1) NIV is effective for acute hypercapnic respiratory failure caused by COPD exacerbations to prevent intubation and reduce mortality.
2) NIV is most effective when started early in respiratory failure before severe acidosis develops. It improves blood gases and respiratory status within 1-2 hours.
3) While NIV success rates are high initially, late failure can still occur in around 23% of patients and is associated with increased mortality if intubation is then required. Close monitoring is needed.
Basic information on the Graphics displayed on the Ventilators. Prepared to educate about the graphics to train the professionals who work with Ventilators.
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask or nasal mask. Learn more about NIV in this presentation by Dr Somnath Longani, consultant Anaesthesiologist & Intensivist, Midland Healthcare & Research Center, lucknow
https://midlandhealthcare.org/
Basic information on the Graphics displayed on the Ventilators. Prepared to educate about the graphics to train the professionals who work with Ventilators.
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask or nasal mask. Learn more about NIV in this presentation by Dr Somnath Longani, consultant Anaesthesiologist & Intensivist, Midland Healthcare & Research Center, lucknow
https://midlandhealthcare.org/
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
Mechanical Ventilation in COPD Lecture presented by Dr Lluis Blanch at Venti Cairo Mechanical Ventilation Course held on 14-15 November at Cairo, Egypt.
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
Mechanical Ventilation in COPD Lecture presented by Dr Lluis Blanch at Venti Cairo Mechanical Ventilation Course held on 14-15 November at Cairo, Egypt.
Oxygen Therapy is not Beneficial in COPD Patients with Moderate HypoxaemiaGamal Agmy
A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation
The Long-Term Oxygen Treatment Trial Research Group*
N Engl J Med. 2016 October 27; 375(17): 1617–1627
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Presentation by Dr. S.K Jindal on "PAP Therapy" | Jindal Chest ClinicJindal Chest Clinic
Positive airway pressure (PAP) therapy is a sleep apnea treatment that uses compressed air to support the airway. It involves wearing a mask and a portable machine blowing pressurized air into the upper airway through a tube connected to the mask. This positive airflow prevents apnea collapse and allows normal breathing. In this presentation "PAP Therapy" has been described including its use, indications, complications, etc. For more information, please contact us: 9779030507.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
15. Standard interfaces
Facial masks
advantages:
– sufficient ventilation also
during mouth breathing
– sufficient ventilation in patients
with limited co-operation
disadvantages:
– coughing is difficult
– skin lesions (bridge of the nose)
16. Nasal masks
advantages:
– better comfort
– good seal
– coughing is possible
– communication is possible
disadvantages:
– effective in nose breathing only
– good co-operation is necessary
Standard interfaces
17. Nasal prong/nasal pillow systems
for patients with
claustrophobia
for patients with allergies
against straps
for low to moderate
pressures only
(< 20 cmH2O)
Standard interfaces
18. total-face masks
• Safe interface for acute respiratory
insufficiency with high pressures
• well tolerated by the patients
Standard interfaces
19. helmet
• well tolerated by the patient
• no direct contact to the skin of
the face
• large dead space
• may influence the triggering of
the patient; use with CPAP
• very noisy
Standard interfaces
20. mouthpieces
• simple and cheap
• short-interval alternative
interface for long-term
ventilated patients
Custom-made masks
• for long-term ventilation
• if standard masks are not
tolerated
Standard interfaces
21. Physiologic evaluation of three
different interfaces
cohort: 26 stable patients with hypercapnic COPD or interstitial lung disease.
intervention: three 30 minute tests in two ventilatory modes with
facial mask / nasal mask / nasal prongs
Conclusions: NIPPV was effective with all interfaces.
patients„ tolerance: nasal mask > facial mask or nasal prongs
pCO2 reduction: facial mask or nasal prongs > nasal mask
Navalesi P et al. Crit Care Med 2000;28:2139-2140
32. Rationale for
Non-invasive Ventilation (NIV)
to improve respiratory function and symptoms
• blood gases
• dyspnea
• respiratory rate
to avoid intubation and related complications
• ventilator-associated pneumonia (VAP)
- i.e. tube associated pneumonia
• local complications related to tube (early & late)
• complications related to catheterization
• tracheostomy and weaning failure
to improve outcome
• to reduce length of ICU and hospital stay
• mortality
39. MORTALITY OF PATIENTS WITH COPD
REQUIRING INVASIVE MECHANICAL
VENTILATION FOR ACUTE RESPIRATORY
FAILURE
study year In-hospital Mortality, %
Knaus 1989 42
Stauffer et al 1993 33
Rieves et al 1993 43
Seneff et al 1995 32
Brochard et al 1995 29
Corrado et al 1998 27
Hill et al 1998 49
41. Lightowler JV. et al. BMJ 2003; 326:185-
• NIV prevents intubation
(NNT = 5)
• NIV reduces mortality
(NNT = 8)
NNT = number needed to treat
42. META-ANALYSIS (N=8)
• NIV resulted in
– decreased mortality (RR 0.41; 95% CI 0.26,
0.64),
– decreased need for ETI (RR 0.42; 95%CI
0.31, 0.59)
• Greater improvements within 1 hour in
– pH (WMD 0.03; 95%CI 0.02, 0.04),
– PaCO2 (WMD -0.40 kPa; 95%CI -0.78, -
0.03),
– RR (WMD –3.08 bpm; 95%CI –4.26, -1.89).
• Complications associated with treatment (RR
0.32; 95%CI 0.18, 0.56) and length of hospital
stay were also reduced with NPPV (WMD –
3.24 days; 95%CI –4.42, -2.06)
Lightowler, Elliott, Wedzicha & Ram BMJ 2003; 326:185
43. Lightowler JV. et al. BMJ 2003; 326:185-
189
Conclusions
NIV should be the first line intervention in addition to
usual medical care to manage respiratory failure
secondary to an acute exacerbation of chronic
obstructive pulmonary disease in all suitable
patients.
NIV should be tried early in the course of respiratory
failure and before severe acidosis,
to reduce mortality, avoid endotracheal intubation,
and decrease treatment failure.
first
line
pH:
7.20–7,35
Improves
outcome
NIV:
44. Confalonieri, et al. AJRCCM 1999; 160: 1585-1591
• 56 Pats with Pneumonia
• 23 COPD - 33 non-COPD
• Prospektive RCT:
- PSV + Standard-treatment
- O2 + Standard-treatment
45. Am J Respir Crit Care Med 1999;160:1585-15
*
PaCO2 [mmHg]
Intubation [%]
ICU – length of stay [d]
2-Mo-moratliy [%]
NIV Standard
73
0
<1
11
68
55
8
63
32
38
3
43
34
47
5
33
NIV Standard
*p < 0.05
COPD (n = 23) Non-COPD (n = 33)
* *
*
* *
46. NIV in weaning: Early extubation
NIV in the weaning of patients with respiratory
failure due to COPD
47. NIV in weaning: Early extubation
24-36 hrs of PSV
50 patients
2 hr T-piece trial
failed
Randomized
NIV to 25 br/min, ABGs
6 by 2-4 cmH20/day
SBT 2 x/day
IPSV to 25 br/min, ABGs
“gradually” 6
CPAP or T piece, 2 x/day
Nava et al. Ann Intern Med 1998;128:721-8
NIV in the weaning of patients with respiratory failure due to
COPD
48. Invasive MV
NIV
Weaning success with NIV
NIV in the weaning of patients with ARF due to COPD
Nava et al. Ann Intern Med. 1998;128:721-8
NIV in weaning: Early extubation
49. NIV to wean from respirator in stable COPD
Nava et al. Ann Intern Med 1998;128:721-8
Invasive Non-invasive
MV days 17 10*
ICU days 24 15*
60d wean success 68% 88% *
60 d survival 72% 92% *
Pneumonia 25% 0% *
wean failure: death from MV and reintubation in 72h
52. Moretti M. et al. Thorax 2000;55:819-82
N= 137
Patients with
NIV success*
*NIV > 24 Std.
N= 31
Patients with late
NIV-failure after
primary NIV-success*
23%
Acute exacerbation of COPD
after 48 hours
Mortality IMV 53%, continuing NIV 92%
(NIV group pH 7.1 IMV 7.29)
Late failure predicted by low ADL scores,
pH and co-morbidity at admission
53. Moretti M. et al. Thorax 2000;55:819-8
Late NIV failure:
• lower pH at admission
• higher complication rates
• ICU-Mortality
• 92% when NIV was continued
• 53% when intubation was performe
54. Invasive MV instead of NIV
- in terms of clinical issues
Invasive MV
Lavage
bei Hypersecretion
Unloading
respir. muscles
Improvement of
neurophysiologic
situation
Aim: Extubation after 2-3 day
- with/without consecutive NIV
Massive hypersecretion Massive Load
on respir. muscles
Neurophysiologic
disaster
60. Flandreau G et al. Management and long-term outcome of patients with chronic
neuromuscular disease admitted to the intensive care unit for acute respiratory failure:
a single-center retrospective study. Respir Care 2011; 56: 953 – 960
Special indication for NIV in acute hypercapnia
Neuromuscular disease
73. Targets of ventilation in
cardiogenic pulmonary oedema
• improvement of oxygenation
• improvement of respiratory acidosis
• reduction of work of breathing
• improvement of cardiac performance
• reduction of patient’s distress
81. Conclusions
Multiple organ failure and pneumonia were the main factors associated with
NIV failure and death in morbidly obese patients in hypoxic ARF. On the
opposite, NIV was constantly successful and could be safely pushed further in
case of severe hypercapnic acute respiratory decompensation of OHS.
82. Potential goals of noninvasive ventilation (NIV) in severe acute asthma.
Dean R Hess Respir Care 2013;58:950-972
(c) 2012 by Daedalus Enterprises,Inc.
83. Bronchoscope inserted through the swivel adaptor of a face mask for noninvasive ventilation.
Dean R Hess Respir Care 2013;58:950-972
(c) 2012 by Daedalus Enterprises,Inc.
85. AIMS
Goals of monitoring
Types of monitoring
Setting for monitoring
Goals of monitoring
Types of monitoring
Setting for monitoring
86. Why we need Monitoring during MV?
To Assess the effectiveness of MV in
-Unloading respiratory muscles
-Correcting gas exchange abnormalities
-Improving alveolar ventilation
To Identify complications during MV
-correlated with MV
-correlated with ARF
To predict patient’s outcome in terms of
-Survival
-Dependence on MV
-Autonomy in performing ADLs
87. Is Monitoring less important during
NIV? Airways not protected
Presence of leaks
Lack of sedation
Use outside ICU
88. Which goals of Monitoring during NIV?
To Assess the effectiveness of NIV in
-Unloading respiratory muscles
-Correcting gas exchange abnormalities
-Improving alveolar ventilation
-Patient-ventilatory synchrony
To Identify complications during NIV
-correlated with NIV
-correlated with ARF
To predict patient’s outcome in terms of
- NIV failure (i.e. Need of ETI)
-Survival
-Dependence on MV
-Autonomy in performing ADLs
To Assess the effectiveness of NIV in
-Unloading respiratory muscles
-Correcting gas exchange abnormalities
-Improving alveolar ventilation
-Patient-ventilatory synchrony
To Identify complications during NIV
-correlated with NIV
-correlated with ARF
To predict patient’s outcome in terms of
- NIV failure (i.e. Need of ETI)
-Survival
-Dependence on MV
-Autonomy in performing ADLs
104. 46 pts with ARF under NIV (Range PaCO2: 33-91 mmHg) -TCM4: trunk
PtCO2 sensor
Under-estimation of PaCO2 in pts
with greater hypercapnia (PaCO>60
mmHg)
105. TREND OF TC-PCO2
Kocher S et al, J Clin Monitor Comput 2004
Domingo Ch et al, Arch Bronchoneumol 2006
106. Arterial blood gas-analysis
Gold standard
Oxygenation status (PaO2/FiO2
ratio)
Ventilatory status (PaCO2)
Metabolic status (pH/HCO3)
Co-oximetry (COHb)
Weak points:
-Invasive
procedure
-Spot data
Prognostic
value
-Baseline
-After 1-2 hrs
-Late failure
107. Antonelli M. et al. Crit Care Med 2007;35(1):18-25
PaO2/FiO2 during NIV in
ARDS
108. pH at baseline in COPD exacerbations
Nava S. et al., Intensive Care Med 2006; 32(3):361-70.
110. How to assess RR on spont
breathing?
Clinical
evaluation
Impedenzometry
Capnography
Pnemotacograph
111. Schettino G. et al., Crit Care Med 2008;36(2):441-7
Reasons for NIV failure
Cardiovascular
monitoring
(ECG, NIBP, PR)
112. Helpful in
Understanding the causes of nocturnal desaturations
Re-Setting the ventilator
Janssens JP et al. Thorax 2011;66(5):438-45
Sleep monitoring
124. Berg KM et al., Respir Care 2012;57:1548-54
Respiratory pattern and NIV
Failure
INTUBATION
aRSBI= RR/exp- TV during NIV
Exp TV = pt TV
HOW COULD WE MONITOR exp-TV and RR DURING NIV?
129. How to Reduce Air Leaks During NIV
Proper interface type and
size
Proper securing system
Mask-support ring
Comfort flaps
Tube adapter
Hydrogel or foam seals
Chin strap
Lips seal or mouth taping
Nava S et al. Respiratory Care 2009; 54: 71-82
Mask occlusion pressure = Pmask-fit – Paw
130.
131. How to Reduce the Risk of Skin
Damage During NIV
Proper harness and tightening
Skin and mask hygiene
ava S et al. Respiratory Care 2009;54:71-82
Nasal-forehead spacer
• To reduce the pressure on the bridge of the
nose
Forehead and skin pads
• To obtain the most comfortable position
Cushioning system between mask prong and
forehead
Remove patient’s dentures when making
impression for moulded mask
In home care, replace the mask according
to the patient’s daily use
136. • Not always appear
where expected!!!
Pressure ulcer
137. Predictors of failure: NIV for hypercapnic
respiratory failure
Advanced age
Higher acuity of illness (APACHE score)
Uncooperative
Poor neurological score
Unable to coordinate breathing with ventilator
Large air leaks
Edentulous
Tachypnoea (>35/min)
Acidaemia (pH <7.18)
Failure to improve pH, heart and respiratory rates or
Glasgow Coma Score within the first 2 hours
Soo Hoo et al. Crit Care Med 1994; 22: 1253–61
Ambrosino et al. Thorax 1995; 50: 755–7
Confalonieri et al. Eur Respir J 2005; 25: 348–55
142. • Eight ICUs
• n=354:
• Success: 246
• Failure: 108
Other predictors of
failure:
Higher SAPS
Lower PaO2/FIO2 and
failure to improve
Low pH
Older age
Septic shock, MOF
143. Common reasons for NIV failure
Environmental/caregiver team
factors
• Lack of skilled, experienced caregiver
team
• Poor patient selection
• Lack of adequate monitoring
Selection guidelines for NIV in the acute setting
Appropriate diagnosis with potential reversibility (COPD,
congestive heart failure, …..)
Establish need for ventilatory assistance:
• Moderate to severe respiratory distress
and
• Tachypnoea (>24/min for COPD, >30/min for CHF)
• Accessory muscle use or abdominal paradox motion
• Blood gas derangement: pH <7.35, PaCO2 >45, or
PaO2/FiO2 <300
144. Contraindications of NIV
Respiratory or cardiac arrest
Too unstable patient:
• Shock
• Myocardial infarction
requiring intervention
• Uncontrolled ischemia or
arrhythmias
• Uncontrolled upper GI bleed
• Non-evacuated pneumothorax
Unable to protect airway*
• Excessive secretions
• Poor cough
• Impaired swallowing
*Relative contraindications?
Aspiration risk*
• Distended bowel; obstruction
or ileus
• Frequent vomiting
Uncooperative or agitated*
Unable to fit mask
Recent upper airway or
oesophageal surgery
Multiple organ system failure
(>2)
145. Common reasons for NIV failure
Patient-related factors
• Intolerance
• Mask problems:
• Discomfort
• Poor fit
• Skin ulceration
• Claustrophobia
• Agitation
• Excessive secretions, inability to protect
airway
• Progression of underlying disease
147. Common reasons for NIV failure
Technical factors
• Inadequate equipment
• Failure to ventilate
• Failure to oxygenate
• Patient–ventilatorasynchrony
• Air leaks
148. Successful NIV: Important
factors
More likely with a good team
• A skilled, experienced staff helps to optimize outcomes
The underlying disease is an important
determinant
• Selecting appropriate patients and monitoring them
closely
Severity at presentation
Change in physiology after a short period of NIV
• If failure to ventilate or oxygenate, rapidly assess for
reversible contributing factors
• Be prepared to intubate without undue delay if rapid
reversal cannot be achieved (particularly in hypoxemic
patients)
A systematic approach to troubleshooting can help