RESPIRATIONSCENTER VEST Århus Universitetshospital - Skejby

Transkript

1 RESPIRATIONSCENTER VEST Århus Universitetshospital - Skejby Ole Nørregaard Januar 2013

2 Respiratory Center West Respiratory Center East Respiratory Center South

3 SKEJBY SYGEHUS

4 Respirationscenter Vest har højt specialiseret funktion for diagnostik, behandling og opfølgning af patienter med kronisk respirationsinsufficiens i bredeste forstand, herunder søvnrelaterede sygdomme.

5 Disposition RCV's historiske udvikling (incl. vækst) Epidemiologi Patofysiologi Diagnostik Hvornår henvisning til RCV? Behandling Ventilation Non-invasiv Invasiv (organisering, hjælperoplæring)

6 Historie: 1952 Polioepidemien 1954 Etablering af center på Blegdamshospitalet 1978 Flyttes til Rigshospitalet 1990 Sundhedsstyrelsens vejledning vedr. visitation og sygehusbehandling af patienter med kronisk respirationsinsufficiens Respirationscentrene RCV-RCØ

7 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 RCV Skejby åbner med 8 sengepladser og udvidet ambulant funktion.

8 Afdelingen: 8 senge Enestuer med plads til hjælper/pårørende Søvnambulatorium Ambulatorium 24 timers hotline funktion

9 Personale på RCV: 4 Overlæger Respirations teamet 3 socilal rådgivere 32 Sygeplejersker RCV 3 Sekretærer 5 SoSuassistenter Servicemedarbejder

10 Samarbejdspartnere Kompleks logistik kræver et bredt samarbejde Lægfolk (patienter, pårørende, hjælpere) Leverandører af teknisk udstyr Medicotekniske afdelinger Sociale myndigheder Patientforeninger Kliniske afdelinger/praktiserende læger/speciallæger Respirationcenter Øst Udenlandske centre

11 Patientkategorier: Neuromuskulære sygdomme Thoraxdeformiteter Tetraplegi Adipositasbetinget hypoventilation KOL Cystisk fibrose Børn med syndromer og kroniske lungesygdomme (BPD) Søvnudløste respirationsforstyrrelser (SDB) Søvnforstyrrelser

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18 Duchenne s muscular dystrophy --- National data Start of the respiratory centers in Denmark

19 Patientudvikling (RCV)

20 Home mechanical ventilation in Denmark (5 mill inhibitants)

21 240 ventilated via trachesostomy 1035 ventilated via mmask 81 % ventilated via NIV Respiratory Centre West (55% of the population): 20 % of ventilated individuals are children

22 Age distribution (percent) 100% 80% 66 years + UK Sweden Spain Portugal Poland Norway Netherlands Italy Ireland Greece Germany France Finland Denmark Belgium Austria ALL 60% 40% 20% 0% yrs yrs 16 or less

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24 RESPIRATORY PHYSIOLOGY AND PATHOPHYSIOLOGY

25 Søvnudløste ventilationsændringer SØVN RESPIRATORISK KONTROL Kemoreceptor følsomhed Cortical input Respiratoriske motorneuroner RESPIRATORISK MUSKELFUNKTION Intercostal Diafragma Accesesoriske LUNGE-MEKANIK Luftvejsmodstand FRC V/Q match

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30 Raw - patophysiology Congenital malformations (laryngomalacia, epiglottic anomalies, tonsils, membraneous obstruction, vascular ring etc) tumor mediastini sekretions, foreign bodies age 1-3 years

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42 KARAKTERISTIKA Små dimensioner => luftvejsmodstand adenoide vegetationer & tonsiller compliant chest wall => paradoks respiration => energitab(wasted ventilation) horisontale costae immature muskler FRC => vulnerabel for hypoxæmi

43 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

44 KARAKTERISTIKA Neuromuskulær sygdom er oftest associeret med HYPERKAPNISK respirationsinsufficiens (i modsætning til hypoxæmisk)

45 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

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50 diagnostics Pulmonary function tests Pulse oxymetry cardio-respiratory monitoring (CRM)(flow, thoraco-abdominal movements, SaO 2, CO 2 ) polysomnography (PSG)(= CRM + sleep stages) SYMPTOMS

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53 Cardiorespiratorisk monitorering (CRM) Airflow tcco2 EKG Chest- and abdominal movements SaO2

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55 CRM

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58 Why PSG?? 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

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60 Polysomnografi(PSG) EEG EOG Airflow EMG tcco2 EKG Chest- and abdominal movements SaO2 Leg movements

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63 Polysomnografi

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65 HENVISNING TIL RESPIRATIONSCENTER HVORNÅR??

66 Physiological criteria Vital capacitet < 15 ml/kg PCEF < 2-3 l/sec (180 l/min) (Bach) PaCO 2 > 6.0 kpa (45 mmhg) PaO 2 < 9.3 kpa (70 mmhg) SaO 2 < 97 % (on room air) 1998;113:289S-344S Chest

67 Indications for NIPPV (neuromuscular, restrictive a.o.) Symptoms (fatigue, dyspnea etc.) PaCO 2 > 45 mmhg (6 kpa) Nocturnal desat. < 88% for 5 consecutive minutes Pi max < 60 cm H 2 O or FVC < 50% predicted Chest, 1999;116:521

68 Referral of children signs and/or symptoms of nocturnal hypoventilation (NH) during the night daytime symptoms of NH failure to thrive

69 Referral of children 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)

70 TREATMENT

71 Problems with NIPPV in children with neuromuscular disease Impaired ability to trigger in child => child-ventilator dyssynchrony => increased work of breathing discomfort, potentially => poor compliance (treatment) (and thus) lack of effect

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74 Choose the right interface and put it in the right position

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77 Choose the right ventilator Trigger pressure (sensitivity, inspiratory and expiratory) Time delay Flow rise time Durability, noise, simpliticity in setting etc

78 Is it complicated Yes No

79 Clinical mode VE, SaO2, respiratory rate, patient comfort Scientific/invasive mode Clinical + Pes, Pga

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84 Thorax Abdomen BiPAP Figure 3

85 Long term/chronic setting

86 Simonds, Thorax 1998;53:949

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88 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:?

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90 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 $ >

91 30 patients aged yrs IPAP/EPAP: 13.9 (8-19)/4.4 (3-8) cm H2O Ventilated for 25.3 (8-60) mos

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97 Questionnaire 24 + NIV, 11 no NIV Ventilation > 36 mos

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111 Adverse effects of long term non-invasive ventilation Fauroux, ICM 2005

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113 Retrograde position of maxillar teeth Figure 5

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118 Appetite improved in 7 of 12 Dyspnea disappeared in 8 of 11 Swallowing improved in 6 of 7

119 Cough assist/ in-exufflator

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125 INVASIV VENTILATION

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127 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

128 PERCUTANEOUS DILATION

129 Ventilator invasive treatment

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144 SUMMARY NIV & TIV works in children in the Acute setting Chronic setting Perform appropiate diagnosis Use appropiate equipment Use appropiate ventilator settings Adverse effects should be monitored In particular facial malformation Trained staff very important

145 Referral of children signs and/or symptoms of nocturnal hypoventilation (NH) during the night daytime symptoms of NH failure to thrive

146 Referral of children 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)

147 Mistanke om en evt henvisning til RCV er relevant? Ring / Skriv

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