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 RCV's historiske udvikling (incl. vækst) Epidemiologi Patofysiologi Diagnostik Hvornår henvisning til RCV? Behandling Ventilation Non-invasiv Invasiv (organisering, hjælperoplæring)
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. 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 3 socilal rådgivere 32 Sygeplejersker RCV 3 Sekretærer 5 SoSuassistenter Servicemedarbejder
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
Patientkategorier: 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)
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% 80% 66 years + UK Sweden Spain Portugal Poland Norway Netherlands Italy Ireland Greece Germany France Finland Denmark Belgium Austria ALL 60% 40% 20% 0% 26 65 yrs 17 25 yrs 16 or less
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, SaO 2, CO 2 ) polysomnography (PSG)(= CRM + sleep stages) SYMPTOMS
Cardiorespiratorisk monitorering (CRM) Airflow tcco2 EKG Chest- and abdominal movements SaO2
CRM
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
Polysomnografi(PSG) EEG EOG Airflow EMG tcco2 EKG Chest- and abdominal movements SaO2 Leg movements
Polysomnografi
HENVISNING TIL RESPIRATIONSCENTER HVORNÅR??
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
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
Referral of children signs and/or symptoms of nocturnal hypoventilation (NH) during the night daytime symptoms of NH failure to thrive
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)
TREATMENT
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
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
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 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 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