Post on 19-Sep-2018
COMPLICACIONS DE LA VENTILACIÓ MECÀNICA NO INVASIVA
www.idibapsrespiratoryresearch.org
Dr. Miquel FerrerUVIIR, Servei de Pneumologia, Hospital
Clínic, IDIBAPS, CibeRes, Barcelona. E-mail: miferrer@clinic.ub.es
Barcelona, 3 de novembre de 2010
Complicaciones y resolución de problemas
Complicaciones de la VNI
Predictores de fracaso:• IR hipercápnica
• IR hipoxémica
• Causas frecuentes de fracaso
Factores que contribuyen al fracaso de la VNI• Relacionados con el entorno y/o equipo asistencial
• Contraindicaciones de la VNI
• Relacionados con el paciente
• Técnicos
How to Reduce Air Leaks During NIV
Proper interface type and size
Proper securing system
Mask-support ring
Comfort flaps
Tube adapter
Hydrogel or foam seals
Chin strap
Lips seal or mouth taping
Nava S et al. Respiratory Care Jan 2009 vol 54 no1
How to Reduce the Risk of Skin Damage During NIV
Proper harness and tightening
Skin and mask hygiene
Nasal-forehead spacer• To reduce the pressure on the bridge of the nose
Forehead pads• To obtain the most comfortable position on the forehead
Cushioning system between mask prong and forehead
Remove patient’s dentures when making impression for molded mask
In home care, replace the mask according to the patient’s daily use
Skin pad
Nava S et al. Respiratory Care Jan 2009 vol 54 no1
Úlceras cutáneas
Riesgo de lesión cutánea
Una solución posible: la máscara facial total
Otra solución: “Helmet”
• No siempre aparecen donde se espera!!!
Úlcera por presión
Predictores de fracaso de la ventilación no invasiva
Insuficiencia respiratoria hipercápnica Insuficiencia respiratoria hipoxémica
Predictors of failure: NIV for hypercapnic respiratory failure
Advanced age
Higher acuity of illness (APACHE score)
Uncooperative
Poor neurological score
Unable to coordinate breathing with ventilator
Large air leaks
Edentulous
Tachypnoea (>35/min)
Acidaemia (pH <7.18)
Failure to improve pH, heart and respiratory rates or Glasgow Coma Score within the first 2 hours
Soo Hoo et al. Crit Care Med 1994; 22: 1253–61Ambrosino et al. Thorax 1995; 50: 755–7
Confalonieri et al. Eur Respir J 2005; 25: 348–55
Non-COPD conditions: Pneumonia (n=37) Neuromusculoskeletal disorders (n=11) Pulmonary edema (n=9) Bronchiectasis (n=5) Sepsis (n=3) Asthma (n=3)
Outcomes of NIV in non-COPD patients by specific diagnosis
Variables associated with in-hospital NIV failure (n=22/120)
Risk stratification of NPPV failure in 1,033 consecutive patients admitted to experienced hospital units
• Two intensive care units
• Six respiratory intermediate care units
• Five general wards
NPPV was successful in 797 patients
At admission
After 2 h of NIV
Predictors of failure: NIV for hypoxaemic respiratory failure
Diagnosis of ARDS or pneumonia SAPS ≥35 Lower PaO2/FIO2 (100 or below) Low pH Age >40 years Septic shock Multiorgan system failure Failure to improve PaO2/FIO2 >146 within first hour
Antonelli et al. Intensive Care Med 2001; 27: 1718–28.Rana et al. Crit Care 2006; 10: R79.
• Eight ICUs• n=354:
• Success: 246• Failure: 108
ICU mortality
%
0 20 40 60 80 100
Trauma
CPE
Extrapulmonary ARDS
Pulmonary ARDS
HAP
CAP
NIV-success
NIV-failure
n=7
n=10
n=7
n=0
n=0
n=18
n=9
n=1
n=4
n=0
n=33
n=8
Independent predictors of NIV failure: Age > 40 yrs PaO2/FiO2 <146 ARDS or CAP SAPS >35
Failure rate: 70%
• Patients with shock: 100%
Independent predictors of NIV failure (excluded patients with shock):
• Metabolic acidosis
• Severe hypoxemiap<0.01
Mortality in patientsfailing NIV
Actual Predicted
%
0
20
40
60
80
100
Causas frecuentes de fracaso de la ventilación no invasiva
Relacionados con el entorno o el equipo asistencial Relacionados con el paciente Factores técnicos
Common reasons for NIV failure
Environmental/caregiver team factors
• Lack of skilled, experienced caregiver team
• Poor patient selection
• Lack of adequate monitoring
Selection guidelines for NIV in the acute setting Appropriate diagnosis with potential reversibility (COPD,
congestive heart failure
Establish need for ventilatory assistance
• Moderate to severe respiratory distress
and
• Tachypnoea (>24 for COPD, >30 for CHF)
• Accessory muscle use or abdominal paradox
• Blood gas derangement: pH <7.35, PaCO2 >45, or PaO2/FiO2 <300
Contraindications of NIV Respiratory or cardiac arrest
Too unstable:• Shock
• Myocardial infarction requiring intervention
• Uncontrolled ischaemia or arrhythmias
• Uncontrolled upper GI bleed
• Unevacuated pneumothorax
Unable to protect airway*• Excessive secretions
• Poor cough
• Impaired swallowing
*Relative contraindications
Aspiration risk*
• Distended bowel; obstruction or ileus
• Frequent vomiting
Uncooperative or agitated*
Unable to fit mask
Recent upper airway or oesophageal surgery
Multiorgan system failure (more than 2)
Common reasons for NIV failure
Patient-related factors
• Intolerance
• Mask problems:
• Discomfort
• Poor fit
• Skin ulceration
• Claustrophobia
• Agitation
• Excessive secretions, inability to protect airway
• Progression of underlying disease
Approach to the agitated/intolerant patient using NIV
Common reasons for NIV failure
Technical factors
• Inadequate equipment
• Failure to ventilate
• Failure to oxygenate
• Patient–ventilator asynchrony
• Air leaks
How do ventilators perform in the presence
of leaks?
Portable or “NIV” ventilators ICU ventilators
• With NIV modes• Without NIV modes
Varying conditions had a generally small effect on triggering times, suggesting that :
• There is a largely unavoidable element to the triggering delays intrinsic to the design of the ventilators
• Effective compensation of leaks
Eight ICU ventilators featuring an NIV mode. Tests conducted in:
• Absence of leaks
• Presence of leaks with and without activation of the NIV mode
Trigger delay
Workload of triggeringInspiratory trigger
pressure drop
In most ventilators, leaks:
• Increased trigger delay and workload
• Decreased pressurization and delayed cycling
NIV mode partly corrected these problems:
• Large variations between machines
• In some ventilators the NIV mode worsened the leak-induced dysfunction
Leaks interfere with several key functions of ICU ventilators
• NIV modes can correct part or all of this interference
• Wide variations between machines in terms of efficiency
August 2010
NIV algorithms can reduce asynchronies due to leaks:• This confirms bench test results, but …• Some of these algorithms can generate premature cycling
65 patients included 5 different ICU ventilators, with and without NIV algorithm
Bilevel or ICU ventilators in the presence of leaks?
Comparison of nine ICU ventilators with NPPV function with a bilevel ventilator in the presence of leaks
At baseline all ventilators:
• Delivered adequate tidal volumes
• Maintained airway pressure
• Synchronized with the simulator (no missed efforts or auto-triggering)
As the leak was increased, all ventilators except the Vision and Servo I:
• Needed adjustment of sensitivity or cycling criteria to maintain adequate ventilation
• Some transitioned to backup ventilation
Significant differences in triggering and cycling were observed between the Servo I and the Vision ventilators.
The Vision appears the optimal ventilator for NIV conditions:• No need for adjustment of sensitivity or cycling criteria • Optimal triggering performance
Fracaso de la ventilación
Válvula espiratoria
Evita la re-inhalación de CO2
Nunca olvidar la válvula!!!
Successful NIV: Important factors
More likely with a good team • A skilled, experienced staff helps to optimize outcomes
The underlying disease is an important determinant• Selecting appropriate patients and monitoring them closely
Severity at presentation
Change in physiology after a short period of NIV• In failure to ventilate or oxygenate, rapidly assess for
reversible contributing factors
• Be prepared to intubate without undue delay if rapid reversal cannot be achieved
A systematic approach to troubleshooting can help assure the best possible NIV outcomes