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Update Nicht-invasive Beatmung
in der akuten Exazerbation
Wolfram Windisch
Lungenklinik Köln-Merheim
Conflicts of interest
Open research grants:
Speaking fees and editorial boards
 Weinmann, Germany
 Heinen und Löwenstein, Germany
 Vivisol, Germany
 VitalAire, Germany
 VitalAire, Germany
 ResMed, Germany
 Respironics, USA
 Maquet, Germany
 Breas Medical, Sweden
 Respironics, USA/Germany
 Fischer & Paykel Healthcare
 Linde, Germany
 Radiometer, Germany
Entlassung
Tod
Funk GC. et al. Eur Respir J 2013; 41:792-799
Rationale for
Non-invasive Ventilation (NIV)
to improve respiratory function and symptoms
• blood gases
• dyspnea
• respiratory rate
to avoid intubation and related complications
• ventilator-associated pneumonia (VAP)
• complications related to catheterization
• tracheostomy and weaning failure
to improve outcome
• to reduce length of ICU and hospital stay
• mortality
• NIV prevents intubation
(NNT = 5)
• NIV reduces mortality
(NNT = 8)
NNT = number needed to treat
Lightowler JV. et al. BMJ 2003; 326:185-189
Funk GC. et al. Eur Respir J 2013; 41:792-799
Trends in Mechanical Ventilation among Patients
Hospitalized with Acute Exacerbation of COPD in the
United States, 2001 to 2011
Mihaela S. Stefan, MD1-3, Meng-Shiou Shieh, PhD1, Penelope S. Pekow, PhD1,4,
Nicholas Hill, MD5, Michael B. Rothberg, MD, MPH6, Peter K. Lindenauer, MD, MSc1-3
mit Pneumonie
ohne Pneumonie
NIV
IMV
Stefan MS. et al. Chest 2014; in press
Andreassen SL. et al. Clin Respir J 2014; 8:93-99
Chandra D. et al. Am J Respir Crit Care Med 2012; 185:152-159
High NIV expertise in RCTs – transferrable to real world?
To address avoidable conditions leading to NIV failure!
Bayarassou AH. et al. Minerva Pneumol 2013; 52:39-53
Bayarassou AH. et al. Minerva Pneumol 2013; 52:39-53
Ineffective
ventilation
Failing
synchrony
NIV-failure
Bayarassou AH. et al. Minerva Pneumol 2013; 52:39-53
Ineffective triggering:
Inspiratory timing asynchrony:
Neural breath effort is
Delay between
not translated to
• Neural inspiration and
mechanical inflation
• Mechanical inflation
Piquilloud L et al. Intensive Care Med 2012; 38:1624-1631
Gattinoni L. et al. Br J Anaest 1978; 50:753-758
Median pH before PECLA = 7.28
Patients with
NIV-failure
Kluge S et al. Intensive Care Med 2012; 38:1632-1639
Moerer O. et al. Minerva Anestesiol 2011; 77:537-5344
Patients with
NIV-failure
Tracheostomised patients could require prolonged weaning
Kluge S et al. Intensive Care Med 2012; 38:1632-1639
Despite increasing experience in weaning from mechanical ventilation the clinical
outcomes worsen – likely as a consequence of admitting more severely ill patients.
Polverino E. et al. Intensive Care Med 2010; 36:137-142
Schönhofer B. et al. Pneumologie 2014; 68:19-75
Dauer der Beatmung
(externe ICU)
vor Verlegung ins
Weaning-Zentrum:
32,5 (19-50) Tage
Schönhofer B. et al. Intensive Care Med 2002; 28:908-916
Health-related quality of Life and Living Conditions in
Tracheotomised Patients with Invasive Home Mechanical Ventilation
Huttmann S, Windisch W, Storre JH
• Neuromuscular disorder/private home
• Neuromuscular disorder/nursing facility
• COPD/private home
Following unsuccessful prolonged weaning after
intubation und subsequent tracheostomy
to treat acute hypercapnic respiratory failure
• COPD/nursing facility
Median value: 53.3
SRI = Severe Respiratory Insufficiency Questionnaire (Windisch W. et al. J Clin Epidemiol 2003; 56:752-759)
Huttmann S. et al. In preparation; 2014
COPD (N = 20)
Initial NIV
(N = 7)
Weaning failure
(N = 2)
Invasive MV: failed SBT
(N = 11)
V-V ECCO2R
15.5 F double-lumen
• jugular
• femoral
Mean blood flow: 431 ±74 mL/min
Burki NK. et al. Chest 2013; 143:678–686
(n=23)
Intubation
pH
7.20 ± 0.05
7.20 ± 0.05
PaCO2
85 ± 16
87 ± 14
PaO2/FiO2
168 ± 38
RR
33 ± 2
NPPV
mmHg
mmHg
min-1
171 ± 38
34 ± 2
(n=26)
mmHg
mmHg
min-1
48% avoided intubation
Conti G. et al. Intensive Care Med 2002; 28:1701-1707
14.5 Fr
19 Fr
Hemodialysis
Catheter
Bicaval Dual
Lumen Catheter
Karagiannidis C. et al. Crit Care 2014;18:R124
Del Sorbo L. et al. Crit Care Med 2014; in press
Femoral 14F
Double-lumen
catheter
Del Sorbo L. et al. Crit Care Med 2014; in press
Complications of extracorporeal circuits
•
•
•
•
•
Severe Bleeding
Thrombosis and haemolysis
Vessel perforation
Cerebral bleeding
Neurological complications unclear
Carefully select the patient!