Non invasive ventilation

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Non-invasive ventilation

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Non invasive ventilation

  1. 1. NON-INVASIVE VENTILATION
  2. 2. Objectives:• Definitions• Advantages and Disadvantages• Indications• Contraindications• Modes
  3. 3. Non-invasive ventilation“The delivery of mechanical ventilation to the lungsusing techniques that do not require endotracheal intubation”
  4. 4. Background• Initially used in the treatment of hypoventilation with Neuromuscular Disease• Now accepted modality in treatment of acute respiratory failure
  5. 5. Respiratory mechanics• Respiratory effort required for inspiration needs to overcome – Elastic work (stretch) – Flow resistance work ( airway obstruction)• Respiratory failure – forces opposing inspiration exceed respiratory muscle effort
  6. 6. Respiratory failureFailure to maintain adequate gas exchange• Hypoxic ( Type 1) or Hypercapnic /Hypoxic (Type 2)• Acute /Chronic / Acute on Chronic
  7. 7. Effects of NIV• Improves alveolar ventilation to reverse respiratory acidosis and hypercarbia• Recruits alveoli and increases FRC to reverse hypoxia• Reduces work of breathing
  8. 8. AdvantagesNoninvasiveness• Application - easy to implement or remove• Improves patient comfort• Reduces the need for sedation• Oral patency (preserves speech, swallowing, and cough)
  9. 9. Advantages 2• Avoid the resistive work of ETT• Avoids the complications of ETT – Early (local trauma, aspiration) – Late (injury to the the hypopharynx, larynx, and trachea, nosocomial infections)• Reduced Cost and Length of Stay
  10. 10. Disadvantages1.System Slower correction of gas exchange abnormalities Gastric distension (occurs in <2% patients)2.Mask Air leakage Eye irritation Facial skin necrosis (most common complication)
  11. 11. Disadvantages3.Lack of airway access and protection Suctioning of secretions Aspiration4. Compliance / claustrophobia5. Work load and supervision
  12. 12. Which mode?• Hypoxaemia = CPAP• Hypercapnia and hypoxaemia= Bi Level
  13. 13. CPAP CONTINUOUS POSITIVE AIRWAY PRESSURE (AKA PEEP) • Constant positive airway pressure throughout cycle • Improves oxygenation • Decreases work of breathing by alveolar recruitment (Dec elastic work) and unloads insp muscles • Decreases hypoxia by alveolar recruitment and reduces intrapulmonary shunt
  14. 14. Indications • Acute pulmonary oedema • Pneumonia
  15. 15. Bi-level Pressure Support• Combination of IPAP and EPAPInspiratory PAP = Pressure SupportExpiratory PAP = CPAP
  16. 16. Respiratory Effects Bi-PAP • EPAP – Provides PEEP – Increases Functional Residual Capacity – Reduces FiO2 required to optimise SaO2 • IPAP – Decreases work of breathing + oxygen demand – Increases spontaneous tidal volume – Decreases spontaneous respiratory rate
  17. 17. Indications for Bi Level• Acute Respiratory Failure• Chronic Airway Limitation/COPD• Asthma?
  18. 18. When to use NIV/CPAP• Indication: APO, COAD• Contraindications excluded• Assessment – Sick not moribund – Able to protect airway – Conscious/cooperative – Haemodynamic stability• Premorbid state / Ceiling of therapy?
  19. 19. Contraindications• Impaired consciousness, confusion, agitation• Inability to protect airway• Excessive secretions or vomiting• Haemodynamic instability• Untreated pneumothorax• Bowel obstruction• Facial trauma, burns, recent surgery• Fixed upper airway obstruction
  20. 20. Complications• Hypoxia• Pulmonary barotrauma• Reduced cardiac output• Vomiting and aspiration• Pressure areas• Gastric distension
  21. 21. Ventilator Settings- LVF• CPAP at 5-8 and increase to 10-15 cm H20• Mask is held gently on patient’s face.• Increase the pressures until adequate Vt (7ml/kg), RR<25/min, and patient comfortable.• Titrate FiO2 to achieve SpO2>90%.• Keep peak pressure <25-30 cm
  22. 22. COAD exacerbation: NIV• increases pH, reduces PaCO2, reduces the severity of breathlessness in first 4 h of treatment• decreases the length of hospital stay• mortality and intubation rates are reduced
  23. 23. Ventilator settings COAD• Mode- Spontaneous/Timed• EPAP- 4-5 cm H20 IPAP- 12- 15 cm H20• Trigger- maximum sensitivity• Back up rate- 15 breaths/min• Back up I:E 1:3
  24. 24. Setting It Up• No contraindications• O2 medical therapy underway• Explanation and reassurance• Correct mask size• Ventilator set up• Commence NIV hold mask in place• Reassure and fix mask• Monitor and observe, regular assessment
  25. 25. Monitoring responsePhysiological a) Continuous oximetry b) Exhaled tidal volume c) ABG- Initial, 1, 2-6 hrsObjective a) Respiratory rate b) Chest wall movement c) Coordination of respiratory effort with NIV d) Accessory muscle use e) HR and BP f) Mental stateSubjective a) Dyspnoea b) Comfort
  26. 26. Documentation• Mode of ventilation• Flow rate of oxygen, percentage of oxygen• TPR and BP• Respiratory assessment• Conscious level (GCS)Obs - 15 minutely for first hour, then hourly if condition stable
  27. 27. Treatment Failure• Deterioration in condition• Worsening or non improving ABG• Intolerance or failure to coordinate with machine
  28. 28. Treatment Failure• Back to the patient- ABC• Medical therapy optimised• Treatment of complications
  29. 29. Criteria to discontinue NIV• Inability to tolerate the mask• Inability to improve gas exchange or dyspnoea• Need for endotracheal intubation• Hemodynamic instability• ECG – ischaemia/arrhythmia
  30. 30. Withdrawal of NIV• Clinical improvement• Aim for – RR<24 – HR <110 – pH>7.35 – Sats >90% on <40%
  31. 31. Most important THPs• Selection of patient really vital to success - need to have reversible pathology• Aim for gradual improvement over hours with good supportive nursing• In ED, main use is to avoid intubation / ventilation in LVF and COAD

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