VENTILACIÓN MECÁNICA NO INVASIVA BASES Y ORGANIZACION

Presentación del tema: "VENTILACIÓN MECÁNICA NO INVASIVA BASES Y ORGANIZACION"— Transcripción de la presentación:

1 VENTILACIÓN MECÁNICA NO INVASIVA BASES Y ORGANIZACION
Dr. Antonio M. Esquinas Rodríguez, FCCP, International Fellow AARC Unidad de Cuidados Intensivos Hospital Morales Meseguer. Murcia. España

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3 CONCEPT. Alternatives in ARF-Hypoxemic.
NIMV ETI Oxygen therapy IOT Acute Respiratory Hypoxemic

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5 JUSTIFICAN ANÁLISIS DEL PRONÓSTICO
Nueva tecnología VMNI CRITERIOS VENTILACIÓN MECÁNICA VMNI-VMI. FACTORES PRONÓSTICO Y RESPUESTA AL TRATAMIENTO

6 INDICACIÓN DE VMNI ASISTENCIAL ECONÓMICA PRONÓSTICO COMORBILIDAD TRATAMIENTO ASOCIADOS MONITORIZACIÓN INGRESO EN UNIDADES DE MAYOR COSTE -UCI SUBGRUPO POSIBILIDAD INCREMENTO FRECUENCIA REINGRESOS

7 ORGANIZACIÓN DE LA VMNI EN EL HOSPITAL

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9 FLUJOGRAMA DE ASISTENCIA

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11 ORGANIZACIÓN DE LA VMNI EN SALA DE HOSPITALIZACION

12 ESTRUCTURA EN VMNI Monitorización.
Servicios responsables. Monitorización. Ventiladores e interfaces adecuados en número y calidad. Sistema de mantenimiento y control del material. Cursos de formación.

13 Acute Hypercapnic Respiratory Failure
Interface- clinical-technical factors

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15 ELEMENTOS DE VMNI

16 Aumento Resistencia Nasal
NIV pathophysiology. Leaks Resistencia Nasal -& Pérdida/Respiración Oral Pérdida oral Aumento Resistencia Nasal Flujo Unidireccional Mouth breathing or mouth leak, during noninvasive ventilation can cause a serious drying affect. Nasal CPAP is probably the most common form of noninvasive ventilation, typically provided to obstructive sleep apnoea sufferers. However, if the patient opens their mouth air goes in their nose and leaks out of their mouth. The CPAP machine will realise that the correct pressure is not been met and will force additional air through the breathing circuit until the set pressure is achieved. This unidirectional airflow leads to mucosal drying, and rebound congestion, this can then increase nasal airway resistance, which in turn increases the patients desire to breath through their mouth, creating a vicious cycle which often ends with the patient removing or failing the therapy. This phenomenon can be explained by a study from Richards several years ago. Sequedad Mucosa & Rebote Congestión

17 FACTORES DE RESPUESTA

18 HIPERCAPNICOS HIPOXEMICOS

19 MONITORIZACION DE LA VMNI

20 SITUACION ACTUAL EN NUESTRO PAIS

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22 ¿ COMO REALIZAR LA VMNI EN SALAS DE HOSPITALIZACION?

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24 THE WARD STUDIES Early (pH < 7.35, RR > 23) intervention beneficial 80% patients with pH > 7.30 will get better anyway Outcome in patients with pH < 7.30 is poor without NIV

25 Conclusions: … experience with NIV may progressively allow more severely ill patients to be treated without changing the rate of success.

26 Eur Respir J 2008; 31: 874–886

27 TECNICAS ENDOSCOPICAS APLICACIONES Y BENEFICIOS

28 Bronchoscopy

29 Bronchoscopy Acute HospitalApplications

30 Acute HospitalApplications
TRANSESOPHAGEAL ECHOCARDIOGRAPHY

31 Acute HospitalApplications
UPPER GASTROENDOSCOPY

32 FACTORES PRONÓSTICOS

33 FACTORES PRONÓSTICOS Edad avanzada Fumador activo
EPOC DE LARGA DURACIÓN. EPOC CON OBSTRUCCIÓN AL FLUJO AÉREO GRAVE (FEV1 < 30%) EXISTENCIA DE CO-MORBILIDAD ELEVADA (CARDIOPATÍA, DESNUTRICIÓN, ARRITMIAS) FRECUENCIA DE REINGRESOS PREVIOS SEVERIDAD DE LA AGUDIZACIÓN ( NIVEL DE ACIDOSIS E HIPERCAPNIA Y OXIGENACIÓN) Edad avanzada Fumador activo Pobre respuesta broncodilatadora Hipoxemia severa no controlada Cor pulmonale Pobre capacidad funcional residual

34 FACTORES DE RESPUESTA

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36 After two hours

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38 Exito Fracaso Precoz 7-50% Tardio FACTORES DE RESPUESTA- VMNI-
Factores Respiratorios No Respiratorios Exito Fracaso Precoz 7-50% Tardio

39 PERFIL CLINICO VMNI. FACTORES PRONOSTICOS EPOC REAGUDIZADO I
Acidosis: Basal pH (sensivilidad 97%, especifidad 71%). (7,22 vs 7,28 Ambrosino, Brochard). Hipercapnico: (PaCO2). ( 30 min, 1 hora, largos periodos) Frecuencia Respiratoria ( no siempre vista) Indice de Severidad APACHE II (21(4), (Ambrosino ) SAPS II Benhamou. CVF (Capacidad Vital Forzada) FEV. (Flujo Espiratorio Forzado) Anton et al Bajo peso.

40 Causa de Reagudización del EPOC (variable) Consolidación Radiologica.
PERFIL CLINICO VMNI. FACTORES PRONOSTICOS EPOC REAGUDIZADO-II Causa de Reagudización del EPOC (variable) Consolidación Radiologica. Edad Status Neurologico( nivel de conciencia / 1 hora ( Bronchard) Tolerancia VMNI (Benhamou, Ambrosino) Compliance (Soo Hoo) Nivel de fugas Falta de Dentición (Soo Hoo et al) Patología de base. Afectación otros órganos.

41 STAFF

42 Who should administer NPPV and in what location ?
Recommendations NPPV in ED : when staff is expert NPPV should be managed in ICU or in a high-level monitoring enviroment in selected hyperCO2 COPD with ARF (pH  7.30) NPPV may be initiated and maintained in the GW when staff is expert if signs of NPPV unsuccess outside the ICU appear patients should be transferred to ICU Consensus Conferences Am J Respir Crit Care Med 2001

43 COST EFFECTIVE?

44 COST EFFECTIVE? Effectiveness - meta analysis
more effective than conventional treatment Decision tree constructed and probability determined at each node Costs - saving of $2,500 per patient per admission “…...More effective and less expensive” Keenan et al. Crit Care Med 2000; 28:

45 RECOMENDACIONES INTERNACIONALES DE LA VMNI

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47 • The best venue depends on local factors such as the training and experience of the staff, available resources (beds, staff, equipment), and monitoring capacity. • NPPV can be initiated in the ED when staff have been adequately trained. • … most patients receiving NPPV should be managed in an ICU or within a system of care capable of providing high-level monitoring, … • When NPPV is initiated outside the ICU, failure to improve gas exchange, pH, respiratory rate, or dyspnea, or deterioration in hemodynamic or mental status, should prompt referral to the ICU service.

48 NIV in DNI pts: outcome Levy et al Crit Care Med 2004;32:2002-7
N=114 of 1211 screened % survived to discharge

49 Impact of acute NIV on nursing workload Plant et al Thorax 1997;52
1st hour* nd rd th 24 Conv (4) (12) 122 (17) 129 (17) (15) (13) NIV (6) (13) (9) (10) (10) 88 (11) *p= ie. Only difference in nursing time during first hour of therapy COPD patients : 31 Conv NIV pH on entry PaCO2 > 6 kPa VPAP ventilator (Protocol)

50 Staff workload: HDU Nurses Doctors Respiratory therapists

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