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NIPPV for cardiogenic pulmonary edema. Dr Romain Pirracchio, MD Anesthesiology & Critical Care Lariboisière University Hospital University Paris 7 Diderot [email protected]. ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416. European guidelines. - PowerPoint PPT Presentation
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NIPPV for cardiogenic pulmonary NIPPV for cardiogenic pulmonary edemaedema
Dr Romain Pirracchio, MDDr Romain Pirracchio, MDAnesthesiology & Critical Care Anesthesiology & Critical Care Lariboisière University HospitalLariboisière University Hospital
University Paris 7 DiderotUniversity Paris 7 [email protected]@lrb.aphp.frlrb.aphp.fr
ESC Guidelines: Management of AHF Niemenen et al. Eur. Heart J. 2005, 26 : 384-416
European guidelinesEuropean guidelines
LV Dysfonction
WOBWOB
Impairment in ventilatory mechanic
afterload preload
MvOMvO22
Pleural Pressure
VOVO22
Hypoxemia
DODO22
shunt
Impairment in alveolar gas exchanges
VICIOUS CIRCLE
LV Dysfonction
WOBWOB
Impairment in ventilatory mechanic
afterload preload
MvOMvO22
Pleural Pressure
VOVO22
Hypoxemia
DODO22
shunt
Impairment in alveolar gas exchanges
Inotropes
préchargeNitrates diuretics
Vasodilators
O2
??
PPV effects on PPV effects on heart-lung interactionheart-lung interaction
pressure
Afterloadcardiac output
preload
Inspiratory drops in pleural pressure
Alveolar recrutment WOB
CPAPCPAP Effects on cardiac failureEffects on cardiac failure
Naughton, Circulation 1995Naughton, Circulation 1995 Lin, Chest 1995Lin, Chest 1995
Effects on respiratory failure : Effects on respiratory failure : WOB, WOB, pulm compliance, pulm compliance, FRC, FRC, intubations intubations
Lenique, AJRCCM 1997Lenique, AJRCCM 1997 Bersten, NEJM 1991Bersten, NEJM 1991
Rasanen, Am J Cardiol 1985Rasanen, Am J Cardiol 1985
Non invasive vs Invasive PPV:Non invasive vs Invasive PPV: pulmonary infectionspulmonary infections
Girou, JAMA 2000Antonelli, N Eng J Med 1998
CPAP & Cardiac CPAP & Cardiac outputoutput
ZEEP
PEEP
7.
5
ZEEP
PEEP
10
100100
9090
8080
7070
5050
4040
3030
70 -70 -
50 -50 -
30 -30 -
15 2015 20SvOSvO22
SV (ml)SV (ml)
PCWP (mmHg)PCWP (mmHg)
11
22
33
CPAP & central venous saturationCPAP & central venous saturation
44
1: dobu1: dobu2: dobu + IAoCPB2: dobu + IAoCPB3: dobu + IAoCPB + 3: dobu + IAoCPB + EnoximoneEnoximone4: dobu + IAoCPB + CPAP4: dobu + IAoCPB + CPAP
Pery N, Chest Pery N, Chest 19911991
CPAP
CPAP & WOBCPAP & WOB
Lenique, AJRCCM 1997
A randomised study of Out-of-Hospital A randomised study of Out-of-Hospital CPAP for Acute Cardiogenic CPAP for Acute Cardiogenic
Pulmonary Oedema: physiological and Pulmonary Oedema: physiological and clinical effects. clinical effects.
3 questions : 3 questions :
– Benefit of CPAP applied early and alone ?Benefit of CPAP applied early and alone ?– Benefit of adding medical treatment to CPAP ?Benefit of adding medical treatment to CPAP ?– Effects of an early CPAP withdrawal ?Effects of an early CPAP withdrawal ?
Pirracchio et al. Eur Heart J, in press
PatientsPatients
Pre-hospital, prospective, randomised studyPre-hospital, prospective, randomised study
InclusionInclusion : : – Severe cardiogenic pulmonary edema (SpOSevere cardiogenic pulmonary edema (SpO22 90% with O 90% with O22 15 L/mn) 15 L/mn)
Non inclusionNon inclusion : : – History of COPD, asthma History of COPD, asthma – ComaComa– Cardiogenic shockCardiogenic shock– Valvular stenosisValvular stenosis
Pirracchio et al. Eur Heart J, in press
Venturi CPAP deviceVenturi CPAP deviceVital Signs (Gamida)Vital Signs (Gamida)
PEEP valve
Venturi flux generator
FiO2
monitor
ProtocolProtocol« Early CPAP »
T0 T15’ T30’ T45’
CPAP 7.5 cmH2O
CPAP 7.5 cmH2O + MT
O2 + MT
T0 T15’ T30’ T45’
« Late CPAP »
O2 + MT CPAP 7.5 cmH2O + MT
O2 + MT
DCS, HR, RR, BP, SpO2, blood gases
OUTCOME
Pirracchio et al. Eur Heart J, in press
Early CPAPEarly CPAP Late CPAPLate CPAP
sBP sBP (mmHg)(mmHg) 176 ± 38 174 ± 40 NS
dBP dBP (mmHg)(mmHg) 95 ± 23 96 ± 23 NS
HR HR (bpm)(bpm) 104 ± 23 105 ± 21 NS
RR RR (cycles/mn)(cycles/mn) 34 ± 8 34 ± 7 NS
DSC (/10)DSC (/10) 8 ± 1 8 ± 1 NS
SpOSpO22 (%)(%) 82 ± 6 81 ± 5 NS
PaOPaO22 (mmHg)(mmHg) 50 ± 6 49 ± 6 NS
PaCOPaCO22 (mmHg)(mmHg) 46 ± 10 46 ± 8 NS
COCO22t t (mmol/L)(mmol/L) 22.6 ± 2.4 22.5 ± 2.0 NS
pHpH 7.32 ±0.09 7.32 ±0.09 NS
SaOSaO22 (%)(%) 86 ± 3 86 ± 3 NS
Pirracchio et al. Eur Heart J, in press
Evolution of Dyspnea Clinical ScoreEvolution of Dyspnea Clinical Score
1
2
3
4
5
6
7
8
9
10
T0 T15 T30 T45
DC
S
$
Early CPAP
Late CPAP
* p<0.05 early CPAP vs late $ p<0.05 early CPAP T15 vs T0
*
Pirracchio et al. Eur Heart J, in press
Arterial blood gasesArterial blood gases
30
50
70
90
110
130
T0 T15 T30 T45
PaO
2
(mm
Hg
)
*
*$
30
35
40
45
50
55
T0 T15 T30 T45
*
PaC
O2
(mm
Hg
)
$
Early CPAP Late CPAP
* p<0.05 CPAP early vs late $ p<0.05 CPAP early T15 vs T0
OutcomeOutcome IntubationIntubation : : (p=0.01)(p=0.01)
– « early CPAP » : n=6« early CPAP » : n=6– « late CPAP » : n=16« late CPAP » : n=16
InotropesInotropes : : (p=0.02)(p=0.02) – « early CPAP » : n=0« early CPAP » : n=0– « late CPAP » : n=5« late CPAP » : n=5
In hospital mortalityIn hospital mortality : : (p=0.05)(p=0.05)– « early CPAP » : n=2« early CPAP » : n=2– « late CPAP » : n=8« late CPAP » : n=8
Pirracchio et al. Eur Heart J, in press
CPAP or BiPAP (BLPAP) ?CPAP or BiPAP (BLPAP) ?
CPAP vs BiPAP ?CPAP vs BiPAP ?
CPAP > BiPAP ?CPAP > BiPAP ?– Metha, Crit Care Med 1997 :Metha, Crit Care Med 1997 :
BiPAP associated with more AMI ++BiPAP associated with more AMI ++
BiPAP > CPAP ?BiPAP > CPAP ?– Chadda, Crit Care Med 2002 : BiPAP>CPAP Chadda, Crit Care Med 2002 : BiPAP>CPAP
CPAP = BiPAP +++CPAP = BiPAP +++– Bellone, Crit Care Med 2005Bellone, Crit Care Med 2005– Moritz, Ann Emerg Med 2007Moritz, Ann Emerg Med 2007– Ferrari, Chest 2007 in press (No difference in AMI +++)Ferrari, Chest 2007 in press (No difference in AMI +++)
Metaanalyses BiPAP et VNIMetaanalyses BiPAP et VNI
Massip, JAMA 2005Massip, JAMA 2005
Metaanalyses BiPAP vs VNIMetaanalyses BiPAP vs VNI
Massip, JAMA 2005
On scene or in the ER: On scene or in the ER: – CPAP for CPE (G1+)CPAP for CPE (G1+)– BiPAP can be used :BiPAP can be used :
For CPE or COPD ,For CPE or COPD , ONLYONLY by trained teams by trained teams and withand with ventilators allowing ventilators allowing
NIPPV (G2+)NIPPV (G2+)
Consensus SFAR, SPLF, SRLF 2006Consensus SFAR, SPLF, SRLF 2006
CPE even with hypercarbia => CPAPCPE even with hypercarbia => CPAPCOPD => BiPAPCOPD => BiPAP
Consensus ATS-ESICM-SRLF-ERS 2000
CPAP or BiPAPCPAP or BiPAP
ConclusionConclusion
PPV is the only way to break the vicious PPV is the only way to break the vicious circle due to deleterious heart-lung circle due to deleterious heart-lung interactions interactions
PPV improves the outcomePPV improves the outcome CPAP and BiPAP have similar resultsCPAP and BiPAP have similar results As more simple, CPAP might be used as As more simple, CPAP might be used as
first line ventilatory therapy for CPE out of first line ventilatory therapy for CPE out of the ICUthe ICU
Respiratoy muscles consumptionRespiratoy muscles consumption
Blo
od
flow
ded
icate
d t
o r
esp
irato
ry m
uscle
sB
lood
flow
ded
icate
d t
o r
esp
irato
ry m
uscle
s(m
L/1
00
gr/
Lof
card
iac o
utp
ut)
(mL/1
00
gr/
Lof
card
iac o
utp
ut) 20 -20 -
15 -15 -
10 -10 -
5 -5 -
0 -0 -
restrestRespiratory failureRespiratory failure
CPAP « Boussignac »CPAP « Boussignac »
CPAP « Venturi »
EFFETS CARDIOVASCULAIRESDE LA VENTILATION MÉCANIQUE
PRESSION ALVEOLAIRE
VG
PRECHARGE VD: Résistances veineuses gradient par POD
POSTCHARGE VD: RVP
PRECHARGE VG: VES VD
POSTCHARGE VG: PtmVG elastance Ao gradient PIT-PIA
VDPRESSION
THORACIQUE (Ppl)
PRESSION ATMOSPHERIQU
E
POMPECARDIAQUE
POMPE RESPIRATOIRE
Cap. Pulm.
TISSUSPMS
PVC
"Pompe dans la pompe"
Metaanalyses BiPAP vs VNIMetaanalyses BiPAP vs VNI
Ho KM, Crit Care, 2006
