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NON-INVASIVE VENTILATION
Objectives:
•   Definitions
•   Advantages and Disadvantages
•   Indications
•   Contraindications
•   Modes
Non-invasive ventilation

“The delivery of mechanical ventilation to the lungs
using techniques that do not require endotracheal
 intubation”
Background
• Initially used in the treatment of hypoventilation
  with Neuromuscular Disease

• Now accepted modality in treatment of acute
  respiratory failure
Respiratory mechanics
• Respiratory effort required for inspiration needs
  to overcome
   – Elastic work (stretch)
   – Flow resistance work ( airway obstruction)

• Respiratory failure – forces opposing inspiration
  exceed respiratory muscle effort
Respiratory failure
Failure to maintain adequate gas exchange

• Hypoxic                   ( Type 1)
  or
  Hypercapnic /Hypoxic      (Type 2)

• Acute /Chronic / Acute on Chronic
Effects of NIV
• Improves alveolar ventilation to reverse
  respiratory acidosis and hypercarbia

• Recruits alveoli and increases FRC to reverse
  hypoxia

• Reduces work of breathing
Advantages
Noninvasiveness

•   Application - easy to implement or remove
•   Improves patient comfort
•   Reduces the need for sedation
•   Oral patency
    (preserves speech, swallowing, and cough)
Advantages 2
• Avoid the 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
Disadvantages
1.System
  Slower correction of gas exchange abnormalities
  Gastric distension (occurs in <2% patients)

2.Mask
  Air leakage
  Eye irritation
  Facial skin necrosis (most common complication)
Disadvantages
3.Lack of airway access and protection
   Suctioning of secretions
   Aspiration

4. Compliance / claustrophobia

5. Work load and supervision
Which mode?
• Hypoxaemia = CPAP

• Hypercapnia and hypoxaemia= Bi Level
CPAP
  CONTINUOUS POSITIVE 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
Indications

 • Acute pulmonary oedema

 • Pneumonia
Bi-level Pressure Support

• Combination of IPAP and EPAP

Inspiratory PAP      = Pressure Support

Expiratory PAP       = CPAP
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
Indications for Bi Level

• Acute Respiratory Failure

• Chronic Airway Limitation/COPD

• Asthma?
When to use NIV/CPAP
• Indication: APO, COAD
• Contraindications excluded
• Assessment
   – Sick not moribund
   – Able to protect airway
   – Conscious/cooperative
   – Haemodynamic stability
• Premorbid state / Ceiling of therapy?
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
Complications

•   Hypoxia
•   Pulmonary barotrauma
•   Reduced cardiac output
•   Vomiting and aspiration
•   Pressure areas
•   Gastric distension
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
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
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
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
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
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
Treatment Failure
• Deterioration in condition

• Worsening or non improving ABG

• Intolerance or failure to coordinate with machine
Treatment Failure
• Back to the patient- ABC

• Medical therapy optimised

• Treatment of complications
Criteria to discontinue NIV
• Inability to tolerate the mask

• Inability to improve gas exchange or dyspnoea

• Need for endotracheal intubation

• Hemodynamic instability

• ECG – ischaemia/arrhythmia
Withdrawal of NIV
• Clinical improvement
• Aim for
   – RR<24
   – HR <110
   – pH>7.35
   – Sats >90% on <40%
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

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Non invasive ventilation

  • 2. Objectives: • Definitions • Advantages and Disadvantages • Indications • Contraindications • Modes
  • 3. Non-invasive ventilation “The delivery of mechanical ventilation to the lungs using techniques that do not require endotracheal intubation”
  • 4. Background • Initially used in the treatment of hypoventilation with Neuromuscular Disease • Now accepted modality in treatment of acute respiratory failure
  • 5. Respiratory mechanics • Respiratory effort 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 to maintain 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
  • 8.
  • 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 • Avoid the 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 Slower correction 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 airway access 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 CONTINUOUS POSITIVE 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 • Acute pulmonary 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 Bi Level • Acute Respiratory Failure • Chronic Airway Limitation/COPD • Asthma?
  • 19. When to use NIV/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
  • 22.
  • 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 • Deterioration in condition • Worsening or non improving ABG • Intolerance or failure to coordinate with machine
  • 30. Treatment Failure • Back to the patient- ABC • Medical therapy optimised • Treatment of complications
  • 31. Criteria to discontinue NIV • 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