post-extubation: quelle technique pour quel patient...
TRANSCRIPT
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Post-extubation: quelle
technique pour quel patient ?
Créteil – 24ème Journée d’Actualités en Ventilation Artificielle 2017
Department of Critical Care Medicine and Anesthesiology (DAR B) Saint Eloi University Hospital and Montpellier School of Medicine
Clinical and experimental research unit = INSERM U1046 80 Avenue Augustin Fliche; 34295 Montpellier. FRANCE
Mail : [email protected] ; Tel : +33 4 67 33 72 71
Samir JABER
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Conflict of interest
*Consultants with honorarium
- Dräger
- Xenios
- Fisher-Paykel
- Medtronic
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1. Background : preventive and/or curative
2. Rationale for use high-flow oxygen ; CPAP and NIV
after extubation
Ventilatory Support after extubation to prevent reintubation
3. In non-selected patients
4. In selected post-operative patients
5. Bedside application : main optimal settings ?
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Noninvasive respiratory support during weaning
Pre-Weaning
Weaning from
mechanical ventilation
Extubation Reintubation
Acute
Respiratory
Failure
Facilitative
(NIV)
1
Prophylactic
(NIV, HFNC)
2
Curative
(NIV, HFNC)
3
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Standard-
Oxygen
Spontaneous
Breathing
CPAP (=PEEP=8)
Paw
PEEP= 0
Flow
NIV (PSV+PEEP)
PEEP= +8
High-Flow
Oxygen
Spontaneous
breathing
(Optiflow)
What are the main Ventilatory Support after extubation to prevent reintubation ?
PSV = +7
(PSV+PEEP) = +15
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Ventilatory Support Management after extubation to prevent reintubation
Curative
Prophylactic (preventive)
ARF : yes (Present)
Objectif : to avoid intubation !
ARF : no (not present…at risk!)
Objectif : to avoid the development of ARF
CPAP (1 pressure level)
CPAP (1 pressure level)
NIV (2 pressure levels)
NIV (2 pressure levels)
Grey zone
Optiflow (1 low pressure )
Optiflow (1 low pressure )
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ICM 2016
Rationale for use
High-Flow Oxygen
Therapy to
prevent or treat acute respiratory
failure after extubation
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1. Haute FiO2
2. Pression Positive – PEP (CPAP-like)
3. Qualité de l’humidification de l’oxygène++
4. Meilleur confort
5. Lavage espace mort
6. Diminution du travail respiratoire
7. Autres…..
Principaux effets de « l’optiflow »
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Rationale for use CPAP and NIV (BIPAP)
to prevent or treat acute respiratory failure after extubation
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Mécanisme(s) de
l’insuffisance respiratoire aigüe ?
1
(poumon)
Insuffisance de
l’échangeur gazeux
Hypoxémie isolée Hypercapnie +/- Hypoxémie
(Diaphragme +/- poumon)
2
Insuffisance de
la pompe ventilatoire
Traitement :
Oxygénation
Traitement :
Ventilation
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VNI
Intubation
+
Ventilation invasive CPAP (mask)
Oxygénation Ventilation +/-Oxygénation
Optiflow (haut débit d’oxygène)
O2
lunettes (faible débit < 5 L/min) Ventilation
Invasive (sonde d’intubation)
O2
Masque Haute
Concentration (faible débit > 10 L/min)
Ventilatory Support
after extubation
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1. Background : preventive and/or curative
2. Rationale for use high-flow oxygen ; CPAP and NIV
after extubation
Ventilatory Support after extubation to prevent reintubation
3. In non-selected patients
4. In selected post-operative patients
5. Bedside application : main optimal settings ?
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Facilitative NIV for weaning in COPD patients
mortality
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Optiflow vs Venturi mask after extubation
Inclusion Criteria: mechanical ventilation> 24h, P/F ≤ 300 at the beginning of SBT, successful
SBT (1 hour: PSV 6-8 cmH2O - PEEP 0, or T-piece)
Exclusion Criteria: tracheostomy, anticipated need for NIV post-extubation (prophylactic),
age<18, pregnancy
Randomization: NHF vs Venturi mask oxygen therapy after extubation
Settings: FiO2 set to obtain SpO2 92-98% (88-95% in COPD), gas flow 50 L/min (with NHF)
Measurements (at 1, 3, 6, 12, 24, 36, and 48 hours):
arterial blood gases, respiratory rate, discomfort related to the interface and to dryness symptoms
(patients’s rating on a numerical scale from 0 – min – to 10 – max), incidence of desaturations
and interface’s displacement, need for reintubation or NIV
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Maggiore SM et al. AJRCCM 2014;190:282-288
Optiflow vs Venturi mask after extubation
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The RINO Trial
(ReINtubation rate after
Oxygen therapy)
• Multicenter, randomized, controlled, phase III, open trial
(NCT02107183)
• 500 patients
• Nasal high-flow vs Venturi mask after extubation
• Study hypothesis: using Optiflow for delivering oxygen therapy
after extubation may reduce the extubation failure rate and the
need for reintubation as compared with the Venturi mask
Inclusion : finished 2016 …..
Analysis in progress……..?
Salvatore Maggiore
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Optiflow to prevent reintubation in low risk patients
Hernandez G et al. JAMA 2016;315:1354-61
Primary outcome: reintubation within 72 h
Low risk for post-extubation ARF: • Age <65 years
• APACHEII <12 at extubation
• BMI<30
• Adequate secretions management
• Simple weaning
• 0-1 comorbidity
• No heart failure or COPD
• No airway patency problems
• No prolonged MV
527 patientswith MV>12h:
263 O2 vs. 264 HFNT for 24h (31 L/min)
12%
5%
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Optiflow vs NIV to prevent post-ext. ARF in high risk patiens
Hernandez G et al. JAMA doi:10.1001/jama.2016.14194, published online October 5, 2016
Primary outcome: reintubation within 72 hours
& post-extubation ARF (non-inferiority)
High risk for post-extubation ARF:
• Age >65 years
• APACHEII >12 at extubation
• BMI >30
• Inadequate secretions management
• Difficult or prolonged weaning
• >1 comorbidity
• Heart failure or mod.-sev. COPD
• Airway patency problems
• Prolonged MV
604 patientswith MV>12h:
314 NIV vs. 290 HFNT for 24h (50L/min)
23%
19%
Postextubation ARF with NIV (40% vs. 27%)
Similar hosp. mortality (18% vs. 20%)
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28%
15%
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Prophylactic NIV only in patients at risk
mortality
We suggest that NIV be used to prevent post-
extubation respiratory failure in high-risk patients
post-extubation. (Conditional recommendation, low certainty of evidence)
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Decrease of lung volumes:
VC ; FRC ; VT
Diaphragmatic dysfunction
Warner. Anesthesiology 2000
Jaber Anesthesiology 2011
Post-operative period = Modifications of respiratory function
Atelectasis
Pain
HYPOXIA, PNEUMONIA
Residual effects of anesthesia-
analgesia cough
Fluid overload
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Thoracic Surgery
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21
50
13
38
0
20
40
60
Intubation Mortalité
VNI
(n = 24)
Standard
(n = 24)
* *
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• Multicenter, randomized,
noninferiority trial
• 830 pts after cardiothoracic surgery
• 1. Pts with post-extubation ARF
(curative strategy), or
2. pts at risk for developing ARF
(preventive strategy)
• HFNT (50 L/min) or NIV (i8/e4)
• PRIMARY OUTCOME: treatment
failure (ETI, switch, or stop) within 7
days
Optiflow vs NIV after cardiothoracic surgery
Stéphan F et al. JAMA 2015;313:2331-2339
Similar reintubation rate (13.7% vs
14%)
Post-hoc analysis
Curative strategy: similar treatment failure rate (27% vs 28%)
Preventive strategy: lower treatment failure with optiflow (6% vs 13%)
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1. Background : preventive and/or curative
2. Rationale for use high-flow oxygen ; CPAP and NIV
after extubation
Ventilatory Support after extubation to prevent reintubation
3. In non-selected patients
4. In selected post-operative patients
5. Bedside application : main optimal settings ?
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Abdominal Surgery
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NIV (Bi-PAP)
Intubation
+
Invasive ventilation CPAP (mask)
Oxygenation Oxygenation
+ ventilation
Optiflow (High Flow Oxygen)
O2 canulae (Low flow < 5 L/min)
Invasive
Ventilation (Intubation-tube)
O2
Mask high
Concentration (High flow > 10 L/min)
OPERA study
(ICM 2016 dec)
Squadrone Study
JAMA 2005
NIVAS study
(JAMA 2016 april)
Post-Operative Ventilatory Support
after abdominal surgery (RCT)
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Optiflow after abdominal surgery (High Flow Oxygen)
OPERA study
(ICM 2016 dec)
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To test the hypothesis that direct (preventive)
application of HFNC after elective extubation,
compared with standard oxygen therapy, can
decrease the incidence of hypoxemia
after major abdominal surgery
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Study Outcomes OPERA study
• Primary outcome: Hypoxemia (defined as an
PaO2/FiO2<300) 1 hour after extubation and at
the end of allocated treatment
• Secondary outcomes
- Postoperative pulmonary complications due to any cause
- Need for additional oxygen therapy after day 1
- Reintubation and/or use of curative NIV because of postoperative
respiratory failure
- Postoperative gas exchange after discontinuation of the treatment
- Respiratory comfort
- Unexpected intensive care unit (ICU) admission or readmission
- ICU and hospital length of stays
- In-hospital mortality
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0
25
50
75
100
0 1 2 3 4 5 6 7
Days since extubation
Pa
tie
nts
wit
ho
ut p
os
top
era
tiv
e
pu
lmo
na
ry c
om
pli
ca
tio
ns
(%
)
HFNC oxygen
Usual care
No. at risk
Usual care
HFNC oxygen
therapy
112
108
62
75
52
66
48
55
47
53
45
52
44
51
44
50
Adjusted Hazard ratio 0.81 (95%CI 0.57-1.15)
Patients without any pulmonary complications until day 7
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Before NIV After NIV
NIV effects (30 min - PSV+15; PEEP+5) on pulmonary volumes (recruitement - atelectasis) in a patient with ARDS at D3 peritonitis surgery
Jaber . Anesthesiology 2010
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- Three-dimensional reconstruction
and volumetry of CT data.
- Specifically designed software
according to methods previously
described (semi-automatic).
- Time acquisition of the whole
lung: 3 - 4 s.
Volumetric analysis of the CT-scans
Before NIV After NIV Jaber . Anesthesiology 2010
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Volumetric analysis of the CT-scans
-900/ -1000
-600/ -900
-200/-600
0/-200
-1000 / -900 : Hyperinflated
-900 / -500 : Normally aerated
-500 / -100 : Poorly aerated
-100 / +100: Non aerated
Before NIV After NIV
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Impact of PEEP on :
1. Lung
2. Upper Airway
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Post-extubation NIV in Acute Respiratory Failure (ARF)
Positive Negative
- Reintubation - ICU and Hospital stay - Nosocomial Infections
Improve outcome ?
- Reintubation delay - Morbidity ? - mortality ?
Worsen outcome ?
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Post-extubation NIV in Acute Respiratory Failure (ARF)
Positive
- Reintubation - ICU and Hospital stay - Nosocomial Infections
Improve outcome ?
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JAMA 2005
Control
CPAP
• N=209 postoperative patients with postoperative hypoxemia
(= PaO2/FiO2<300)
• CPAP 7.5 cmH2O for 6 hours
« Early » application of CPAP may decrease the incidence of endotracheal intubation and other
severe complications in patients who develop hypoxemia after elective major abdominal surgery.
(10%)
(1%)
CPAP Preventive
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Post-extubation NIV in Acute Respiratory Failure (ARF)
Negative
- Reintubation delay - Morbidity ? - mortality ?
Worsen outcome ?
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p<0.05
0
10
20
30
40
50
Intubation (%) mortalité réa (%) Délai de
réintubation (h)
VNI
(n=114)
Standard
(n=107)
NS
p<0.05
Mortality (%) Reintubation delay (h)
p<0.05
In non selected
mixed patients
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NIV to treat post-extubation ARF in non selected patients
mortality
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Post-extubation NIV in Acute Respiratory Failure (ARF)
Positive Negative
- Reintubation - ICU and Hospital stay - Nosocomial Infections
Improve outcome ?
- Reintubation delay - Morbidity ? - mortality ?
Worsen outcome ?
curative NIV on outcome in patients who developed ARF in postoperative period after
abdominal surgery
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Cu
mu
lati
ve In
cid
en
ce o
f In
tub
ati
on
P=0.027 by log-rank test
Jaber et al., JAMA 2016; 315:1345-1353.
Oxygen: 46%
NIV: 33%
293 patients
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P=0.145 by log-rank test
22 vs 15 %
(p= 0.148)
D-90
Mortality (D90)
MORTALITY
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1. Background : preventive and/or curative
2. Rationale for use high-flow oxygen ; CPAP and NIV
after extubation
Ventilatory Support after extubation to prevent reintubation
3. In non-selected patients
4. In selected post-operative patients
5. Bedside application : main optimal settings ?
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Pressure (Paw)
Time
2. Slope
3. Pressure Support level
4. Expiratory Trigger (cyclage I/E)
1. Inspiratory trigger
5. PEEP
More sensitive without auto-triggering (-1 to – 2l/min or -1 à -2 cmH2O)
Mild to max
5 < PSV < 15 cmH2O
Cycling flow : 40-60% Cycling time : 1,0 < Ti max < 1,2 s
Auto-track = automatic
5 < PEEP < 10 cmH2O
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OK STOP
NIV ?
Clinical and gas exchange
improvement
NO Clinical and gas
exchange
improvement
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Post-extubation:
quelle technique pour
quel patient
?
Take Home Message
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Ventilatory Support Management after extubation to prevent reintubation
Curative
Optiflow Optiflow NIV NIV
Prophylactic
1) low-risk pts,
2) moderately
hypoxemic pts
3) postoperative pts at
risk (cardiac and
thoracic surgery)
1) alternative to NIV
in cardio-thoracic pts
2) high-risk ICU pts
1) high-risk pts 1) postoperative
pts (thoracic
and abdominal
surgery)
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1. NIV (BIPAP) requires training and motivation of all the
medical teams (surgeons and others) and paramedical teams (nurses,kine, physiotherapists…)
2. CPAP more easy to use and could be first-line therapy to prevent and/or treat “hyopxemia”
3. Optiflow could be proposed - As first-line therapy to prevent and/or treat “hyopxemia”
- As an alternative to CPAP/BIPAP in selected patients
- Studies are needed ?
Take Home Message (1/2)
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- Post-operative ARF = always eliminate a surgical complication
- Optiflow and/or NIV should not delay "the time of reintubation"
Take Home Message (2/2)