The non-invasive mechanical ventilation: the experience of the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena
ARF may be due to alterations in gaseous diffusion in alveolar-capillary level (type “1” acute respiratory failure), or to alterations in the functioning of the respiratory pump (type “2” acute respiratory failure) or to an association of the above causes.
ARF specific etiological treatment must be associated to oxygen administration, through ventilation, which may be spontaneous or mechanical (non-invasive or invasive).
The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014, examining clinical parameters and outcomes.
- Partial pressure of arterial oxygen (PaO2) <60 mmHg;
- Partial pressure of carbon dioxide in the arterial blood (PCO2)> 45 mmHg;
- Association of both previous.
- ARF type “1”, with gas exchange impairment and hypoxemia (associated with hypo/normocapnia). The pathophysiological mechanism behind is an important intrapulmonary shunt with changes in ventilation/perfusion ratio.
Generally diseases responsible for this condition are acute pulmonary edema, ARDS, severe pneumonia and pulmonary embolism.
- ARF type “2”, with hypoventilation and hypercapnia.
- Etiological therapy: it is directed to the treatment of the specific cause that induced ARF, it can be delivered with inotropic agents, antibiotics, bronchodilators, steroids etc.
- Supportive therapy (or symptomatic): aimed at correcting hypoxemia and respiratory acidosis, is indicated in all respiratory insufficiencies and it is based on the administration of O2 and postural therapy.
Premises to the study
Aim of the study
Materials and methods
From January 1st, 2010 to December 31, 2014, 1.764 patients were hospitalized in IMCA Intensive Care Unit (I.I.C.U) of the Polyclinic Hospital of Modena. The gender distribution was 60% male and 40% female, with an average age of 75.5 per years. The average length of stay was 7 days. The Tab. 1 shows the data relating to the activity of IMCA Intensive Care Unit (I.I.U.C) of the Polyclinic Hospital of Modena in the period 01/01/2010 – 31/12/2014.
Table 1. Features of the IMCA Intensive care Unit (I.I.C.U) of the Polyclinic Hospital of Modena (data of hospitalized patients, patients treated with NIV and discharged patients in the period 2010-2014 in absolute numbers and percentage of total)
Table 2 shows the general features of the patients undergoing NIV with the arrival mode in the emergency department and the cause that determined the start of ventilation. The larger proportion of patients consists of females (54% versus 46% of males), the average age is around 80 years and patients with multiple diseases, defined as having four or more chronic diseases, representing approximately 25% of the total. The number of patients undergoing NIV who came to the hospital by ambulance remains clearly dominant, with a percentage of 81% over the 5 years of observation.
For what concerns the diagnosis that conducts to NIV, during the years of observation it has been noticed a prevalence, not statistically significant, of the heart cause compared to others. The trend over the years shows a progressive increase in the proportion of patients with respiratory causes in 2012, while for the other two causes such behaviour has not been underlined.
Tab. 3 shows the data related to the treatment of patients undergoing NIV, analyzed by year of hospitalization. The oxygen-therapy is used already in ambulance in the majority of cases (on average in 66% of patients), toward 80% of patients that are dispensed with antibiotic, the 93% is subjected to diuretic therapy, 72% to steroids (predominantly inhalers), and 39% of the patients is subjected to filling fluid challenge of at least 1000 cc/day. Among the non-specific drugs for the treatment of the ARF, more than 80% of patients were undergoing treatment with proton pump inhibitors.
The trend in the adoption of these drugs during the various years of hospitalization, with few not significant variations, was stable without showing significant trends.
Tab. 3 shows also the data related to the beginning of NIV, from 1 to 3 days from the start of hospitalization in each year of study, and the duration of NIV, around 4-5 days. It also gives details about the period of time spent from the end
of NIV and the patient discharge from hospital: with the exception of the first year of the protocol application, where this figure stood at around 13 days, in other years were recorded values of about 10 days.
The average hospitalization length is 16 days, a decrease in the years 2011 to 2014 compared to 2010 (around 15 and 18 days respectively).
As evidenced by Chart 2, during various years of study, there is a progressive decrease in both pulmonary advices (from 40% in 2010 to 17% in 2014), and resuscitation advices (from 50% in 2010 to 17% of 2014). In both cases it has been observed a linear trend that reaches statistical significance for resuscitation advices. Instead this trend is not clear for cardiology advices that decrease approximately from 50% in 2010 to 40% in 2014, showing although no significant fluctuations over the years.
Concerning the data on patients transferred to other departments of the Polyclinic Hospital of Modena, both long-term care and ordinary stay department and intensive ones (Respiratory Intensive Care Unit-RICU and Post-Operative Intensive Care-POIC), it results that on average, 77% of patients haven’t been transferred in any other department. Only the 15% of them were transferred in Intensive Care Unit (Respiratory Intensive Care Unit or Post-Operative Intensive Care) and the 8% were not transferred to another non-intensive department/long-term care. Analyzing each year, as shown in Chart. 3, it appears that the non-transferred patients remained essentially the same, while the proportion of transferred patients to intensive departments decreases from 2012 to 2014, from 22% to 7%, mainly because of the reduction in transfers to Post-Operative Intensive Care (POIC). This trend is associated with a corresponding increase of the number of transferred patients in other non-intensive department.
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