Overview

• Definition of NIV and AHF

• NIV related changes in mortality

• NIV related patient benefits

• Clinical summary and cases

• NIV in AHF in Switzerland, a short questionaire

Definition of NIV and AHF

AHF= gradual or rapid change in heart failure signsand symptoms resulting in a need for urgent therapy.

NIV=Administration of ventilatory support without using an invasive artificial airway. NIV includes CPAP and NPPV

Gheorghiade M, Pang PS. Acute heart failure syndromes. J Am Coll Cardiol. 2009;53:557-73.

NIV adaptation

23.06.2016 Jochen.ruediger@kssg.ch 3TIME

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Mechanical Ventilation in acute heartfailure 2nd to myocardial infarction8 years retrospective analysis

Inclusion: STEMI and NSTEMI, single center study

1610 Patients, 136 NIV, 157 ETI

More STEMI in ETI than NIV

Trend to higher Trop in ETI

Pesaro AE et al. PLoS One. 2016;11:e0151302.

Overview

• Definition of NIV and AHF

• NIV related changes in mortality

• NIV related patient benefits

• Clinical summary and cases

• NIV in AHF in Switzerland, a short questionaire

The 3CPO trialMulticenter UK Study

2003-2007, 1069 Pat.

1:1:1 randomization

Gray A et al, N Engl J Med. 2008; 359:142-51.

There may be no differences in survival

Overview

• Definition of NIV and AHF

• Introduction and clinical cases

• NIV related patient benefits

• NIV related changes in mortality

• NIV in AHF in Switzerland, a short questionaire

NIV in ARF, acute response (1h)Chr. Horvath et al, St. Gallen

Jochen.ruediger@usb.ch

Overview

• Definition of NIV and AHF

• NIV related changes in mortality

• NIV related patient benefits

• Clinical summary and cases

• NIV in AHF in Switzerland, a short questionaire

Treatment recommodation

Collins S et al Early Management of Patients With Acute Heart Failure: J Card Fail. 2015;21:27-43.

USE NIV FOR respiratory rate > 20/min (ESC)

Westhoff M, et al. Pneumologie. 2015;69:719-56.

Clinical CaseTIME 0

pH 7.43

ptCO2

pCO2 5.3

SpO2 94

HCO3 26

O2 suppl 2

HR 117

RR 30

BP 164/103

VAS 7

Support -

80 y o female

Normal weight non-smoker

Dyspnea, Denial of chest pain

Arrival via ambulance

Prefers to sit, but may lay back.

ECG: no specific signs of acute myocardial ischemia

eFAST: absence of pneumothorax , kerley B- lines

Nitro transdermal 20 mg, furosomide

NIV was considered23.06.2016 11

Indications and contraindicationsagainst NIV in AHF

• Symptomaticpersistant AHF

– Persistant hypoxia

– Hypercarbia

– Tachypnea

– Severe Dyspnea

• Comorbidities– GCS <10, – severe agitated person– GI (e.g. vomiting)– Pneumothorax– Metabolic acidosis /

cause for dyspnea

• Relative CI: – hypotension, – facial abnormalities,

Clinical CaseTIME 0 15 30 45 60

pH 7.43

ptCO2 5.1 5.1 7.6 7.25

pCO2 5.3

SpO2 94 94 96 94 93

HCO3 26 17 20

O2 suppl 2 2 lpm 2lpm 2 2

HR 117 105 104 83 84

RR 30 17 20 15 12

BP 164/103 151/75 132/64 94/49 119/55

VAS 7 3 2

Support - 8 8/10 5/14 5/14

80 y o female

Normal weight non-smoker

Dyspnea, Denial of chest pain

Arrival via ambulance

Prefers to sit, but may lay back.

ECG: no specific signs of acute myocardial ischemia

eFAST: absence of pneumothorax , kerley B- lines

Nitro transdermal 20 mg, furosomide

Trop positive

23.06.2016 Jochen.ruediger@kssg.ch 13

Overview

• Definition of NIV and AHF

• Introduction and clinical cases

• NIV related patient benefits

• NIV related changes in mortality

• NIV in AHF in Switzerland, a shortquestionaire

Use of NIV on Swiss EdsBingisser / Rüdiger

Methods: formalized surveymonkey questionairto all educating Swiss EDs (2 Ti, 10 F, 55 G)

- use of NIV / CPAP

- usefulness

- resources involved

- Knowledge about current CHOP issues

Demographic differences in Switzerland

0%

25%

50%

75%

100%

Responses: NIV Use

Swiss German

Swiss romand

Value of NIV in AHF

nTotally agree Agree Indifferent

Not agreed

Cornerstone therapy 27 44% 41% 11% 4%

Important treatment option

24 54% 46% 4% 0%

Patients profit from NIV

26 46% 54% 0% 0%

NIV needs considerable amount of resources

23 22% 22% 17% 39%

80-100 % agreement

44 versus 39 %

Do you know about CHOP 93.9E?(NIV outside ICU reimbursement)

unaware; 24

In preparatio

n; 5

in use; 180 % are unaware thatthe CHOP code created tocover additional expensesof NIV outside of theIntensive Care Units / Intermediate Care Units

Summary

Non-invasive ventilation in acute heart failure

• ... mostly symptomatic, time matters

• ... is a powerful but demanding tool

• ... Should be considered in short term persistant severe dyspnea, hypoxemia, hypercapnia

• ... appears to be better implemented by Swiss romands