Download Noninvasive ventilation in acute heart failure: patient

ORIGINAL ARTICLE
Noninvasive ventilation in acute heart failure: patient
characteristics and clinical course in cases treated
in a hospital emergency department
JOSÉ MANUEL CARRATALÁ, PERE LLORENS, BENJAMÍN BROUZET, JOSÉ CARBAJOSA,
ALEJANDRO R. ALBERT, ELENA MARTÍNEZ-BELOQUI, ROGELIO PASTOR, INMACULADA JIMÉNEZ,
FRANCISCO ROMÁN
Servicio de Urgencias, Unidad de Corta Estancia y Unidad de Hospitalización a Domicilio. Hospital General
Universitario de Alicante, Spain.
CORRESPONDENCE
José Manuel Carratalá Perales
Servicio de Urgencias-Unidad
de Corta Estancia
Hospital General Universitario
de Alicante
Calle Pintor Baeza, 12
03010 Alicante, Spain
E-mail: [email protected]
RECEIVED:
15-1-2010
ACCEPTED:
26-4-2010
CONFLICT OF INTEREST:
None
Objectives: Our aim was to analyze patient characteristics and clinical course in acute
cardiogenic pulmonary edema (PE) treated with noninvasive ventilation (NIV) in our
hospital emergency department (ED) and to find out factors related to NIV failure and
mortality.
Methods: Prospective, observational study of all patients with acute CPE requiring NIV
in our ED. We analyzed clinical characteristics and blood gas analyses on admission and
at 60 minutes, type of ventilation applied, destination on discharge, complications, need
for orotracheal intubation, and duration of stay in the ED. Comorbidity was assessed on
the Charlson and Barthel indices. Mortality in the emergency department, on the ward,
or 7 and 21 days after discharge was registered on follow-up.
Results: We studied 133 patients; 69 (51%) were men and the mean (SD) age was 76.2
(10.9) years. Continuous positive airway pressure was used in 60% of the cases.
Symptoms and results of arterial blood gas analysis improved 1 hour after starting NIV.
Meanduration of NIV was 4.25 (2.54) hours. Dry mucus membranes (69%) and
erythematous facial sores (50%) were the most common complications. NIV failed in
9,8% of patients. ED mortality was 3%. Risk factors for death due to heart failure were
age >65 years, blood pressure <120 mm Hg, urea >45 mg/dL, sodium <136 mEq/L,
and respiratory frequency >35 breaths/min on admission. Choice of NIV modality was
not a factor in clinical or blood gas improvements, mortality, or failure of NIV
treatment. Forty-five (33.8%) patients were admitted to the short-stay unit, 35 (26.3%)
to the cardiology ward, 25 (18.8%) to the internal medicine ward, and 7 (5.2%) to the
intensive care unit.
Conclusions: Early application of NIV to treat acute CPE improves symptoms and blood
gases quickly, with few complications and short ED stays. The NIV modality chosen does
not affect mortality or failure of the technique. The possibility of using NIV in all hospital
ED should be considered. [Emergencias 2010;22:187-192]
Key words: Acute pulmonary edema. Noninvasive ventilation. Emergency health
services. Complications. Mortality.
Introduction
Acute heart failure (AHF) in the form of acute
pulmonary edema (APE) is the most common
cause of acute respiratory failure (ARF) in an
emergency department (ED) 1. It accounts for a
large percentage of hospital admissions, and is
the leading cause of hospitalization and ED consultation in patients over 65 years2. In a recent reEmergencias 2010; 22: 187-192
view of data from the United States and Europe,
between 18-40% of patients with APE required
admission to the intensive care unit (ICU) and
6.7% required ventilatory support (72.4% non-invasive and 27.6% invasive)3. Non-invasive ventilation (NIV) has been used in recent decades as an
alternative method of oxygenation in the treatment of APE. Compared to traditional systems,
NIV improves early clinical parameters and blood
187
J. M. Carratalá et al.
gases, decreases the rate of orotracheal intubation
(OTI) and ICU admissions, with few complications
and without increasing the risk of a coronary
event4-7. There is sufficient evidence that NIV reduces mortality of patients with APE treated with
CPAP, but not with the BiPAP mode, but in daily
clinical practice this is not so8. No meta-analysis
concludes that one mode of ventilation is superior
to the other in the treatment of APE9.
The aim of this study was to define the epidemiological and clinical profile of patients with
APE treated with NIV in the ED, differences between ventilatory modes used, clinical response
and arterial blood gases at 60 minutes, total ventilation time, need for OTI during ED stay, patient
destination, mortality and risk factors.
Method
We performed a prospective, observational
study of all patients with APE treated with NIV in
the ED between January 2006 and March 2009.
We included patients over 18 years with AHF and
moderate-severe dyspnea (modified Borg scale)10,
use of accessory muscles (Patrick scale > 3)11, arterial oxygen saturation (SaO 2 ) <90%, ratio
PaO2/FIO2 <300, PaCO2> 45 mmHg and infiltration shown by bilateral chest X-ray. We excluded
patients under 18 years, patients with an immediate need for OTI, systolic pressure <90 mmHg,
acute myocardial infarction (MI) or uncontrolled
ventricular arrhythmia, pneumothorax and uncooperative patients.
Informed consent was verbally obtained from
all patients or family caregivers and the study was
approved by the Hospital Ethics Committee.
We calculated the Charlson comorbidity index12 and Barthel Index (BI)13, the data being obtained directly from the patient when possible or,
in cases of cognitive impairment or confusion,
from the primary caregiver.
Pharmacological treatment was performed
without intervention following the recommendations of the European Society of Cardiology10. NIV
modes used were CPAP (Boussignac® valve) and
BiPAP (Vision by Respironics®) S/T with naso-oral
interfaces. The choice of ventilatory mode depended on clinical criteria and the experience of
the attending physician. Ventilation parameters
were selected following our ED protocol without
waiting for response to conventional therapy before initiating NIV 15. Inspired oxygen fraction
(FIO2) used in each patient was that required to
maintain SaO2 > 90%.
188
On ED arrival, the following data were recorded: respiratory frequency (RF), heart rate (HR),
systolic and diastolic blood pressure (SBP, DBP),
SaO2, temperature, degree of dyspnea and use of
accessory muscles, and on admission ABG was
performed, noting the FIO2 at the time. After 60
minutes of NIV, we re-scored the above parameters and obtained a new ABG. In addition, we
monitored SaO2, heart rate, SBP and patient comfort every 15 minutes during the first hour. After
the initial adjustment period (first 10-15 min), we
recorded CPAP values, inspiratory positive pressure
in alveoli (IPAP), expiratory positive pressure in
alveoli (EPAP), tidal volume (TV), ramp and volume leakage (VF), and scheduled a breathing rate
of 15 breaths minutes for BIPAP mode. We recorded the same parameters at 60 minutes after starting NIV.
During ED stay, we requested a chest X-ray, a
12-lead electrocardiogram, complete blood test,
and lab tests including creatinase, troponin T, glucose, sodium, potassium, creatinine, urea, CRP, aspartate aminotransferase and basic coagulation
with D-dimer.
Mortality and its causes was recorded during
ED stay, NIV failure defined as need for OTI, complications related to the technique, which included myocardial infarction, total NIV time in the ED,
destination, hospital mortality, and outcome at 7
and 21 days after discharge by telephone contact.
The EFFECT scale was used to analyze 16 mortality risk factors in AHF.
Results are expressed as mean ± standard
(quantitative variables) and as absolute values and
percentages (qualitative variables). For comparisons between variables, Student's t-test for related samples was used for the former and chisquare or exact Fisher test (as required) for the
latter.
Results
Of 133 patients, 69 (51.8%) were male, and
mean age was 76.2 ± 10.9 years.
More than half (56%) had high comorbidity
(Charlson 3). The most frequent pathologies
were associated with hypertension (HT) (76.2%),
chronic heart failure (68.4%), diabetes mellitus
(DM) (43.6%) and chronic obstructive pulmonary
disease (COPD) (33.8%). Nearly two thirds
(65.4%) had a severe limitation for daily living activities (BI ≤ 80 points).
The most frequently used mode of ventilation
was CPAP (60.1%) with average pressure of 8.4
Emergencias 2010; 22: 187-192
NONINVASIVE VENTILATION IN ACUTE HEART FAILURE: PATIENT CHARACTERISTICS AND CLINICAL COURSE IN CASES TREATED IN A HOSPITAL EMERGENCY DEPARTMENT
Table 1. Clinical parameters and blood gases on ED admission
and after 1 hour of non-invasive ventilation (NIV)
cm H2O. With BiPAP, average pressure was 9cm
H2O. Most patients had severe dyspnea and used
accessory muscles on admission (81.3 and 93.2%
respectively) and showed great improvement after
60 min of NIV (3% severe dyspnea, 11.2% use of
accessory muscles). RF, HR, SaO2 and blood gas
parameters improved after one hour of NIV (Table
1) regardless of ventilatory mode used (Data not
shown).
Average time on NIV in the ED was 4.25
hours, 3.75 h for CPAP and 5.45 hours for BIPAP.
The most common complications were dry
mucous and facial erythema (Table 2) which
proved similar in both modes except that significantly more dry mucous membranes were found
in patients receiving BiPAP (P <0.05). Only two
cases of discomfort and headache were found,
which signalled failure of the technique. There
were no cases of barotrauma, superinfection or
AMI.
Four patients died in the ED (3%), 3 by cardiogenic shock and 1 from sepsis secondary to pneumonia. Hospital mortality was 12% (16 patients)
and, after discharge, 3% and 1% at 7 and 21
days, respectively; 70% of the deceased had a
Barthel index 80 (48 ± 35) (Table 3). We did
not find any particular variable associated with increased mortality (Table 4).
The use of BiPAP was not associated with
greater mortality (Table 4). The NIV technique
failed in 9.8% (13 patients). The most common
causes were discomfort, intolerance of the mask
interface and poor control of secretions. We did
not identify any particular factor (clinical, analytical, comorbidity, functional status or mode of
ventilation) associated with failure other than a
low respiratory rate (Table 5). The risk factor most
frequently associated with NIV failure in the emergency department was no improvement in pH
and persistence of hypercapnia after 1 hour of
NIV.
In terms of destination, most patients entered
the short stay unit (33.8%), followed by cardiolo-
ED admission
Mean (SD)
60 min NIV
Mean (DE)
P
HR, beats pm
115 (26.8)
92 (18.9)
< 0.001
RF, breaths pm
36.3 (8.1)
25.6 (6.1)
< 0.001
SBP, mmHg
156 (40.4)
135 (24)
< 0.001
67.2 (20.5)
87.3 (18.5)
< 0.001
PaO2, mmHg
PaCO2, mmHg
57.5 (22.2)
50 (14.8)
< 0.001
pH
7.26 (0.16)
7.35 (0.07)
< 0.001
PaO2/FIO2
214 (71)
*
HCO3, mEq/L
27 (7.7)
28.2 (6.7)
NS
SaO2, %
83.7 (12.8)
93.7 (6.7)
< 0.001
ED: Emergency department. HR: Heart rate. pm: per minute.
RF: respiratory frequency. SBP: systolic blood pressure. PaO2: arterial
oxygen pressure. PaCO2: arterial pressure of carbon dioxide.
PaO2/FIO2: Quotient arterial oxygen pressure / inspired oxygen
fraction. COH3: Bicarbonate. SaO2 % blood oxygen saturation.
*The value at 60 minutes was not assessable since a value
of FIO2 0.85 was applied to all patients. NS: not significant.
gy department 26.3%, internal medicine 18.8%
and ICU 5.2%.
Discussion
The present study is one of the first to analyze
the use of NIV in the treatment of APE in a Spanish ED, and confirms that early use rapidly improves clinical and blood gas parameters, with a
reduced number of complications, minimal shortterm mortality and no differences between types
of NIV.
A recent publication describes the epidemiological profile of patients with AHF as an older
male (65-80 years) 17 with high comorbidity 18,
which is repeated in this series. In addition, in this
case, most of these patients had significant constraints on basic daily life activities, typical of a
progressively aging population.
The rapid improvement in cardiopulmonary
symptoms is consistent with various studies showing that the early use of NIV (both CPAP and BIPAP) versus conventional oxygen therapy for APE
rapidly improves clinical parameters and blood
Table 2. Complications following the use of noninvasive ventilation
Complications
Total
N = 133
Dry mucous [n (%)]
92 (69)
Nasal skin rash [n (%)]
50 (37.6)
Headache[n (%)]
10 (7.5)
Eye irritation [n (%)]
6 (4.5)
Discomfort [n (%)]
6 (4.5)
Vomiting [n (%)]
3 (2.2)
Gastric distension [n (%)]
3 (2.2)
Other [n (%)]
3 (2.2)
Other: 2 epistaxis, 1 hypotension. NS: not significant.
Emergencias 2010; 22: 187-192
CPAP
N = 80
49 (61.25)
35 (38.75)
6 (7.5)
5 (6.25)
5 (6.25)
1 (1.25)
3 (3.75)
2 (2.50)
BiPAP
N = 53
43 (81.13)
15 (28.30)
4 (7.54)
1 (1.88)
1 (1.88)
2 (3.77)
0 (0)
1 (1.88)
P
< 0.05
NS
NS
NS
NS
NS
NS
NS
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J. M. Carratalá et al.
Table 3. Differential characteristics of patients who died during the episode of heart failure
Risk Factor
Total
N = 133
Total
deaths
N = 24
ED
deaths
N=4
Hospital
deaths
N = 16
7-day
mortality
N=3
21-day
mortality
N=1
Age > 65 years [n (%)]
112 (84.2)
20 (83.3)
2 (50)
14 (87.5)
3 (100)
1 (100)
RF > 35 bpm [n (%)]
94 (70.7)
13 (54.1)
3 (75)
9 (56.2)
1 (33.3)
0
SBP < 120 mmHg [n (%)]
26 (18.5)
7 (29.1)
2 (50)
4 (25)
0
1 (100)
Urea > 45 mg / dl [n (%)]
91 (68.4)
18 (75)
4 (100)
11 (68.7)
2 (66.7)
1 (100)
Na < 136 mEq / L [n (%)]
54 (40.6)
10 (41.6)
2 (50)
7 (43.7)
0
1 (100)
Hb < 10 g / dl [n (%)]
18 (13.5)
4 (16.6)
1 (25)
3 (18.7)
0
0
COPD [n (%)]
45 (3.8)
8 (33.3)
2 (50)
3 (18.7)
2 (66.7)
1 (100)
Cancer [n (%)]
12 (9.0)
4 (16.6)
1 (25)
3 (18.7)
0
0
Barthel Index <80 points [n (%)]
92 (69.2)
17 (70.8)
3 (75)
11 (68.7)
2 (66.7)
1 (100)
RF: respiratory frequency. bpm: breaths per minute. SBP: Systolic Blood Pressure. Na: Plasma Sodium plasma. Hb: Plasma Hemoglobin. COPD: Chronic
obstructive pulmonary disease.
gases and reduces the number and percentage of
OTI and ICU admission rates19-23.
With regard to mortality, there is not sufficient
evidence to be able to affirm the superiority of
NIV over conventional oxygen therapy, although
in two meta-analyses and a study with 89 APE patients over 75 years, reduced early mortality (first
24-48 hours) was found with the use of CPAP and
BiPAP, but not significantly so24-26. Surprisingly, in a
questionable study by Gray et al, no benefit was
found in the use of NIV (both CPAP and BiPAP
modes) versus conventional oxygen for the treatment of the APE (no differences in mortality and
percentage of OTI) 27. Our results show low ED
mortality and in-hospital mortality similar to that
previously reported. Overall mortality was not influenced by the ventilatory mode selected, which
is consistent with the studies cited above, although high severity patients (extreme dyspnea,
hypoventilation, hypoxemic-hypercapnic respiratory failure) required BiPAP at entry or as rescue
therapy when CPAP failed, which has also been
noted elsewhere9. However, recent reviews fail to
recommended one NIV mode over the other28,29.
Certain risk factors have been associated with
NIV failure in the treatment of ARF30,31. In our se-
ries, we found no such factors (Table 5) and no
differences in the ventilatory technique failure, as
in other studies. Predicting prognosis and mortality of AHF patients in the ED is difficult; etiology,
functional status, age, comorbidity and various biological data must be considered together32,33. As
an example of this difficulty, this study did not allow us to predict poor outcome.
A notable finding was the low percentage of
patients admitted to the ICU and the high number of patients admitted to the short-stay unit;
this reflects the attention needed by the APE patients and the role of these units in the management of elderly patients with multiple comorbidity
and functional dependency often associated with
this acute disease34,35.
Limitations of this study include the observational study design and non-randomization which
preclude drawing conclusions on the best mode
of ventilation. Second, the choice of NIV mode or
even the use of conventional oxygenation systems
was made by the attending ED physician. Third,
the limited sample size does not allow us to deduce a decrease in mortality so our results cannot
be extrapolated to other populations. However,
we can conclude that the use of NIV rapidly im-
Table 4. Study of factors associated with mortality during the episode of acute heart failure treated with invasive ventilation
Factors studied
Total
N = 133
Survival
N = 109
Deaths
N = 24
P
Age > 65 años n (%)
112 (84.2)
92 (84.4)
20 (83.3)
NS
RF > 35 rpm n (%)
94 (70.7)
81 (74.3)
13 (54.2)
NS
SBP < 120 mmHg n (%)
26 (18.5)
19 (17.4)
7 (29.2)
NS
Urea > 45 mg/dl n (%)
91 (68.4)
73 (66.9)
18 (75.0)
NS
Na < 136 mEq/L n (%)
54 (40.6)
44 (40.3)
10 (41.6)
NS
Hb < 10 g/dl n (%)
18 (13.5)
14 (12.8)
4 (16.6)
NS
COPD. n (%)
45 (3.8)
37 (33.9)
8 (33.3)
NS
Cancer n (%)
12 (9.0)
8 (7.3)
4 (16.6)
NS
Barthel Index <80 points n (%)
92 (69.2)
75 (68.8)
17 (70.8)
NS
BiPAP as a form of VNI n (%)
53 (39.8)
39 (35.7)
14 (58.3)
NS
NS: not significant. RF: respiratory frequency. bpm: breaths per minute. SBP: systolic blood pressure. Na: Plasma Sodium. Hb: Plasma Hemoglobin.
COPD: chronic obstructive pulmonary disease.
190
Emergencias 2010; 22: 187-192
NONINVASIVE VENTILATION IN ACUTE HEART FAILURE: PATIENT CHARACTERISTICS AND CLINICAL COURSE IN CASES TREATED IN A HOSPITAL EMERGENCY DEPARTMENT
Table 5. Study of factors associated with failure of non-invasive ventilation (NIV)
Factors associated
Total
N = 133
Tolerate NIV
N = 120
Not tolerate NIV
N = 13
P
Age > 65 años [n (%)]
112 (84.2)
103 (85.9)
9 (69.2)
NS
RF > 35 rpm [n (%)]
94 (70.7)
92 (70.7)
2 (15.3)
< 0.001
SBP < 120 mmHg [n (%)]
26 (18.5)
24 (20.0)
2 (15.3)
NS
Urea > 45 mg/dl [n (%)]
91 (68.4)
80 (66.7)
11 (84.6)
NS
Na < 136 mEq/L [n (%)]
54 (40.6)
49 (40.8)
5 (38.4)
NS
Hb < 10 g/dl [n (%)]
18 (13.5)
15 (12.5)
3 (23)
NS
COPD [n (%)]
45 (3.8)
41 (34.1)
4 (30.7)
NS
Cancer [n (%)]
12 (9.0)
11 (9.1)
1 (7.7)
NS
Barthel Index < 80 points n (%)
92 (69.2)
82 (68.3)
6 (46.1)
NS
BiPAP as the form of VNI n (%)
53 (39.8)
45 (37.5)
8 (61.5)
NS
NS: not significant. RF: respiratory frequency. bpm: breaths per minute. SBP: systolic blood pressure. Na: Plasma Sodium. Hb: Plasma hemoglobin.
COPD: chronic obstructive pulmonary disease.
proved clinical and blood gas parameters in APE
patients, with few complications, short ventilation
times in the ED and low failure rate, and no differences between ventilatory modes in incidence
of complications, mortality or technical failure, so
the possibility of implementing NIV in all EDs
should be considered.
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Ventilación no invasiva en insuficiencia cardiaca aguda: perfil clínico y evolución de pacientes
atendidos en un servicio de urgencias hospitalario
Carratalá JM, Llorens P, Brouzet B, Carbajosa J, Albert AR, Martínez-Beloqui E, Pastor R, Jiménez I, Román F
Objetivos: El objetivo es evaluar el perfil clínico y la evolución de los pacientes con edema agudo de pulmón (EAP)
tratados con ventilación no invasiva (VNI) en un servicio de urgencias hospitalario (SUMH) y los factores asociados con
el fracaso de la técnica y la mortalidad.
Método: Estudio observacional y prospectivo que incluyó a todos los pacientes atendidos en el SUMH por con EAP que
precisaron VNI. Se analizaron los parámetros clínicos y gasométricos al ingreso y a los 60 minutos, el modo ventilatorio,
destino, complicaciones, necesidad de intubación orotraqueal, y tiempo de permanencia en urgencias. Se calcularon el
índice de comorbilidad de Charlson y el índice de Barthel (IB). Se evaluó la mortalidad en el SUH, durante el ingreso
hospitalario y a los 7 y 21 días tras el alta.
Resultados: Se estudió a 133 pacientes, 69 varones (51%), la edad media fue de 76,2 ± 10,9 años. En el 60% se utilizó la presión positiva constante en la vía aérea (CPAP) como modo ventilatorio. Los parámetros clínicos y gasométricos
mejoraron tras una hora de VNI. El tiempo de tratamiento de VNI fue 4,25 ± 2,54 horas. La sequedad de mucosas y el
eritema facial fueron las complicaciones más frecuentes (69 y 50% respectivamente). La técnica fracasó en el 9,8% y la
mortalidad en urgencias fue del 3%. Los factores de riego de mortalidad asociada a insuficiencia cardiaca fueron la
edad > 65 años, la presión arterial < 120 mmHg, la urea > 45 mg/dl, el sodio < 136 mEq/L y la frecuencia respiratoria
al ingreso > 35 rpm. La modalidad ventilatoria no influyó en la mejoría clínico-gasométrica, mortalidad ni en el fracaso
de la técnica. El 33,8% (45) de los pacientes ingresó en la unidad de corta estancia (UCE), 26,3% (35) en cardiología,
18,8% (25) en medicina interna y el 5,2% (7) de cuidados intensivos.
Conclusión: El uso precoz de la VNI en el EAP mejora de forma rápida los parámetros clínicos y gasométricos del paciente, con escasas complicaciones, y estancia en urgencia corta, sin influir el modo ventilatorio en la mortalidad y el fracaso
de la técnica. Debería valorarse su incorporación en todos los SUH. [Emergencias 2010;22:187-192]
Palabras clave: Edema agudo de pulmón. Ventilación no invasiva. Servicio de urgencias. Complicaciones. Mortalidad.
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