Acute respiratory failure in the ED: the white lung

1. Doc, respira male, polmone bianco ...
Roberto Cosentini
Gruppo NIV
Fondazione IRCCS Ca’ Granda Policlinico - Milano Varese, 06.03.15

2. Gruppo NIV
Policlinico - MI

3. Gruppo NIV
Policlinico - MI

4. Gruppo NIV
Policlinico - MI

5. Quale di questi NON vorresti incontrare?

6. Quale di questi NON vorresti incontrare?

7. Quale di questi NON vorresti incontrare?

11. AH 38.9ºC
Admitted for AECB
Acute pancreatitis

12. AH 38.9ºC Admitted for AECB
Acute pancreatitis

13. AH 38.9ºC Admitted for AECB
Acute pancreatitis

14. AH 38.9ºC Admitted for AECB
Acute pancreatitis
210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

15. AH 38.9ºC Admitted for AECB
Acute pancreatitis
210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

16. AH 38.9ºC Admitted for AECB
Acute pancreatitis
210/110 122r 36’ 85% 110/55 114r 34’ 88% 90/60 122r 36’ 85%

17. history
DG
phys. exam.
Tx
imaging

18. history
DG
phys. exam.
Tx
imaging

19. history
DG
phys. exam.
site of care
Tx
imaging

21. Admitted for AECB
Acute pancreatitis
90/60 122r 36’ 85%

22. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB

23. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:

24. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

25. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis

26. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea

27. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

28. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

29. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51
?

30. 2008, 6:16
ARDS and Lung US
Mantuani D et al.

31. 2008, 6:16
ARDS and Lung US
Mantuani D et al.
ARDS ACPE

32. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB

33. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:

34. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º

35. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis

36. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea

37. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

38. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51

39. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51
NIV?

40. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51
NIV?
1 h after NIV (IPAP 20 EPAP 8 FiO2 .6)

41. 76 ys, severe emphysema
Dec 4, 2013: admission for AECB
Dec, 13:
BP 90/60 HR 102r RR 26’ SpO2 90% BT 37.4º
Acute pancreatitis
Progressive dyspnoea
VM .5: pH 7.30 pCO2 49 pO2 54 HCO3 24 SAPS II 51
NIV?
1 h after NIV (IPAP 20 EPAP 8 FiO2 .6)
pH 7.31 pCO2 47 pO2 60 HCO3 23

42. ?

43. ?

44. ?

45. • 12 episodi di ALI/ARDS in 10 pazienti
• In pazienti emodinamicamente stabili, la NIV ha una elevata
percentuale di successo (50%)
• Considerare NIV nelle fasi precoci dell’ALI/ARDS.

46. • 70% di fallimenti
• Fattori predittivi di fallimento:
• shock, acidosi metabolica, ipossiemia severa
• Nei pazienti che hanno fallito la NIV, la mortalità
osservata è risultata essere > alla mortalità predetta
(Apache II)

50. • Successo 54% dei pazienti.
• F a t t o r i p r e d i t t i v i d i
fallimento:
SAPS II > 34
incapacità a migliorare
PaO2/FiO2 dopo un’ora
dall’inizio della NIV

51. Independent risk factors for ETI
ARDS & NIV

52. Independent risk factors for ETI
SAPS II > 34
ARDS & NIV

53. Independent risk factors for ETI
SAPS II > 34
ARDS & NIV
SHOCK

54. Independent risk factors for ETI
SAPS II > 34
No↑PaO2/FIO2 after 1 h of NIV
ARDS & NIV
SHOCK

55. Independent risk factors for ETI
SAPS II > 34
No↑PaO2/FIO2 after 1 h of NIV
ARDS & NIV
Independent risk factors for mortality
SHOCK

56. Independent risk factors for ETI
SAPS II > 34
No↑PaO2/FIO2 after 1 h of NIV
ARDS & NIV
Independent risk factors for mortality
NIV FAILURE
SHOCK

57. Gruppo NIV
Policlinico - MI

58. Gruppo NIV
Policlinico - MI

59. Quale di questi NON vorresti incontrare?

60. Quale di questi NON vorresti incontrare?

61. Quale di questi NON vorresti incontrare?

62. AH
210/110 122r 36’ 85%

63. AH
210/110 122r 36’ 85%

64. RCT
Gruppo NIV
Policlinico - MI
courtesy of F. Piffer

65. RCT
Gruppo NIV
Policlinico - MI
courtesy of F. Piffer

66. NIV in ACPE: a meta-analysis of RCTs
Mariani et al. J Card Fail 2011
Mortality

67. 210/110 122r 36’ 85%
VM .5
pH 7.22
pCO2 59
pO2 54
HCO3 24
So2 85%
?
TNG --> 15 mcg/min

68. 210/110 122r 36’
VM .5
pH 7.22
pCO2 59
pO2 54
HCO3 24
So2 85%

69. 210/110 122r 36’
VM .5
pH 7.22
pCO2 59
pO2 54
HCO3 24
So2 85%
TNG --> 15 mcg/min
1h
PEEP 10 FiO2 .5
pH 7.27
pCO2 52
pO2 89
HCO3 24
So2 92%
150/90 111r 28’

70. 210/110 122r 36’
VM .5
pH 7.22
pCO2 59
pO2 54
HCO3 24
So2 85%
TNG --> 15 mcg/min
1h
PEEP 10 FiO2 .5
pH 7.27
pCO2 52
pO2 89
HCO3 24
So2 92%
2h
PEEP 10 FiO2 .5
pH 7.27
pCO2 52
pO2 89
HCO3 24
So2 92%
150/90 111r 28’ 140/90 110r 30’

71. 210/110 122r 36’
VM .5
pH 7.22
pCO2 59
pO2 54
HCO3 24
So2 85%
TNG --> 15 mcg/min
1h
PEEP 10 FiO2 .5
pH 7.27
pCO2 52
pO2 89
HCO3 24
So2 92%
2h
PEEP 10 FiO2 .5
pH 7.27
pCO2 52
pO2 89
HCO3 24
So2 92%
150/90 111r 28’ 140/90 110r 30’
?

72. history
DG
phys. exam.
pH 7.28
PaCO2 77
PaO2 41
HCO3- 36
SO2% 86%
lab, imaging
site of care
Tx

75. EPAc in stenosi mitralica misconosciuta

76. EPAc in stenosi mitralica misconosciuta

77. EPAc in stenosi mitralica misconosciuta

78. rythm inotropism ischemia mechanics
EPAc in stenosi mitralica misconosciuta

81. 30
www.thennt.org ken milne

82. 30
www.thennt.org ken milne

83. 30
www.thennt.org ken milne

84. 30
NNT = 8 for ETI
13 for death
www.thennt.org ken milne

85. 30
NNT = 8 for ETI
13 for death
100 ACPE pts_NIV
www.thennt.org ken milne

86. 30
NNT = 8 for ETI
13 for death
100 ACPE pts_NIV
Avoid 13 ETI
www.thennt.org ken milne

87. 30
NNT = 8 for ETI
13 for death
100 ACPE pts_NIV
Avoid 13 ETI
Avoid 8 deaths
www.thennt.org ken milne

91. vs

92. vs

93. vs
www.acpe.it

94. vs
www.acpe.it 1.000 ACPE patients treated w NIV

95. vs
www.acpe.it 1.000 ACPE patients treated w NIV
Mortality = 9%

98. S’ha da fare ...

99. S’ha da fare ...
Adelante Pedro
... con juicio

100. S’ha da fare ...
Adelante Pedro
... con juicio
ACPE = syndrome

101. S’ha da fare ...
Adelante Pedro
... con juicio
ACPE = syndrome

102. Gruppo NIV
Policlinico - MI

103. Gruppo NIV
Policlinico - MI

104. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic

105. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
RLL echo

106. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
RLL echo

107. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
Home or
RLL echo

108. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
Home or
RLL echo

109. 55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
Home or
BGA:
pH 7.48
pCO2 34
pO2 54
HCO3 25
RLL echo

110. SpO2 # pO2
55 ys, cough and fever, otherwise healthy
120/70 84r 25’ SpO2 94%
CXR = non-diagnostic
Home or
BGA:
pH 7.48
pCO2 34
pO2 54
HCO3 25
RLL echo

115. 110/55 114r 34’ 88% 38.9ºC

116. 110/55 114r 34’ 88% 38.9ºC

117. h 8.55 M, 64 aa BPCO, fumatore
da tre giorni febbre fino a 39º
tosse, astenia GB 11.000
Hb 15.4
PCR 7
crea 0.98
Na 129, CK 417

118. h 8.55 M, 64 aa BPCO, fumatore
da tre giorni febbre fino a 39º
tosse, astenia
lucido, vigile
PA 140/70 FC 96 Sat 88% FR 40 TA 38.9º
GB 11.000
Hb 15.4
PCR 7
crea 0.98
Na 129, CK 417
VM .5
pH 7.39
pCO2 40
pO2 58
HCO3 21.7
lattati 2.3
sat 88%

119. h 8.55 M, 64 aa BPCO, fumatore
da tre giorni febbre fino a 39º
tosse, astenia
lucido, vigile
PA 140/70 FC 96 Sat 88% FR 40 TA 38.9º
GB 11.000
Hb 15.4
PCR 7
crea 0.98
Na 129, CK 417
VM .5
pH 7.39
pCO2 40
pO2 58
HCO3 21.7
lattati 2.3
sat 88%
NIV ?

120. Gruppo NIV
Policlinico - MI

121. Gruppo NIV
Policlinico - MI

122. Cochrane Database Syst Rev. 2012 Mar
OXYGEN THERAPY FOR PNEUMONIA IN ADULTS (REVIEW)

123. Cochrane Database Syst Rev. 2012 Mar
OXYGEN THERAPY FOR PNEUMONIA IN ADULTS (REVIEW)

124. Conclusioni

125. Intensive Care Med. 2014 Jul;40(7):942-9.

126. inclusion criteria
pneumonia
distress, RR> 30, PF<250

127. inclusion criteria
pneumonia
distress, RR> 30, PF<250
Number Needed to Treat (NNT) = 2 (CI95% = 1-3)

128. 43

129. entro le 12 ore
peggioramento

130. entro le 12 ore
peggioramento

132. NNT = 3 for ETI criteria

133. NNT = 3 for ETI criteria
criteria

134. NNT = 3 for ETI criteria

135. Venturi 50% levofloxacina
FiO2 0.5
FR 42
pH 7.39
pCO2 38
pO2 62
HCO3 23
Sat 96%
PF 124

136. Venturi 50% levofloxacina
FiO2 0.5
FR 42
pH 7.39
pCO2 38
pO2 62
HCO3 23
Sat 96%
PF 124
CPAP

137. Venturi 50% levofloxacina
FiO2 0.5
FR 42
pH 7.39
pCO2 38
pO2 62
HCO3 23
Sat 96%
PF 124
dopo 1 ora
CPAP
FiO2 0.5 PEEP 10
FR 38
pH 7.35
pCO2 44
pO2 96
HCO3 24
sat 99%
PF 216

138. Venturi 50% levofloxacina
FiO2 0.5
FR 42
pH 7.39
pCO2 38
pO2 62
HCO3 23
Sat 96%
PF 124
dopo 1 ora
CPAP
FiO2 0.5 PEEP 10
FR 38
pH 7.35
pCO2 44
pO2 96
HCO3 24
sat 99%
PF 216
dopo 2 ore

139. Venturi 50% levofloxacina
FiO2 0.5
FR 42
pH 7.39
pCO2 38
pO2 62
HCO3 23
Sat 96%
PF 124
dopo 1 ora
CPAP
FiO2 0.5 PEEP 10
FR 38
pH 7.35
pCO2 44
pO2 96
HCO3 24
sat 99%
PF 216
dopo 2 ore
FiO2 0.5 PEEP 10
FR 36
pH 7.25
pCO2 55
pO2 95
HCO3 24
sat 99%
PF 216

140. Is something wrong?

141. Is something wrong?

142. modified from Aliberti

143. FiO2 + NIV
modified from Aliberti

144. Transfusion Fluids Vasopressors
FiO2 + NIV
modified from Aliberti

145. Transfusion Fluids Vasopressors
FiO2 + NIV
ABX
modified from Aliberti

146. Nitrates
Transfusion Fluids Vasopressors
FiO2 + NIV
ABX
modified from Aliberti

147. Nitrates
Transfusion Fluids Vasopressors
FiO2 + NIV
ABX
modified from Aliberti

148. Nitrates
Transfusion Fluids Vasopressors
FiO2 + NIV
ABX
modified from Aliberti

149. Nitrates
Transfusion Fluids Vasopressors
FiO2 + NIV
ABX
modified from Aliberti

153. STUDIO PROSPETTICO OSSERVAZIONALE
MULTICENTRICO “REAL LIFE” SULL’USO DELLA
CPAP/NIV NEL TRATTAMENTO DELLA
POLMONITE
studio “3P”
Pneumonia
Positive
Pressure
nel 2013, 20 Centri Italiani, 342 polmoniti trattate con CPAP/NIV
protettivi
obesità
BPCOr
CPAP (171) NIV (171)
Efficacia 106 (62%) 108 (63%)
Interruzione x
intolleranza
10 (6%) 12 (7%)
Passaggio a NIV 33 (19%) /
IOT 11 (6.4%) 22 (12.9%)
mortalità 43 (25%) 40 (23.4%)
età
polmonite bilaterale
anemia
azotemia alta
PSI alto
DNI
neoplasia
sepsi grave
Fattori prognostici
di mortalità

154. pneumonia

155. pneumonia
± sepsis

156. pneumonia
± sepsis = severity

157. pneumonia
± sepsis = severity
= survival

158. pneumonia
± sepsis = severity
= survival

159. pneumonia
± sepsis = severity
= survival

160. pneumonia
± sepsis = severity
= survival
Hypercapnia

161. pneumonia
± sepsis = severity
= survival
Hypercapnia
HDU or ICU

162. history
DG
phys. exam.
pH 7.28
PaCO2 77
PaO2 41
HCO3- 36
SO2% 86%
lab, imaging
site of care
Tx

163. history
DG
phys. exam.
pH 7.28
PaCO2 77
PaO2 41
HCO3- 36
SO2% 86%
lab, imaging
site of care
Tx
skill
monitoring

164. history
DG
phys. exam.
pH 7.28
PaCO2 77
PaO2 41
HCO3- 36
SO2% 86%
lab, imaging
site of care
Tx
skill
monitoring
High mortality
10% 25% 50%

165. Livestream App
http://new.livestream.com
@rob_cosentini

166. Livestream App
http://new.livestream.com
@rob_cosentini
www.foamem.com www.googlefoam.com

168. • Fatti non foste a viver come bruti ...

169. • Fatti non foste a viver come bruti ...

170. • Fatti non foste a viver come bruti ...

171. • Fatti non foste a viver come bruti ...
• don’t forget the brain ...

172. • Fatti non foste a viver come bruti ...
• don’t forget the brain ...