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. SPONT. PARTIAL ASSIST. TOTAL ASSIST. Mofied from Synder 1984

Mofied from Synder 1984

Effects PEEP on venous return

Fessler 1992Fessler 1992

PEEPPEEP

Basal conditionBasal condition

Interrelationship between the venous return and cardiac function

Pinsky R 1987 Pinsky R 1987

HEART

ITP ITP and BLOOD FLOW

effort = - ITP and VR and RV blood volume

LV afterload and LV blood volume

chest blood volume

ITP and BLOOD FLOW

effort = - ITP and VR and RV blood volume

LV afterload and LV blood volume

chest blood volume

THORAXTHORAX

VC

ITP and LV function

effort =- ITP = Ptm(trans. Pressure)= LV afterload

ITP and LV function

effort =- ITP = Ptm(trans. Pressure)= LV afterload

ITP and RV function

+ ITP= Pra Pms (upstream pressure)]

VR and RVEDV

ITP and RV function

+ ITP= Pra Pms (upstream pressure)]

VR and RVEDV

AO

RV 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 1987Pinsky 1987

Vt and (Vd/Vt) Va inspiratory effort load imposed by spontaneous

ventilation VCO 2

PaC02

Vt Va/Q inspiratory effort

V02

Pa02

PaC02 KVCO2

Va

PaC02 KVCO2

Va

How does ABG improve ?How does ABG improve ?

Effects of MV during CPE

TRATTAMENTO

CPAP/IPPVCPAP/IPPV

Net filtration =LpS x [(Pcap - Pif) - s(cap - if)]

LV failureLV failure

Pulmonaryedema

Pulmonaryedema

Pulmonary compliance

Pulmonary compliance

Airwayresistance

Airwayresistance

NegativeIntrathoracic

Pressure Swing

NegativeIntrathoracic

Pressure Swing

Work of

breathing

Work of

breathing

CO CO

PaO2 PaO2

Respiratory muscle fatigue

Respiratory muscle fatigue

DaO2 DaO2

LV failureLV failure

Pulmonaryedema

Pulmonaryedema

Pulmonary compliance

Pulmonary compliance

Airwayresistance

Airwayresistance

NegativeIntrathoracic

Pressure Swing

NegativeIntrathoracic

Pressure Swing

LV transmural pressure

LV transmural pressure

O2Cost of breathing

O2Cost of breathing

LV afterload LV afterload

ITP WOB

Negative Pleural Pressure RV pre-load

LV after-load

Resp. muscles O2 demand Cardiac O2 demand

R esolution T im e*30(IQ R 15-53) m in

1(5% ) ET I

19 P ts. N IPSV (FM)

R esolution T im e*105(IQ R 50-230) m in

6(33% ) ET I

18 P ts S ta nda rd MT

P<0.037

Masip, Lancet, 2000;356:212640 patients with CPE 3 patients withdrawn

P<0.002

*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 20.54.7° cmH20 plus Peep 3.5 2.3 cmH20

• Sa02 73.8 11* vs 8412°; PaC02 6218.5* 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 1998Pang 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 vs BiPAP

BiPAP CPAP

• FC

• FR

• Ph

• PaCO2

• Dyspnea score (30 min)(p<0.05)

Mehta S et al. Crit. Care Med. 1997, 25, 4

• FR

CPAP plus SMT vs NIPPV plus SMTMehtaMehta S et al. S et al. Crit Crit. Care. Care Med Med. 1997. 1997

NIPPV (14pts)* CPAP (13pts)

FC

FR

FR

Ph

PaCO2

Dyspnea score (30 min) (p<0.05)

FR

Pang D Chest 1998Pang D 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 1998Pang Chest 1998

Randomized Studies: Hypoxiemic ARF timingEarly=to prevent (1) and established=to treat (2)

Hypox.ARF

Yr

Timing

Level of Evidence

Interf Type

Mode of MV

No.

NPPV

Outcome Measure

Wysocki et al., Chest

1995 1 I F PSV + PEEP 21 ETI, surv

Antonelli et al., NEJM

1998 2 I F PSV + PEEP 32 ABG, ETI, LOS, surv

Confalonieri et al.,AJRRCCM

1999 1 I F PSV + PEEP 28 ABG, ETI, LOS, surv

Antonelli et al., JAMA

2000 1 I F PSV + PEEP 20 ABG, ETI, LOS, surv

Martin et al., AJRCCM

2000 1 I N IPAP +EPAP 14 ETI, surv

Hilbert et al., NEJM

2001 1 I F PSV + PEEP 26 ABG, ETI, LOS, surv

Auriant et Al CCM

2001 4 I N IPAP+EPAP 24 ABG, ETI, LOS, surv

Antonelli et Al CCM

2002 1/2 II H/F PSV+PEEP 99

ABG, ETI, LOS, surv

Antonelli et Al Int Care Med

2002 1/2 II F PSV+PEEP 354

ABG, ETI, LOS, surv

Carlucci et Al AJRCCM

2001 1 II F PSV+PEEP 15

ABG, ETI, LOS, surv

Girault et Al CCM

2003 1/2 II F Psv+peep 37

ABG, ETI, LOS, surv

Hypox.ARF

Yr

Timing

Level of Evidence

Interf Type

Mode of MV

No.

NPPV

Outcome Measure

Wysocki et al., Chest

1995 1 I F PSV + PEEP 21 ETI, surv

Antonelli et al., NEJM

1998 2 I F PSV + PEEP 32 ABG, ETI, LOS, surv

Confalonieri et al.,AJRRCCM

1999 1 I F PSV + PEEP 28 ABG, ETI, LOS, surv

Antonelli et al., JAMA

2000 1 I F PSV + PEEP 20 ABG, ETI, LOS, surv

Martin et al., AJRCCM

2000 1 I N IPAP +EPAP 14 ETI, surv

Hilbert et al., NEJM

2001 1 I F PSV + PEEP 26 ABG, ETI, LOS, surv

Auriant et Al CCM

2001 4 I N IPAP+EPAP 24 ABG, ETI, LOS, surv

Antonelli et Al CCM

2002 1/2 II H/F PSV+PEEP 99

ABG, ETI, LOS, surv

Antonelli et Al Int Care Med

2002 1/2 II F PSV+PEEP 354

ABG, ETI, LOS, surv

Carlucci et Al AJRCCM

2001 1 II F PSV+PEEP 15

ABG, ETI, LOS, surv

Girault et Al CCM

2003 1/2 II F Psv+peep 37

ABG, ETI, LOS, surv

Studies: Hypoxiemic ARF a total of 176 pts randomized to NIV

Level of evidence

No. of patients

Physiological improvement

Mortality ETI or failure criteria

Complications

Wysocki I

21 vs. 20 Only if

PaCO2 > 45

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 na Girault II 37 of 124 Yes na na

Level of evidence

No. of patients

Physiological improvement

Mortality ETI or failure criteria

Complications

Wysocki I

21 vs. 20 Only if

PaCO2 > 45

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 na Girault II 37 of 124 Yes 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)

Mortality22%

NP11(10%)

LoS in ICU5.1(5.7) days

Duration of MV8(6.3) days

NIVN=108 (16%)

Mortality41%

NP72(19%)

LoS in ICU7.8(9.8) days

Duration of MV13.9(14.5) days

ETIN=581

P<0.002

P= 0.03

P<0.001

P<0.04

SAPSII 36(20) SAPSII 47(21)*

*P<0.001

689 pts MV689 pts MV

NIVNIV14% pts Hypoxemic ARF14% pts Hypoxemic ARF27% pts CPE27% pts CPE50% Pts HypercapnicARF50% Pts HypercapnicARF

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N° patients % failures • 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