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High Dependency Units Definitions
L’organizzazione di una UTIR oggi Andrea Vianello S.C. Fisiopatologia Respiratoria Ospedale-Università di Padova Non-Invasive Ventilation “a form of ventilatory support that avoids airway invasion” Hill et al Crit Care Med 2007; 35:2402-7 Tipi di IRA trattabili mediante NIV Diagnosi di IRA Ostruttiva Restrittiva Parenchimale Cardiogenica BPCO Asma Fibrosi cistica Ostruzione delle vie aeree superiori Cifoscoliosi Malattie neuro-muscolari Sdr obesità-ipoventilazione Polmonite ARDS Infezioni polmonari Edema polmonare acuto Metha & Hill, AJRCCM 2001 NIV: Change in practice over time • 1992-1996 (mean pH = 7.25+/-0.07) 1997-1999 (7.20+/-0.08; P<0.001). • > 1997 - risk of failure pH <7.25 three fold lower than in 1992-1996. • > 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 Intens Care Med 2003; 3:419-25 NIV VS TRATTAMENTO STANDARD Keenan S et al NIV VS TRATTAMENTO STANDARD Keenan S et al Paziente con riacutizzazione acidotica di BPCO Terapia medica + O2 q.b. per SpO2 89-92% Airway narrowing & obstruction Airway Inflammation Shortened muscles curvature muscle strength Frictional WOB AutoPEEP Elastic WOB Gas trapping VT VA VE PaCO2 pH PaO2 VCO2 usa i farmaci e bene ! Airway Inflammation Steroids Abx Shortened muscles curvature strength Frictional WOB AutoPEEP BDs Elastic WOB Gas trapping Teophylline muscle Airway narrowing & obstruction VT VA VE PaCO2 pH PaO2 VCO2 usa i farmaci e bene ! Airway Inflammation Steroids Abx Shortened muscles curvature VT strength MV PEEP Elastic WOB Gas trapping VE MV VA Frictional WOB AutoPEEP BDs Teophylline muscle Airway narrowing & obstruction PaCO2 pH PaO2 MV VCO2 Paziente con riacutizzazione acidotica di BPCO Terapia medica + O2 q.b. per SpO2 89-92% Ripetizione di EGA pH > 7.35 NIV non indicata >7.30 pH < 7.35 pH < 7.30 pH < 7.20 NIV consigliata l’80% dei pazienti migliora comunque con terapia standard Ogni 10 pazienti trattati con NIV si evita 1 ETI; NIV migliora la dispnea NIV altamente consigliata Senza NIV 1 paziente su 2 necessita di ETI NIV migliora la sopravvivenza NIV altamente consigliata 1 paziente su 2 fallisce NIV Tuttavia con NIV migliora outcome ospedaliero e sopravvivenza a 1 anno Keenan S et al Keenan S et al Definition of the three levels of care European Task Force on Respiratory Intermediate Care Survey Corrado et al, ERJ 2002;20:1343-50 Flow chart of the management of acute exacerbations of COPD Ambrosino et al, ERJ 2008; 31: 874–886 Respiratory Intensive Care Unit Patients who require, or may soon require ETI More than one organ/system failure Haemodynamic instability Patients needing invasive monitoring Severe acidosis Respiratory Intermediate Care Unit Patients with life threatening High level monitoring respiratory illness but not likely to Patients with a tracheostomy need ETI in the near future Require mask CPAP for RF One organ/system system failure General Ward Intubation unlikely, not indicated Elective, semi-elective NIV pH > 7,30 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 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 HUMAN WORKLOAD in RICU Nava et al.Chest 97;111:1631 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 NIV NELL’IRA IN BPCO • EBM dell’efficacia della NIV vs il trattamento standard e vs VM invasiva • A quale paziente, in quale ambiente, con che strumenti? • Fallimento della NIV Portable ventilator ICU ventilator ICU ventilator Portable ICU Mode availability limited maximal Monitoring limited expanded Alarm function limited expanded Handling simple complex Trigger problems rarely possible Oxygen blender depending always CO2 re-breathing potentially no Weight light heavy Costs less expensive expensive Staff familiarity is key Leak compensation frequently to success! limited BTS Equipment Recommendations Staff familiarity is key to success Interfaces ATS-ERS position paper: Standards for COPD. ERJ 2004; 23:932 Punto chiave Flow-chart for the use of noninvasive positive pressure ventilation (NPPV) during exacerbation of COPD complicated by acute respiratory failure. Management of tracheal intubation in the respiratory intensive care unit by pulmonary physicians. A.VIANELLO, G. ARCARO, F. BRACCIONI, F. GALLAN, C. GREGGIO, A. MARANGONI, C. ORI, M. MINUZZO Attento monitoraggio e rapido accesso ad ETI in caso di mancata risposta! Respir Care 2007; 52:26-30 Problemi legati all’uso di NIV in acuto • Fallimento primario: legato all’operatore • Fallimento secondario: legato all’affezione sottostante Fallimento primario di NIV • Selezione del paziente • Scelta della maschera e settaggio del ventilatore • Ambiente inadeguato Totale desincronizzazione durante PSV cortesia del dott.G. Polese Un eccesso di supporto cortesia del dott.G. Polese Totale desincronizzazione durante PSV (perdite) cortesia del dott.G. Polese Fallimento secondario di NIV in acuto dopo successo iniziale nella COPD • Fallimento complessivo di NIV 10-20% • Fallimento tardivo (>48 ore) 5-40% • Fattori di rischio: basso ADL, comorbidità mediche, basso pH • Trattamento con ETI+MV (mortalità 52.6%) o NIV più agggressiva (mortalità 91.6%) • Complessiva mortalità ospedaliera 67.7% Moretti at al Thorax 2000;55:819-25 After two hours Location summary SITE Respiratory WARD No resp ward RICU ICU advantages Contra More enthusiasm, skills, No aggressive location, RT presence Cough assistance combination, cost effectiveness No sufficient staff Night duty ? Delay in EI Low monitoring on ventilators No adequate devices cost effectiveness geriatric skills Beds availability No sufficient staff Night duty ? Delay in EI Low monitoring on ventilators No adequate devices Low case mix Low respiratory skills High enthusiasm, skills, RT presence Cough assistance combination, cost effectiveness Rapid worsening in Hypox Monitoring EI availability Complexity case mix Low expertize on NIV and chronic diseases Costs