Non Invasive Ventilation Update

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Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com

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  • Hess, Mechanical Ventilation
  • Hess, Mechanical Ventilation
  • Non Invasive Ventilation Update

    1. 1. Dean R. Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care Noninvasive Ventilation: Update 2010
    2. 2. NIV versus CPAP CPAP = EPAP = PEEP No ventilation assistance with CPAP
    3. 3. Mask CPAP <ul><li>Obstructive sleep apnea </li></ul><ul><li>Cardiogenic pulmonary edema </li></ul><ul><li>Treat post-operative atelectasis </li></ul><ul><li>Acute hypoxemic respiratory failure? </li></ul>
    4. 4. Evidence for NIV COPD Exacerbations ★★★★★ Acute cardiogenic pulmonary edema ★★★★ Prevent extubation failure ★★★ Transplantation, immunocompromise ★★ Respiratory failure following lung resection ★ Acute hypoxemic respiratory failure ? Asthma ? Do not intubate/Do not Resuscitate ★ /− Failed extubation −
    5. 5. COPD Exacerbation <ul><li>14 studies included in the review </li></ul><ul><li>Decreased risk of intubation: NNT 4 </li></ul><ul><li>Lower mortality with NIV: NNT 10 </li></ul>Picot, Cochrane Database of Systematic Reviews 2008
    6. 6. Cardiogenic Pulmonary Edema <ul><li>Decreased intubation: CPAP - NNT 9 NIV - NNT 14 </li></ul><ul><li>Reduced mortality CPAP - NNT 6 NIV - NNT 8 </li></ul><ul><li>No difference between CPAP and NIV </li></ul><ul><li>No additional harm (acute MI) with NIV </li></ul>Vital, Cochrane Database of Systematic Reviews 2008
    7. 7. Post-Extubation NIV <ul><li>Earlier extubation; extubate directly to NIV </li></ul><ul><ul><li>Nava, Ann Intern Med 1998;128:721 </li></ul></ul><ul><ul><li>Ferrer, Am J Respir Crit Care Med 2003;168:70 </li></ul></ul><ul><li>Prevent extubation failure in patients at risk; extubate directly to NIV </li></ul><ul><ul><li>Nava, Crit Care Med 2005;33:2465 </li></ul></ul><ul><ul><li>Ferrer, Am J Respir Crit Care Med 2006;173:164 </li></ul></ul><ul><li>Rescue failed extubation; evidence does not support </li></ul><ul><ul><li>Keenan, JAMA 2002;287:3238 </li></ul></ul><ul><ul><li>Esteban, N Engl J Med 2004;350:2452 </li></ul></ul>
    8. 8. Copyright ©2009 BMJ Publishing Group Ltd. Burns et al. BMJ 2009;338:b1574 Effect of non-invasive and invasive weaning on mortality in critically ill adults
    9. 9. Hypoxemic Respiratory Failure <ul><li>NIV decreased the need for intubation and ICU mortality </li></ul><ul><li>Diagnoses included pneumonia, cardiogenic pulmonary edema, thoracic trauma, ARDS, severe asthma, and postoperative respiratory failure </li></ul>Ferrer, Am J Respir Crit Care Med 2003; 168:1438 The literature does not support the routine use of NIV in all patients with acute hypoxemic respiratory failure. Keenan, Crit Care Med 2004; 32:2516
    10. 10. NIV for Acute Asthma <ul><li>ED RCT of 30 patients with severe asthma </li></ul><ul><li>NIV group had more rapid improvement in FEV 1 and reduced hospital admission </li></ul>Soroksky, Chest 2003; 123:1018
    11. 11. <ul><li>52 immunosuppressed patients with hypoxemic acute respiratory failure </li></ul><ul><li>NIV every 3 hrs for at least 45 min </li></ul><ul><li>Fewer patients in the NIV group than in the standard-treatment group required endotracheal intubation (12 vs. 20), died in the ICU (10 vs 18), or died in the hospital (13 vs 21) </li></ul>N Engl J Med 2001;344:481
    12. 12. Crit Care Med 2005;33:1976
    13. 13. Copyright ©2009 BMJ Publishing Group Ltd. Burns et al. BMJ 2009;338:b1574 Effect of alternative weaning strategies on VAP in critically ill adults
    14. 14. Nosocomial Pneumonia NIV compared with invasive mechanical ventilation patients assigned to NIV or invasive mechanical ventilation patients assigned to NIV or standard therapy Hess, Respir Care 2005;50:924
    15. 15. Patient Selection for NIV <ul><li>Respiratory distress with dyspnea, use of accessory muscles, abdominal paradox </li></ul><ul><li>Respiratory acidosis; pH < 7.35 with PaCO2 > 45 mm Hg </li></ul><ul><li>Tachypnea; rate > 25/min </li></ul><ul><li>Diagnosis shown to respond well to NIV (e.g., COPD, CPE) </li></ul>Step 1: Patient needs mechanical ventilation
    16. 16. Exclusions for NIV <ul><li>Airway protection: respiratory arrest, unstable hemodynamics, high aspiration risk, unable to protect airway, copious secretions </li></ul><ul><li>Unable to fit mask: facial surgery, craniofacial trauma or burns, anatomic lesion of upper airway </li></ul><ul><li>Uncooperative patient: anxiety </li></ul><ul><li>Patient wishes </li></ul>Step 2: No exclusions for NIV
    17. 17. When to Stop <ul><li>Lack of improvement within 1-2 hrs </li></ul><ul><li>Patient intolerance of therapy </li></ul><ul><li>Adverse effects: hypotension </li></ul><ul><li>Patient wishes </li></ul>When to Transfer to ICU <ul><li>Failure of NIV </li></ul><ul><li>Mask intolerance </li></ul><ul><li>Better monitoring </li></ul>
    18. 18. Is NIV Appropriate? Is NIV NOT Appropriate? When To Stop?
    19. 19. The Interface <ul><li>Mask </li></ul><ul><ul><ul><li>Nasal </li></ul></ul></ul><ul><ul><ul><li>Oronasal </li></ul></ul></ul><ul><ul><ul><li>Total face </li></ul></ul></ul><ul><li>Pillows </li></ul><ul><li>Mouthpiece </li></ul><ul><li>Helmet </li></ul>
    20. 20. nasal total face oronasal pillows mouthpiece helmet
    21. 21. Choice of Interface <ul><li>The internal volume of masks had no short-term effect on gas exchange, minute ventilation, or effort (Crit Care Med 2009; 37:939) </li></ul><ul><li>Nasal versus oronasal mask: failure more often with nasal mask (Crit Care Med 2009; 37:124) </li></ul><ul><li>Nasal versus oronasal mask: oronasal mask better tolerated (Crit Care Med 2003; 31:468) </li></ul><ul><li>Nasal mask versus oronasal mask versus nasal pillows: nasal mask better tolerated; PaCO2 lower with oronasal and pillows (Crit Care Med 2000; 28:1785) </li></ul><ul><li>Oronasal mask versus mouthpiece: tolerance better and less staff time required for mask (Anaesthesia 2006; 61:20) </li></ul>
    22. 22. Mouth Leak <ul><li>Decreased comfort </li></ul><ul><li>Less effective ventilation </li></ul><ul><li>Ineffective trigger/cycle </li></ul><ul><li>NIV failure (Soo Hoo 1994, Fraticelli 2009) </li></ul><ul><li>Increased nasal resistance (Richards 1996) </li></ul><ul><li>Upper airway drying (De Araujo 2000) </li></ul><ul><li>Disrupted sleep (Meyer 1997; Tescheler 1999) </li></ul>Oronasal mask; coaching?; chin strap?
    23. 23. Skin Breakdown <ul><li>Use correctly fitted mask </li></ul><ul><li>Try different interface; rotate interfaces </li></ul><ul><li>Adjust headgear </li></ul><ul><li>Duoderm </li></ul>photo courtesy Dr. Nick Hill
    24. 24. Ventilators for NIV
    25. 25. Ventilators for NIV <ul><li>Ventilators for NIV are typically pressure support devices: IPAP EPAP PS = IPAP - EPAP </li></ul>Trigger Pressure vs volume (PCV vs PSV vs PAV) Rise time Cycle Back-up rate
    26. 26. AVAPS: Average Volume Assured Pressure Support <ul><li>Estimates patient tidal volume over several breaths and compares it to target tidal volume </li></ul><ul><li>Gradually changes IPAP (0.5 – 1 cm H 2 O/min) </li></ul><ul><li>Similar to PRVC, Autoflow, and VS </li></ul>
    27. 27. blower & pressure controller single hose leak <ul><li>Rebreathing: </li></ul><ul><li>Increase EPAP level ≥4 cm H2O </li></ul><ul><li>Increase leak in system </li></ul><ul><li>Fixed leak in mask rather than hose </li></ul><ul><li>Titrate O 2 into mask rather than hose </li></ul>mask
    28. 28. Inhaled Bronchodilators <ul><li>Nebulizer therapy inline with NIV </li></ul><ul><li>MDI therapy inline with NIV </li></ul>Hess, J Aerosol Med 2007; 20:S85 Iosson, N Engl J Med 2006; 354:e8
    29. 30. Managing Dys-Synchrony <ul><li>Trigger dys-synchrony </li></ul><ul><ul><li>Leaks </li></ul></ul><ul><ul><li>Auto-PEEP </li></ul></ul><ul><ul><li>High levels of support </li></ul></ul><ul><li>Flow dys-synchrony </li></ul><ul><ul><li>Rise time </li></ul></ul><ul><li>Cycle dys-synchrony </li></ul><ul><ul><li>Leaks </li></ul></ul><ul><ul><li>High levels of support </li></ul></ul>
    30. 31. Practical Application <ul><li>Select appropriate patient </li></ul><ul><li>Choose a ventilator capable of meeting patient needs (usually pressure ventilation) </li></ul><ul><li>Choose interface; avoid mask that is too large </li></ul><ul><li>Explain therapy to the patient </li></ul>
    31. 32. Practical Application <ul><li>Silence alarms; choose low settings </li></ul><ul><li>Initiate NIV while holding mask in place </li></ul><ul><li>Secure mask, avoid tight fit </li></ul><ul><li>Titrate pressure support (IPAP) to patient comfort </li></ul>
    32. 33. Practical Application <ul><li>Titrate FIO2 to SpO2 > 90% </li></ul><ul><li>Avoid PIP > 20 cm H2O </li></ul><ul><li>Titrate PEEP/EPAP/CPAP per trigger effort and SpO2 </li></ul><ul><li>Coach and reassure patient; make adjustments per patient compliance </li></ul>
    33. 34. Complications <ul><li>Leaks </li></ul><ul><li>Mask discomfort and facial soreness </li></ul><ul><li>Eye irritation </li></ul><ul><li>Sinus congestion </li></ul><ul><li>Oronasal drying </li></ul><ul><li>Patient-ventilator dyssynchrony </li></ul><ul><li>Gastric insufflation </li></ul><ul><li>Hemodynamic compromise </li></ul>(Complications are usually minor)
    34. 35. Cough Assist
    35. 36. NIV Success clinician skills equipment selection patient selection

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