Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU

1. NON-INVASIVE VENTILATION
DR SHAHNA ALI
DEPARTMENT OF ANAESTHESIOLOGY&
CRITICAL CARE

4. WHAT IS NON INVASIVE VENTILATIONWHAT IS NON INVASIVE VENTILATION????
“NIV is the delivery of mechanical ventilation to
the lungs using techniques that do not require an
endotracheal airway.”

5. WHERE TO USE NIV??
A) Acute respiratory failure
1. Hypercapnic acute respiratory failure
• Acute exacerbation of COPD
• Post extubation
• Weaning difficulties
• Chest wall deformities/ neuromuscular disease
• Cystic fibrosis
• Status asthmaticus
• Acute respiratory failure in obesity hypoventilation
INDICATIONS

6. 2)Hypoxemic acute respiratory failure
• Cardiogenic pulmonary edema
• Community acquired pnemonia
• ARDS
• Weaning difficulties

8. B)Chronic respiratory failure
C)Immuno-compromised patients
D)Do not intubate patients
E) Post surgical respiratory support

9. WHY TO USE NIV ?? (Advantages)WHY TO USE NIV ?? (Advantages)
1) Noninvasiveness
Avoids the complications of endotracheal intubation
- Early (local trauma, aspiration)
- Late (injury to the the hypopharynx, larynx, and
trachea, nosocomial infections)
2 ) Ease of application
- Easy to implement
- Easy to remove

10. 3) Allows intermittent application
4) Can be used in non ICU settings
5) Improves patient comfort
6) Reduces the need for sedation
7) Oral patency (preserves speech,
swallowing, and cough)

11. Disadvantages of NIVDisadvantages of NIV
1.System
– Increased initial time commitment,
– Gastric distension
– manpower consuming
2.Mask
- Air leakage
- Eye irritation
- Facial skin necrosis/ulcers
3.Lack of airway access and protection
- Suctioning of secretions

12. WHAT IS THE SELECTION CRITERIA ??WHAT IS THE SELECTION CRITERIA ??
A) ACUTE RESPIRATORY FAILURE
Atleast 2 of the following criteria must be
present
1. Respiratory distress with dyspnoea
2. Use of accessory muscles of respiration
3. Abdominal paradox
4. Respiratory rate > 24/min
5. ABG shows pH< 7.35 or PaCO2 >45 mmHg
or PaO2/FiO2 <200

13. B) CHRONIC RESPIRATORY
FAILURE( OBSTRUCTIVE LUNG
DISEASE)
1. Fatigue, Hypersomnalence, dyspnea
2. ABG shows Ph<7.35. Paco2>55 mmHg
3. Oxygen saturation <88% for >10 min
despite O2 supplementation

14. C) THORACIC RESTRICTIVE/CEREBRAL
HYPOVENTILATION DISEASES
1. Fatigue, morning headache, hypersomnalence,
nightmares, enuresis, dyspnea
2. ABG shows PaCo2 >45 mmHg
3. Nocturnal SaO2 <90% for more than 5 minutes
sustained
Eg: Muscular dystrophy
Multiple sclerosis
Amyotrophic lateral scloresis
Kyphpscoliosis

15. WHAT TO SEE BEFORE STARTING NIV ??WHAT TO SEE BEFORE STARTING NIV ??
• Cardiac or respiratory arrest
• Nonrespiratory organ failure
Severe encephalopathy (eg, GCS <10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac arrhythmia
• Facial or neurological surgery, trauma, or deformity
• Upper airway obstruction
• Inability to cooperate/protect airway
• Inability to clear secretions
• High risk for aspiration

16. WHAT EQUIPMENTS ARE REQUIRED FOR NIV???WHAT EQUIPMENTS ARE REQUIRED FOR NIV???

17. • PORTABLE NIV MACHINES
– Advantages
• Portability
• Ease of use
– Disadvantages
• Cannot develop pressures >30cm H2O
• Lack of sophisticated alarm systems, battery backup
• CRITICAL CARE VENTILATORS

18. PRESSURE MODES
Better tolerated than
volume‐cycled vents
– Constant positive airway
pressure(CPAP)
– Bilevel or biphasic
positive airway pressure
(BiPAP)
– Pressure support
ventilation(PSV)
VOLUME MODES
Initial tidal volumes
range from 10 to 15 mL/kg
– Control
– Assist control
– Proportional assist control
WHAT ARE THE MODES OF NIV ??WHAT ARE THE MODES OF NIV ??

19. © 2014 ResMed I
MODES OF NIV
19
CPAP - Pure Obstructive Sleep Apnea, Cardiogenic Pulmonary Oedema
S Mode – Best for spontaneously breathing patients (chronic RF), if breathing efforts
are good – there is good synchrony with the ventilator – but be cautious of apneas
ST Mode - Patients with central hypoventilation, significant central apneas,
inappropriately low respiratory rate, and those who unreliably trigger (mode of choice in
Acute RF)
T Mode – Rarely Used. Can be tried in patients failing ST – on max pressures, or as a
rescue mode if invasive vent not available
PAC Mode – Mainly used in weaning off from invasive vent, or recovery from acute
injury (similar to PACV mode in invasive vent)
iVAPS - Best for chronic use with changing lung compliance over a longer period –
excellent results in OHS, Restrictive Diseases, Chronic COPD. For acute scenario,
clinical investigations underway – to be used with caution

20. © 2014 ResMed I
COMMON SETTINGS IN NIV
To be prescribed
•Mode
•EPAP
•IPAP
•Backup Rate / Target Patient Rate
•Inspiratory time (minimum and maximum)
•(Inspiratory) Trigger Sensitivity
•Cycle (Expiratory Trigger) Sensitivity
•Rise Time
Important but often missed
•Mask Type
•Tube Type
•AB Filter
20

21. CPAP
• Continuous Positive
Airways Pressure
– Same pressure (5‐10 cmH2O)
throughout respiratory cycle
• Increases intra‐alveolar and
intra‐bronchiolar pressure
– Recruits alveoli
– Dec Pulmonary oedema
– Increase FRC
– Dec WOB
5‐10cmH2O

22. BIPAP
• Bi‐level Positive Airways
Pressure
– Lower positive pressure
during expiration (EPAP)
(equivalent to CPAP)
– Higher positive airways
pressure during
inspiration (IPAP)
5‐10cmH2O12‐20cmH2O
IPAPEPAP

23. BIPAP
• EPAP (PEEP)
– Recruits alveoli
– Increases VQ matching
– Improves oxygenation
• IPAP – EPAP (pressure support)
– Increases tidal volume
– Reduces CO2
– Improves Ventilation and
decrease work of breathing
5‐10cmH2O
12‐20cmH2O
IPAP
EPAP

24. © 2014 ResMed I
BACKUP RATE / TARGET PATIENT RATE
• Target Patient Rate is the rate where you want your patient to be ideally
breathing
• This is usually higher in case of patients with restrictive disorders
• The backup rate should be set to 3-4 breaths less than the target patient
rate – this prevents aschrony, while also ensuring adequate ventilation
• The S Mode does not require a backup rate
24

25. WHAT IS INTERFACE??
“The device that makes physical contact between
the patient and the ventilator is termed the
Interface.”
• Interfaces should be comfortable,
offer a good seal,
minimize leak,
limit dead space

26. CHOOSING THE INTERFACECHOOSING THE INTERFACE

27. Nasal Masks
360°
swivel
standar
d elbow

28. Anatomic Landmarks for
Nasal Mask Fit
• Anatomic LandmarksAnatomic Landmarks
a)a) Sides of noseSides of nose
b)b) Bridge of noseBridge of nose
(caution)(caution)
c)c) Above the lipAbove the lip
Foam “bridges” that attach to the end of the mask and rest on the
forehead help reduce pressure on the bridge of the nose.
Nasal template to size.

30. Full Face Masks
• Most often successful in the critically ill patient
Full Face Mask
Entrainment
valve
Adjustable
Forehead Support
Ball and
Socket Clip
Double-foam
cushion
Pressure
pick-off
port

31. Fitting Full Face Mask
• Landmarks
a) Below the lower lip
with mouth open
b) Corners of the
mouth
c) Just below the
junction of nasal
bone and cartilage
1
a
b
c
b

33. Pillow Cushion
Nasal Cushion
Nasal Pillows
to seal nares
Nasal pillows/cushions

35. 1. Appropriately monitored location, oximetry, respiratory impedance, vital signs as clinically indicated
2. Patient in bed at >30 angle
3. Select ventilator
4. Select interface, check fit
5. Connect interface to ventilator tubing and turn on ventilator, hold the mask initialy
6. Apply headgear; avoid excessive strap tension (one or two fingers under strap)
7. Start with low pressure in spontaneously triggered mode with backup rate; pressure limited: 8 to 10
cm H2O inspiratory pressure; 4 to 5 cm H2O expiratory pressure; PS 5-6 cm of H2O. CPAP is 5 cm of
H2O
8. Gradually increase inspiratory pressure IPAP should be increased by 2–3 cm increments at a rate of
approximately every 10 mins, with a usual IPAP target of 20 cm H2O (10 to 20 cm H2O) as tolerated to
achieve alleviation of dyspnea, decreased respiratory rate, increased tidal volume (if being monitored),
and good patient-ventilator synchrony
9. Provide O2 supplementation as need to keep O2 sat >90 percent
10. Check for air leaks, readjust straps as needed
11. Add humidifier as indicated
12. Monitor blood gases (1 Hour)

36. O2CO2

37. WHAT TO MONITOR??WHAT TO MONITOR??

38. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??

39. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??
Goals

40. HOW TO WEAN FROM NIV??HOW TO WEAN FROM NIV??
No NO
Continue with
NPPV therapy
Continue with
NPPV therapy
Does
patient meet
weaning
guidelines? Clinically stable
 RR < 24
 HR < 110
 pH > 7.35
 SpO2 >90%
on< 50% If patient status does
not improved consider
intubation
NO
YES
Restart NPPV at
previous settings
Restart NPPV at
previous settings
YES
Trial off NPPV with
supplemental
oxygen
Trial off NPPV with
supplemental
oxygen
Slowly titrate IPAP
downward in decrements
of 2-3 cm H2O
Slowly titrate IPAP
downward in decrements
of 2-3 cm H2O
Does
patient demonstrate
clinical evidence
of respiratory
distress?
Discontinue NPPV and place on
supplemental oxygen

41. •Worsening pH and arterial partial pressure of carbon
dioxide (PaCO2 )
•Tachypnea (over 30 breaths/min)
•Hemodynamic instability
•Oxygen saturation by pulse oximeter (SpO2 ) less than 90%
•Decreased level of consciousnees
•Inability to clear secretions
•Inability to tolerate interface
WHEN TO TERMINATE NIV AND SWITCH TOWHEN TO TERMINATE NIV AND SWITCH TO
INVASIVE MECHANICAL VENTILATION??INVASIVE MECHANICAL VENTILATION??
Call for
help !!

43. Claustrophobia
1. Try using a nasal interface or,
2. Try using a total face mask, or
3. Try mild sedation (use caution).
Gastric Insufflation (Aerophagia) and Gastric Distention
1. Excessive pressure or air swallowing can cause
air gastric inflation (insufflation) and gastric
distention
2. Use pressures less than 20 to 25 cm H2O

44. Use of Nasogastric Tubes
1.The tube increases leaking around the mask
2.The tube itself blocks a nasal passage
3.Compression of tube against the skin by the mask
may increase risk of skin breakdown
NG tube applied to groove
Flat surface applied on patient’s
face
Mask interface across beveled
side
NG Sealing PadNG Sealing Pad

45. Eye Irritation
1. Eye irritation may result from air blowing in the eye
2. Be sure mask fit is appropriate
3. Spacers used on the forehead or the bridge of the
nose
4. Readjust headgear straps

46. Skin Problems Due to Interface
1. Pressure lesions (skin
breakdown, necrosis) if mask
is to tight or left on for
extended periods of time
2. Use of skin dressings
Possible Solutions to Skin Irritation
1.Use the least amount of pressure to fit the mask that
still prevents excessive leaks
2.Use spacers
3.Alternate devices to reduce skin breakdown
4.Use a skin barrier lotion and/or topical corticosteroids

47. Nasal or Oral Dryness, Nasal Congestion, Mucus
Plugging
When these problems occur, possible solutions include
the following:
1. Add or increase humidification
2. Irrigate nasal passages with a saline spray
3. Use topical decongestants or steroids

48. Hypotension
1. If hypotension was present prior to therapy,
treat the cause
2. Be sure ventilating pressures are not excessively
high (peak pressures < 20 cm H20)
1.Maintain a policy of selecting patients appropriately
for NPPV patients who can protect their own airway
Risk of Aspiration