09 13 september 2017 - ers-educationpalliation, discharge planning and community care, and setting...
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ERS Annual Congress Milan
09–13 September 2017
Postgraduate Course
PG4 Noninvasive ventilation in respiratory failure
Saturday, 9 September 2017
09:30-13:00
Space 3 + 4 (South) MICO
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Postgraduate Course : PG4
Noninvasive ventilation in respiratory failure
Aims : To review the physiological rationale for providing noninvasive support in patients with
hypercapnia and hypoxemic failure; to present a state-of-the-art overview of the usefulness of NIV in
specific patient categories (including COPD, weaning from invasive ventilation, and congestive heart
failure); to discuss the limitations of noninvasive ventilation; to discuss new developments in
noninvasive ventilator support.
Tracks: Acute and chronic respiratory failure/sleep - Exercise, rehabilitation and physiology
Tags: Clinical
Target audience: Anaesthesiologist - Clinician - Emergency medicine doctor - Fellow -
Intensivist/critical care physician - Junior member - Nurse - Pharmaceutical industry representative -
Physiologist - Physiotherapist - Pulmonologist - Resident - Respiratory physician - Respiratory therapist
– Trainee
Chairs : Mark W. Elliott (Leeds, United Kingdom), Lara Pisani (Bologna, Italy)
09:30 Using physiology to set the ventilator during NIV
Leo M.A. Heunks (Amsterdam, Netherlands)
10:00 NIV in hypercapnic failure
Michael Dreher (Aachen, Germany)
10:30 Group assignment
11:00 Break
11:30 NIV in hypoxemic failure and difficult weaning Elise Morawiec (Paris, France)
12:00 Role of ventilator mode and interface in optimising patient-ventilator interactions
under NIV Paolo Navalesi (Milan, Italy)
12:30 Group assignment
Th e ERS Practical Handbook of Noninvasive Ventilation provides a concise ‘why and how to’ guide to NIV from the basics of equipment and patient selection to discharge planning and community care.
Editor Anita K. Simonds has brought together leading clinicians and researchers in the fi eld to provide an easy-to-read guide to all aspects of NIV. Topics covered include: equipment, patient selection, paediatric indications, airway clearance and physiotherapy, acute NIV monitoring, NIV in the ICU, long-term NIV, indications for tracheostomy ventilation, symptom palliation, discharge planning and community care, and setting up an NIV service.
Th is Practical Handbook is a valuable reference and training resource for all NIV practitioners.
• User-friendly format with key point summaries• Focused on practical aspects and problem solving• Multiple choice questions to enable self-assessment
To buy printed copies, visit the ERS Bookshop in the World Village at the ERS International Congress 2017.
Electronic: WWW.ERSPUBLICATIONS.COMPrint: WWW.ERSBOOKSHOP.COM
ERS Practical Handbook of Noninvasive VentilationEdited by Anita K. Simonds
ISBN (print) 978-1-84984-075-0ISBN (ebook) 978-1-84984-076-7
€30 (ERS members)€40 (non-members)
NONINVASIVE VENTILATION...how to do it, why to do it,
when to do it and when to stop!
Thank you for viewing these presentations.
We would like to remind you that these
materials are the property of the authors.
It is provided to you by the ERS for your
personal use only, as submitted by the
authors.
2017 by the authors
Usinf physiology to set the ventilator
during noninvasive ventilation
Leo Heunks, MD, PhD
Pulmonologist - intensivist
Radboudumc Nijmegen
The Netherlands
Conflict of interest disclosureI have the following, real or perceived direct or indirect conflicts of interest that
relate to this presentation:
Affiliation / financial interest Nature of conflict / commercial company name
Tobacco-industry and tobacco corporate affiliate related conflict of interest
N/A
Grants/research support (to myself, my institution or department):
Biomarin, Bayer, Orion, Maquet
Honoraria or consultation fees: Biomarin, Orion, Maquet
Participation in a company sponsored bureau: N/A
Stock shareholder: N/A
Spouse/partner: N/A
Other support or other potential conflict of interest: N/A
This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.Drug or device advertisement is strictly forbidden.
Introduction
AIMS
• Aim 1: Understand principles of NIV in acute setting
• Aim 2: Understand role of NAVA in NIV
• Aim 3: Understand principles and role of HFNC
Principles modes
Assisted Mandatory
Pressure CPAP
PSV, ASB, BIPAP
P-PCV
NAVA, PAV
PCV, PRVC
Volume P-VCV
VSV
VCV
Principles setting PSV
Optimal
trigger sensitivity
Optimal
pressurization
Optimal
PS level
Optimal
cycle-off
criterium
Patient-ventilator interaction
Neural expiration
Neuralinspiration Patient
Mechanical expiration
Mechanicalinspiration
Ideal ventilator
Patient-ventilator asynchrony
Vignaux ICM 2010
Patient-ventilator dyssynchrony
Trigger delay
Vignaux ICM 2010
Inspiration Expiration
EPAP
0
IPAP
Flo
wP
ress
ure
Inspiration
PS = IPAP - EPAP
1. PS level
Effect of PS level on TV
800
1000
1200
1400
1600
0 10 20 30
PS (cmH2O)
Van der Graaff, Chest 1991
Setting pressure support level
» Unload respiratory muscles
» Enhance minute ventilation
» But too high levels of assist
» Inactivity of the respiratory muscles
» Patient - ventilator asynchrony
» Patient intolerance
» Leaks
» In practice
» Titrate to patient comfort and minute ventilation
» Note: Due to leaks often TV is unreliable!
Setting EPAP level
» Why do we need EPAP
1.Enhance oxygenation by alveolar recruitment
2.Prevent upper airway collapse
3.Improve hemodynamics
4.Counteract intrinsic PEEP
Intrinsic PEEP
Tobin, principles and practices MV, 2013
Setting EPAP level
Lung Vent
0 0
PEEPTrigger
0-1
Trigger sensitivity -1cmH2O
Setting EPAP level
Lung Vent
10 0 810
10PEEPi
PEEPTrigger
0-1
10PEEPiPEEPTrigger
8-1
Intrinsic PEEP: increased WOB for triggering
Tobin, principles and practices MV, 2013
Not easy to determine in clinical practice: Pes
2. Ventilator triggering
» Change in pressure, flow or volume sensed by ventilator
» Too sensitive: autotriggering
» Insensitive: high WOB and wasted efforts
Shape signal method
Autoriggering ↑
Wasted efforts ↓
Inspiration Expiration
EPAP
0
IPAP
Flo
wP
ress
ure
Inspiration
3. Inspiratory rise time
Inspiratory rise time
Sassoon, Resp Care 2011
Inspiration Expiration
EPAP
0
IPAP
Flo
wP
ress
ure
Inspiration
4. Cycle off / expiratory triggering
% of max inspiratory flow
Affects Ti
Should match neural Ti
Premature cycling vs. late cycling
40%
Inspiration Expiration
EPAP
0
IPAP
Flo
wP
ress
ure
Inspiration
Cycle off / expiratory triggering
75%40%
Cycle off / expiratory triggering
COPD
ARDS
Gentille, Resp Care 2011Ti,neural
Conclusion ventilator settings
» Support level to provide adequate VE and patient comfort
» PEEP to improve oxygenation and counteract PEEPi (COPD)
» Trigger sensitivity to prevent wasted efforts / auto triggering
» Rise time at least match patient inspiratory flow
» Early cycle off in COPD
What’s new?
» Neural triggering in NIV
Neurally adjusted ventilator assist (NAVA)
NAVA
Neurally adjusted ventilator assist (NAVA)
“Uses diaphragm electrical
activity to control the ventilator”
Neurally adjusted ventilator assist (NAVA)
Case 2
» Male 70 yrs
» PMH: CHF and COPD
» Admitted to hospital for hypercapnia exacerbation COPD
NIV: PSV versus NAVA
• 30 min each
• Same level of support
• COPD patients (N = 12)
BiPAP VisionPSV
Servo-iPSV
Servo-iNAVA
Doorduin, Crit Care 2014
NIV: PSV versus NAVA
Doorduin, Crit Care 2014
NIV: PSV versus NAVA
Doorduin, Crit Care 2014
Sinderby, in P & P of mechanical ventilation. Tobin Ed, 2013
NIV-NAVA
» Improves patient ventilator interaction
» Ventilator triggering not affected by leaks
» Clinical outcome studies not available
» Allows monitoring of patient ventilator interaction
Monitoring during NIV
Reasonable during NIV, but evidence lacking
High flow nasal cannula
60 L/min
High flow nasal cannula
» Physiological effects
» High Fio2
» Reduced dead space
» Provide PEEP
» Humidification
High flow nasal cannula
Parke, Resp Care 2011
» P/F < 300 mmHg @ 10Lo2 /min (>75% pneumonia)
» Paco2 < 45 mmHg
» No chronic resp failure
Randomization
» NRM
» 10 L o2 /min to maintain SpO2 > 92%
» Until recovery of ETI
» HFNC
» Flow rate 50 L/min
» O2 adjusted to maintain SpO2 > 92%
» ≥ 2 days; D/C switch to standard O2 therapy
» NIV
» TV 7-10 ml/Kg PBW, PEEP 210 cmH2O
» Adjust PEEP and Fio2 to maintain Spo2 > 92%
» ≥ 8 h / day, between sessions high flow O2 (HFNC)
Endotracheal intubation @28 d
Frat, NEJM, 2015All patients
± N=100/group
38%47%
50%
High flow nasal cannula
Frat, NEJM, 2015Pao2/Fio2 <200 mmHg
35%
53%
58%
High flow nasal cannula
Frat, NEJM, 2015
88%
77%
72%
Conclusion HFNC
» Does not reduce ETI rate for whole group (neither NIV), but
» Reduces ETI if P/F < 200 mmHg
» Decreases mortality
» Improves patient comfort
Conclusions
» Ventilator settings during NIV based on patient physiology
» NAVA improves patient ventilator interaction during NIV
» HFNC may be alternative to NIV in selected patients
Prof. Dr. med. Michael DreherDivision of Pneumology
University Hospital AachenGermany
Noninvasive Ventilation in
Hypercapnic Failure
• Speaking fees from ResMed, Philips Respironics, Weinmann,
Hamilton, Linde
• Fees for consulting from ResMed, Philips Respironics, Linde
• Research grant from ResMed
Disclosures
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
Long-term survival with NIV
0
20
40
60
80
100
0 1 2 3 4 5
Jahre
%
Poliomyelitis
Post-Tbc-Syndrom
Neuromusculär
COPD
Bronchiektasen
Kyphoskoliose
n = 172
Simonds AK et al. Thorax 1995; 50:604-609
Impact of home mechanical ventilationon health-related quality of life
Windisch W. Eur Respir J 2008; 32:1328-1336
• COPD
• restrictive disorders
• Obesity
Hypoventilation-Syndrome
• Neuromuscular disease
• others
N = 137
W. Windisch* on behalf of the quality of life in home mechanical
ventilation study group#
45
55
65
T0 T1 T12
COPD
Restriktiv
Neuromuskulär Changes in Quality of Life
independent from the underlying disease
MANOVA; F=0,62; P=0,65.
P < 0.001 COPD
P < 0.001 neuromuscular
P < 0.001 restrictive thoracic
45
55
65
T0 T1 T12
COPD RTD NMD
SR
I-S
um
mary
Scale
(S
RI-
SS
)
IPAP/EPAP(mbar)
20/3
19/4
25/1
Windisch W. Eur Respir J 2008; 32:1328-1336
Windisch W. et al. Pneumologie 2010, 64:640-652
lung / airways
thoracic cage
neuromuscular
Lloyed-Owen SJ.et al. Eur Respir J 2005; 25:1025-1031
Mehta et al. Am J Respir Crit Care Med Vol 163. pp 540–577, 2001
Windisch W. et al. Pneumologie 2010, 64:640-652
Windisch W. et al. Pneumologie 2010, 64:640-652
Windisch W. et al. Pneumologie 2010, 64:640-652
Windisch W. et al. Pneumologie 2010, 64:640-652
AJRCCM Vol 161. pp 688–691, 2000
Is home mechanical noninvasive ventilation indicated in
patients with COPD?
Long-term survival with NIV
Dreher et al. Thorax. 2010 Apr;65(4):303-8
Low-intensity
14.6 ± 0.8
4.0 ± 0
8.0 ± 0
PSV
High-intensity
28.6 ± 1.9
4.5 ± 0.7
17.5 ± 2.1
assPCV
IPAP [cmH20]
EPAP [cmH20]
bf [min-1]
Mode
Dreher et al. Chest 2011; 140(4):1–7Dreher et al. Thorax 2010 Apr;65(4):303-8
+Compliance
Sleep quality
+FEV1 (L)
+Quality of life (SRI-SS)
+Dyspnoea (BDS)
high-intensity NPPVlow-intensity NPPV
Köhnlein et al. Lancet Respir Med 2014
Köhnlein et al. Lancet Respir Med 2014
NPPV was targeted to reduce baseline PaCO2
by at least 20% or to achieve PaCO2 values
lower than 6.5 kPa (48.1 mmHg).
Köhnlein et al. Lancet Respir Med 2014
Windisch W. et al. Pneumologie 2010, 64:640-652
“However, it was concluded that current data would support the following recommendations. Patientswith COPD with a waking PaCO2 >50 to 52 mmHg, an overnight PaCO2 >55 mmHg, or both who aresymptomatic and compliant with other therapies should be eligible for NIV.”
White et al. Chest. 2015 Jun 1;147(6):1704-5
Chicago, Januar 2015
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
Standard(N = 42)
Intubation
Complications
Mortality
Hospitalization
Standard + NIV(N = 43)
74 % 26 %
48 % 16 %
35 ± 33 d 23 ± 17 d
29 % 9 %
Brochard L. et al. N Engl J Med 1995;333:817-822
Lightowler JV. et al. BMJ 2003; 326:185-189
• NIV avoids endotracheal intubation
(NNT = 5)
• NIV reduces mortality
(NNT = 8)
NNT = number needed to treat
What happens to those patients
once they are discharged from hospital
after acute hypercapnic respiratory failure
has been treated sufficiantly?
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
50%
Chu CM. et al. Thorax 2004; 59:1020-1025
35%
70%
80%
Chu CM. et al. Thorax 2004; 59:1020-1025
Does pursuing noninvasive ventilation
after acute respiratory failure
reduce rehospitalization and
improve long term surival
in hypercapnic COPD patients?
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
RESCUE trial
• COPD patients with ARF
• needing mechanical ventilation
• prolonged hypercapnia (6kPa)
Struik et al. Thorax 2014;0:1–9
NIV in COPD patients with prolonged hypercapnia after
ventilatory support for acute respiratory failure
NIV
standard treatment
randomization /
prolonged hypercapnia:
>48 h after termination
of ventilatory support
n = 201
Struik et al. Thorax 2014;0:1–9
Primary endpoint:
• time to readmission for respiratory causes or death
Secondary endpoints:
• blood gases, lung function, HRQL, daily activities, …
NIV in COPD patients with prolonged hypercapnia after
ventilatory support for acute respiratory failure
Struik et al. Thorax 2014;0:1–9
time to readmission or death
Struik et al. Thorax 2014;0:1–9
randomization /
prolonged hypercapnia:
>48 h after termination
of ventilatory support
NIV in COPD patients with prolonged hypercapnia after
ventilatory support for acute respiratory failure
Mod. N. Murphy et al. JAMA 2017
NIV after acute hypercapnic
respiratory failure
NIV
standard treatment
randomization /
prolonged hypercapnia:
14 -21 days
post index event
Murphy et al. JAMA. doi:10.1001/jama.2017.4451 Published online May 21, 2017
Murphy et al. JAMA. doi:10.1001/jama.2017.4451 Published online May 21, 2017
Murphy et al. JAMA. doi:10.1001/jama.2017.4451 Published online May 21, 2017
Murphy et al. JAMA. doi:10.1001/jama.2017.4451 Published online May 21, 2017
HOT-HMV reduced the likelihood of readmission or death by almost 50%
AGENDA
• Noninvasive ventilation for stable hypercapnic respiratory failure
• Noninvasive ventilation for acute hypercapnic respiratory failure
• Outcome after acute hypercapnic respiratory failure in COPD
• Noninvasive ventilation after acute hypercapnic COPD exazerbation
NIV in hypoxemic respiratory failureand difficult weaning
Elise Morawiec, MD
PG course: NIV in respiratory failure
Conflict of interest disclosure
I have no real or perceived conflicts of interest that relate to this presentation.
I have the following real or perceived conflicts of interest that relate to this presentation:
Affiliation / Financial interest Commercial Company
Grants/research support:
Honoraria or consultation fees:
Participation in a company sponsored bureau:
Stock shareholder:
Spouse / partner:
Other support / potential conflict of interest:
This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosureis not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial productsor services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remainsfor audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of theseinterests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.
NIV in hypoxemic respiratory failure
PG course: NIV in respiratory failure
NIV IN HARF: AN OLD CONTROVERSY
« non invasive pressure support ventilation is of no benefit when
used systematically in all forms of acute respiratory failure not
related to COPD »
Wysocki et al, Chest 1995
BENEFITS AND RISKS OF NIV
Increased oxygenation, alveolar
recruitment, relieves a high
WOB…
+
avoids the complications of
invasive MV
NIV failure: an independant risk
factor for mortality ?
from Demoule ICM 2006
BENEFITS AND RISKS OF NIV
Increased oxygenation, alveolar
recruitment, relieves a high
WOB…
+
avoids the complications of
invasive MV
delayed « last minute »
intubation ?
NIV-induced lung injury ?
From Carteaux, Crit Care Med 2015
A NEW PLAYER IN THE GAME:
THE RISE OF HFNOT
from Frat et al. NEJM 2015
THE IMPORTANCE OF ETIOLOGYetiology % of NIV failure
cardiogenic pulmonary edema 10%
chest trauma 12-18%
post surgery 33% (abdominal surgery)
ARDS 35-75% (depending on studies and
severity )
Mild: 22 to 31%
Moderate: 42 to 62%
Severe: 47 to 84%
non ARDS “medical” ARF (pneumonias,
atelectasis, pleural effusion…)
35 to 50 %
ARDS
The LUNGAFE cohort: a survey of « real life » practice
• 15% of ARDS receive NIV• Crude mortality IV vs NIV : ns
ARDS
PaO2/FiO2 > 150PaO2/FiO2 < 150
from Bellani AJRCCM 2016
LUNGSAFE cohort: NIV use is independentlyassociated with ICU mortality
PREDICTIVE FACTORS OF NIV FAILURE
• Overall patient severity
• Active cancer
• Cause of ARF
• PaO2/FiO2 < 150-200 mmHg
• Lower PEEP level, higher tidal volume
from Antonelli ICM 2001, Thille Crit Care 2003, Carteaux CCM 2015
IMMUNOCOMPROMISED: TOWARDS THE END OF
A SPECIAL TREATMENT ?
From Lemiale JAMA 2015
NIV IN HYPOXEMIC ARF: CONCLUSION
• Success or failure depend on the cause
• Use with caution
• Not recommended in moderate/severe ARDS
• High flow nasal oxygen ?
NIV in difficult weaning
PG course: NIV in respiratory failure
DIFFICULT WEANING
difficult weaning:
• 25% of patients
• 40 to 60 % of COPD patients
• higher morbidity, mortalityand health costs
patients at risk:
• age >65 years old
• underlying respiratory and cardiac disease
• ventilation >7days
• ineffective cough
NIV AND WEANING
• « curative NIV »
post extubation ARF
• « preventive/prophylactic NIV »
Successful SBT but high risk of extubation failure
• NIV to provide earlier extubation
(repeated) SBT failure
NIV IN POST EXTUBATION ARF
• unselected population
• NIV does not decrease reintubation rate
• NIV does not improve survival … higher mortality in NIV group !
NIV IN POST EXTUBATION ARF
• not recommended in unselected PE-ARF
• in selected populations ?
Lung/ abdominal surgery
Jaber, JAMA 2016Auriant, AJRCCM 2001
PROPHYLACTIC NIV
population protocol PE-ARF reintubation survival
Nava CCM 2005 hypercapnia/ congestive HF / >1 comorbidity
ineffective cough/excessivesecretions/UA obtruction
1 SBT failure
> 8 hrs
V V
Ferrer AJRCCM 2006 65 yo CF as the cause of intubation APACHE II >12
24 hrs (19)V X V
Ferrer Lancet 2009 chronic resp disease + hypercapnic 24 hrs (18) V X VKilhani Anesth IC2011
COPD > 8 hrs XThille CC 2016(before/after study)
> 65 yo resp disease cardiac disease
> 8 hrsV X
Vargas, ICM 2017 chronic respiratory disease 8 hrs V X X
PROPHYLACTIC NIV
• ACCP/ATS: « strong recommandation » to use preventive NIV
for at risk patients ventilated for >24h, immediately after
extubationOuelette Chest 2017
PROPHYLACTIC NIV
• What to look for in the future:
– Better definition of « at risk patients »
– Optimal protocol (duration ?)
– HFNO in weaning
NIV TO PROVIDE EARLY EXTUBATION
invasive ventilation
weanedinvasive ventilation
intubation
SBT
SBT
SBT
invasive ventilation
intubation
SBT
NIV
NIV TO PROVIDE EARLY EXTUBATION
• Heterogeneous studies
• conventional strategy protocol ?
• increased survival : only 1 study
• other outcomes ?
• « While useful in very selected population its use cannot be
recommanded for all patients failing a SBT » Boles ERJ 2007
Ferrer, AJRCCM 2003
3 SBT failures
NIV IN PROLONGED WEANING
• NIV has a central place in prolonged weaning
• In weaning centers, 30-45% of patients are discharged with NIV
as home ventilation
• Optimal protocol unknown
NIV IN WEANING: CONCLUSION
• Prophylactic NIV: « at risk » patients
• Curative NIV: post operative patients
• NIV for early extubation: controversial
Thank you !
ROLE OF VENTILATOR MODE AND INTERFACE IN OPTIMISING PATIENT-
VENTILATOR INTERACTIONS UNDER NIV
Paolo Navalesi
Anesthesia and Intensive Care
Department of Medical and Surgical Sciences
University of Magna Graecia
Catanzaro - Italy
Conflict of interest disclosure
I have no real or perceived conflicts of interest that relate to this presentation.
I have the following real or perceived conflicts of interest that relate to this presentation:
Affiliation / Financial interest Commercial Company
Grants/research support: Maquet Critical Care, Intersurgical S.p.A., Draeger,
Honoraria or consultation fees: Maquet, Resmed, Hillrom
Participation in a company sponsored bureau:
Stock shareholder:
Spouse / partner:
Other support / potential conflict of interest: Royalties form Intersurgical S.p.A. for Helmet Next invention
This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosureis not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial productsor services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remainsfor audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of theseinterests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.
Introduction
AIMS
• Describe how leaks affect patient-ventilator interaction
• Show the behavior of various modes during NIV
• Consider how different interfaces affect patient-ventilator
interaction
AI[10%, indicating severe
asynchrony, was present in 26
patients (43%)
The comfort VAS was higher in
patients with an AI\10% (6.5 vs. 5.7,
P = 0.027)
Flow cycling OFF with leaks
Calderini et al. Intensive Care Med 1999; 25:662-667
n-PSV
FLOW[L/s]
PES[cmH2O]
PAW[cmH2O]
Leak
Missed efforts
Failed to cycle off
Calderini et al. Intensive Care Med 1999; 25:662-667
n-PSVn-PCV
60/resp. rate x 0.4
n-PSV n-PCVSB
n-PSV n-PCVSB
n-PSVn-PCV
Co
mfo
rt S
co
re
Calderini et al. Intensive Care Med 1999; 25:662-667
Calderini et al. Intensive Care Med 1999; 25:662-667
n-PSVn-PCV
1 sec
40
20
3
-101
Paw(cmH2O)
Pdi(cmH2O)
Volume(l)
Flow(l/s)
Airleaks during n-PAV
From Navalesi et al. “Proportional Assist Ventilation”
in Torri-Calderini “Tecniche di ventilazione artificiale”
0
1.5
-1.5
15
30
0
8 sec
Flo
w (
L/s
)P
aw (
cmH
2O
)
From Cammarota et al. ICM 2011
0
1.5
15
30
0
8 sec
Flo
w (
L/s
)P
aw (
cmH
2O
)
-1.5
0
2
VT
(L)
0.51 L
From Cammarota et al. ICM 2011
(Crit Care Med 2009; 37:939 –945)
(Crit Care Med 2009; 37:939 –945)
Navalesi P et al. Intensive Care Med 2007
Anesthesiology. 2016 Jan;124(1):101-8
Conclusion
1. Leak compensation is crucial for NIV success
2. NAVA is the only mode unaffected by leaks
3. Interfaces for NIV are largely interchangeable
4. The helmet offers advantages, but patient-ventilator
interaction may be problematic for problems other than leaks