cpap, niv, high-flow: how to choose? - siva-qc.org€“ maquet (nava) – air liquide ... clinical...
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CPAP, NIV, high-flow:How to choose?
Laurent Brochard
Toronto
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Conflicts of interest
• Our clinical research laboratory has received research grantsand/or equipment for clinical research projects from the following companies: – Covidien (PAV+)
– Dräger (SmartCare)
– General Electric (FRC)
– Philips (NIV-sleep)
– Fisher Paykel (High flow)
– Maquet (NAVA)
– Air Liquide (Helium)
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Outcomes of Non-invasive Ventilation for Acute Exacerbations of COPD in the United States, 1998-2008
Chandra et al. AJRCCM 2012
7,511,267 admissions for acute exacerbations occurred from 1998-2008
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NIV & COPD
2006
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• Invasive MV: 7 /20 pts vs. 20
• Complications: 7 in 20 pts vs.
23 in 20
• Duration of MV 14 vs. 27 d
• LOH 5 vs. 22 d
• 1-year survival 55 vs. 50%
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0
-20
-40
-60
-80
*
**
0
-20
-40
-60
-80
*
*
*WOB DPdi
NIV + helium-O2 = external + internal Assistance
Noninvasive Ventilation with Helium–Oxygen in Acute Exacerbations
of Chronic Obstructive Pulmonary Disease
VS-HeO2 NIV-HeO2NIV-AirO2 VS-HeO2 NIV-HeO2NIV-AirO2
Jaber,….Brochard. AJRCCM 2000; 161: 1191
% %
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Respiratory rate /min.
pHSpO2
PaCO2 mmHg
Physiological effects during 1st 72 hours
p <0.0001 - all time points
p <0.0001 - all time points
mean ± 95% CI
mean ± 95% CImean ± 95% CI
mean ± SD
Jolliet P et al in revision
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Encephalopathy score over first 72 hrs
mean ± 95% CI
Jolliet P et al in revision
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Jolliet P et al in revision
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N= 4400
CCM 2013
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Thorax 2004
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Lenique et al AJRCCM 1997, 155:500
9 patients
CPAP 10 cmH2OImprovement in compliance & resistance.
CPAP and CPO
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(1%)
(10%)
« Early » application of CPAP (+7.5 cmH2O)» decreases endotracheal intubation and severe complications in patients with hypoxemia after elective major abdominal surgery
0
2
4
6
8
10
12
Pneumonia Sepsis Mortality
N o
f p
ati
en
ts (
%)
Control CPAP
* *
0.12
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JAMA 2016
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Demoule A et al ICM 2006
Mortality
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PaO2/FiO2Respiratory mechanics
May preventor be useless
Insufficientor risky
May help
Dangerous
Needed
May help or worsen
NIV ETI
Time window
Time (hours/days)
Severity window
Brochard et al. Semin Resp Med. 2014
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High
Gas Flow
Washout of nasopharyngeal dead space
The high gas flow decreases the
upper airway dead space like
trans-tracheal airway insufflation
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Resp Care 2012
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Acute Respiratory Failure
RR >25 c/min ; PaO2/FiO2 300, PaCO2 <45 mmHg
Consent
(patient, Family, emergency)
Delay between random. and Tt <3 h
stratification on cardiac disease
NIV / O2-HFH O2-HFH O2
( ≥8h/d, D0,D1,D2 min.) (24/24h, D0,D1,D2 min.) (24h/24)
Clinical Effect of the Association of Noninvasive Ventilation and High Flow Nasal Oxygen
Therapy
in Resuscitation of Patients With Acute Lung Injury (FLORALI Study)
JP Frat
Poitiers University Hospital
ClinicalTrials.gov Identifier:
NCT01320384
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Cumulative incidence of Being Intubated in the Overall Population
0.2
0.4
0.6
0.8
0
0 4 8 12 16 20 24 28
Days After Enrollment
1.0C
um
ula
tive In
cid
en
ce o
f B
ein
g In
tub
ate
d
High-Flow Oxygen group
Standard oxygen group
NIV group
Number at risk
High-Flow Oxygen group 106 68 67 67 65 65 65 65
Standard Oxygen group 94 52 50 49 49 49 48 48
NIV group 110 64 57 53 53 53 53 52
P=0.17 by log-rank test
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0 4 8 12 16 20 24 28
0
0.2
0.4
0.6
0.8
1
Days After Enrollment
Cu
mu
lati
ve
In
cid
en
ce
of
Be
ing
In
tub
ate
d
High-Flow Oxygen group
Standard Oxygen group
NIV group
Cumulative Incidence of Being Intubated in the Patients With a PaO2:FiO2 ≤ 200 mm Hg
Number at risk
High-Flow Oxygen group 83 55 54 54 53 53 53 53
Standard Oxygen group 74 37 35 34 34 34 33 33
NIV group 81 41 34 32 32 32 32 32
P=0.009 by log-rank test
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0
0.2
0.4
0.6
0.8
1.0
0 15 30 45 60 75 90
Cu
mu
lati
ve
P
rob
ab
ilit
y o
f S
urv
iva
l
Days After Enrollment
Kaplan-Meier Plot of the Probability of Survival from Randomization to Day 90
P=0.015 by log-rank test
High-Flow Oxygen group
Standard oxygen group
NIV group
Number at risk
High-Flow Oxygen group 106 100 97 94 94 93 93
Standard Oxygen group 94 84 81 77 74 73 72
NIV group 110 93 86 80 79 78 77
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Maggiore SM et al AJRCCM 2014
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JAMA 2016
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Hernandez et al. JAMA 2016
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Coudroy et al. AOIC 2016
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Impact of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: post hoc analysis of a randomized trial.
0 4 8 12 16 20 24 28
0.2
0.4
0.6
0.8
1.0
Pro
bab
ility
of
Intu
bat
ion
P=0•04 by log-rank
NIV
Standard oxygen
HFNC
Days since enrollment
Frat JP et al Lancet Resp Med 2016
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0.2
0.4
0.6
0.8
1.0P
rob
abili
ty o
f su
rviv
al
0 15 30 45 60 75 90
Days since enrollment
P=0•03 by log-rank
NIV
Standard oxygen
HFNC
Frat JP et al Lancet Resp Med 2016
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Nasal Cannula High Flow therapy
• Needs more rigorous clinical and physiological assessment to understand mechanisms and indications
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CPAP, NIV, Nasal Cannula High Flow therapy
• NHFC Needs more rigorous clinical and physiological assessment to understand mechanisms and indications
• NIV (BIPAP) save lives in COPD
• NIV or CPAP improves distress in pulmonary edema amd may save lives
• NIV or CPAP reduce reintubation and infections after (abdominal) surgery