; (8) University of Porto, Department of Cardiology, São João Hospital, Porto, Portugal; (9) National Institute of Cardiology, Intensive Cardiac Therapy Clinic, Warsaw, Poland; (10) University of Brescia, Department of Experimental and Applied Medicine, Cardiology, Brescia, Italy; (11) Sapienza University of Rome, Department of Emergency Medicine, Sant'Andrea Hospital, Rome, Italy; (12) University of Barcelona, Hospital Sant Joan Despí Moisès Broggi, Critical Care Department, 

Consorci Sanitari Integral, Barcelona, Spain

CLINICAL CHARACTERISTICS

220 patients included

• Those 58 (26%) treated only with oxygen mask/nasal cannulas were excluded

• 8 NIV patients were intubated (= NIV-failure) Ø3 within first 24 hours,   5 after that 

* P-value NS for all

* values are mean

Clinical presentation  MV NIV p-valueblood pressure (mmHg) * 78/46 82/49 NSheart rate (bpm) * 92 86 NSLVEF (%) * 32 32 NSconfusion (%) 83 36 < 0.001

Laboratory tests      lactate, mmol/l * 4.9 2.9 < 0.001TroponinT, ng/l * 5081 7892 0.023NT-proBNP, pg/l * 7727 11115 0.041

Use of vasoactive drugs 0-24 h (%)      Noradrenaline 85 68 0.031Adrenaline 28 0  Dobutamine 57 14 < 0.001Levosimendan 20 57 < 0.001

CLINICAL PICTURE AND BIOCHEMISTRY ON ADMISSION, VASOACTIVE TREATMENT

VENTILATORY PARAMETERS

• In-hospital mortality was lower in NIV group  (21% vs. 46%, p= 0.02)

OUTCOME

*) model also included  gender and center 

•   13 % were treated with NIV 

•   In-hospital mortality was lower in NIV group 

•   NIV seems to be a safe option for properly chosen cardiogenic shock patients

• Mean FiO2 0-24 h was an independent predictor 

CONCLUSIONS OF NIV IN SHOCK

Crucial moments in patients with heart diseasewho require invasive mechanical ventilation:

Intubation

Weaning

Invasive ventilation

Urgent

Elective

85%

Pre-hospital

In-hospital

60%

Kouraki K et al, BEAT registry. Clin Res Cardiol 2011

N=458 MV patients

Intubation scenario in patients with AMI

2001-2002

Mortality 48%

Pre-hospitalIn-hospital

66%

Ariza et al EHJ Acute Cardiovasc Care 2013

MV IN THE PCI ERA

N= 1821 patients 106 (5.8%) required IMV

In hospital mortality: 29%

2010 - 2012

Heart failure Shock Cardiac arrest n=27 n=14 n=65

Age 68 69 58 .000Diabetes 59 43 22 .002HTA 82 86 46 .001Smoker 26 21 83 .001In hospital ETI (%) 63 54 16 .001Swan Ganz (%) 37 36 14 .024IABP (%) 56 50 15 .001Renal RT (%) 15 15 2 .030Hypothermia (%) 37Major bleeding (%) 11 29 3 .006Transfusions (%) 26 36 11 .032In H mortality (%) 22 43 33 0.4Mortality (%) 41 43 33 0.4Non-card. mortality 36 17 52 0.2

Ariza A et al Eur Heart J Acute Card Care 2013

PREVENTIVE NIV IN PRIMARY PCI

WEANING

Simple weaning: weaning to successful extubation on the first attempt

Difficult weaning Patients who fail initial weaning and require up to 3 SBT or as long as 7 days from the first SBT

Prolonged weaning Fail at least 3 weaning attempts or require >7 days of weaning after the first SBT

Spontaneous Breathing Trial (SBT)30-120 min

PROTOCOL OF WEANING

Cabello B, et al. Intensive Care Med (2010)

PCWP: 21 mmHgPCWP: 17 mmHgResp. rate:19 b/m

Resp. rate:27 b/m

Ptients with difficult weaning

Lower Tidal volumeHeart failure may be responsible for nearly 40% of SBT failures in the ICU with general population, but is higher in the CCU

Mechanisms: myocardial ischemia excessive increased LV afterload increased cardiac preload

Swan-Ganz catheterPICCO

Echocardiography

The diagnosis of HF may be confirmed by measuring the elevation of PCWP or less invasive tools: such as echocardiography, measurements of plasma protein concentration or biomarkers.

Use of diuretics, nitrates, NIV or inotropes should be considered after careful analysis of the main contributing mechanisms.

BaselineBNP > 263 ng/L NTproBNP > 1,343 ng/Lare predictive HF

An increase in :BNP 48 ng/LNTproBNP 21 ng/L are diagnostic of HF

100 patients for SBT32 failed:12 (38%) for Heart Failure

Zapata L et al ICM 2011

CARDIAC BIOMARKERS IN WEANING

Impact of negative balance in the success of weaning

Upadya A et al. Intensive Care Med 2005

Weaning Failure

Weaning Success

ml

Conclusions

Patients who require ventilatory support in the CICU are particularly different than those in the ICU

NIV should be considered in the majority of patients with AHF and ARF, even in some with cardiogenic shock

Hyperoxia should be avoided

Adequate protocols for intubation, ventilation and weaning are crucial for the success

Thank you for your attention