Acute Res espiratory ry Fail ilure The right strategy for the - - PowerPoint PPT Presentation

Acute Res espiratory ry Fail ilure

The right strategy for the right patient

Abdullah Almutairi

MD,FRCPC,FCCP Pulmonary / Critical care Medicine

• Mr. N.A. is an 65 years old, known DM, presented to the ER with

Dyspnea, cough and fever that was progressively worse over the last 4

• days. He is none smoker and had no Hx of cardiac disease. His RR was

32 / m and HR 115 (regular). Temp was 38.5 , his BP 110/60. his O2

• sat. was 75% on RA improved to 87% on 10 L non-rebreather mask.
• The CXR showed right middle to lower lung zone infiltrates. His ABG

7.35/42/60/20 What would be your best intervention to improve his oxygenation:

• A. Start him on NIV.
• B. Start High flow nasal cannula.
• C. Call for intubation / mechanical ventilation.
• D. Increase the oxygen flow on the none-rebreather mask

• Mr. M.R is a 75 years male who presented to the ER with SOB, cough

and fever, and respiratory distress. He was using his accessory muscles of breathing. Hemodynamically stable but sat.80% on RA

• He is known DM, HTN and COPD
• Still smoking 1 ppd
• ABD: 7.21/75/52/35

What would be your best intervention to improve his oxygenation:

• A. Start him on NIV.
• B. Start High flow nasal cannula.
• C. Call for intubation / mechanical ventilation.
• D. Start the patient on non-rebreather mask at 10 L/m

What is the main function of the respiratory system

• How do we measure the efficiency of the respiratory system?

Acute respiratory failure

• “inability to perform adequately the fundamental functions of

respiration: to deliver oxygen to the blood and to eliminate carbon dioxide from it”

Acute Respiratory failure

• Causes of Acute respiratory failure:
• Pulmonary edema
• Pneumonia
• COPD exacerbation
• Asthma exacerbation
• Trauma
• Pulmonary embolism
• Aspiration
• Post op
• Post extubation
• others

Assessment

• Proper assessment of respiratory failure in the ER:
• Proper history
• Quick examination
• ABG
• Among other assessment

Acute respiratory failure

• Further subdivided into:

Acute hypercapnic respiratory failure PaCO2 > 45 mmHg Acute Hypoxic respiratory failure PaO2 <60 mmHg

Assessment of oxygenation

• A-a gradient calculation
• Oxygen index 0I = (MAP x FIo2 x 100)/ Pao2
• P/F ratio : PaO2/FIO2

Tools for management of acute respiratory failure

• Oxygen therapy
• Non Invasive Ventilation
• High flow nasal cannula
• Intubation / mechanical ventilation

Non Invasive Ventilation

Eur Respir J 2017; 50

Acute hypercapnic respiratory failure

• Extensively studied compared with Acute hypoxic respiratory failure
• COPD exacerbation is the typical example but other causes are

included such as neuromuscular insufficiency

• The role of NIV (BiLevel) is considered the standard of care for such

patients presenting acutely.

• ATS/ERS guidelines Strongly recommend the use of NIV in acute on

chronic COPD exacerbation with acidosis(pH<7.35)

ERS/ATS guidelines for hypercapnic RF

• Bilevel NIV should be considered when the pH is ⩽7.35, PaCO2 is >45

mmHg and the respiratory rate is >20–24 b/m despite standard medical therapy.

• Bilevel NIV remains the preferred choice for patients with COPD who

develop acute respiratory acidosis during hospital admission. There is No lower limit of pH below which a trial of NIV is inappropriate; however, the lower the pH, the greater risk of failure, and patients must be very closely monitored with rapid access to endotracheal intubation and invasive ventilation if not improving.

Acute cardiogenic pulmonary edema

• More than 30 trials have been published studying the role of CPAP

/NIV in cardiogenic pulmonary edema

• Several meta-analysis concluded that:
• 1. NIV decreases the need for intubation
• 2. NIV is associated with a reduction in hospital mortality
• 3. NIV is not associated with increased myocardial infarction
• 4. CPAP and NIV have similar effects on these outcomes
• ATS/ERS guidelines:

“We recommend either bilevel NIV or CPAP for patients with ARF due to cardiogenic pulmonary oedema” STRONG recommendtion

Acute Hypoxic respiratory failure

• Role of NIV???

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% Antonelli, M et al Critical care

• med. 2007

Thille, AW et al critical care 2013 Frat JP. Et al NEJM 2015

47.50% 62% 50%

NIV failure rate in Patient with AHRF

NIV failure rate

• Prospective observational study in

multiple French ICUs

• Application of NIV in denovo

respiratory failure (not due AECOPD OR CPE) was associated with increased risk

• f mortality Nosocomial Pneumonia

and hospital length of stay

Entire population P/F <150 P/F >150

• NIV was used in 15% of patients

with ARDS, irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FIO2 lower than 150 mm Hg

Failure of NIV in AHRF

• Why the high failure rates in such patients:
• High level of PEEP is required
• Excessive air leak
• Patient intolerance
• Excessive tidal volumes that will worsen lung injury

• CCM. 2016, (44):2
• A Vte target range of 6 mL/kg was impossible to achieve in

the majority of patients receiving NIV for de novo AHRF

• A higher Vte was independently associated with NIV

failure.

• In the subgroup of patients with a Pao2/Fio2 ratio up to

200 mmHg, a mean Vte of more than 9.5 mL/kg PBW over the first four cumulative hours of NIV accurately predicted NIV failure.

Can we predict when NIV is failing ???

• NIV failed in 30% of the patient
• The highest intubation rate was in ARDS or

CAP

• The lowest intubation rate was in CPE and

pulmonary contusion

• Multivariate analysis showed that:

 Age  SAPS II  Presence of ARDS or CAP  P/F ratio < 148 after 1 hr of NIV Are factors independently associated with NIV failure

Duan J. et al ICM 2017 43:192-199

HACOR scale

Score of > 5 in 1, 12, 24 , 48 hours Is indicative of NIV failure in acute hypoxic RF and need for intubation

If NIV is associated with high failure rate, then what else can we do?

High flow nasal cannula

High flow nasal canula in hypoxemic respiratory failure

12 MA 7 concluded that HFNC is no different than conventional O2 or NIV 5 concluded that HFNC is better than Conventional O2 NOT NIV 1 concluded that HFNC is better than both conventional O2 and NIV **Only one trial was included in all 12 MA **

Xu Z. et al Respir Res. 2018 Wu X et al Medicine (Baltimore) 2018 Zhu Y et al BMC Pulm Med. 2017 Ni YN et al BMC Pulm Med. 2017 Ni YN et al Am J Emerg Med. 2018 Huang HW et al J Intensive Care Med. 2018 Ou X et al CMAJ. 2017 Corely A. et al Cochrane database 2017 Monro-Somerville T et al CCM 2017 Nedel WL et al Resp. Care 2017 Lee et al Resp. Medicine 2016 Ni YN et al Chest 2017

• Multicenter, open label randomized trial
• Acute hypoxic respiratory failure,(P/F ratio < 300)
• Three groups:

1- high flow oxygen through nasal cannula. 2- oxygen through face mask. 3- Non-invasive positive pressure ventilation.

• 23 ICUs in France and Belgium.

FLORALI Trial

• Population:
• Consecutive patients who were 18 years of age or older
• All four of the following criteria:

1. RR> 25 2. P/F ratio < 300 (while breathing oxygen 10 l/min for 15 min.) 3. PaCO2 < 45 mmHg 4. No chronic respiratory diseases

• Exclusion Criteria:
• PaCo2 >45 / COPD / Asthma / Cardiogenic pulmonary edema/ contraindication to NIV/ GCC< 12

/ DNR / urgent need for endotracheal intubation

Other Tools for the initial management of AHRF

JAMA 2016

CCM 2018 46:7

Word of f cautio ion

• Mr. N.A. is an 65 years old, known DM, presented to the ER with

Dyspnea, cough and fever that was progressively worse over the last 4

• days. He is none smoker and had no Hx of cardiac disease. His RR was

32 / m and HR 115 (regular). Temp was 38.5 , his BP 110/60. his O2

• sat. was 75% on RA improved to 87% on 10 L non-rebreather mask.
• The CXR showed right middle to lower lung zone infiltrates. His ABG

7.35/42/60/20 What would be your best intervention to improve his oxygenation:

• A. Start him on NIV.
• B. Start High flow nasal cannula.
• C. Call for intubation / mechanical ventilation.
• D. Increase the oxygen flow on the none-rebreather mask

• Mr. M.R is a 75 years male who presented to the ER with SOB, cough

and fever, and respiratory distress. He was using his accessory muscles of breathing. Hemodynamically stable but sat.80% on RA

• He is known DM, HTN and COPD
• Still smoking 1 ppd
• ABD: 7.21/75/52/35

What would be your best intervention to improve his oxygenation:

• A. Start him on NIV.
• B. Start High flow nasal cannula.
• C. Call for intubation / mechanical ventilation.
• D. Start the patient on non-rebreather mask at 10 L/m

Take home message

• Acute respiratory failure is a major cause of morbidity and mortality
• Proper diagnosis and assessment including ABG in the initial assessment of patients
• Treat the primary cause of respiratory failure
• In Acute hypercapnic respiratory failure the role of NIV is well established and is a

standard of care esp in acute COPD exacerbation

• In ARF due cardiogenic pulmonary edema NIV (CPAP or BiLevel) are strongly

recommended as initial therapy with standard of care

• In acute hypoxemic respiratory failure, a trial of HFNC may be an appropriate initial

approach with close monitoring to anoid delayed intubation

• Use of NIV in acute hypoxic RF may be used with caution and close monitoring to watch

for early signs of failure

• Helmet NIV need further studies to be recommended for early ARDS or acute hypoxic RF
• Avoid hyperoxia with treatment of ARF (target lower sat. <94%)

Thank you