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Non invasive ventilation
- 1.
- 2. Objectives: • Definitions • Advantages and Disadvantages • Indications • Contraindications • Modes
- 3. Non-invasive ventilation “The deliveryof mechanical ventilation to the lungs using techniques that do not require endotracheal intubation”
- 4. Background • Initially usedin the treatment of hypoventilation with Neuromuscular Disease • Now accepted modality in treatment of acute respiratory failure
- 5. Respiratory mechanics • Respiratoryeffort required for inspiration needs to overcome – Elastic work (stretch) – Flow resistance work ( airway obstruction) • Respiratory failure – forces opposing inspiration exceed respiratory muscle effort
- 6. Respiratory failure Failure tomaintain adequate gas exchange • Hypoxic ( Type 1) or Hypercapnic /Hypoxic (Type 2) • Acute /Chronic / Acute on Chronic
- 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
- 9. Advantages Noninvasiveness • Application - easy to implement or remove • Improves patient comfort • Reduces the need for sedation • Oral patency (preserves speech, swallowing, and cough)
- 10. Advantages 2 • Avoidthe 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
- 11. Disadvantages 1.System Slowercorrection of gas exchange abnormalities Gastric distension (occurs in <2% patients) 2.Mask Air leakage Eye irritation Facial skin necrosis (most common complication)
- 12. Disadvantages 3.Lack of airwayaccess and protection Suctioning of secretions Aspiration 4. Compliance / claustrophobia 5. Work load and supervision
- 13. Which mode? • Hypoxaemia= CPAP • Hypercapnia and hypoxaemia= Bi Level
- 14. CPAP CONTINUOUSPOSITIVE 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
- 15. Indications • Acutepulmonary oedema • Pneumonia
- 16. Bi-level Pressure Support •Combination of IPAP and EPAP Inspiratory PAP = Pressure Support Expiratory PAP = CPAP
- 17. 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
- 18. Indications for BiLevel • Acute Respiratory Failure • Chronic Airway Limitation/COPD • Asthma?
- 19. When to useNIV/CPAP • Indication: APO, COAD • Contraindications excluded • Assessment – Sick not moribund – Able to protect airway – Conscious/cooperative – Haemodynamic stability • Premorbid state / Ceiling of therapy?
- 20. 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
- 21. Complications • Hypoxia • Pulmonary barotrauma • Reduced cardiac output • Vomiting and aspiration • Pressure areas • Gastric distension
- 23. 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
- 24. 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
- 25. 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
- 26. 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
- 27. Monitoring response Physiological a) Continuous oximetry b) Exhaled tidal volume c) ABG- Initial, 1, 2-6 hrs Objective a) Respiratory rate b) Chest wall movement c) Coordination of respiratory effort with NIV d) Accessory muscle use e) HR and BP f) Mental state Subjective a) Dyspnoea b) Comfort
- 28. 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
- 29. Treatment Failure • Deteriorationin condition • Worsening or non improving ABG • Intolerance or failure to coordinate with machine
- 30. Treatment Failure • Backto the patient- ABC • Medical therapy optimised • Treatment of complications
- 31. Criteria to discontinueNIV • Inability to tolerate the mask • Inability to improve gas exchange or dyspnoea • Need for endotracheal intubation • Hemodynamic instability • ECG – ischaemia/arrhythmia
- 32. Withdrawal of NIV •Clinical improvement • Aim for – RR<24 – HR <110 – pH>7.35 – Sats >90% on <40%
- 33. 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