· · 2017-01-12draft reviewer guidance for ventilators, july, 1995. for ventilator dependent...
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INDICAZIONI ALLA
VENTILAZIONE MECCANICA NON
INVASIVA A LUNGO TERMINE
WWW.FISIOKINESITERAPIA.BIZ
INDICAZIONI ALLA VMD
La ventilazione meccanica (VM) è
indicata quando gli sforzi respiratori
spontanei del paziente non sono in
grado di sostenere un’adeguata
ventilazione alveolare.
Selection Guidelines for NIMV in CRF
Selection Guidelines for NIMV in CRF
Slowly progressive respiratory failure due to:-NEUROMUSULAR DISEASE
Muscular dystrophiesPostpolio syndromeMultiple sclerosisALS
- THORACIC WALL DEFORMITIESKyphoscoliosisPost-thoracoplasty
- OBSTRUCTIVE SLEEP APNEA- IDIOPATHIC HYPOVENTILATION- COPD (efficacy not established)Meyer and Hill Ann.Intern.Med. 120;1994
THE MAIN OBJECTIVES OF LT-MV ARE:
IMPROVE SURVIVAL
IMPROVE QUALITY OF LIFE
REDUCE THE IMPACT OF DISEASE
(POTENTIALLY) REDUCE COSTS
THE MAIN OBJECTIVES OF LT-MV ARE:
IMPROVE SURVIVAL
IMPROVE QUALITY OF LIFE
REDUCE THE IMPACT OF DISEASE
(POTENTIALLY) REDUCE COSTS
VMD NON INVASIVA:applicazione mediante interfaccia
nasale o oro-nasale
VMD INVASIVA:applicazione mediante interfaccia
tracheostomico
VMD NON INVASIVA:applicazione mediante interfaccia
nasale o oro-nasale
VMD INVASIVA:applicazione mediante interfaccia
tracheostomico
LIFE SUSTAINING:for ventilator dependent patients(respiratory autonomy < 8 hrs/day).
Needs back-up ventilation
LIFE SUPPORT:for partially ventilator dependent
patients (respiratory autonomy > 8 hrs/ day).
Does not need back-up ventilation.Draft Reviewer Guidance For
Ventilators, July, 1995.
LIFE SUSTAINING:for ventilator dependent patients(respiratory autonomy < 8 hrs/day).
Needs back-up ventilation
LIFE SUPPORT:for partially ventilator dependent
patients (respiratory autonomy > 8 hrs/ day).
Does not need back-up ventilation.Draft Reviewer Guidance For
Ventilators, July, 1995.
LONG-TERM MECHANICAL VENTILATION
• Uncontrollable airway secretions
• Impaired swallowing
• Persistent symtomatic RF despite NIMV
• Need for >20 hours ventilatory support
• Patient’s willingness
Indications for IMV beyond the ICU
(from ACCP Consensus 1998. Chest 1998;113:289-321S)
Pao
VT
Pes
MODES OF POSITIVE PRESSURE MV
VOLUME-CYCLED MECHANICAL VENTILATION
PRESSURE-CYCLED MECHANICAL VENTILATION
BILEVEL POSITIVE AIRWAY PRESSURE
VENTILATORE PAZIENTE
TRIGGER
QUANTITA’ E TIPOLOGIA DI
FLUSSO
CICLAGGIO INSP/ESP
DRIVE DELPAZIENTE
RICHIESTA VENTILATORIA
CICLO RESPIRATORIO
Onyx PV102Harmony
ReCV Helià
0123456789
10111213
0123456789
10111213
0123456789
10111213
0123456789
10111213
0123456789
10111213
HarmonyOnyx
PV 102Helià Re CV
n° pts n° pts
n° pts n° pts n° pts
% OC % OC
% OC % OC % OC
@
best worse
COPD
RCWD
10 50 100 10 50 100
10 50 100 10 50 100 10 50 100
1. MALATTIE RESTRITTIVE DEL TORACE
• Patologie neuromuscolari• Cifoscoliosi• Postumi di malattie neurologiche e della
gabbia [polio-toracoplastica]
NPPV and Restrictive Thoracic Disorders
(ACCP Conference Report. Chest 1999;116:521-534)
Clinical indicators
1. Disease documentationi. hystory, physical examination, diagnostic testsii. appropiate diagnosis
2. Indications for usagei. symptomsii. physiologic criteria
(PaCO2 >45, SatO2 <88% for 5 consecutive min, MIP <60 cmH2O or FVC <50% prd.)
Symptoms
Ambulatory
VC < 1.5 L.
Abnormal nocturnal gas exchange
H.M.V.
Abnormal diurnal ABG
NOYES
Assessment annually
Assessment 3-6 months
NO
YES
NOYES
LTMV in LTMV in hypoventilationhypoventilation fromfrom RTDRTD((MetanalysisMetanalysis basedbased on 4 on 4 RCTsRCTs))
(from Annane D. et al. The Cochrane Library Issue 2. 2000; Oxford)
RESULTS• Reversal of day-time related symptomsRisk of no improvement -0.417 in favor of LTMV• Reversal of day-time hypercapniaRisk of no improvement -0.635 in favor of LTMV• One-year mortalityRisk of no improvement -0.259 in favor of LTMV
Thorax 1998
2. MALATTIE DELLE VIE AEREE E DEL POLMONE
• BPCO• Fibrosi Cistica• Bronchiectasie
OLT rappresenta il gold-standardper il trattamento della BPCOcon IR stabile
NPPV and COPD
(ACCP Conference Report. Chest 1999;116:521-534)
Clinical indicators
1. Disease documentationi. hystory, physical examination, diagnostic testsii. appropiate diagnosis (COPD, BK, CF)
2. Indications for usagei. symptomsii. physiologic criteria
(PaCO2 >55, PaCO2 54<50 + SatO2 <88% for 5 consecutive min while on oxygen >2 L/min, PaCO2 54<50 + recurrent hypercapnic ARFs
(from Aida A. et al. AJRCCM 1998; 158: 188-193)
Eur Respir J 2002
-20
-10
0
10
20Symptoms ActivityImpacts Total
LTOT NPPV
-20
-10
0
10
20 Cognitive behaviour ActivityDisability OthersTotal
Scor
e ch
ange
from
bas
elin
e
LTOT NPPV
4
5
6
7
8
9
M0 M12 M24
* *PaCOPaCO2 2 on oxygenon oxygen
1
2
3
4
5
M0 M12 M24
LTOT
NPPV
* *MRC MRC dyspneadyspnea
La ventilazione meccanica notturna non invasiva con pressione La ventilazione meccanica notturna non invasiva con pressione positiva (NPPV) aggiunta al regime corrente di OLT positiva (NPPV) aggiunta al regime corrente di OLT in pazientiin pazientiipercapniciipercapnici puopuo’’ determinare: determinare: -- stabilizazionestabilizazione della della capniacapnia ((BB))-- riduzione della sintomatologia riduzione della sintomatologia ((BB))-- miglioramento della miglioramento della QualitaQualita’’ di Vita e delldi Vita e dell’’outcomeoutcome clinico (ma clinico (ma non della sopravvivenza) (non della sopravvivenza) (BB))
UTILIZZO DELLA VNI A DOMICILIO
TUTTAVIA NON VI ETUTTAVIA NON VI E’’ EVIDENZA ATTUALE EVIDENZA ATTUALE PER UNA PRESCRIZIONE GENERALIZZATAPER UNA PRESCRIZIONE GENERALIZZATA
HOSPITAL ADMISSIONS
00,5
11,5
22,5
33,5
4
Follow-back
Follow-up
Total hospital admissions (nr/pt/year)
0
0,5
1
1,5
2ICU admissions (nr/pt/year)
NPPVLTOTNPPVLTOT
DIAGNOSI E PROBABILITA’ DI SOPRAVVIVENZA
• VMD non INVASIVA• VMD INVASIVA
from Leger et al. Chest 1994;105:100
0
25
50
75
100
0 6 12 18 24 30 36
months
prob
abili
ty to
con
tinue
NIM
V (%
)
KyphoscoliosisTB sequelaeCOPDBronchiectasisDuchenne
0102030405060708090
100
0 1 2 3 4 5 6 7 8 9
Polio (41)MP (13)KP (53)TB (55)COPD (50)BR (10)
HOME MECHANICAL VENTILATION (HMTV)
From Robert 1983
% survival
years
RACCOMANDAZIONI PER LA VENTILAZIONE MECCANICA DOMICILIARE
Position paper joitly by AIPO and SIMRI
(Rassegna Patologia Apparato Respiratorio 2003; 18: parte 1 e parte 2)