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 FIo 2 x 100)/ Pao 2 • 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???
NIV failure rate in Patient with AHRF 62% 70.00% 50% 47.50% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Antonelli, M et al Critical care Thille, AW et al critical care Frat JP. Et al NEJM 2015 med. 2007 2013 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 of mortality Nosocomial Pneumonia and hospital length of stay
• 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 Pa O2 /F IO2 lower than 150 mm Hg P/F <150 P/F >150 Entire population
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
HACOR scale Score of > 5 in 1, 12, 24 , 48 hours Is indicative of NIV failure in acute hypoxic RF and need for intubation Duan J. et al ICM 2017 43:192-199
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 Corely A. et al Cochrane database 2017 Zhu Y et al BMC Pulm Med. 2017 Monro-Somerville T et al CCM 2017 Ni YN et al BMC Pulm Med. 2017 Nedel WL et al Resp. Care 2017 Ni YN et al Am J Emerg Med. 2018 Lee et al Resp. Medicine 2016 Huang HW et al J Intensive Care Med. 2018 Ni YN et al Chest 2017 Ou X et al CMAJ. 2017
FLORALI Trial • 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.
• 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
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