09 13 September 2017 - ERS-education€“13 September 2017 ... PG4 Noninvasive ventilation in...

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!

http://erspublications.com/

http://www.ersbookshop.com/

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 ↓


EPAP

0

IPAP

Flo

wP

ress

ure

Inspiration

3. Inspiratory rise time

Inspiratory rise time

Sassoon, Resp Care 2011


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%


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


“Uses diaphragm electrical

activity to control the ventilator”


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





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


» Physiological effects

» High Fio2

» Reduced dead space

» Provide PEEP

» Humidification


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%


Frat, NEJM, 2015Pao2/Fio2 <200 mmHg

35%

53%

58%


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





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





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


NPPV was targeted to reduce baseline PaCO2

by at least 20% or to achieve PaCO2 values

lower than 6.5 kPa (48.1 mmHg).



“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





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





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





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


Primary endpoint:

• time to readmission for respiratory causes or death

Secondary endpoints:

• blood gases, lung function, HRQL, daily activities, …




time to readmission or death


randomization /


>48 h after termination

of ventilatory support



Mod. N. Murphy et al. JAMA 2017

NIV after acute hypercapnic

respiratory failure

NIV

standard treatment

randomization /


14 -21 days

post index event

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





Seite 40

Prof. Dr. med. Michael Dreher

University Hospital Aachen

Germany

[email protected]

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


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


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


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



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

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