Nichtinvasive
Beatmung
bei COPD
Wolfram Windisch
Lungenklinik Merheim
• Diaphragmale Abflachung
• Vordehnung der M.-Fasern
• Systemmanifestation • Inflammation
• Steroide
• VIDD
• Co-Morbiditäten• Herzinsuffizienz
• Pulmonale Hypertonie
• Diabetes mellitus
• Verkürzung der Insp.-Zeit
• Atemwegsobstruktion
• Dynamische Überblähung • Intrinsic PEEP
• Thorakale Vordehnung
• Erhöter ventilatorsicher
Bedarf• Oxygenierungsstörung
• Anämie
• Herzinsuffizienz
Jolley CJ and Moxham J. Eur Respir Rev 2009; 18:112,1-14
Evans TW. Intensive Care Med 2001; 27:166-178
Lightowler JV. et al. BMJ 2003; 326:185-189
Conclusions NPPV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients.
NPPV should be tried early in the course of respiratory failure and before severe acidosis,
to reduce mortality, avoid endotracheal intubation, and decrease treatment failure.
NPPV = noninvasive positive pressure ventilation
first line
pH:7.20–7,35
Improvesoutcome
NPPV:
Lightowler JV. et al. BMJ 2003; 326:185-189
• NIV verhindert Intubation (NNT = 5)
• NIV reduziert die Mortalität (NNT = 8)
NNT = number needed to treat
Chu CM. et al. Thorax 2004; 59:1020-1025
35%
70%
80%
Cheung APS. et al. Int J Tuberc Lung Dis 2010; 14:642–649
15/5 cmH2O
5 cmH2O
Funk GC. et al. Respir Med 20011; 105:427-434
20/5 cmH2O
N = 13 N = 13
6-min-Gehstrecke nach 3 Monaten
Wijkstra PJ. et al. Chest 2003; 124:337-343
IPAP(cmH2O)
EPAP(cmH2O)
ΔPaCO2(mmHg)
Survival
Casanaovaet al.
12 4 NPPV: +0.4LTOT: -0.9
No benefit(1 year)
Cliniet al.
14 2 NPPV: -1.0LTOT: +0.5
No benefit(2 years)
Casanova C. et al. Chest 2000; 118:1582-1590 Clini E. et al. Eur Respir J 2002; 20:529-538
1 year follow-up 2 years follow-up
NPPV + LTOT vs. LTOT alone
McEvoy RD. et al. Thorax 2009; 64:561-566
McEvoy RD. et al. Thorax 2009; 64:561-566
mean adherenceto NIV:4.5 ± 3.2 hours
McEvoy RD. et al. Thorax 2009; 64:561-566
Windisch W. Breathe 2011; 8:114-123
Wolfram Windisch
If the targeted physiological parameter (PaCO2) remains unaffected by the specific treatment modality (long-term NPPV)…
If artificial ventilation does not improve alveolar ventilation …
How can we expect an improved outcome?
Windisch W. et al. Respir Med 2002; 96:572-579 Days
mmHg
NPPV (assPCV)
- mean IPAP 30 ±4 mbar
- mean bf 23 ±2 /min
Windisch W. et al. Chest 2005; 128:657-662
NPPV (assPCV): IPAP 28 ±6 mbar; bf 21 ±3 /min
2-year survival: 86%
N = 34
Budweiser S. et al. Respir Care 2006; 51:126-132
BMI <20 kg/m2 = 21%
N = 141
NPPV (assPCV)
- mean IPAP 20 ±4 mbar
- mean bf 20 ±4 /min
Severe Respiratory InsufficiencyQuestionnaire SRI
ATS homepage:http://www.atsqol.org/sections/instruments/pt/pages/sri.html
SRI
Summary
Scale
SS
RespiratoryComplaints RC
PhysicalFunctioning PF
Attendant Symptomsand Sleep AS
Well-Being WB
Anxieties AX
Social Functioning SF
Social Relationships SR
Windisch W. et al. J Clin Epidemiol 2003; 56:752-759Windisch W. et al. Intensive Care Med 2003; 29:615-621 Windisch W. et al. J Clin Epidemiol 2008; 61:848-853
• German• English• French• Spanish• Dutch• Swedish• Norwegian• Polish• Greek• Hebrew• Japanese
Windisch W. Eur Respir J 2008; 32:1328-1336
• COPD• Restrictive thoracic diseases• Obesity- Hypoventilations-Syndrome• Neuromuscular disorders• Miscellaneous
N = 137
Changes in SRI-SS independent from the underlying disease MANOVA; F=0,62; P=0,65.
P < 0.001 COPD
P < 0.001 neuromuscular
P < 0.001 restrictive thoracic
SR
I-Su
mm
ary
Sca
le (
SR
I-S
S)
IPAP/EPAP(mbar)
20/3
19/4
25/1
Windisch W. Eur Respir J 2008; 32:1328-1336
Windisch W. et al. Int J Med Sci 2009; 6:72-76
N = 73
5-year survival: 58%
Dreher M. et al. Thorax 2010, 65:303-308
Low-intensity 14.6 ± 0.8
4.0 ± 0
8.0 ± 0 2.2 ± 0.8
High-intensity 28.6 ± 1.9
4.5 ± 0.7
17.5 ± 2.1 2.2 ± 0.8
IPAP [cmH20]
EPAP [cmH20]
Breathing frequ. [min-1]
Oxygen [L* min-1]
Insp. volume (pneumotachygraph):
Mean treatment effect: 325 mL
95%CI [159 , 492 mL]; P=0.002
Exp. volume (pneumotachygraph):
Mean treatment effect: 96 mL
95%CI [23 , 169 mL]; P=0.015
Leak volume (pneumotachygraph):
Mean treatment effect: 226 mL
95%CI [28 , 425 mL]; P=0.030
Primary outcome:Nocturnal PaCO2
Mean treatment effect: -9.2 mmHg
95%CI [-13.7 , -4.6 mmHg]; P<0.001
No period effect: P=0.96
No carry over effect: P=0.87
Compliance (daily use):
Mean treatment effect: 3.6 hours
95%CI [0.6 , 6.7 hours]; P=0.024
Low-intensity
High-intensity
Dyspnea (BDS)
QoL (SRI-SS)
FEV1 (L)
+++
Dreher M. et al. Thorax 2010, 65:303-308
high: 29 cmH2O; controlled ventilationlow: 15 cmH2O; assisted ventilation
+ 110 ml
Dreher M. et al. Chest 2011, 140:939-945
Mean IPAP:high: 29 cmH2O; low:14 cmH2O
Dreher M. et al. Eur Respir J 2007; 29:930-936
PaCO2[mmHg]
50
53
50
51
BorgDyspnea
ScaleP<0.001
Walkingdistance
[m]P<0.05
6
4
209
252
P<0.001
n.s.
Rehab + NPPV Rehab alone
baseline baseline3 months 3 months
Duiverman ML. et al. Thorax 2008; 63:1052-1057
Rehab
Rehab + NPPV [20/6 cmH20; 18 breaths/min]
Windisch W. et al. Pneumologie 2010, 64:207-240
Windisch W. et al. Pneumologie 2010, 64:207-240