ブックタイトル第43回日本集中治療医学会学術集会プログラム・抄録集

概要

第43回日本集中治療医学会学術集会プログラム・抄録集

－280－JS1-3 For Respiratory support in AHFDepartment of Intensive Care Medicine, University of Barcelona, SpainJosep MasipAlthough the vast majority of patients with acute heart failure（AHF）have shortness of breath, less than half show significanthypoxemia. Mild hypoxemia may be treated with conventional oxygen therapy（COT）, but for patients with acute cardiogenicpulmonary edema（ACPE）and some with cardiogenic shock, noninvasive ventilation（NIV）must be considered. There areessentially three forms of NIV in AHF:CPAP is the oldest and simplest technique and may be administered without a ventilator, which is an advantage in low-equippedareas like pre-hospital or emergency rooms. There is strong evidence of its benefit in terms of reducing respiratory distress,endotracheal intubation（EI）rate and even mortality in high risk patients, as shown in some meta-analyses.HFNC is a novel technique consisting of the application of heated and humidified high flow gas through an adjusted nasalcannula. The device provides a low level of CPAP reducing upper airflow resistance and producing a tracheal gas insufflationeffect. It has been mainly used in mild or sub-acute cases of AHF.NIPSV is the basis of NIV. It is always used with PEEP（bilevel）. NIPSV provides an inspiratory help that seems moreappropriate in patients with concomitant COPD or significant hypercapnia. Expertise and appropriate equipment are necessaryto get synchrony between patient’s efforts and the ventilator. There is significant evidence of the advantages of NIPSV inpatients with ACPE, with faster improvement in respiratory distress and a reduction in the EI. Its impact on mortality or itssuperiority versus CPAP is still inconclusive.The success rate using NIV in APE is high. Patients with altered mental status, ARDS, high severity index, copious secretions,extremely high respiratory rate, severe hypoxemia and shock are more likely to fail. Lack of improvement after 60-120 min maybe an indication for EI. The EI rate has dramatically decreased in the last decades. After EI patients generally show hypotensionthat requires vasoactive agents. Because mechanical ventilation（MV）may reduce preload and afterload, AHF decompensationmay be seen after its withdrawal during weaning. Ultrasound-guided therapy, negative cumulative fluid balance and biomarkersmay be useful in this context.A particularly difficult scenario may be seen in patients with acute right ventricular（RV）failure because MV increases RVafterload. In addition to RV infarction or severe pulmonary embolism, RV failure may occur in nearly 25% of ARDS patients.Protective MV with low plateau and driving pressures, limitation of CO2, PEEP settings according to RV function and theprompt use of prone position are some of the goals for the prevention.Patients with refractory hypoxemia and those who also have inotropic resistant cardiogenic shock may require extra-cardiacmembrane oxygenation（ECMO）.