Transcript Interazione tra aumento della pressione intratoracica e CO

Acute cardiac decompensation: the
role of MV
Massimo Antonelli, MD
Dept. of Intensive Care & Anesthesiology
Università Cattolica del Sacro Cuore,
Rome-Italy
Effects of different ventilatory mode
on cardiopulmonary performance
SPONT.
PARTIAL ASSIST.
TOTAL ASSIST.
Mofied from
Synder 1984
Effects PEEP on venous return
Basal condition
PEEP
Fessler 1992
Interrelationship between the venous
return and cardiac function
Pinsky R 1987
ITP and RV function
 + ITP=  Pra  Pms (upstream pressure)]
 VR and RVEDV
ITP and LV function
 effort =- ITP = Ptm(trans. Pressure)=
 LV afterload
THORAX
ITP
ITP and BLOOD FLOW
 effort =  - ITP and  VR and  RV
blood volume
LV afterload and  LV blood volume
 chest blood volume
HEART
V
C
RV
AO
LV
CARDIOVASCULAR
EFFECTS of MV
  ITP during CHF
 pre-load due to the decrease of the venous
returrn
 Ptransm LV e  afterload of LV
 CI,  SVi when PCWP > 12 mm Hg
Buda AJ NEJM 1979; Farden F NEJM 1981; T.D.Bradley et al.
Am.Rev.Respir.Dis. 1992; 145: 377 M.T.Naughton e al. Circulation
1995; 91: 1725 F. Lenique 1994
Effect of ITP on CO in CHF patients
Pinsky 1987
How does ABG improve ?
 Vt and  (Vd/Vt)   Va
 inspiratory effort
 load imposed by spontaneous ventilation
 VCO 2
PaC02 KVCO2
Va


 PaC02
 Vt   Va/Q
 inspiratory effort
 V02


 Pa02
Effects of MV during CPE
TRATTAMENTO
CPAP/IPPV
Net filtration =LpS x [(Pcap - Pif) - s(cap - if)]
LV failure
CO
DaO2
Pulmonary
edema
Pulmonary
compliance
Airway
resistance
PaO2
Respiratory muscle
fatigue
Negative
Intrathoracic
Pressure Swing

Work of
breathing
LV failure
LV afterload
Pulmonary
edema
LV transmural
pressure
Pulmonary
compliance
Airway
resistance
Negative
Intrathoracic
Pressure Swing
O2
Cost of breathing
 ITP

 WOB


 Negative Pleural Pressure   RV pre-load
 LV after-load

 Resp. muscles O2 demand

 Cardiac O2 demand
Masip, Lancet, 2000;356:2126
40 patients with CPE
3 patients withdrawn
19 Pts. NIPSV (FM)
18 Pts Standard MT
1(5%) ETI
6(33%) ETI
Resolution Time*
30(IQR 15-53) min
P<0.037
P<0.002
Resolution Time*
105(IQR 50-230) min
*Time needed for SAT >96% and RR<30b/min
NPPV plus SMT
• One randomized controlled trials
• Case Series and Case Reports (1989-1996)
22 patients. 8 (36.3%) required intubation
NPPV plus SMT vs SMT
Hoffmann B* 1999 (29 pts) vs. Rusterholtz T °1999 study (26 pts)
• *PSV 12 to 24 (mean 16,6)* plus Peep 2 to 8 (mean
5.5) cmH20 vs. °PSV 20.54.7° cmH20 plus Peep 3.5 
2.3 cmH20
• Sa02 73.8  11* vs 8412°; PaC02 6218.5* vs 54.2
15°; pH 7.22 0.1° vs 7.25  0.11*
• 1 pts reqired intubation ( 3.4%)*
• 5 pts required intubation (19.2%)°
NIPPV vs SMT compared to NIPPV vs CPAP
Hoffmann and Rusterholtz studies (55pts)* vs Metha study (27 pts)°
• 6 pts were intubated (11%)*
• 2 pts were intubated (7%)°
NIPPV plus SMT vs CPAP and SMT
Mehta SJ, Gregory D, Woolard RH, et al.
Randomized prospective trial of bilevel
versus continuous positive
airway
pressure in acute pulmonary
edema.
Crit.Care Med.1997; 25(4):620-28.
Pang D Chest 1998
NPPV plus SMT vs CPAP plus SMT
Mehta S et al. Crit. Care Med. 1997
• no differences between CPAP and NPPV in the need
for intubation and mortality
• MI 71% (NIPPV) vs il 31% (CPAP)
CPAP plusCSMT
P A P vs
v s NIPPV
B iP A P plus SMT
Mehta S et al. Crit
Crit.. Care Med
Med.. 1997
• FC
NIPPV (14pts)*
BiPAP
 FC
• FR
• Ph
• PaCO2
CPAP (13pts)
CPA P
 FR
•
FR
FR
FR
 Ph
PaCO2
• D yspnea score
(3 0 m i n)
 Dyspnea score
(p < 0 .0 5)
(30 min) (p<0.05)
Pang
DDChest
1998
Mehta S et al. Cr it. Care Med.
1997,
25,
4
Pang
Chest
1998
CPAP plus SMT vs NIPPV plus SMT
Mehta S et al. Crit. Care Med. 1997
• no differences between CPAP and NIPPV in
the need for intubation and mortality
• MI occurred in 71% (NIPPV) vs il 31%
(CPAP) even though baseline differences
showed a trend toward more patients with
chest pain in the NIPPV group vs CPAP
group.
Pang Chest 1998
Hypox.ARF
Wysocki et al.,
Chest
Antonelli et al.,
NEJM
Confalonieri et
al.,AJRRCCM
Antonelli et al.,
JAMA
Martin et al.,
AJRCCM
Hilbert et al.,
NEJM
Auriant et Al
CCM
Antonelli et Al
CCM
Antonelli et Al
Int Care Med
Carlucci et Al
AJRCCM
Girault et Al
CCM
Interf
Timing Level of
Yr
Mode of MV
Randomized
Studies:
Hypoxiemic
Type
Evidence
No.
ARF
NPPV
Outcome
timingMeasure
Early=to
prevent
(1) and established=to treat (2)
I
1
1995
1998
2
I
1999
1
I
2000
1
I
2000
1
I
2001
1
I
2001
4
I
2002
1/2
II
2002
1/2
II
2001
1
II
2003
1/2
II
F
PSV + PEEP
21
ETI, surv
F
PSV + PEEP
32
ABG, ETI, LOS, surv
F
PSV + PEEP
28
ABG, ETI, LOS, surv
F
PSV + PEEP
20
ABG, ETI, LOS, surv
14
ETI, surv
N
IPAP +EPAP
F
PSV + PEEP
26
ABG, ETI, LOS, surv
N
IPAP+EPAP
24
ABG, ETI, LOS, surv
H/F
PSV+PEEP
99
F
PSV+PEEP
354
F
PSV+PEEP
15
F
Psv+peep
37
ABG, ETI, LOS, surv
ABG, ETI, LOS, surv
ABG, ETI, LOS, surv
ABG, ETI, LOS, surv
Level of
evidence
No. of
patients
ETI or
Physiological
Mortality
Complications
a total of
176 pts failure
randomized
to NIV
improvement
criteria
Studies: Hypoxiemic ARF
Wysocki
I
21 vs. 20
Only if
PaCO2 > 45
«
«
«
Ї
«
Ї
Ї
Antonelli
I
32 vs. 32
Yes
Confalonieri
I
28 vs. 28
Yes
Antonelli
I
20 vs. 20
Yes
Martin
I
14 vs. 11
Yes
Hilbert
I
26 vs. 26
Yes
Auriant
I
24 vs 24
Yes
Antonelli
II
255
Yes
na
Antonelli
II
99
Yes
na
Carlucci
II
15 of 108
Yes
na
Girault
II
37 of 124
Yes
na
«
Ї
«
Ї
Ї
Ї
Ї
Ї
Ї
Ї
Ї
«
Ї
«
Ї
«
Ї
«
Ї
Ї
na
na
Noninvasive vs Conv. Mechanical Ventilation:
an epidemiologic survey: hypoxemic, hypercapnic ARF and CPE
Carlucci at al. (SRLF collaborative group), AJRCCM 2001;163:874-80
(prospective survey 3 wk, 42 ICU)
689 pts MV
SAPSII 36(20)
NIV
N=108 (16%)
ETI
N=581
SAPSII 47(21)*
Duration of MV
8(6.3) days
Duration of MV
13.9(14.5) days
LoS in ICU
5.1(5.7) days
LoS in ICU
7.8(9.8) days
P<0.002
NIV
14% pts Hypoxemic ARF
27% pts CPE
50% Pts HypercapnicARF
NP
11(10%)
Mortality
22%
P<0.04
P= 0.03
P<0.001
NP
72(19%)
Mortality
41%
*P<0.001
N° patients
% failures
120
100
90
70
80
60
60
50
40
40
30
20
20
Pulm fibr/PE (n=5)
ARDSexp (n=59)
CAP (n=38)
ARDSp (n=27)
NP (n=18)
Atelect. (n=28)
Inh PN (n=8)
0
Pulm cont (n=72)
10
0
percentage of failures
80
CPE (n=99)
No. of patients
100
• 354 consecutive
patients with
hypoxemic ARF
• in 7 Centers (Europe
and USA):
•
•
•
PaO2/FiO2 < 200 breathing
O2 (Venturi)
RR>30, AC accessory
muscles or paradoxical abd.
Mot.
COPD excluded
86 ARDS (P/F < 200, bil.
Pulm.infiltrates, absence
of LVF)
• 108 (30%) failure
• 264 (70%) success.
Antonelli et Al.
Intensive Care Med
2001;27:1718-28