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Final newer modes and facts niv chandan
The document outlines various aspects of non-invasive ventilation (NIV) managed by Dr. Chandan Kumar Sheet, covering key topics such as NIV waveforms, interfaces, monitoring, and newer modes of NIV. It provides insights into terminology like positive pressure ventilation and emphasizes the importance of patient comfort, trigger sensitivity, and potential complications associated with NIV use. It also discusses monitoring parameters, weaning strategies, and advancements in NIV techniques for chronic respiratory issues.
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Final newer modes and facts niv chandan
- 1. NIV: Interesting facts Dr.Chandan Kumar Sheet MD (Pulmonary Medicine) Pulmonologist, Calcutta Heart Clinic & Hospital
- 2. Points to becovered NIV Wave forms NIV Interface Monitoring Newer modes of NIV Weaning from NIV New trends of NIV use Miscellaneous issues
- 3. NIV Terminology PPV- Positivepressure ventilation BIPAP- Bi-level positive airway pressure CPAP – Continuous positive airway pressure EPAP- Expiratory positive airway pressure IPAP- Inspiratory positive airway pressure PEEP- Positive end expiratory pressure RATE- - Number of breaths per minute - Determined by the patient in NIV
- 4. NIV Terminology RISETIME- - Time taken to reach to IPAP from EPAP - This is set for patient comfort INSPIRATORY TIME- How long BIPAP unit stays at IPAP PRESSURE SUPPORT- - Difference between IPAP & EPAP - This is the amount of assistance applied to the inspired breath. - Determines the tidal volume - Higher the pressure support larger the breath
- 5. NIV Terminology TRIGGER- -Point where the BIPAP unit transitions from EPAP to the IPAP - Initiation of inspiration or initiation of IPAP in BIPAP - In BIPAP initiation of inspiration is patient trigger CYCLE- - Point where the BIPAP unit transit from IPAP to EPAP - Beginning of EPAP & end of inspiration SENSITIVITY – - Refers to triggering & cycling of the device - Sense inspiratory effort to trigger IPAP
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- 7. Titration – SetRise Time Rise time- Time from EPAP to IPAP Obstructive airway disease- Short rise time Restrictive disease- Prolonged rise time CAUTION- Long rise time with high respiratory rate not compatible
- 8. Most NIV devicesare pressure cycled Most NIV ventilators are pressure cycled NIV apply positive pressure to the airways until a preset pressure limit is reached. Tidal volume is adjusted by increasing or decreasing the pressure limit. Although peak pressure will remain constant, the volume will change as lung compliance and/or airway resistance change.
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- 11. Inspiratory Time Thisis very important and is often missed in the initial settings This decides the I:E ratio Ti-Max should be limited in COPD patients – so there is enough time for exhalation Ti-Min should be higher for restrictive patients, as these patient tend to take very feeble breaths, and they may not get adequate oxygenation
- 12. Setting Ti times– ready reckoner
- 13. Trigger sensitivity (Inspiratory)Trigger is an input required by the device to increase the pressure from EPAP to IPAP The input could be flow, pressure, volume or time Usually, bi-level ventilators trigger on flow, as it is more sensitive Trigger Sensitivity defines how much flow should the patient create to increase the pressure
- 14. Flow trigger- Mostcommon
- 15. Trigger settings areflow sensitive 5 Trigger sensitivities Very High Quick to trigger 2.4L/min High Sensitive 4 L/min Med Default 6 L/min Low Less sensitive 10 L/min Very Low Slow to trigger 15 L/min Very High Very Low
- 16. Issues with Trigger Auto Trigger Failure to trigger
- 17. Auto triggering Triggertoo sensitive Recoil of tubing Leak - Mimics inspiratory flow - Drags EPAP below trigger threshold Reduce Trigger Sensitivity to overcome this problem
- 18. Failure to trigger The most common causes are: - Intrinsic PEEP in case of COPD patients - Upper airway obstruction (in all patients) Increasing the EPAP almost always solves the failure to trigger problem In case the problem still persists, the trigger sensitivity can be increased
- 19. Cycle sensitivity Cycle(Expiratory Trigger) sensitivity is a trigger for the device to drop the pressure from IPAP to EPAP
- 20. Very High Quickto cycle 50 % of peak flow High Sensitive 35% Med Default 25% Low Less sensitive 15% Very Low Slow to cycle 8% Wide cycle sensitivity Very High Very Low 5 cycle sensitivities • It is recommended to keep a higher cycle sensitivity for COPD patients keep a lower sensitivity for restrictive patients
- 21. NIPPV Interface Nasalmasks Oronasal mask Full Facemask NIV Helmet Nasal Pillow
- 22. Nasal MaskADVANTAGES Lessrisk of aspiration Enhanced secretion clearance Less Claustrophobia Easier speech Less dead space Best suited for cooperative patients Better in patient with less severity of illness DISADVANTAGES Mouth leak Less effectiveness with nasal obstruction Nasal irritation & rhinorrhea Mouth dryness
- 23. Oronasal mask ADVANTAGE Goodseal More effective ventilation Best suited for less cooperative patients Better for higher severity of disease Better for mouth breather or purse lip breathing Preferred in edentulous patients DISADVANTAGE Claustrophobia Regurgitation &aspiration Asphyxia
- 24. Nasal pillows Morecommonly used in CPAP therapy Consists 2 small cushions that fit within the nostrils. They are an alternative to nasal, oro-nasal, or full face masks. Since this interface has lower pressure range (3-20 Cm H2O), nasal pillows are not as effective when used in the BIPAP.
- 25. Full Facemask Coversalmost the entire face Easy to fit Less air leaks as covers nasal bridge & mouth No pressure sore around nose & mouth Edentulous patients Mouth breathers Patient with facial abnormality
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- 28. Monitoring PARAMETERS Monitoringis important not only for optimizing ventilator setting, but also to warn against impending catastrophe if NIV falls Monitoring includes 1)Subjective Response 2)Physiological Response 3)Gas exchange Response
- 29. Monitoring SUBJECTIVE RESPONSE Smoothadaptation of the patient to the ventilator Alleviation of symptoms like dyspnea Improved tolerance
- 30. Monitoring Physiological Response Simple vital signs should show an improvement. Assess - chest wall movement, - heart rate - respiratory rate - BP - mental status & - patient coordination with ventilator
- 31. Monitoring Gas exchange response Pulse oxymetry oxygen saturation should be maintained >92%. ABG should be cheeked at baseline & at 1-4 hours Improvement in ABG particularly in PH ,after a short period of NIV predicts successful outcomes
- 32. Monitoring Others :Clinical monitoring Exhaled tidal volume and flow/pressure waveforms Continuous ECG Severe neurologic deterioration Main indications for rapid endotracheal intubation
- 33. Problems & Complicationsof NIV
- 34. Problems & Complications Relatedto Air Pressure & Flow Pressure sore over nose & forehead Air pressure in nose & sinus causes pain, burning, coldness or ear pain (10-30%) Nasal congestion (20-50%) Nasal dryness (10-20%) Oral dryness Gastric distention Eye irritation
- 35. Problems & Complications MajorComplications Infrequent (5%) Delay in intubation Major desaturation & cardiac arrest in hypoxemic respiratory failure Aspiration pneumonia (5%) Hypotension Pneumothorax
- 36. Increased headstraps tensionto reduce air leaks Air leaks Skin breakdown
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- 38. Not always occurwhere they are expected!!! Pressure skin ulceration
- 39. Headstraps tension Avoid airleaks Avoid skin breakdown
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- 41. Volume assuredpressure support (VAPS) modes combine the advantages of pressure support ventilation, such as patient-synchrony and comfort, with the assurance of a volume target. VAPS modes are particularly suitable for patients with progressive lung pathologies, as the pressure support will adapt to the changing ventilatory needs of the patient iVAPS (Intelligent Volume Assured Pressure Support) mode targets Minute Alveolar Ventilation. Volume Assured Pressure Support (VAPS)
- 42. Adaptive servo‐ventilation • Specificallyto treat central sleep apnea (CSA) • Designed to vary support according to a patient’s individual breathing rate • Automatically calculates a target ventilation • Adjusts the pressure support to achieve it
- 43. Assisted PCV (APCV) This is very similar to the assist control mode in invasive ventilation This is very useful in patients who are weaned off from invasive ventilation or who are recovering This mode allows the patient to trigger the ventilator, while ensuring the breaths provided are of the same length When the patient starts to improve triggering on the PAC mode, they may be moved to the ST mode
- 44. Weaning from NIV Weaning strategy • Continue NIV for 16 hours on day 2 • Continue NIV for 12 hours on day 3 including 6–8 hours overnight use • Discontinue NIV on day 4, unless continuation is clinically indicate
- 45. New Trends ofNIV use
- 46. NIV in DifficultWeaning NIV is effective in avoiding respiratory failure after extubation NIV prevent reintubation after weaning from invasive mechanical ventilation in an acute respiratory failure NIV to Manage Extubation Failure • Perform NIV application immediately after extubation. • Closely monitor the success of the NIV treatment. • Do not use NIV to treat post- extubation failure.
- 47. Restrictive ThoracicDisorders Chest wall disorders Obesity Hypoventilation Progressive Neuromuscular disorders Spinal Cord Injury Hypercapnic/non-hypercapnic Central Apnoea Chronic Stable COPD Obstructive sleep apnoea Cystic Fibrosis, Bronchiectasis, Post-tubercular lung NIV in Chronic care setting Goal of NIV in Chronic CARE - Relieve or improve symptoms - Enhance quality of life - Increase survival - Improve mobility
- 48. Conditions mode chronic respiratoryfailure in restrictive thoracic disorders who can protect their airways NIV OSA CPAP nocturnal desaturation and hypoventilation NIV Symptomatic restrictive thoracic disease with severe pulmonary dysfunction VC <50% NIV moderate to severe OSA not responding to CPAP NIV severe symptomatic stable COPD despite optimal treatment NIV COPD-OSA / OHS NIV
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- 50. Sedation during NIV Ideally, before considering analgo-sedation, all the other nonpharmacologic measures should be applied to improve NIV tolerance dexmedetomidine, a new a2-adrenoreceptor agonist, and a sedative, anxiolytic, analgesic agent has been widely used. Midazolam iv can also be used
- 51. Leak compensation Flowsensors in the NIV continuously monitor and adjust flow (variable up to 180 L/min) based on the set pressure, the patient’s inspiratory and expiratory efforts, and leak. compensation for leaks makes it easier for the patient PILBEAM’S mechanical ventilation: 5th edition ,J.M. Cairo, phd, RRT, FAARC Humidification Issues During NIV Passover heated humidifiers should be used to treat or prevent nasal congestion and improve patient comfort. Bubble humidifier and heat-moisture exchangers increase airway resistance and will increase inspiratory WOB
- 52. PILBEAM’S mechanical ventilation:5th edition ,J.M. Cairo, phd, RRT, FAARC Oxygen delivery FIO2 can vary and is affected by four factors: 1. Oxygen flow rate 2. Type of leak port in the system 3. Site where oxygen is bled into the circuit Max FiO2 achieved - If leak port is in the circuit, the oxygen is blend into the patient’s mask - If leak port is in the mask, the oxygen is blend into the circuit at the machine outlet. lowest FiO2 - leak port is in the mask and oxygen is bled into the mask. 4. IPAP and EPAP-Lower IPAP and EPAP levels also yield higher oxygen concentrations.
- 53. CO2-Rebreathing CO2-Rebreathing isa concern with any NIV with single-circuit gas-delivery system because exhalation occurs through the intentional leak port and depends on the continuous flow of gas in the circuit. If gas flow is inadequate, exhaled gases not be adequately flushed from the system and the patient may rebreathe exhaled CO2. flow of gas through the leak port depends on the EPAP I:E At low EPAP settings (<4 cm H2O) and with fast respiratory rates, flow may not be adequate to flush CO2 from the circuit. EPAP of 4 cm H2O or higher improves continuous flow of gas through the system and minimizes CO2 rebreathing PILBEAM’S mechanical ventilation: 5th edition ,J.M. Cairo, phd, RRT, FAARC
- 54. Aerosol delivery inNIV Patients may be removed from the NIV and given aerosolized medications via nebulizer or MDI + Spacer, but this may cause rapid deterioration of the patient’s condition. Bronchodilators given inline with the NIV single-limb circuit by either a nebulizer or MDI with a spacer are effective Factors Affecting Aerosol Delivery During NIV 1. Presence or absence of a humidifier in the circuit 2. Position of the leak port 3. Synchronization of MDI actuation with inspiration 4. IPAP and EPAP levels 5. Volume of the mask
- 55. If theleak port in the mask, aerosol delivery from an MDI is more efficient than from a nebulizer Increased aerosol delivery is also more likely when using high inspiratory pressures and low expiratory pressures Aerosol delivery to the lower airways is less effective when administered through a humidified circuit PILBEAM’S mechanical ventilation: 5th edition ,J.M. Cairo, phd, RRT, FAARC
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Editor's Notes
- #21 The default setting is at 25% of peak flow. This % is not an absolute value rather it is based on the mechanics of the device. According to a study by Patitis the default setting of 25% is ok for COPD patients but for restrictive patients it is advisable to extend it out so that the cycle occurs at 15% or 8% of peak flow.