RESPIRATIONSCENTER VEST Århus Universitetshospital

RESPIRATIONSCENTER VEST
Århus Universitetshospital - Skejby
Ole Nørregaard
Januar 2013
Respiratory Center West
Respiratory Center East
Respiratory Center South
SKEJBY SYGEHUS
Respirationscenter Vest
har højt specialiseret funktion for
• diagnostik,
• behandling og
• opfølgning
af patienter med kronisk respirationsinsufficiens
i bredeste forstand, herunder søvnrelaterede
sygdomme.
Disposition
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RCV's historiske udvikling (incl. vækst)
Epidemiologi
Patofysiologi
Diagnostik
Hvornår henvisning til RCV ?
Behandling
– Ventilation
• Non-invasiv
• Invasiv (organisering, hjælperoplæring)
Historie:
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1952 Polioepidemien
1954 Etablering af center på Blegdamshospitalet
1978 Flyttes til Rigshospitalet
1990 Sundhedsstyrelsens vejledning vedr. visitation og
sygehusbehandling af patienter med kronisk
respirationsinsufficiens.
• 1991 Respirationscentrene – RCV-RCØ
Historie:
• 1991 RCV oprettes som en del af int.afd.N, ÅKH
med 1-4 sengepladser
• 1998 RCV etableres som selvstændigt afsnit med 4-7
sengepladser og ambulatorium
• 2010 Sundhedsstyrelsens specialeudmelding for det
anæstesiologiske speciale definerer området som en højt
specialiseret funktion.
• 1.6.11 RCV Skejby åbner med 8 sengepladser og udvidet
ambulant funktion.
Afdelingen:
• 8 senge
– Enestuer med plads til hjælper/pårørende
• Søvnambulatorium
• Ambulatorium
• 24 timers
hotline funktion
Personale på RCV:
4 Overlæger
Respirations
teamet –
32 Sygeplejersker
3 socilal
rådgivere
RCV
5 SoSuassistenter
3 Sekretærer
Servicemedarbejder
Samarbejdspartnere
Kompleks logistik kræver et bredt samarbejde
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Lægfolk (patienter, pårørende, hjælpere)
Leverandører af teknisk udstyr
Medicotekniske afdelinger
Sociale myndigheder
Patientforeninger
Kliniske afdelinger/praktiserende
læger/speciallæger
• Respirationcenter Øst
• Udenlandske centre
Patientkategorier:
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Neuromuskulære sygdomme
Thoraxdeformiteter
Tetraplegi
Adipositasbetinget hypoventilation
• KOL
• Cystisk fibrose
• Børn med syndromer og kroniske lungesygdomme (BPD)
• Søvnudløste respirationsforstyrrelser (SDB)
• Søvnforstyrrelser
Duchenne’s muscular dystrophy --- National data
Start of the respiratory centers in Denmark
Patientudvikling (RCV)
2500
2000
1500
1000
500
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Home mechanical ventilation in
Denmark (5 mill inhibitants)
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240 ventilated via trachesostomy
1035 ventilated via mmask
81 % ventilated via NIV
Respiratory Centre West (55% of the
population): 20 % of ventilated individuals are
children
Age distribution (percent)
100%
66 years +
80%
26 – 65 yrs
60%
40%
17 – 25 yrs
20%
16 or less
0%
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RESPIRATORY PHYSIOLOGY AND
PATHOPHYSIOLOGY
Søvnudløste ventilationsændringer
SØVN
RESPIRATORISK
KONTROL
• Kemoreceptor følsomhed
• Cortical input
• Respiratoriske
motorneuroner
RESPIRATORISK
MUSKELFUNKTION
•Intercostal
•Diafragma
•Accesesoriske
LUNGE-MEKANIK
• Luftvejsmodstand
• FRC
• V/Q match
Raw - patophysiology
• Congenital malformations (laryngomalacia,
epiglottic anomalies, tonsils, membraneous
obstruction, vascular ring etc)
• tumor mediastini
• sekretions, foreign bodies
• age 1-3 years
KARAKTERISTIKA
• Små dimensioner =>  luftvejsmodstand
• adenoide vegetationer & tonsiller
• compliant chest wall => paradoks respiration
=> energitab(wasted ventilation)
• horisontale costae
• immature muskler
•  FRC => vulnerabel for hypoxæmi
KARAKTERISTIKA
• Alveolær ventilation:FRC hos små børn =
5.0:1.0, hos voksne 1.5:1.0
• Apnøer kraftigt REM-associerede
• hypoxæmisk respiratorisk respons svækkede
hos små børn
• med alderen ofte aftagende compliance af
thorax => øgning af det respiratoriske arbejde
KARAKTERISTIKA
• Neuromuskulær sygdom er oftest associeret
med HYPERKAPNISK respirationsinsufficiens (i
modsætning til hypoxæmisk)
Pediatric characteristics
• FRC very small (unmodified 15 % of TLC, 40 %
modified)
• Modified with
– Expiratory breake
– High respiratory frequency
– Maintanence of muscular tone
• Periodic closure of the airways during tidal
breathing
diagnostics
• Pulmonary function tests
• Pulse oxymetry
• cardio-respiratory monitoring (CRM)(flow,
thoraco-abdominal movements, SaO2, CO2)
• polysomnography (PSG)(= CRM + sleep stages)
• SYMPTOMS
Cardiorespiratorisk monitorering (CRM)
Airflow
tcCO2
EKG
Chest- and abdominal movements
SaO2
CRM
Why PSG ??
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Document prescence of vulnerable (REM) sleep
PSG determines diagnosis
PSG can possibly identify differential diagnosis
PSG can contribute to prognosis
Evaluate severity
Contributes to the evaluation of perioperative
risc
• Determines base line for follow-up comparison
Polysomnografi(PSG)
EOG
tcCO2
EEG
Airflow
EMG
EKG
Chest- and abdominal movements
SaO2
Leg movements
Polysomnografi
HENVISNING TIL
RESPIRATIONSCENTER
HVORNÅR ??
Physiological criteria
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Vital capacitet < 15 ml/kg
PCEF < 2-3 l/sec (180 l/min) (Bach)
PaCO2 > 6.0 kPa (45 mmHg)
PaO2 < 9.3 kPa (70 mmHg)
SaO2 < 97 % (on room air)
1998;113:289S-344S
Chest
Indications for NIPPV
(neuromuscular, restrictive a.o.)
• Symptoms (fatigue, dyspnea etc.)
• PaCO2 > 45 mmHg (6 kPa)
• Nocturnal desat. < 88% for 5 consecutive
minutes
• Pimax < 60 cm H2O or FVC < 50% predicted
Chest, 1999;116:521
Referral of children
• signs and/or symptoms of nocturnal
hypoventilation (NH) during the night
• daytime symptoms of NH
• failure to thrive
Referral of children
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IVC < 60 % (=> SBD, < 40% => noct hypovent)
MIP < 4.0 kPa (=> SDB, < 2.5 => noct hypovent)
CPF < 270 l/min
Daytime PaCO2 > 45 mmHg (=> noct
hypovent)
TREATMENT
Problems with NIPPV in children with
neuromuscular disease
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Impaired ability to trigger in child =>
child-ventilator dyssynchrony =>
increased work of breathing
discomfort, potentially =>
poor compliance (treatment) (and thus)
lack of effect
Choose the right interface and put it in
the right position
Choose the right ventilator
• Trigger pressure (sensitivity, inspiratory and
expiratory)
• Time delay
• Flow rise time
• Durability, noise, simpliticity in setting etc
Is it complicated
• Yes
• No
• Clinical mode
– VE , SaO2 , respiratory rate, patient comfort
• Scientific/invasive mode
– Clinical + Pes, Pga
Thorax
Abdomen
BiPAP
Figure 3
Long term/chronic setting
Simonds, Thorax 1998;53:949
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Method: record review
N = 14 (DMD, cong myopathy, myoton dyst)
Age 7.7 yrs (1.5 – 16)
Treatment: BiPAP (reg tm)
– Settings: ?
– Duration: 30 mos (6 – 84)
– h/day: ?
Results
• Hospitalization:
– 41.7 days/y before treatment -> 10.5 days/y
– Number of hosp stays: 3.8/y - > 0.7/y
– PICU days: 10.2/y -> 2.3/y
• Annual direct cost og health care/patient
– $ 55.129 -> 14.914
• 30 patients aged 12.4 + 4.1 yrs
• IPAP/EPAP: 13.9 (8-19)/4.4 (3-8) cm H2O
• Ventilated for 25.3 (8-60) mos
• Questionnaire
• 24 + NIV, 11 no NIV
• Ventilation > 36 mos
Adverse effects of long term non-invasive ventilation
Fauroux, ICM 2005
Retrograde position of maxillar teeth
Figure 5
• Appetite improved in 7 of 12
• Dyspnea disappeared in 8 of 11
• Swallowing improved in 6 of 7
Cough assist/ in-exufflator
INVASIV VENTILATION
WHEN ?
WHEN ?
• NIPPV is insufficient to oxygenate and/or
ventilate the ventilator assisted individual
(VAI) satisfactorily
• VAI is unable to be weaned
• VAI with no spontaneous respiration
• VAI with (advanced) bulbar insufficiency or
other upper airway impairment
PERCUTANEOUS DILATION
Ventilator – invasive treatment
SUMMARY
• NIV & TIV works in children in the
– Acute setting
– Chronic setting
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Perform appropiate diagnosis
Use appropiate equipment
Use appropiate ventilator settings
Adverse effects should be monitored
– In particular facial malformation
• Trained staff very important
Referral of children
• signs and/or symptoms of nocturnal
hypoventilation (NH) during the night
• daytime symptoms of NH
• failure to thrive
Referral of children
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IVC < 60 % (=> SBD, < 40% => noct hypovent)
MIP < 4.0 kPa (=> SDB, < 2.5 => noct hypovent)
CPF < 270 l/min
Daytime PaCO2 > 45 mmHg (=> noct
hypovent)
Mistanke om en evt henvisning til RCV
er relevant ?
• Ring
– 78451350/78451340
• Skriv
– olenorre@rm.dk