S. Nava

CASO CLINICO I
• Uomo 64 anni
• Forte fumatore
• Nessuna terapia specifica
• Dispnea da sforzo moderato
• Tosse e catarro nei mesi invernali
• Mai eseguito alcun accertamento
Giorno I ore 22,15 P.S.
• Tachipnea = 26 a/m
• Dispnea a riposo = 6 Borg
• Edemi declivi
• MV molto ridotto con qualche fischio e sibilo
• PA= 170/95
• FC= 94 b/m
• TC= 36.4°
ACCERTAMENTI
• Rx-torace= ipertrasparenza, ombra cardiaca
leggermente ingrandita. Non lesioni p.p.
• ECG= P-polmonari in ritmo sinusale
• EGA in aria ambiente:
pH=7.32
PaCO2= 62.1 mmHg
PaO2= 55.5 mmHg
• EGA in ossigeno (Venturi 30%)
pH=7.32
PaCO2= 64.1 mmHg
PaO2= 67.2 mmHg
h. 23,50
Paziente trasferito in Medicina.
Terapia impostata:
• Teofillina 1 fiala ev
• 02 terapia 3 L/m
• Nebulizzazione con salbutamolo x
2/die
• NAC 1 bustina /die
GIORNO II
Dal diario clinico:
“ Condizioni generali stazionarie,
prosegue terapia in atto”
Si prescrive ossigenoterapia al bisogno
GIORNO III
h.13,15
•
Dispnea importante post-prandiale Borg 6
• Cianosi (messo 02 terapia= AL BISOGNO)
• Frequenza Respiratoria= 28
• Fischi e sibili diffusi + segni di ipersecrezione bronchiale.
• Emogasanalisi in 02 (4 L/m)
pH=7.28
PaCO2= 66.1 mmHg
PaO2= 59.2 mmHg
h. 14,30
•
•
•
•
•
•
•
Terapia impostata:
Teofillina 1 fiala ev x 3/die
02 terapia 3 L/m CONTINUA
Nebulizzazione con salbutamolo x 3/die
Metilprednisolone 40 mg ev
NAC 1 bustina /die
Amoxicillina + ac.Clavulanico
Furosemide 1 fiala ev
GIORNO IV
Dal diario clinico:
“ Condizioni generali stazionarie, prosegue
terapia in atto”
GIORNO IV
h. 18,20
• Paziente estremamente dispnoico ed agitato
• Sensorio leggermente obnubilato
• Frequenza respiratoria > 35
• Respiro alternante
• Emogasanalisi arteriosa in O2 (4 L/m)
pH=7.18
PaCO2= 96.1 mmHg
PaO2= 60.2 mmHg
PROVVEDIMENTO
TERAPEUTICO
Chiamato l’Anestesista
Rianimatore
UN PASSO INDIETRO
GIORNO I
pH=7.32
PaCO2= 64.1 mmHg
PaO2= 67.2 mmHg
QUALCHE ALTRA POSSIBILITA’ in
REPARTO ?
YONIV Study - pH
7.35
7.34
7.33
Conventional
NIV
7.32
7.31
7.3
7.29
0
1hr
4hr
Difference at 1 & 4hrs p <0.001 for both groups
NIV v conventional - difference p=0.02 at 1 hr
NIMV in the MEDICAL WARD
Plant PK
UN ALTRO PASSO
INDIETRO
GIORNO III
pH=7.28
PaCO2= 66.1 mmHg
PaO2= 59.2 mmHg
QUALCHE ALTRA POSSIBILITA’ ?
Authors
pH
PaC02
Meduri,1989
Elliott, 1990
Brochard,1990
Meduri,1991
Pennock,1991
Foglio,1992
Benhamou,1992
Bott,1993
Fernandez,1993
Wysocki,1993
Vitacca,1993
Confalonieri,1994
Servera,1995
Brochard,1995
Kramer,1995
Meduri,1996
Confalonieri,1996
Vitacca,1996
Nava,1997
Hilbert,1997
7.23
7.32
7.31
7.27
7.38
7.33
7.28
7.35
7.27
7.28
7.27
7.30
7.30
7.28
7.27
7.28
7.29
7.28
7.21
7.29
82.5
65,0
68,0
75.3
49.2
73.5
69.5
61.5
68.0
69.2
83.0
66.9
75.0
67.0
80.9
70.5
72.3
83.0
88.2
74.5
7.28
72.3
mean
WARD, ICU or RICU ?
 ICU ( 8 studies)
pH=7.25
PaC02=72.5 mmHg
 RICU (5 studies)
pH=7.24
PaC02=75.5 mmHg
 WARD (8 studies)
pH=7.31
PaC02=62.5 mmHg
RATE OF DEATH
SMT
NIMV
Rate of of Death (%)
50
40
30
*
*
*
20
10
0
Bott
Brochard
Kramer
Barbè
Plant
Multicenter Survey on NIV
42 ICUs
1337 pts admitted to ICU
689 pts on mechanical ventilation
581 ETI
(84%)
108 NIV
(16%)
56 success
(53%)
52 premature stop
(47%)
43 ETI
(39%)
Carlucci A. AJRCCM 2001;163:874
Hypercapnic Respiratory Failure
(n=100)
36% SAMU
50%
28% ER
29%
36% Other
21%
ETI outside
ETI in ICU
NIV in ICU
• NIV is the first attempt of MV in ICU in 63% of Pts
• Success rate is 64%
Carlucci A. AJRCCM 2001;163:874
INCIDENCE OF NOSOCOMIAL
PNEUMONIA
30
*
*
Patients (%)
20
ETI
NIV
10
0
Total
Hypercapnic
RF
Hypoxemic
RF
Pulmonary
edema
Trends for mortality in an ICU
for COPD and CPE
Ventilated patients deceased in the ICU
NIV patients
100
p<0.0001
90
80
70
60
50
40
30
20
24%
7%
10
p=0.028
0
1994
(n=41)
1995
(n=54)
1996
(n=66)
1997
(n=62)
Year
1998
(n=69)
1999
(n=56)
Girou et al. 2002
Where NIMV in COPD ?
Medical Ward:
• To prevent “overt” ARF (pH>7.30<7.35)
RICU:
• To treat severe ARF (pH<7.30) if:
- hemodynamic stability
- PaO2/FiO2 > 1.5
- no sepsis
- Minimal spontaneous capacity
- Normal sensorium
ICU:
- PaO2/FiO2< 1.5
- > 1 organ failure
DUE PASSI INDIETRO
GIORNO IV
pH=7.18
PaCO2= 96.1 mmHg
PaO2= 60.2 mmHg
E’ PROPRIO NECESSARIO
INTUBARE QUESTO PAZIENTE ?
NIV
(n=64)
ETI+MV
(n=64)
p
Value
Age, mean, yr
69 (6)
70 (5)
.51
FEV 1% of predicted
35 (7)
34 (6)
.62
SAPS II, score
35 (7)
35 (6)
.95
pH before ventilation
7.18
(0.05)
7.18
(0.06)
.91
104
(14)
100 (13)
.06
39 (4)
38 (4)
.07
ICU mortality, no. (%)
5 (8)
11 (17)
.14
Post-ICU hospital mortality, no. (%)
6 (9)
5 (8)
.74
Duration of ventilation, mean (SD),
days
10 (8)
12 (3)
.39
13 (8)
15 (3)
.43
24 (37)
40 (62)
.012
Matching Criteria
Characteristics
PaCO2 before ventilation, mmHg
HCO3 before ventilation
Outcomes
ICU stay, mean (SD), days
Navalesi et al. ERJ 2001
Patients with serious complications,
no.(%)
HOW to SET NIMV
1. Explain the technique to the patient
2. Choose the mask
3. Set Pressures (i.e PS ~8 cmH2O and
CPAP 2)
4. Hold the mask manually
5. Start gentle mask fitting
6. Avoid excessive tight fit
7. Set FiO2
8. Set alarms
9. Ask the patients about his/her feelings
10.Re-set Pressures (PS to achieve
Vtexp>6ml/Kg)