Non invasive Non invasive ventilation and LV ventilation and LV dysfunctiondysfunction

Fekri Abroug

ICU. CHU F.Bourguiba

Monastir. Tunisia

How can cardiogenic pulmonary edema-inducedHow can cardiogenic pulmonary edema-induced

respiratory dysfunctionrespiratory dysfunction aggravate aggravate cardiac dysfunctioncardiac dysfunction

and circulatory failure ?and circulatory failure ?

Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema

Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure

at inspirationat inspiration

Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema

Hypoxemia Hypoxemia WOB WOB

risks of risks of myocardial myocardial

ischemia ischemia

risks of risks of critical organs critical organs hypoperfusionhypoperfusion

Viires et a. Viires et a. J Clin InvestJ Clin Invest 1983 1983

Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema

HypoxemiaHypoxemia WOBWOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure

at inspirationat inspiration

Increase in LV afterload Increase in LV afterload

Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema

HypoxemiaHypoxemia WOBWOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure

at inspirationat inspiration

risks of risks of myocardial myocardial

ischemia ischemia

Increase in LV afterload Increase in LV afterload

risks of risks of decrease in decrease in

Stroke Volume Stroke Volume

Cardiogenic Pulmonary edemaCardiogenic Pulmonary edema

Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure

at inspirationat inspiration

risks of risks of myocardial myocardial

ischemia ischemia

decrease decrease in CaOin CaO22

risks of risks of critical organs critical organs hypoperfusionhypoperfusion

Increase in LV afterloadIncrease in LV afterload

risks of risks of decrease in decrease in

Stroke Volume Stroke Volume

Risks of aggravation of cardiac dysfunction (vicious circle) Risks of aggravation of cardiac dysfunction (vicious circle)

and of circulatory failureand of circulatory failure

How can positive pressure ventilation improve How can positive pressure ventilation improve

cardiac dysfunctioncardiac dysfunction and circulatory failure and circulatory failure

in patients with cardiogenic pulmonary edema?in patients with cardiogenic pulmonary edema?

Positive pressure ventilation in cardiogenic pulmonary edemaPositive pressure ventilation in cardiogenic pulmonary edema

Hypoxemia Hypoxemia WOB WOB Exaggerated decrease Exaggerated decrease in pleural pressure in pleural pressure

at inspirationat inspiration

risks of risks of myocardial myocardial

ischemia ischemia

decrease decrease in CaOin CaO22

risks of risks of critical organs critical organs hypoperfusionhypoperfusion

risks of risks of decrease in decrease in

Stroke Volume Stroke Volume

Postive pressure ventilation by breaking the vicious circle Postive pressure ventilation by breaking the vicious circle prevents aggravation of cardiac dysfunctionprevents aggravation of cardiac dysfunction

and of circulatory failureand of circulatory failure

NIV and Cardiogenic NIV and Cardiogenic Pulmonary edema (CPE)Pulmonary edema (CPE) NIV: important tool in ARF

Reduces the need for invasive ventilation Reduces IMV complications Reduces ICU complications, stay, mortality

CPE common medical emergency NIV increases cardiac output Improves gaz exchange Decreases endotracheal intubation Trends towards decrease in mortality

Clinical goals in CPEClinical goals in CPE

Improve systemic oxygen saturation Reduction in LV preload Reduction in LV afterload

Oxygen through high flow facemask Morphine Diuretics nitrates

CPAP is effective in CPE CPAP is effective in CPE unresponsive to medical Rxunresponsive to medical Rx

Poulton Lancet 1936Poulton Lancet 1936

Increase in inspiratory and expiratory flow and pressure Increases Vt Unloads inspiratory muscles Improves alveolar ventilation Reexpands flooded alveoli Counteracts intrinsic PEEP

Prevents micro-atelectasis Improves the P-V curve relation Increases in intrathoracic pressure reduces the

left ventricular preload and afterload Increases cardiac output in CHF

Both CPAP and bilevel non-Both CPAP and bilevel non-invasive ventilation proved invasive ventilation proved effective in treating CPEeffective in treating CPE

Better than conventional oxygen therapy

Resolution time: p=0.002

N=19N=18

Intubation rate: 5% vs 33% (p=0.037)

130 patients attending the ED for CPE Randomized to

O2: n=65 NIPSV: n=65

Primary endpoint: need for intubation Secondary endpoints: mortality,

physiological variables

Intubation rate: 25% vs 20% (p=0.5)

Mortality: 14% vs 8% (p=0.4)

Subgroup analysis: no difference

P=0.01

CPAP vs Conventional medical CPAP vs Conventional medical treatment: intubation ratestreatment: intubation rates

NNT=7

CPAP vs Conventional medical CPAP vs Conventional medical treatment: death ratestreatment: death rates

NNT=8

BiPAP vs Conventional medical BiPAP vs Conventional medical treatment: intubation ratestreatment: intubation rates

BiPAP vs Conventional medical BiPAP vs Conventional medical treatment: death ratestreatment: death rates

How does CPAP How does CPAP compare with Bi-compare with Bi-PAP?PAP?

CPAP vs BiPAP: intubationCPAP vs BiPAP: intubation

CPAP vs BiPAP: mortalityCPAP vs BiPAP: mortality

36 patients with CPE and hypercapnia (in the ED)

Randomization to CPAP (n=18) or NIPSV (n=18)

Endpoints: Endotracheal intubation Death rate Resolution time (SpO2>96%, BR<30)

Role of NIV in CPE Role of NIV in CPE due to LV diastolic due to LV diastolic dysfunctiondysfunction

In all types of CPE, CPAP improves oxygenation

In LV diastolic dysfunction, this occurs through a decrease of LV diastolic volume (preload) and in MAP

In LV systolic dysfunction, CPAP both decreases preload and increases LVEF

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