Transcript NPPV

Nichtinvasive
Beatmung
bei COPD
Wolfram Windisch
Lungenklinik Merheim
• Diaphragmale Abflachung
• Verkürzung der Insp.-Zeit
• Vordehnung der M.-Fasern
• Atemwegsobstruktion
• Systemmanifestation
• Dynamische Überblähung
• Intrinsic PEEP
• Inflammation
• Steroide
• Thorakale Vordehnung
• VIDD
• Erhöter ventilatorsicher
Bedarf
• Co-Morbiditäten
• Herzinsuffizienz
• Oxygenierungsstörung
• Pulmonale Hypertonie
• Anämie
• Diabetes mellitus
• Herzinsuffizienz
Jolley CJ and Moxham J. Eur Respir Rev 2009; 18:112,1-14
Evans TW. Intensive Care Med 2001; 27:166-178
NPPV:
Conclusions
NPPV should be the first line intervention in addition to
usual medical care to manage respiratory failure secondary
to an acute exacerbation of chronic obstructive pulmonary
disease in all suitable patients.
NPPV should be tried early in the course of respiratory
failure and before severe acidosis,
to reduce mortality, avoid endotracheal intubation, and
decrease treatment failure.
NPPV = noninvasive positive pressure ventilation
first
line
pH:
7.20–7,35
Improves
outcome
Lightowler JV. et al. BMJ 2003; 326:185-189
• NIV verhindert Intubation
(NNT = 5)
• NIV reduziert die Mortalität
(NNT = 8)
NNT = number needed to treat
Lightowler JV. et al. BMJ 2003; 326:185-189
80%
70%
35%
Chu CM. et al. Thorax 2004; 59:1020-1025
5 cmH2O
15/5 cmH2O
Cheung APS. et al. Int J Tuberc Lung Dis 2010; 14:642–649
6-min-Gehstrecke nach 3 Monaten
20/5 cmH2O
N = 13
N = 13
Funk GC. et al. Respir Med 20011; 105:427-434
Wijkstra PJ. et al. Chest 2003; 124:337-343
2 years follow-up
1 year follow-up
NPPV + LTOT vs. LTOT alone
IPAP
(cmH2O)
Casanaova 12
EPAP ΔPaCO2
Survival
(cmH2O)
(mmHg)
4
NPPV: +0.4
LTOT: -0.9
No benefit
NPPV: -1.0
LTOT: +0.5
No benefit
et al.
Clini
14
2
et al.
Casanova C. et al. Chest 2000; 118:1582-1590
(1 year)
(2 years)
Clini E. et al. Eur Respir J 2002; 20:529-538
McEvoy RD. et al. Thorax 2009; 64:561-566
mean adherence
to NIV:
4.5 ± 3.2 hours
McEvoy RD. et al. Thorax 2009; 64:561-566
McEvoy RD. et al. Thorax 2009; 64:561-566
Wolfram Windisch
Windisch W. Breathe 2011; 8:114-123
If the targeted physiological parameter (PaCO2)
remains unaffected by the specific treatment
modality (long-term NPPV)…
If artificial ventilation does not improve alveolar
ventilation …
How can we expect an
improved outcome?
BGA
(mmHg)
mmHg
100
90
80
70
60
BGA
(mmHg)
PaCO2
PaO2
100
90
80
NPPV (assPCV)
70
60
50
- mean IPAP 30
±4
mbar
- mean bf
±2
/min
23
50
40
40
30
301
2
3
5
1
2
Days
Zeit
(Tage)
9
3
5
Zeit (Tage)
9
Windisch W. et al. Respir Med 2002; 96:572-579
N = 34
NPPV (assPCV): IPAP 28
±6
mbar; bf 21
±3
/min
2-year survival: 86%
Windisch W. et al. Chest 2005; 128:657-662
N = 141
NPPV (assPCV)
- mean IPAP 20
±4
mbar
- mean bf
±4
/min
20
BMI <20 kg/m2 = 21%
Budweiser S. et al. Respir Care 2006; 51:126-132
Severe Respiratory Insufficiency
Questionnaire SRI
Social
Functioning SF
Respiratory
Complaints RC
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ATS homepage:
SRI
Physical
Functioning PF
Summary
Scale
SS
Attendant Symptoms
and Sleep AS
http://www.atsqol.org/sections/instruments/pt/pages/sri.html
Well-Being WB
Anxieties AX
Social
Relationships SR
Windisch W. et al. J Clin Epidemiol 2003; 56:752-759
Windisch W. et al. Intensive Care Med 2003; 29:615-621
Windisch W. et al. J Clin Epidemiol 2008; 61:848-853
N = 137
• COPD
• Restrictive thoracic diseases
• ObesityHypoventilations-Syndrome
• Neuromuscular disorders
• Miscellaneous
Windisch W. Eur Respir J 2008; 32:1328-1336
SRI-Summary Scale (SRI-SS)
65
IPAP/EPAP
(mbar)
P < 0.001
restrictive thoracic
20/3
19/4
P < 0.001
neuromuscular
25/1
P < 0.001
COPD
55
kulär
Changes in SRI-SS
independent from the underlying disease
MANOVA; F=0,62; P=0,65.
45
T0
T1
T0
COPD
T12
T1
RTD
T12
NMD
Windisch W. Eur Respir J 2008; 32:1328-1336
N = 73
5-year survival: 58%
Windisch W. et al. Int J Med Sci 2009; 6:72-76
IPAP [cmH20]
EPAP [cmH20]
Breathing frequ.
Oxygen [L* min-1]
[min-1]
Insp. volume
Low-intensity
14.6 ± 0.8
4.0 ± 0
8.0 ± 0
2.2 ± 0.8
(pneumotachygraph)
Mean treatment effect: 325
High-intensity
28.6 ± 1.9
4.5 ± 0.7
17.5 ± 2.1
2.2 ± 0.8
:
mL
95%CI [159 , 492 mL]; P=0.002
Exp. volume
(pneumotachygraph)
Mean treatment effect: 96
:
mL
95%CI [23 , 169 mL]; P=0.015
Leak volume
(pneumotachygraph)
:
Mean treatment effect: 226
95%CI [28 , 425 mL]; P=0.030
mL
Dreher M. et al. Thorax 2010, 65:303-308
high: 29 cmH2O; controlled ventilation
low: 15 cmH2O; assisted ventilation
Primary outcome:Nocturnal PaCO2
Mean treatment effect: -9.2
mmHg
95%CI [-13.7 , -4.6 mmHg]; P<0.001
No period effect: P=0.96
No carry over effect: P=0.87
Compliance (daily use):
Mean treatment effect: 3.6
hours
95%CI [0.6 , 6.7 hours]; P=0.024
Lowintensity
Dyspnea (BDS)
QoL (SRI-SS)
FEV1 (L)
Highintensity
+
+
+
Dreher M. et al. Thorax 2010, 65:303-308
Mean IPAP:
high: 29 cmH2O; low:14 cmH2O
Dreher M. et al. Chest 2011, 140:939-945
P < 0.001
85
50
80
PaO2 (mmHg)
75
P<0.001
70
65
6
209
Borg
Dyspnea
Scale
Walking
distance
P<0.001
P<0.05
4
252
53
60
55
50
45
mean
before
after
mean
PaCO2
[mmHg]
P < 0.001
110
[m]
100
50
PaO2 (mmHg)
90
80
n.s.
70
51
60
50
mean
before
after
mean
Dreher M. et al. Eur Respir J 2007; 29:930-936
Rehab
Rehab + NPPV [20/6 cmH20; 18 breaths/min]
Rehab + NPPV
baseline
3 months
Rehab alone
baseline
3 months
Duiverman ML. et al. Thorax 2008; 63:1052-1057
Windisch W. et al. Pneumologie 2010, 64:207-240
Windisch W. et al. Pneumologie 2010, 64:207-240