Quali pazienti ventilare nelle divisioni internistiche e con quale monitoraggio? Ospedale di San Giovanni in Persiceto

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1 Congresso Nazionale Interdisciplinare "Buona pratica clinica i e ricerca scientifica nell'urgenza-emergenza" Roma, 2-4 Novembre 2011 Il trattamento non invasivo dell insufficienza respiratoria acuta dal domicilio al domicilio : dalla pratica clinica alle evidenze scientifiche Quali pazienti ventilare nelle divisioni internistiche e con quale monitoraggio? Il ruolo delle Medicine Interne Federico Lari UO Medicina Interna AUSL Bologna Ospedale di San Giovanni in Persiceto

2 BACKGROUND NIMV in ARF 80 ICUs Avoid ETI general, respiratory 90 ED First Line 2000 General Respiratory Wards General Medical Wards

3 BACKGROUND NIMV in ARF in general medical wards 1 - knowledge in the experience 2 - in elderly patients with comorbidities that need to be treated outside the intensive care units 3 COPD Pts 4 - presence of clinical conditions in which conventional mechanical ventilation (with oro-tracheal intubation) will lead to frequent complications - worsening of prognosis: cancer patients, immunocompromised ethical issues: DNI patient (do not intubate) 6 - lack of available beds in intensive care units 7 - technological evolution with devices more and more manageable

4 BACKGROUND NIMV in ARF: safe in the wards! Correct selection of Pts: COPD, ACPE It s not an alternative to ETI Early application Staff training: technical, motivational Monitoring Organization / Logistics ATS 2000 BTS 2002

5 NIMV in ARF in Italian general medical wards

6 NIMV in ARF in general medical wards Which Patients? Heart Failure, acute and chronic 429 COPD 491 Cerebrovascular Disease Pneumonia ICD-9-CMCM

7 COPD: NPPV vs usual medical care: 2009 ETI Mortality Lenght of hospital stay Lenght of ICU stay Complication of treatment ph, PaO2 PaCO2, RR symptom

8 Riacutizzazioni Trattamento delle riacutizzazioni del paziente ospedalizzato Valutare la gravità dei sintomi ed i valori di PaO2 e PaCO2, Rx torace, ECG Somministrare O2 terapia fino a raggiungere SaO2>90% e <96% (pulsossimetria) ed eseguire EGA dopo 30 min Broncodilatatori: Corticosteroidi orali o e.v. Antibioticoterapia NIMV (PSV+CPAP) In ogni caso: - valutare nutrizione e bilancio idrico - considerare l utilizzo di eparina a basso peso molecolare - identificare e trattare le possibili comorbidità (insufficienza di altri organi, aritmie) - monitorare lo stato del paziente Considerare intervento riabilitativo post-acuto precoce (Evidenza B)

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11 S.Nava 2008

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13 Dec 2009 Anno V Vol 5 pp 6-17 (30%) (49%) 6 (8%) 10 (7%) (7%) (14%) 4 (5.5%) 3 IOT/ICU, (20.5%) 40%

14 Dec 2009 Anno V Vol 5 pp 6-17

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18 NIMV and pneumonia exudate, difficult recruitment, shock, sepsis

19 N patients % failures No. of patients percentage of failures CPE (n=99) Pulm cont (n=72) Inh PN (n=8) Atelect. (n=28) NP (n=18) ARDSp (n=27) CAP (n=38) ARDSexp (n=59) Pulm fibr/pe (n=5) Antonelli M, et al. Int Care Med 2001

20 Boussignac CPAP in CAP 20 Pz consecutivi IRA PaO2 < 60mmHg, Ventimask FiO % P/F<200 FR>25/min, distress respiratorio CAP severa (no BPCO) ATS BTS PSI CURB 65 - SCAP

21 Boussignac CPAP in CAP Fallimento CPAP IOT, VM, UTI 6(33%) (33%), 3(16 (16.5 % - 50%) Peggioramento P i t del sensorio (Kelly > 4): 1 Pz incapacità di correggere il distress respiratorio (segni di fatica): 4 Pz PaOP O 2 <65 mmhg con FiO 2 70%: 1 Pz

22 Sleep Disorders (OSAS CSA) cause and effect COPD Stroke Heart Failure Myocardial Infarction High Blood Pressure Pulmonary Hypertension Arrhythmias Obesity Diabetes Metabolic Syndrome Chronic Renal Failure

23 A multidisciplinary strategy is critical to appropriate evaluation of sleep-related disease and heightened interaction between specialists in cardiovascular and sleep medicine hold promise for future improved and integrated patient care. Because of the emerging evidence of associations between untreated SDB and cardiovascular disease, the National Center on Sleep Disorders Research was established

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25 Sleep Disorders High prevalence in acute stroke >80-90% OSAS 30-40% CSA-CSRCSR CPAP Sleep Apneas NIHSS

26 The importance of CHF High social, economical and epidemiolocial impact Increasing prevalence New non-pharmacological approach non easly available Mortality Quality of life F.Lari, 1734 Azienda The USL project di Bologna, for Italy the SS Salvatore Building, the first public Hospital in Persiceto

27 The importance of Respiratory Sleep Disorders in CHF 1. prevalence: 40-60% OSA, CSA-CSR CSR in CHF OSA in Healthy Subject 4-9% Lofaso Chest 1994, Krachman Chest 1999, Sin AmJRespCritCareMed 1999, Escourrou Rev Mal Resp 2000, Rev Neurol 2001, 2. mortality and morbidity OSA, CSA-CSR CSR in CHF Greenberg et al J Sleep Res 1995, Hanly AmJRespCritCareMed 1996, Burgess Respirology 1997, Lanfranchi Circulation 1999, Leite JACC 2003 U N D E R V A L U E F.Lari, Azienda USL di Bologna, Italy 1920 the surgeon and his co-workers D

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30 The route of Pt with Heart Failure in Internal Medicine: the role of NIMV ACPE NIMV in the ward Sleep Disorders? s Sleep Study in the ward CHF with OSAS/CSA Discharge with NIMV Home Treatment NIMV at home Follow up

31 NIMV in general medical ward: organization / logistic

32 sistemi i semplici i e monitoraggio povero

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35 Monitoraggio del Pz in NIMV 1. Esame Obiettivo: Score Neurologico (Kelly) Pattern Respiratorio ri (FR, segni di fatica) 2. Parametri Clinici Monitor! (SpO2) 3. EGA: di base, a Pz adattato, a ogni modifica 4. Parametri del ventilatore

36 new skills bedside eco

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39 CONCLUSION NIMV in ARF in general medical wards It s essential to disseminate knowledge about NIMV also in medical departments Forms of ARF in patients with particular clinical features can and should be treated in these areas home treatment!!! It is therefore essential to develop shared protocols within healthcare organizations, involving the various professionals in the management of these issues A multidisciplinary NIMV-team is desiderable so that every patient receives the best treatment in the most appropriate setting

40 Thanks!!! The old SS Salvatore Hospital in Persiceto