Niv in covid-19
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This document discusses the use of noninvasive ventilation (NIV) for patients with COVID-19-associated acute hypoxemic respiratory failure (AHRF). It finds that the majority of COVID-19 patients treated with continuous positive airway pressure (CPAP) recovered from moderate-to-severe AHRF. For select patients, NIV may prevent intubation and invasive ventilation. However, patient selection is important and NIV may delay intubation in some cases. Close monitoring is needed to identify patients who require intubation.
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Niv in covid-19
- 20. Main finding was that the vast majority of Covid-19 patients treated by CPAP recovered from moderate-to-severe AHRF
- 24. When and for which patients?
- 33. HFNC vs NC
- 51. COVID-19 & NIV Early series suggested high mortality for patients with COVID-19–associated respiratory failure who received invasive mechanical ventilatory support
- 52. Current thinking suggests that NIV may be an appropriate bridging adjunct in the early part of the disease progress and may prevent the need for intubation or invasive ventilation
- 53. Published cohorts suggest that noninvasive ventilation is a commonly used intervention in COVID-19-related AHRF It is uncertain whether noninvasive ventilation is beneficial or harmful for patients with COVID-19
- 54. A total of 586 confirmed COVID-19-positive patients were hospitalised during the study period, of whom 103 (17.6%) required noninvasive ventilation or invasive mechanical ventilation Among those patients who had an initial trial of noninvasive ventilation, 27/ 58 progressed to invasive mechanical ventilation whereas 31/58 did not require subsequent invasive mechanical ventilation
- 55. Of note, 29/31 (94%) patients in Group NIV alone were discharged from hospital alive with the remaining 2/31 (6%) being alive in the ICU at the time of data collection
- 56. Network Metaanalysis: Ferreyro BL et.al.JAMA. Published online June 4, 2020 Association of helmet NIV with reduced rate of intubation and reduced mortality
- 65. Continuous Positive Airway Pressure (CPAP), a form of NIV, appeared to have a more significant and positive role than initially thought
- 66. For some patients, while NIV may temporarily improve oxygenation and work of breathing, it does not change natural disease progression and is not a replacement for intubation and invasive ventilation
- 67. General Considerations The key to the successful application of noninvasive ventilation is in recognizing its capabilities and limitations Identification of the appropriate patient for the application of noninvasive ventilation (NIV). It may involve a trial of noninvasive ventilation.
- 70. Patient inclusion criteria Patient cooperation (an essential component that excludes agitated, belligerent, or comatose patients) Dyspnea (moderate to severe, but short of respiratory failure) Tachypnea (>24 breaths/min) Increased work of breathing (accessory muscle use, pursed-lips breathing) Hypercapnic respiratory acidosis (pH range 7.10-7.35) Hypoxemia (PaO2/FIO2< 200 mm Hg, best in rapidly reversible causes of hypoxemia)
- 71. Absolute contraindications Coma Cardiac arrest Respiratory arrest Any condition requiring immediate intubation
- 72. Other Contraindications Cardiac instability GI bleeding - Intractable emesis and/or uncontrollable bleeding Inability to protect airway Potential for upper airway obstruction
- 74. Interface Vented Mask Non-Vented Mask
- 76. Full Face Nasal Mask
- 86. NIV Ventilators Critical care Ventilators Specialty NIV Ventilators
- 88. Mode of Ventilation Past experience In part on the capability of ventilators available to provide support In part on the condition being treated.
- 90. Mode of Ventilation The primary NIV mode is the continuous positive airway pressure (CPAP), the pressure is initially set at 10 cm H2O and then adjusted according to SpO2 and clinical tolerance Pressure support ventilation (PSV) should be considered over CPAP in patients who showed respiratory acidosis (pH < 7.35), tachypnea >30/min or a vigorous activity of respiratory accessory muscles
- 94. Boussignac positive pressure valve
- 95. UCL Ventuar CPAP device
- 105. UCL Ventura CPAP Device
- 107. In severe COVID-19, initial CPAP settings have been suggested 10 cmH2O and 60% oxygen
- 109. Initial IPAP/EPAP settings Start at 10 cm water/5 cm water Pressures less than 8 cm water/4 cm water not advised as this may be inadequate Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP)
- 111. Subsequent adjustments Increase IPAP by 2 cm water if persistent hypercapnia Increase IPAP and EPAP by 2 cm water if persistent hypoxemia Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient comfort) Maximal EPAP limited to 10-15 cm water
- 114. NIV Failure A mean VTE higher than 9.5mL/kg over the first four cumulative hours of NIV accurately predicted NIV failure
- 116. Be careful that NIV may unduly delay intubation in non-expert hands We insist on the notion that intubation should not be delayed
- 119. The expiratory limb of the circuit was equipped with an antimicrobial filter
- 121. Surgical Mask on HFNC
- 122. Periods off NIV should be of short duration, to prevent desaturation
- 123. Regular assessment of the patient’s pressure areas on the face must be taken, and protective dressings applied if necessary