15 JAHRE NIV - WO STEHEN WIR - Atmung/Beatmung Dirk Jahnke

15 JAHRE NIV - WO STEHEN WIR
Mittwoch, 22. Februar 12
Dirk Jahnke
Fachkrankenpfleger A&I
Klinikum Oldenburg

Mittwoch, 22. Februar 12
15 Jahre ?
Meduri GU, Conoscenti CC, Menashe P, et al. Noninvasive face
mask ventilation in patients with acute respiratory failure. Chest
1989; 95:865-870

Mittwoch, 22. Februar 12
nicht repräsentative Zahlen
Teilnehmer ?
Wann wird NIV eingesetzt ?
Was ist NIV ?
Definition „Klappt“ ?
subjektive Aussage !
www.atmungbeatmung.de

Mittwoch, 22. Februar 12
Fragebogenaktion 2003
Umfrage zum Stellenwert der non-invasiven Ventilation auf Deutschen Intensivstationen.
Kumle B et al. –Anästhesiol Intensivmed Notfallmed Schmerzther 2003; 38: 32 -37
n = 223 Intensivstationen
13% lehnten NIV ab
Gründe :
11% Risiko
4% Kosten
57% Personalaufwand
4% kein Vorteil
64% kein Gerät

Mittwoch, 22. Februar 12
Arzt / Ärztin
Fachpflegekraft
(Atemtherapeut)
(17.7% for MD, 23.1% for N, and 10.7% for RT).
recorded and divided into direct and indirect components. These
The time elapsed, during the first 30 to 60 min, in Figure 3. N an
data were recorded from a computer-based system developed by
the group that failed NIMV and spent in trying to period of MV.
our hospital. Direct costs were considered to be incurred by
InMV; two aste
diagnostic tests and studies (ie, radiologic studies, hematologic
deliver this modality of ventilation was also recorded.
tests, and pulmonary function tests), disposable supplies (phar-
The addition of these minutes of assistance
macy, personnel supplies), and medical and paramedical salaries.
(16.4�4.6 min for Ns, 25.2�6.6 min for RTs, and
The 48-h indirect cost per patient was calculated as recently
24.8�4.2 min for MDs) did not, however, signifi- noninvasivel
described by Criner and coworkers
cantly increase the staff’s total workload per patient tients) throu
weaning occu
fail the initial NIMV trial.
and MDs sh
Figure 3 shows the minutes spent per day by Ns after the firs
and MDs in the care of the patients ventilated time, respec
As shown
not significa
tients, even
lated patient
table illustra
Group A
Group B
Category
Personnel
Radiograph
Drug
Supplies
Laboratory
Indirect costs
Figure 2. Workload of the whole medical and paramedical Others
personnel (total), Ns, MDs, and RTs, expressed as a percentage
of the first 48 h of MV. Data are mean�SD. Asterisk indicates *Total costs of t
p�0.05 between NIMV and InMV.
costs (upper pa
Human and financial costs of noninvasive
Downloaded from www.chestjournal.org by on Ju
mechanical ventilation in patients affected by
COPD and acute respiratory failure
S Nava, I Evangelisti, C Rampulla, ML
Compagnoni, C Fracchia and F Rubini Chest
1997;111;1631-1638
11 recorded and divided into direct and indirect components. These
data were recorded from a computer-based system developed of variance by for repeated measurements. Statistical significance
our hospital. Direct costs were considered to be incurred was defined by as a two-tailed p value �0.05.
diagnostic tests and studies (ie, radiologic studies, hematologic
tests, and pulmonary function tests), disposable supplies (pharmacy,
personnel supplies), and medical and paramedical salaries.
The 48-h indirect cost per patient was calculated as recently
Results
described by Criner and coworkers
As illustrated in Table 2, the institution of both
as the daily rate of reimbursement
for each full-time staff position assigned only to NIMV and InMV improved the arterial blood gas
patients in the RICU. Indirect costs included overhead to cover values of the patients by hospital discharge, although
some institutional services such as laundry, heating, nondispos- one patient from each group died before the weanable
equipment (ventilators, monitors, arterial blood gas analyzing. The group A patient died of pneumonia on day
ers). The data were expressed in US dollars after having con-
9. Multiple organ failure was the cause of death for
verted the costs from Italian lira (1 US dollar�1,590 Italian lire).
Results are expressed as mean�SD. Comparisons between the the group B patient on day 7.
two groups of patients were performed with a two-sample t test, The upper part of Figure 1 illustrates the total Ns
while short- (48 h) and long-term (until hospital discharge) workload per patient in the first 48 h of MV. No
comparison measurements were analyzed using two-way analysis significant differences were observed in the time of
assistance between the NIMV and InMV patients.
After the first 6 h, there was, however, a common
significant decrease in the two groups that reached a
plateau after 12 h of mechanical ventilation (MV).
The total time of nursing assistance for each patient
in the first 48 h for group A was 540.1�76.4 min vs
527.5�51.1 min for group B (not significant). Table
3 shows the activities related to MV.
The middle part of Figure 1 illustrates the total MDs
workload per patient in the first 48 h of ventilation. The
total time expenditure for MD was 415�110 min for
group A vs 524�156 min for group B (not significant).
The MDs activities that required more time were
similar for the NIMV and the InMV groups (Table 4).
As shown in the lower panel of Figure 1, there was a
significant difference in the total RTs workload per
patient in group A during the first 6 h. While this time
decreased significantly after this period of time during
NIMV, it remained constant in the InMV group
throughout the first 48 h.
The total time of assistance per patient given by
RTs in the first 48 h was 250.8�66.5 min for group
A vs 72.7�38.5 min for group B. The total time of
assistance per patient given by Ns, RTs, and MDs in
the first 48 h was 1,205.67�154.07 min vs
1,126�177.69 min for group A and B, respectively.
11 of variance for repeated measurements. Statistical significance
was defined as a two-tailed p value �0.05.
Results
As illustrated in Table 2, the institution of both
as the daily rate of reimbursement
for each full-time staff position assigned only to NIMV and InMV improved the arterial blood gas
patients in the RICU. Indirect costs included overhead to cover values of the patients by hospital discharge, although
some institutional services such as laundry, heating, nondispos- one patient from each group died before the weanable
equipment (ventilators, monitors, arterial blood gas analyzing. The group A patient died of pneumonia on day
ers). The data were expressed in US dollars after having con-
9. Multiple organ failure was the cause of death for
verted the costs from Italian lira (1 US dollar�1,590 Italian lire).
Results are expressed as mean�SD. Comparisons between the the group B patient on day 7.
two groups of patients were performed with a two-sample t test, The upper part of Figure 1 illustrates the total Ns
while short- (48 h) and long-term (until hospital discharge) workload per patient in the first 48 h of MV. No
comparison measurements were analyzed using two-way analysis significant differences were observed in the time of
assistance between the NIMV and InMV patients.
After the first 6 h, there was, however, a common
significant decrease in the two groups that reached a
plateau after 12 h of mechanical ventilation (MV).
The total time of nursing assistance for each patient
in the first 48 h for group A was 540.1�76.4 min vs
527.5�51.1 min for group B (not significant). Table
3 shows the activities related to MV.
The middle part of Figure 1 illustrates the total MDs
workload per patient in the first 48 h of ventilation. The
total time expenditure for MD was 415�110 min for
group A vs 524�156 min for group B (not significant).
The MDs activities that required more time were
similar for the NIMV and the InMV groups (Table 4).
As shown in the lower panel of Figure 1, there was a
significant difference in the total RTs workload per
patient in group A during the first 6 h. While this time
decreased significantly after this period of time during
NIMV, it remained constant in the InMV group
throughout the first 48 h.
The total time of assistance per patient given by
RTs in the first 48 h was 250.8�66.5 min for group
A vs 72.7�38.5 min for group B. The total time of
assistance per patient given by Ns, RTs, and MDs in
the first 48 h was 1,205.67�154.07 min vs
1,126�177.69 min for group A and B, respectively.
in group B, as compared to the patients who did not
Personal - Aufwand
Table 3—Description of N Workload*
Table 3—Description of N Workload*
NIMV % InMV %
NIMV %
Logging of vital signs
InMV %
28 Logging of vital signs 23
Logging of vital signs Assistance to28 NIMV Logging of vital 21signs Endotracheal23 suctions 20
Assistance to NIMV Administration 21of Endotracheal therapy suctions 14 Administration 20of
therapy 15
Administration of Hygiene therapy of the 14 patient’s Administration body 12 of Change therapy of the 15linens
12
Hygiene of the patient’s Changebody of the 12linens Change of the linens 9 Hygiene of the 12 patient’s body 11
Change of the linens Treatment for9nose Hygiene skin of the 6patient’s Sampling body and11management 9
Treatment for nose skin abrasions 6 Sampling and management of biochemistry 9 tests
abrasions Others of biochemistry 10 Others tests
10
Figure 1. Ns, MDs, and RTs, workload in the first 48
Others
h of MV.
10 Others 10
Figure 1. Ns, MDs, Dataand areRTs, mean�SD. workloadAsterisk in the first indicates 48 h of p�0.05 MV. compared with *The activities are expressed as a percentage of the total amount of
Data are mean�SD. the first Asterisk 6-h period. indicates p�0.05 compared with *The activities are expressed workload in asthe a percentage first 48 h. of the total amount of
the first 6-h period.
workload in the first 48 h.
1634 Clinical Investigations in Critical Care
1634 Downloaded from www.chestjournal.org by on July Clinical 8, 2005 Investigations in Critical Care
Downloaded from www.chestjournal.org by on July 8, 2005

NIV - Indikation - Parameter
Hyperkapnisches Atempumpversagen
Mittwoch, 22. Februar 12
pH < 7,35 (pH > 7,2 )
pCO2 > 50
hypoxämischen ARI - weiter unklare Datenlage

NIV - Indikation - Parameter
Hyperkapnisches Atempumpversagen
Mittwoch, 22. Februar 12
pH < 7,35 (pH > 7,2 )
pCO2 > 50
hypoxämischen ARI - weiter unklare Datenlage

Begriffe CPAP vs. NIV
CPAP-Maske NIV
Atemhilfe
Beatmung ohne invasiven Zugang
Mittwoch, 22. Februar 12
keine aktive Unterstützung
der Atempumpe
pH > 7,35 pCO2 < 50
höherer Totraum
Verbesserung der
Ausgangssituation
/ weniger Atemarbeit
Fragebogenaktion 2003 - 25% „Was ist NIV?“ : CPAP Maske
aktive Entlastung der Atempumpe
pH < 7,35 pCO2 > 50
höherer Totraum wird durch
Beatmung kompensiert
Verbesserung der
Ausgangssituation
/ weniger - keine Atemarbeit

Evidence
Mittwoch, 22. Februar 12
NIV-Indikation
exazerbierte COPD - 82 %
neuromuskuläre Erkrankungen
akutes Lungenödem (4,5) - 50%
nach Extubation / fortgesetztes Weaning
immunsupprimierte Patienten mit ARI
zur Präoxygenierung vor Intubation bei Hypoxämie (6)
Pneumonie 64%
ARDS - 22%
XX % von 223 Intensivstationen - NIV bei ...
Umfrage zum Stellenwert der non-invasiven Ventilation auf Deutschen Intensivstationen

Mittwoch, 22. Februar 12
Kontraindikationen NIV
absolute Kontraindikationen
Apnoe / Schnappatmumg /
Herzkreislaufstillstand
GI Blutung / Ileus - Apsirationsgefahr
Verlegung der Atemweg
Experten Meinung !
Leitlinie „Nichtinvasive Beatmung als Therapie der akuten respiratorischen
Insuffizienz“
relative Kontraindikationen
(hyperkapnisches) Koma (2)
massive Agitation
Instabile Hämodynamik
Sekretverhalt
Unmöglichkeit die Maske zu platzieren
Schwergradige Hypoxämie oder Azidose (pH < 7,1)
Z.n. oberer gastrointestinaler OP

Mittwoch, 22. Februar 12
Modi NIV
PCV (BiLevel / BIPAP / BIPAPassist /ST)
PSV (DU / PS / ASB)
max Entlastung der Atempumpe möglich
Triggerung möglich
„Abholen“ des Patienten möglich

Mittwoch, 22. Februar 12
Intensivrespirator
optimierter NIV Respirator
schneller Wechsel auf invasiv
Mitarbeiterschulung
Sicherheit am Gerät
Technik
freie Alarmgrenzen
optimierte Beatmungsmodi
Triggerung bei Maskeneinsatz
Anschaffungskosten
(Kosten / Beatmungsstunde)
Platzbedarf

Mittwoch, 22. Februar 12
pH steigt , pCO2 fällt
Erfolgskriterien
bessere Oxygenierung (bei niedrigem FiO2 indirektes Zeichen für bessere
Ventilation)
AF sinkt
Bewussteinszustand verbessert sich
Atemmechanik verbessert sich
Hämodynamik stabilisiert sich
Schwitzen lässt nach
Kooperation und Toleranz
innerhalb von
1-2 Stunden
Erfolg nicht vorhersagbar

Mittwoch, 22. Februar 12
Spo2 < 85% bei FiO2 >0,5
pCO2 steigt über initialen Wert
pH Abfall
Sekretverhalt
Aspiration
mangelnde Kooperation
Abbruch
Zunahme der Agitiertheit bzw. Verschlechterung des Bewusstseins
(Unfähigkeit sich die Maske zu entfernen)
jederzeit - wenn
keine Anpassung
möglich

Mittwoch, 22. Februar 12
Aussichten
aktuelle Stellensituation im ICU Bereich -
Qualifizierung / Fluktuation im Intensivbereich -
Studien aus pflegerischer Sicht +
Arbeiten nach Algorithmen +
Atemtherapeut +

ENDE
Danke für ihre Aufmerksamkeit !
Mittwoch, 22. Februar 12
Dirk Jahnke - www.atmungbeatmung.de
1. S3 – Leitlinie -Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz
2.Diaz GG, Alcaraz AC, Talavera JC, et al. Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failure. Chest 2005; 127:952-960
3.Ram FS, Wellington S, Rowe BH, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev
2005:CD004360
4.AJ Gray, S Goodacre,A multicentre randomised controlled trial of the use of continuous positive airway pressure and noninvasive positive pressure ventilation in the early treatment of patients prese
nting to the emergency department with severe acute cardiogenic pulmonary oedema: the 3CPO trial - Health Technology Assessment 2009; Vol. 13: No. 33
5.J Card Fail. 2011 Oct;17(10):850-9. Epub 2011 Jul 8.- Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials.
6.Baillard C, Fosse JP, Sebbane M, et al. Noninvasive Ventilation Improves Preoxygenation before Intubation of Hypoxic Patients. Am J Respir Crit Care Med 2006; 174:171-177
7.Winck JC, Azevedo LF, Costa-Pereira A, et al. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema - a systematic review and meta- analysis. Crit Care
2006; 10:R69
8.Hilbert G, Gruson D, Portel L, et al. Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J 1998; 11:1349-1353
9.Hilbert G, Gruson D, Vargas F, et al. Noninvasive continuous positive airway pressure in neutropenic patients with acute respiratory failure requiring intensive care unit admission. Crit Care Med 2000;
28:3185-3190
10.Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;
339:429-435
11.Girou E, Brun-Buisson C, Taille S, et al. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema.
JAMA 2003; 290:2985-2991
12.Umfrage zum Stellenwert der non-invasiven Ventilation auf Deutschen Intensivstationen - Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie. - Stuttgart [u.a.] : Thieme Vol. 38, No. 01
(1. 2003), p. 32-37
13. Human and financial costs of noninvasive mechanical ventilation in patients affected by COPD and acutt respiratory failure S Nava, I Evangelisti, Chest 1997;111;1631-1638