NIV: dove ventilare il
paziente
Dott Michele Vitacca Divisione Pneumologia Riabilitativae Centro svezzamento Fondazione S. Maugeri IRCCS Lumezzane (BS)
IDENTIFY PATIENTS (according to location ?)
1. Clinical abnormalities
- moderate to severe dyspnea
- RR > 24 b/min in COPD
- RR > 30 – 35 b/min in AHRF
- accessory muscle use, paradoxal breathing
2. Gas exchange abnormalities
- PaCO2 > 45 mmHg, pH < 7.35
- PaO2/FiO2 < 250 mmHg
Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178
Difficult intubation !
Am J Respir Crit Care M d 2001; 163: 283-291; Intensive Care Medicine 2001; 27: 166-178
(according to location ?)
The right location
• Model of health care delivery varies markedly– From country to country– Within a country– Within an institution
• Randomised controlled trials performed in one country may not be generalisable to another
• Have a plan from the outset– This may change!
• What is going to happen if the patient fails?– What is reversible?
– Pre morbid quality of life
• Circumstances of failure
Timing is all…
• Start early but not too early (Barbe study)
• You are too late if…• Pt on verge of respiratory arrest• Pt severely hypoxaemic (PaO2/FiO2 < 75)• Pt comatose or hugely agitated• Medically unstable: acute MI, GI bleed, shock
• What is your unit’s ‘door to mask’ time?
• What are the main limitations?Simonds ERS school
Location
ICU RICU/
HDU
WARD ER
Staff number
Safety
Monitoring
Equipment
Familiarity with NIV
The concept of the traffic light
Strategic use of NIV
• Concentrate staff expertise• Training focus for NIV for medical,
nursing and paramedical staff• Concentrate equipment• Facilitate link with ICU• Audit, data collection• Cost savings (?)
Safety first!
• Patient selection• Safe staffing levels• Rolling programme
of staff training and protocols
• Adequate monitoring
• Ability to intubate & transfer pts to ICU
• Suitable alarms
Simonds ERS school
Staffing of resp int care unit( or location with high number of NIV pts)
• Nurse to pt ratio 1:4 (1:6 ?)• Senior Physician on call for 24 hours• Training for nurses and trainee medical
staff• Dedicated physiotherapist• Technical service• Strong links with ICU
Simonds ERS school
Nava et al.Chest 97;111:1631
HUMAN WORKLOAD in RICU
BTS Equipment Recommendations
Staff familiarity is key to success
Monitoring
• Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance
• Pulse oximetry• Continuous display of ECG and non-invasive BP• Arterial blood gases (ABG machine easily accessed)• Continuous non-invasive monitoring of CO2 helpful eg.
Transcutaneous, end-tidal• Duration of NIV use• Ventilatory settings, FiO2, leak• Severity score• Side effects : skin integrity, GI, nasal symptoms• CXR, screening bloods etc.
Simonds ERS school
25% of the respondents use hand restraints in >30% of the patients.Is this the way to solve the problem ?
Some mild sedation may be prescribed
ETMask ETMask
Endotracheal Tube vs MaskComplimentary role
Respiratory failureRespiratory failureEvolving ARFEvolving ARF Resolving Resolving ARFARF
Pre-hospital setting to use CPAP?
ACADEMIC EMERGENCY MEDICINE 2014;21:960–970 © 2014
Interface: Facial Masks
Thorax 2011;66:43e48. doi:10.1136/thx.2010.153114
232 H units for 9716 patients, 1678 (20%) on admission were acidotic and 6% became acidotic later.
1077 patients received NIV (11%), 55% had a pH <7.26 30% patients with persisting respiratory acidosis did not receive NIV.
Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis.
Only 4% of patients receiving NIV who died had invasive mechanical ventilation.
POPOLAZIONE DELLO STUDIO
N = 3617 (81%)
VENTILAZIONE INVASIVA
(IV) N= 2656 (73%)
VENTILAZIONE NON INVASIVA
(NIV) N= 961 (27%)
NIV failure
N=309 (32%)
Early NIV success
N=652 (68%)
INTUBAZIONE SI
N=309 (32%)
Late NIV failure INTUBAZIONE NO
N=153 (25%)DESISTENZA TERAPEUTICA
(EOLC)
N = 207 (6%)Cortesia dott. Gristina
Reasons for low use of NIV in acute hospitals: US survey
Physicians lack of experience
Equipment not appropriate
Other Poor previous experience
Hospital staff inadequately trained
Maheshwari v et al Chest 2006:129: 1226-33
0
10
20
No. of responses
Hypercapnic Respiratory Failure
• NPPV is the first attempt of MV in ICU in 63% of Pts
• Success rate is 66%
Carlucci A. AJRCCM 2001;163:874
USE in the “REAL” WORLD of ICUs
From 4% to 14%
Shared Decision Making process
Staff
EOLCareEOLCare
FamigliaFamiglia
Malato
SDMprocess
SDMprocess
Proporzionalità
delle Cure
Proporzionalità
delle Cure
Evidence Based
Medicine
Evidence Based
Medicine
Appropriatezza Etica
Appropriatezza Etica
VolontàVolontà
Appropriatezza Clinica
Appropriatezza Clinica
Rappresentante
Rappresentante
V.A.L.U.E.V.A.L.U.E.
Location summary (1)
SITE Preferred diseases Condition
RespiratoryWARD
COPD, restrictive, Elective, semi-elective NIV, pH >7.30
Ph > 7.25Monitoring
No resp ward COPD, CHF, PE, Aged Ph > 7.30No comatose
Hospice All Palliative, ceiling intrevention
ER PE, COPD, Aged Ph > 7.20paO2/FI02 >150 < 200
RICU All, NMALS, 1 system failure, first
12 hours NIV. Confusion, poor tolerance, labile
bronchospasm, disability with high nursing dependency
Ph > 7.20paO2/FI02 >150 < 200
ICU Pure Ipoxemic, Sedation, Post op ARF, comorbidities, Weaning and NIV, Multi system organ
failure. Haemodynamic instability. Severe confusion. Pre coma
Ph <7.20paO2/FI02<150
Pre H PE High expertize
Location summary (2)
SITE advantages Contra
RespiratoryWARD
More enthusiasm, skills,No aggressive location,
RT presence Cough assistance combination, cost
effectiveness
No sufficient staff Night duty ? Delay in EI
Low monitoring on ventilatorsNo adequate devices
No resp ward cost effectiveness geriatric skills
Beds availability
No sufficient staff Night duty ? Delay in EI
Low monitoring on ventilatorsNo adequate devices
Low case mix Low respiratory skills
ER Early good outcome , triage Low expertize on NIV and chronic diseases
Hospice Advanced plan respectPalliative competence
No adequate devices Low case mix
Low respiratory skills
RICU High enthusiasm, skills,RT presence
Cough assistance combination, cost effectiveness
Rapid worsening in Hypox
ICU Monitoring EI availability
Complexity case mix
Low expertize on NIV and chronic diseasesCosts
Pre H Early good outcome High expertize, Delay in EI
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