NIV updated


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Mohd Al-Shamsi

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  • excellent presentation. jazakom allah khairan w ga3alaha fe mezan hasanatekom.really 3elmon yontafa3 beh.thank you very much
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  • The "pneumatic chamber" made by Wilhelm Schwake of Germany was a tank ventilator designed to be operated by the patient. while
  • The 1876 Woillez "spirophore" tank ventilator. (Courtesy of the J.H. Emerson Company.)
  • The rocking bed ventilator (J.H. Emerson Company, Cambridge, MA) used by a patient with poliomyelitis and no autonomous breathing tolerance since 1952.
  • As the first step in an attempt to clarify criteria for use of the rocking bed rather than the respirator as an aid to breathing for patients with weakness of respiratory muscle function caused by poliomyelitis, ventilation studies were done on seven patients with pronounced weakness or paralysis of the respiratory muscles. Average tidal air volume was considerably less when the patient was on the rocking bed than when he was in the respirator.
  • Iron lung polio ward at Rancho Los Amigos Hospital in 1953. Negative-pressure ventilators (“iron lungs”) Non-invasive ventilation first used in Boston Children’s Hospital in 1928 Used extensively during polio outbreaks in 1940s – 1950s
  • In Boston, the nearby Emerson Company made available a prototype positive-pressure lung inflation device, which was put to use at the Massachusetts General Hospital, and became an instant success. Thus began the era of positive-pressure mechanical ventilation (and the era of intensive care medicine Positive-pressure ventilators Invasive ventilation first used at Massachusetts General Hospital in 1955 Negative pressure ventilators (Tank and Cuirass ventilators) were the only non-invasive methods of assisting ventilation for many years mainly for ventilating large number of victims of Polio during their acute illness. In 1980s it was recognized that delivery of continuous positive airway pressure by close fitting nasal masks for treatment of obstructive sleep apnea could also be used to deliver an intermittent positive pressure. This was followed by improvements in the interface and establishment of role of NIMV in patients of COPD. The use of NIMV has increased in last decade in various conditions to avoid complications of intubation.
  • Figure 25.5 Thoracic CT images from a patient with ARDS showing resolution of atelectasis (recruitment) in response to PEEP. Images from Barbas CSV. Lung recruitment maneuvers in acute respiratory distress syndrome and facilitating resolution. Crit Care Med 2003;31(suppl):S265–S271. What is the goal of PEEP? Improve oxygenation Diminish the work of breathing Different potential effects What are the secondary effects of PEEP? Barotrauma Diminish cardiac output Regional hypoperfusion NaCl retention Augmentation of I.C.P.? Paradoxal hypoxemia PEEP increases the end expiratory lung volume (FRC) PEEP recruits collapsed alveoli and prevents recollapse Excessive PEEP has adverse effects - decreased cardiac output - barotrauma (pneumothorax, pneumomediastinum)
  • I will start with oldest mode of niv which was used initeally to treat OSA in 1980. If peep isaplied to spontanously breathing pt is called cpap rosen How does CPAP work Decreases work of breathing Decreases FRC (in COPD) Increases FRC (in CHF) Decreases venous return Increased oxygenation (allows a drop in catecholamines) Decreases LV afterload (higher intrapulmonary pressure mean less stress on heart Recruit atelectatic alveoli
  • Ipap increase tv andhence the alveolar ventilatio. So it has great impacton the decreaseing pco2 level and some impreovemnt on oxygenation. Epap is like peep, it imrove oxygenation by previnting alvolar collapse in exhelation and allow gas exchange even in exhelation, so it has great impact on oxgenation. Question, whatwil hepen of we increase epap without changing he ipap?
  • As we discussed on the previous slide, EPAP is adjusted to increase oxygenation. If EPAP is increased without a corresponding increase in IPAP, the Delta pressure decreases, conversely if EPAP is lowered without lowing IPAP pressure Delta pressure increases. The IPAP pressure is what is set, and it is not PEEP compensated, in other words, IPAP pressure does not increase with increases in EPAP pressure. As you can see on the the blue waveform, EPAP pressure is 5 cm and IPAP pressure is 15 cm, resulting in a Delta pressure of 10 cm. On the yellow waveform, we can see that the EPAP pressure was increased to 10 cm to facilitate an increase in oxygenation. The Delta pressure therefore decreases to 5 cm, this may result in increased CO 2 as tidal volume will likely decrease. On the red waveform we can see that the IPAP pressure was increased by 5 cm, the same amount the EPAP pressure was increased, thus restoring the Delta pressure of 10 cm. Keep in mind that any increase or decrease in the EPAP pressure may need to be accompanied by an equal increase or decrease in IPAP pressure to maintain the same Delta pressure if desired. Also rom this iure we can say that if you increase thepeep by 2 to improve the oxygenation, we should increase he ps by at least same incremets otherwise we will decrease the Vt and impairing ventilation .
  • PAV is a new mode of ventilation that is fundamentally different from the volume and pressure ventilation we practice today. In PAV the ventilator generates a pressure change, then creates airflow that move volume into the lungs. So far nothing special. But unlike conventional ventilation, the pressure is not preset by the physician but is generated in proportion to patient’s effort. With PAV, the machine is able to respond and to adapt to changes in patient breathing pattern and effort.
  • BiPAP® Vision .1 -Assemble the circuit with exhalation port proximal to the patient. A bacterial filter and oxygen analyzer should be placed between the machine’s patient interface port and the patient circuit. If using the O2 module, connect to a 50psi O2 source. 2 -Plug electrical cord in A/C outlet. Press START on the back of the machine. The Vision will perform a self-test as indicated by the display screen, “System Self-Test in Progress. 3 -Perform the “Test Exh Port”, second button from top, left of screen. 3.1 Occlude circuit with thumb throughout the test. 3.2 Press START TEST, top button, right of screen. This tests the leak of the circuit. 4 -Assess appropriateness of physician’s orders and set ventilatory parameters accordingly. Initial settings as well as changes to ventilatory parameters must be accompanied by a physician order. 5 -Select the proper mode by first selecting the mode button at the bottom of screen. 5.1 Choose CPAP or S/T mode, top button, right side of screen, per physician’s order. 5.2 Activate view mode by pressing the “Activate View Mode” button, bottom right of screen. 6- Select the “parameters” button below the screen. 6.1 Choose a parameter from the left and right sides of screen. Press the soft button for the parameter of choice. Once it is highlighted, spin knob clockwise to increase value, and counter clockwise to decrease value in the parameter block. Repress the button for that particular parameter to activate the new value. NOTE: Consult the BiPAP® Vision Ventilatory Support System Clinical Manual for specific information on the modes of operation and set parameters. 7 -Connect the patient’s properly fitted mask or airway adapter to the BiPAP Vision Circuit, and then apply the mask to the patient. 8- Select “alarms” button, below the screen. Set values for Hi Pressure, Lo Pressure, Lo Pressure Delay, Apnea, Lo MinVent, Hi Rate, and Lo Rate as appropriate for the patient.
  • Analyzes leak rate of exhalation port If successful – the value of “Pt. Leak” will be displayed If unsuccessful – “Tot. Leak” will be displayed
  • Orofacial masks (cautions, disadvantages) Claustrophobic Hinder speaking and coughing Risk of aspiration with emesis Nasal masks (general advantages) Best suited for more cooperative patients Better in patients with a lower severity of illness Not claustrophobic   Allows speaking, drinking, coughing, and secretion clearance Less aspiration risk with emesis Generally better tolerated Nasal masks (cautions, disadvantages) More leaks possible (eg, mouth-breathing or edentulous patients) Effectiveness limited in patients with nasal deformities or blocked nasal passages
  • -there are so many different protocol, no standard protocol. These different protocol are never been compared .
  • Why not to start with alow pressure?
  • It is imprtant to set with he pt for he first hour or so after initiatiobn of the therapy to provide support and monitor the pt.
  • Standard of care level A evidence
  • Fig. 34.1 Risk ratio of acute myocardial infarction in the studies comparing nIPSV (noninvasive pressure support ventilation) versus nCPAP (noninvasive continuous positive airway pressure). (Note: In their study, Rusterholtz and coworkers used proportional assisted ventilation [PAV] and not pressure support ventilation)
  • One metaanalysis compared efficasy and savity of bibap vesus cpap in treatment of acpe showed. Puplshed in j of ritical care in 2006 هى
  • No intubation or mortality benefit. 14 Patients with CPAP and noninvasive ventilation (BiPAP) did have more rapid resolution of symptoms and correction of gas exchange abnormalities and pH compared with the oxygen group. No difference was noted between CPAP and noninvasive ventilation (BiPAP).
  • study found no differences between PAV and CPAP in patients with acute respiratory failure subsequent to CPE. There was no evidence of increased risk for myocardial infarction in patients with PAV. Since the implementation of NIV in the prehospital setting and emergency departments is now widely developed, CPAP, an easy to use, relatively cheap method of NIV, remains Changes in physiological parameters were similar in the two groups.the gold standard in these patients.
  • Most asthmatic patients do not present with acute respiratory failure
  • Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999
  • NIV updated

    1. 1. Non-invasive ventilation Updated. Dr Mohammed AL-Shamsi. R5
    2. 2. Outlines <ul><li>Definition of NIV. </li></ul><ul><li>Brief Historical review. </li></ul><ul><li>Mechanism of action </li></ul><ul><li>Indications & contraindications. </li></ul><ul><li>CPAP versus BiPAP. </li></ul><ul><li>NIV and the evidence. </li></ul><ul><li>Conclusion. </li></ul>
    3. 3. NIV: Definition <ul><li>Non-invasive ventilation (NIV) is provision of ventilatory assistance without the need for airway invasion, has seen increasing use in critical care units to avoid endotracheal intubation and its attendant complications </li></ul>
    4. 4. Historical review
    5. 8. Calif Med. 1951 July <ul><li>USE OF THE ROCKING BED TO AUGMENT VENTILATION IN PATIENTS WITH POLIOMYELITIS </li></ul><ul><li>The rocking bed will give artificial respiration in cases of respiratory weakness, but will not provide enough tidal air for the patient with paralysis of the muscles of respiration. </li></ul>
    6. 13. Pressure ventilation vs. volume ventilation Pressure-cycled modes deliver a fixed pressure at variable volume (neonates) Volume-cycled modes deliver a fixed volume at variable pressure (adults) <ul><li>Pressure-cycled modes ( P fixed, Vt variable ) </li></ul><ul><ul><li>Pressure Support Ventilation (PSV) </li></ul></ul><ul><ul><li>Pressure Control Ventilation (PCV) </li></ul></ul><ul><ul><li>CPAP </li></ul></ul><ul><ul><li>BiPAP </li></ul></ul><ul><li>Volume-cycled modes ( Vt fixed, P variable ) </li></ul><ul><ul><li>Control </li></ul></ul><ul><ul><li>Assist </li></ul></ul><ul><ul><li>Assist/Control </li></ul></ul><ul><ul><li>Intermittent Mandatory Ventilation (IMV) </li></ul></ul><ul><ul><li>Synchronous Intermittent Mandatory Ventilation (SIMV) </li></ul></ul>
    7. 14. Peak- end expiratory pressure (PEEP)
    8. 15. Contraindications <ul><li>Respiratory arrest </li></ul><ul><li>Airway obstruction </li></ul><ul><li>Facial trauma or burn. </li></ul><ul><li>Severe acidosis pH <7.2. </li></ul><ul><li>Hypotension , SBP< 90 mmHg. </li></ul><ul><li>Uncontrolled arrhythmias, AMI </li></ul><ul><li>Inability to cooperate( severe agitation, impaired mental status) </li></ul><ul><li>Excessive airway secretion and vomiting </li></ul><ul><li>Recent upper airway of GI surgery </li></ul><ul><li>pneumothorax </li></ul>
    9. 16. Patients selection
    10. 17. Modes of NIPPV <ul><li>3 modes </li></ul><ul><ul><li>1- continuous positive airway pressure ventilation ( CPAP) </li></ul></ul><ul><ul><li>2- Bilevel positive airway pressure ventilation ( S/T) </li></ul></ul><ul><ul><li>3- Proportional Assist Ventilation ( PAV): (optional mode) </li></ul></ul>
    11. 18. CPAP <ul><li>Improve oxygenation by increasing FRC and recruiting collapsed alveoli </li></ul><ul><li>It provides certain positive airway pressure throughout all phases of spontaneous ventilation </li></ul><ul><li>It is similar to breathing with your head stuck out of a moving car </li></ul><ul><li>CPAP  PEEP </li></ul>
    12. 19. <ul><li>CPAP reduces preload and afterload. Hence it is a very effective for treatment of pulmonary oedema. </li></ul><ul><li>Pressures are usually limited to 5-12 cm of H2O, since higher pressure tends to result in gastric distension requiring continual aspiration through a nasogastric tube. </li></ul>
    13. 20. Pressure Waveform CPAP 0
    14. 21. BiPAP <ul><li>IPAP + EPAP( CPAP) </li></ul><ul><li>The higher pressure augments alveolar ventilation and CO2 clearance </li></ul><ul><li>The lower pressure maintains alveolar recruitment </li></ul>
    15. 22. <ul><li>- IPAP: assists in improving tidal volume, thus decreasing CO 2 </li></ul><ul><li>- EPAP : improve FRC, helps recruit more alveoli, thus increasing O 2 . may reduce work of breathing associated with autopeep </li></ul>BiPAP 20 10 0 IPAP = 12 EPAP = 4 PS = 8
    16. 23. NIV - Changes in EPAP Pressure 5 cm Delta P 10 cm 10 cm 15 cm IPAP increased to 20 cm Delta P returned to 10 cm P R E S S U R E Decreasing delta pressure will usually result in lower Vt Delta pressure 5 cm EPAP increased to 10 cm
    17. 24. <ul><li>Differential in pressure between inspiration and expiration allows for better patient-ventilator synchrony and thus more comfort </li></ul><ul><li>EPAP  CPAP  PEEP </li></ul><ul><li>IPAP  PS </li></ul><ul><ul><li>Augments TV </li></ul></ul><ul><ul><li>Reduces Atelectasis </li></ul></ul><ul><ul><li>Reduces WOB </li></ul></ul>
    18. 25. PAV <ul><li>New Assist Mode of Ventilation </li></ul><ul><ul><li>Fundamentally different concept </li></ul></ul><ul><li>Ventilator Generates Pressure in Proportion to Patient Effort </li></ul><ul><ul><li>Follows and adjusts to patient changes </li></ul></ul>
    19. 26. From Pressure Support to PAV Patient Effort Pressure PSV PAV
    20. 27. Non-invasive PAV for Acute Respiratory Insufficiency <ul><li>Peter Gay and coll, Am J Respir Crit Care </li></ul><ul><li>General ICU </li></ul><ul><li>COPD patients with acute exacerbation </li></ul><ul><li>44 patients were randomized to receive NPPV with PAV or Pressure Support ( PS ) </li></ul><ul><li>Mortality and intubation rate were similar but refusal rate was lower with PAV </li></ul><ul><li>Reduction in respiratory rate was more rapid with PAV and there were fewer complications in the PAV group </li></ul>
    21. 28. <ul><li>Plug into AC mains & Connect to 50 psi gas source </li></ul><ul><li>Connect </li></ul><ul><li>BiPAP circuit </li></ul><ul><li>- don’t cap </li></ul><ul><li>Power switch </li></ul><ul><li>RU corner </li></ul><ul><li>on back </li></ul><ul><li>panel – </li></ul><ul><li>ON </li></ul>Initial ventilator settings and adjustments Dispos-able inlet filter Fuses O 2 module
    22. 29.
    23. 30. Power-on-self-test (POST) initiates
    24. 31. After POST, Start “Test Exhalation Port”
    25. 32. Follow steps on screen, block circuit, “Start Test”. Exhalation (castle) port
    26. 33. Exhalation port test in progress
    27. 34. Test Complete, press Monitoring to exit. Monitoring
    28. 35. Monitoring Parameters Mode Alarms Alarm Silence Alarm Reset 21% options SB IPAP 8 EPAP 3 Rate 12 Pt Data Display Area Scale Fz/ UnFz Mode/Messages ALARMS
    29. 36. To change Mode, press Mode, then parameter soft key to adjust, and then “Activate New Mode” soft key 1 2 3
    30. 37. To change settings, press Parameters – then soft key next to parameter and adjust with knob. Soft keys Knob
    31. 40. Ranges <ul><li>CPAP range 4- 20 cmH2O </li></ul><ul><li>O2 % range: Change 4% from 21 - 25%, 5% from 25- 100% </li></ul><ul><li>IPAP 4-40 cmH2O </li></ul><ul><li>EPAP 4 -20 cmH2O </li></ul><ul><li>Rate 4-40 can’t exceed 1:1 ratio </li></ul><ul><li>Inspiratory Time 0.5- 3 seconds </li></ul><ul><li>Rise Time 0.05- 0.4 seconds (0.05, 0.1, 0.2, & 0.4 sec) </li></ul>
    32. 41. Initial IPAP/EPAP settings Start at 10 cm water/5 cm water Pressures less than 8 cm water/4 cm water not advised as this may be inadequate Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP) Subsequent adjustments based on arterial blood gas values Increase IPAP by 2 cm water if persistent hypercapnia Increase IPAP and EPAP by 2 cm water if persistent hypoxemia Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient comfort) Maximal EPAP limited to 10-15 cm water FIO 2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value Back up respiratory rate 12-16 breaths/minute
    33. 44. Hospital NPPV Protocol <ul><li>1- Identify candidates for NPPV </li></ul><ul><li>2- Choose appropriate mask , keep bed up at 45 degree, explain to the patient what you are doing and what to expect </li></ul><ul><li>3- Turn on he NPPV and choose the appropriate mode </li></ul><ul><li>according to diagnosis </li></ul><ul><li>4- Adjust the NPPV: </li></ul><ul><li>Initial setting: S/T mode: </li></ul><ul><li>IPAP =10 (pressures above 20 cm H2O are usually not well tolerated) </li></ul><ul><li>EPAP=4 ( the more hypoxic the patient, the higher the initial EPAP setting may need to be) </li></ul>
    34. 45. <ul><li>Backup rate : 10-12 bpm </li></ul><ul><li>FiO2 : start low and adjust based upon SaO2( minimum FiO2 to keep SpO2> 90%). </li></ul><ul><li>Timed Inspiration : for a timed breath only (mechanical breath) </li></ul><ul><li>CPAP: For patients with cardiogenic pulmonary oedema without hypercapnia, CPAP 8 – 15 cm water via face mask can be tried. The FiO2 can be adjusted according to the arterial blood gases and SpO2 </li></ul><ul><li>5- Apply the mask </li></ul><ul><ul><li>Without ventilator hose attached </li></ul></ul><ul><ul><li>Elicit patient help if possible to hold the mask </li></ul></ul><ul><ul><li>Allow two fingers to be easily inserted between the mask and the patient's face </li></ul></ul><ul><ul><li>Do not fit the mask too tight </li></ul></ul><ul><ul><li>Apply ventilator hose to mask </li></ul></ul>
    35. 46. <ul><li>6- Change the setting to Optimize synchrony, Optimize Vt and /or PCO2, spo2, minimize accessory muscle use , Alleviate dyspnea and decrease RR. </li></ul><ul><li>Adjust IPAP by incements of 2 cm H2O q 5 mits optimize Vt , decrease PCO2 and relieve respiratoy distress symptoms </li></ul><ul><li>Adjust EPAP in incements of 2cm H2O to increase SpO2. </li></ul><ul><li>(Note: When increasing EPAP, increase IPAP by same amount to </li></ul><ul><li>maintain same level of Pressure Support) </li></ul><ul><li>Adjust Rise Time (Rise Time determines how fast the ventilator rises from the baseline/EPAP to the target pressure/IPAP ) to achieve pt comfort and patient/ventilator synchrony </li></ul>
    36. 47. <ul><li>7- Set alarms to appropriate levels </li></ul><ul><li>8-Monitor patients: </li></ul><ul><li>ABGs , SpO2 </li></ul><ul><li>Respiratoy symptoms Improvement shold be seen withi ½ h </li></ul><ul><li>Pt tolerance and comfort </li></ul>
    37. 48. <ul><li>9-help pt accept therapy </li></ul><ul><li>• Involve patients </li></ul><ul><li>• Be supportive( support the pt until he/she feels comfortable with the therapy) </li></ul><ul><li>• Be encouraging </li></ul><ul><li>• Be attentive </li></ul>
    38. 49. First hour…….. <ul><li>Titrate settings and FiO2 </li></ul><ul><li>Close monitoring ( WOB /RR, pt comfort and tolerance, mental status) </li></ul><ul><li>Monitor blood gases initially q 30 min to 1 hour then prn </li></ul><ul><li>Minimal sedation may be used Morphine 2 mg </li></ul><ul><li>Intubate if worsening </li></ul>
    39. 50. Initial Assessment <ul><li>Items reflecting increased success </li></ul><ul><li>- younger age </li></ul><ul><li>- good dentition , less air leak </li></ul><ul><li>- normal mental status , less secretion </li></ul><ul><li>- adequate cooperation , </li></ul><ul><li>- ability to achieve synchrony with the ventilator </li></ul><ul><li>- lower acuity of illness </li></ul><ul><li>- PH >7.1 , pco2 < 92 </li></ul><ul><li>- improvement in clinical and laboratory parameters within 1-2 hours of treatment initiation ( PH , Pco2 , RR) </li></ul>
    40. 51. Discontinuation of Therapy <ul><li>Indictors of NIV failure </li></ul><ul><li>- patient intolerance for NIV </li></ul><ul><li>- deterioration of vital sign </li></ul><ul><li>- failure to improve after 1-2 hours in NIV </li></ul><ul><li>- progressive confusion or sedation </li></ul><ul><li>- inability to handle secretions </li></ul><ul><li>- chest pain </li></ul><ul><li>- arrhythmia </li></ul><ul><li>- apnea </li></ul>
    41. 52. NIPPV and EBM <ul><li>Evidence has been rapidly accumulating to support many applications of NIV in the acute setting </li></ul>
    42. 54. NIPPV in COPD <ul><ul><li>Meta-analysis of fourteen RCT </li></ul></ul><ul><ul><ul><li>Decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76) </li></ul></ul></ul><ul><ul><ul><li>Decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53) </li></ul></ul></ul><ul><ul><ul><li>Reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63) </li></ul></ul></ul><ul><ul><ul><li>Less complications associated with treatment (RR 0.38; 95%CI 0.24 to 0.60) </li></ul></ul></ul><ul><ul><ul><li>Shorter hospital stay ( -3.24 days; 95%CI -4.42 to -2.06) </li></ul></ul></ul><ul><ul><ul><li>“ Data from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD.” </li></ul></ul></ul>Cochrane Database Syst Rev. 2004
    43. 55. NIPPV &COPD
    44. 57. <ul><li>Noninvasive ventilation is most effective in patients with moderate-to-severe disease </li></ul><ul><li>Hypercapnic respiratory acidosis may define the best responders (pH 7.20-7.30).   </li></ul><ul><ul><li>Noninvasive ventilation is also effective in patients with a pH of 7.35-7.30, but no added benefit is appreciated if the pH is greater than 7.35. </li></ul></ul><ul><ul><li>The lowest threshold of effectiveness is unknown, but success has been achieved with pH values as low as 7.10 . </li></ul></ul>
    45. 58. Respir Care. 2005 May <ul><li>NIV in pts with milder COPD exacerbations: RCT. </li></ul><ul><li>Patients with mild COPD + pH of >7.30 were eligible . </li></ul><ul><li>MEASUREMENTS: Borg dyspnea index at baseline, 1 hour, and daily, Length of hospital stay, endotracheal intubation, hospital survival </li></ul><ul><li>RESULTS : NPPV was poorly tolerated, sig. decrease in dyspnea at 1 hour and 2 days, No differences were seen for any measured variable. </li></ul><ul><li>CONCLUSIONS: The effectiveness and cost-effectiveness of the addition of NPPV to standard therapy in milder COPD exacerbations remains unclear. </li></ul>
    46. 59. NIPPV & Cardiogenic pulmonary edema <ul><li>There are clear benefits in meta-analysis of randomized trials for CPAP </li></ul><ul><ul><li>risk of mortality 0.59 </li></ul></ul><ul><ul><ul><li>95%CI 0.38-0.90 </li></ul></ul></ul><ul><ul><li>risk of intubation 0.44 </li></ul></ul><ul><ul><ul><li>95%CI 0.29-0.66 </li></ul></ul></ul><ul><li>Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367: 1155–1163. </li></ul>
    47. 61. <ul><li>In CPAP group all studies showed a significant improvement in : </li></ul><ul><li>Respiratory status </li></ul><ul><li>Cardiovascular parameters </li></ul><ul><li>Blood gas analysis </li></ul><ul><li>No reported complications in any study </li></ul>
    48. 62. CPAP or BiPAP ?
    49. 63. <ul><li>BiPAP group : improvement in PaC02, pH, HR, RR </li></ul><ul><li>(p <0.05) </li></ul><ul><li>CPAP group : improvement in RR only (p <0.05) </li></ul>
    50. 64. CPAP VS BIPAP Risk ratio of acute myocardial infarction
    51. 65. Annals of Emergency Medicine 2007 <ul><li>prospective multicenter RCT , 3 emergency departments </li></ul><ul><li>The main outcome was a combined criterion (tracheal intubation, death, or MI ) </li></ul><ul><li>109 patients were analyzed, 59 in the CPAP arm and 50 in the BiPAP arm. </li></ul>
    52. 68. <ul><li>Results </li></ul><ul><li>After 1 hour of ventilation and at the end of the ventilation period, clinical parameters of respiratory distress and blood gas exchange significantly improved in each treatment arm. </li></ul><ul><li>No significant differences were observed between the CPAP and BiPAP arms for the combined criterion and also for severe complications , duration of ventilation duration of hospitalization . </li></ul><ul><li>Similar results were obtained among hypercapnic patients (PaCO2 >45 mm Hg). </li></ul><ul><li>Whatever the ventilation support used, the combined criterion and severe complications were more frequently observed among hypercapnic patients. </li></ul>
    53. 69. <ul><li>Conclusion </li></ul><ul><li>Both CPAP and BiPAP appeared effective in rapidly improving respiratory distress even in hypercapnic patients, but they were not different in terms of patient outcome. </li></ul>
    54. 70. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema – meta-analysis: critical care, 2006 <ul><li>17 articles were reviewed. </li></ul><ul><li>In a pooled analysis, 10 studies of CPAP compared to standard medical therapy (SMT) showed a significant 22% absolute risk reduction (ARR) in NETI and 13% in mortality . </li></ul><ul><li>Seven studies of BiPAP compared to CPAP showed a non-significant 3% ARR in NETI (95%CI, -4% to 9%) and 2% in mortality (95%CI, -6% to 10%). None of these methods increased AMI risk . In a subgroup analysis, BiPAP did not lead to better outcomes than CPAP in studies including more hypercapnic patients. </li></ul>
    55. 71. Ann Emerg Med 2006 <ul><li>Collins et al. </li></ul><ul><li>Meta-analysis of 494 patients and the use of NIV in the ED for acute CPE </li></ul><ul><li>Results : NIV significantly reduced hospital mortality (relative risk [RR] 0.61, 95% confidence interval [CI] 0.41–0.91). </li></ul>
    56. 72. N Engl J Med 2008; 359:142-151July 10, 2008 <ul><li>Prospective, randomized, controlled trial, 26 EDs in UK. </li></ul><ul><li>Patients were assigned to standard oxygen therapy, CPAP , or NIPPV . </li></ul><ul><li>The primary end point for the comparison between noninvasive ventilation and standard oxygen therapy was death within 7 days after the initiation of treatment, and </li></ul><ul><li>The primary end point for the comparison between NIPPV and CPAP was death or intubation within 7 days . </li></ul>
    57. 73. <ul><li>A total of 1069 patients were randamized. </li></ul><ul><li>oxygen therapy (367 patients), CPAP (346 patients), or NIPPV (356 patients). </li></ul><ul><li>Results: </li></ul><ul><li>No significant difference in 7-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing noninvasive ventilation (9.5%, P=0.87). </li></ul><ul><li>There was no significant difference in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81). </li></ul>
    58. 78. <ul><li>Noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea , heart rate , acidosis and hypercapnia </li></ul><ul><li>No treatment-related adverse events. </li></ul>
    59. 79. CPAP or PAV
    60. 80. Intensive Care Med (2008) <ul><li>A prospective multicenter randomized study in the medical ICUs of three teaching hospitals. </li></ul><ul><li>36 patients with ACPE randomized to undergo either CPAP or PAV </li></ul>
    61. 82. Asthma &NIPPV <ul><li>Number of studies investigating the use of NPPV in acute asthma exacerbations is limited </li></ul><ul><li>Available data suggests that it is safe . </li></ul><ul><li>There are some studies to support the use of BiPAP for acute asthma exacerbations in the pediatric population . </li></ul>
    62. 85. <ul><li>Lot of papers that address the question there are </li></ul><ul><li>Only 3 completed RCTs and all these have relatively small numbers. </li></ul><ul><li>Addition of NIV in treating status asthmaticus is safe and well tolerated. </li></ul><ul><li>NIV shows promise as a beneficial adjunct to conventional medical treatment. </li></ul><ul><li>further prospective investigation is warranted </li></ul>
    63. 86. Conclusion <ul><li>Addition of NIV in treating status asthmaticus is safe and well tolerated. </li></ul><ul><li>NIV shows promise as a beneficial adjunct to conventional medical treatment. </li></ul><ul><li>further prospective investigation is warranted . </li></ul>
    64. 87. MECH ON ACTION <ul><li>May have a direct bronchodilating effect </li></ul><ul><li>Offset intrinsic PEEP, </li></ul><ul><li>Recruit collapsed alveoli, </li></ul><ul><li>Improve ventilation–perfusion mismatch </li></ul><ul><li>Reduce the work of breathing </li></ul>
    65. 88. NIPPV & Pneumonia <ul><ul><li>Noninvasive ventilation not established to be beneficial </li></ul></ul><ul><ul><li>Secretions may be limiting factor </li></ul></ul><ul><ul><li>Improvement with noninvasive ventilation best achieved in patients also with COPD </li></ul></ul><ul><ul><li>Hypercapnic respiratory acidosis may define group likely to respond </li></ul></ul><ul><ul><li>Decrease in intubation rate and mortality may be limited to those also with COPD </li></ul></ul>
    66. 89. Conclusions <ul><li>Indications for NIV in the acute setting have been broadening </li></ul><ul><li>Choosing the right pt for the NIV is very important for success (patients who do not require emergent intubation and lack contraindications to NPPV). </li></ul><ul><li>The best-established indications remain acute exacerbations of COPD ( BiPAP- grade 1A level of evidence) and acute pulmonary edema( CPAP, BiPAP- grade 1A ). </li></ul><ul><li>In ACPE , The greatest benefits are realized in relief of symptoms and dyspnea, but the decrease in intubation and mortality rates is not a universal experience </li></ul><ul><li>Strong evidence supports the use of NIV for immunocompromised patients with acute respiratory failure. </li></ul><ul><li>Weaker evidence supports use in selected patients with acute exacerbations of asthma( grade 1B ) , cystic fibrosis, pneumonia , and deteriorating obstructive sleep apnea. </li></ul><ul><li>. </li></ul>
    67. 90. <ul><li>Higher quality clinical trials are needed to confirm that NPPV is beneficial to patients with severe asthma exacerbations (A trial of NPPV prior to invasive mechanical ventilation seems reasonable for patients having a severe asthma exacerbation despite initial bronchodilator therapy, if they do not require immediate intubation and have no contraindications to NPPV) </li></ul><ul><li>In asthma, NIV showed Improvement in spirometry (main outcome measure) , Fewer admissions with NIV ; but intubation not an outcome measure </li></ul><ul><li>NIPPV needs close attention and monitoring </li></ul>