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Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο ΜΕΜΑ σε οξύ πνευμονικό οίδημα.

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Παρουσίαση με θέμα: "Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο ΜΕΜΑ σε οξύ πνευμονικό οίδημα."— Μεταγράφημα παρουσίασης:

1 Ηρακλής Τσαγκάρης 2 η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο ΜΕΜΑ σε οξύ πνευμονικό οίδημα

2 Acute pulmonary edema represents nearly 20% of acute heart failure cases. The diagnostic criteria of this syndrome have not been universally established. Sudden onset of severe dyspnoea /the presence of typical signs on physical examination /alveolar oedema on chest radiograph / and acute respiratory failure Acute Cardiogenic Pulmonary Oedema Common ,000 hospital admissions per annum in UK Deadly % in- hospital mortality Costly million hospital days per annum in USA Eur Heart J. 2008;29:

3 Differences and similarities of acute pulmonary edema (APE) and acutely decompensated chronic heart failure (ADHF) Parissis, Eur J Heart F, 2010

4 Standard CPE therapy Loop Diuretic Therapy Nitrate Therapy Oxygen Therapy (Opiates) Treat Underlying Cause

5 Οξύ καρδιογενές πνευμονικό οίδημα  ελαστικού φορτίου  φορτίου αντιστάσεων ( Noble, JAP 1975 ) Οι αν. μύες παράγουν  πίεση για ικανοποιητική ροή και V T  αρνητικής ενδοθωρακικής πίεσης   προφορτίου και μεταφορτίου των κοιλιών ( Hall, JAP 1998 )  ενεργειακού κόστους αναπνοής   μεταφοράς Ο 2 στο μυοκάρδιο

6 Targets of ventilation in cardiogenic pulmonary oedema improvement of oxygenation improvement of respiratory acidosis reduction of work of breathing improvement of cardiac performance reduction of patient’s distress

7 Physiological Improvement with CPAP in Pts with CardPE Kelly et al. Eur Heart J 2002;23:

8 “ When the household vacuum cleaner is employed, the machine should be run for some minutes first of all to get rid of dust” Poulton EP, Oxon DM: Left-sided heart failure with pulmonary oedema: Its treatment with the "pulmonary plus pressure machine." Lancet (1936);231: Non-invasive Ventilation In Acute Cardiogenic Pulmonary Oedema

9 354 consecutive pts 7 centers EUR+USA

10

11

12 When to start NIV in CPE Patients with pH <7.25 or systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for NIV. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation. Masip J, et al. Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema. Intensive Care Med 2003;29:

13 NIV failure in CPE: decide early Worsening encephalopathy/agitation Inability to clear secretion Inability to accept any interface Hemodynamic instability Worsening oxygenation Progressive respiratory acidosis (pH<7.2) Persistent tachypnea-tachycardia

14 Effects of Noninvasive Ventilation on Mortality Masip et al, JAMA 2005;294:

15 Masip et al. JAMA 2005;294: Mortality reduced from 22% to 11% RR 0.53 (95% CI ) (Individual Group Sizes of n = 9 to 46)

16 Effects of Noninvasive Ventilation on Need to Intubate Masip et al, JAMA 2005;294:

17 Effects of Continuous Positive Airway Pressure vs Noninvasive Pressure Support Ventilation Masip et al, JAMA 2005;294:

18 NIV for CPE (Cochrane Review): Mortality Vital FMR. et al., 2008

19 NIV for CPE (Cochrane Review): Intubation rate Vital FMR. et al., 2008

20 3-CPO In patients with acute cardiogenic pulmonary oedema: Aims Clinical effectiveness of non-invasive ventilation Comparative effectiveness of CPAP and NIPPV Safety of non-invasive ventilation Hypothesis: Non-invasive ventilation reduces mortality Gray et al NEJM 2008; 359:142-51

21 CPOE3: Standard vs CPAP vs NIPPV 26 hospitals in the UK, open, randomized, controlled, multicentre trial, in the ED Designed to – evaluate the effect of NIV on Pulmonary Edema mortality compared with standard therapy – to compare the effectiveness of CPAP vs. NIPPV 1069 patients, hospitalized with pulmonary edema, tachypnea (>20 breaths/min) and acidosis Randomized to at least 2 h of 60% O 2 delivered either by standard face mask (n=367), CPAP (n=346) or NIPPV (n=356) Gray et al NEJM 2008; 359:142-51

22 3-CPO:baseline characteristics StandardCPAPNIPPVAll Number Age (years) Sex (male)42%45%43% Sx of MI at Presentation22% Ischemic heart disease63%65%60%63% Congestive heart failure45%42%47%44% Valvular heart disease12%11%9%11% COPD19%15%21%18% Hypertension56%55%57%56% Diabetes Mellitus30% 33%31% Hypercholesterolemia30%33%31%32% Current Smoker16%19% 18% PVD10%11%10% Cerebrovascular disease18%17%16%17% Gray et al NEJM 2008; 359:142-51

23 3-CPO:Immediate therapeutic interventions StandardCPAPNIPPVAll Nitrate Therapy93%88%91%90% Diuretic Therapy90%89% Opiate Therapy3%5%4% Inspired Oxygen (L/min)12±413±412±4 Ventilation Pressure (cmH 2 O) -10±414±5/7±2-

24 CPOE3:Standard vs CPAP vs NIPPV StandardCPAPNIPPVP-value Treatment allocated Started allocated treatment 365 (100%)336 (98.2%) 341 (97.2%) 0.07 Completed allocated treatment 298 (83.2%) 284 (84.5%) 265 (77.7%) Not tolerated1 (0.3%)18 (5.4%)30 (8.8%)<0.001 Worsening ABGs26 (7.1%)10 (3.0%)15 (4.4%)0.027 Respiratory distress31 (8.5%)5 (1.5%)12 (3.5%)<0.001 Other reason17 (4.6%)24 (7.1%)25 (7.3%)0.152 Changed to standard3 (0.8%)32 (9.5%)51 (15.0%) Changed to CPAP43 (11.8%)1 (0.3%)12 (3.5%) Gray et al NEJM 2008; 359:142-51

25 3-CPO Physiological Response to Intervention: One Hour Physiology StandardCPAP or NIPPV P Value (t-test) Pulse rate (/min)102±2396±22<0.001 Systolic BP (mmHg)128±30124± Diastolic BP (mmHg)65±2066± Respiratory Rate (/min)26±625± Oxygen Saturation (%)94±693± Arterial pH7.30± ±0.08<0.001 Arterial pO 2 (kPa)14.1± ± Arterial pCO 2 (kPa)6.7±2.56.2±1.9<0.001 Bicarbonate (mmol/L)22±822± Gray et al NEJM 2008; 359:142-51

26 CPOE3:Standard vs CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

27 CPOE3: CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

28 CPOE3:CPAP vs NIPPV CPAPNIPPVOR95% CIP Value 7-Day Mortality 9.6%9.4% to Day Mortality/ Intubation 11.7%11.1% to Day Mortality 15.4% to Gray et al NEJM 2008; 359:142-51

29 3-CPO In patients with acute cardiogenic pulmonary oedema, non-invasive ventilation: Produces more rapid resolution of metabolic abnormalities and respiratory distress Has no major effect on 7-day or 30-day mortality Is beneficial irrespective of the mode (CPAP or NIPPV) of delivery Gray et al NEJM 2008; 359:142-51

30 Masip, Mebazaa, NEJM 2008, 359:2068

31 CPAP vs NIPSV: Intubation rate Argawal, Singapore Med 2009 P=0.97 P0.46 P=0.49

32 Plaisance P et al. Eur. Heart J. 2007; 28:2895 Early vs late CPAP in the out-of-hospital environment

33 Plaisance P et al. Eur. Heart J. 2007; 28:2895 * p < 0,05 Early vs late CPAP

34 Plaisance P et al. Eur. Heart J. 2007; 28:2895 Early CPAP Late CPAP p - value Intubation Rate6160,01 Intubation between T0 and T1518 Need for Dobutamine050,02 In-hospital Mortality280,05 Early vs late CPAP

35 Early vs late CPAP in the out-of-hospital environment Conclusion: When compared to usual medical care, immediate application of CPAP alone in out- of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality. Plaisance P et al. Eur. Heart J. 2007; 28:2895

36 Boussignac CPAP CPAP device: Vygon Boussignac CPAP maximum pressure: 8 mbar Cigada M et al. Novel indications for the Boussignac CPAP valve. Intensive Care Med 2007;33:

37 Πνευμονικό οίδημα και NIV To οξύ πνευμονικό οίδημα αποτελεί προνομιακό πεδίο εφαρμογής του ΝΙV Τόσο η CPAP όσο και ο NIPPV μειώνουν στον ίδιο βαθμό την ανάγκη για διασωλήνωση και βελτιώνουν τη δύσπνοια και τις φυσιολογικές παραμέτρους Ο ΝΙV δεν φαίνεται να επηρεάζει τη θνητότητα

38 Πνευμονικό οίδημα και NIV Αποτελεσματικότερος στους ασθενείς με υπερκαπνία- Ο NIPPV δεν φαίνεται να υπερτερεί της CPAP Δεν φαίνεται να σχετίζεται με επιπλοκές όπως το OEM H προνοσοκομειακή χρήση του συνδυάζεται με θετικά αποτελέσματα.


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