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