• Save
N I V Update
Upcoming SlideShare
Loading in...5

N I V Update






Total Views
Views on SlideShare
Embed Views



6 Embeds 66

http://www.banhachest.blogspot.com 29
http://scribeofegypt.org 28
http://banhachest.blogspot.com 4
http://www.scribeofegypt.com 3
http://www.banhachest.blogspot.com.au 1
http://www.siteliner.com 1



Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment
  • Hess, Mechanical Ventilation
  • Hess, Mechanical Ventilation

N I V Update N I V Update Presentation Transcript

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