non-invasive mv good news it works !!!!!!! warnings not always not for all know the technique be...
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NON-INVASIVE MV
Good news
• It works !!!!!!!
Warnings
• Not always• Not for all• Know the technique• Be skilled
(from Vitacca M. et al. AJRCCM 2001; 164: 638-641)
i-PSV and n-PSV delivered before andafter extubation in patients not weaned
Arterial Blood Gases
i-PSV
7.3859.1206
n-PSV
7.3861
210
pHPaCO2
PaO2/FIO2
T-tube
7.3369183
NIV
INTERFACESTUBING
MT
NURSES
LOCATION
PATIENTS
MONITORING
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
60% Hypercapnic
55% Hypoxic
Conclusions: Use of NIV as the initial ventilation strategy for AECOPD varies across hospitals. Institutions with greater use of NIV have lower rate of IMV usage and better outcomes.
Conclusions: Use of NIV as the initial ventilation strategy for AECOPD varies across hospitals. Institutions with greater use of NIV have lower rate of IMV usage and better outcomes.
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
Appropiate setting for long-term NPSVAppropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (n=23 hypercapnic COPD patients)
Appropiate setting for long-term NPSVAppropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (n=23 hypercapnic COPD patients)
(from Vitacca M. et al. Chest 2000)
-100
-75
-50
-25
0
25
50
75
100
VT f Pdi PTPdi PEEPi
Usual (IPS 16±3, EPAP 3.6±1.4)Physiological (IPS 15±3, EPAP 3.1±1.6)
Ch
ang
e (%
of
SB
)
(from Vitacca M. et al. MACD 2004; 61: 81-85)
Assessment of Physiologic Variablesand Subjective Comfort Under DifferentLevels of Pressure Support Ventilation*Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD;Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; andEnrico Clini, MD, FCCP†
Chest 2004; 126: 851-59
Assessment of Physiologic Variablesand Subjective Comfort Under DifferentLevels of Pressure Support Ventilation*Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD;Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; andEnrico Clini, MD, FCCP†
Chest 2004; 126: 851-59
Study protocolStudy protocol
Time (min)
SB (baseline)
10
V’E, PTP
0setting
V’E, PTPPao, IE RANDOM of ventilatorsRANDOM of ventilators
comfort
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
(from BTS Guideline Thorax 2002;57:192-211)
SVANTAGGI:
•non permette l’espettorazione, né l’alimentazione
•aumenta il rischio di aspirazione
•è altamente traumatica
maschera facciale
Punti critici
• 1- ponte nasale
• 2- lati della bocca
• 3- base inferiore del labbro
22
3
1
VANTAGGI:
•miglior controllo delle perdite
•pressioni più elevate
N.B. La protesi dentaria va rimossa
maschera nasale
Punti critici • 1- ponte nasale
• 2- narici
• 3- base del naso
verificare• 4- pervietà delle cavità nasali
22
3
1
VANTAGGI:
•stabile, comfort maggiore
•bocca libera
•spazio morto ridotto
•svariati modelli
SVANTAGGI:
•perdite d’aria dalla bocca
•maggior resistenza
N.B. La protesi dentaria va conservata
Major problems with mask Major problems with mask during NIV supportduring NIV support
Major problems with mask Major problems with mask during NIV supportduring NIV support
Air leaksSide-effectsSize
Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)
Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)
(from Criner GJ. et al. Chest 1999;116:667-675)
Mask leaksSkin irritationRhinitis / aerophagiaDiscomfort
4323138
%
30
40
50
60
70
Untaped Taped
MOUTH LEAKS IN NASAL NPPVMOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years)(n=9, hypercapnic=7, COPD=6, age 64 years)
MOUTH LEAKS IN NASAL NPPVMOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years)(n=9, hypercapnic=7, COPD=6, age 64 years)
(from Teschler H. et al. ERJ 1999; 14: 1251-1257)
PtcCO2 (mmHg)
0
20
40
60
Untaped Taped
Arousal Index (events h-1)
p<0.001 p<0.0002
Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)
Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)
(from Criner GJ. et al. Chest 1999;116:667-675)
Mask leaksSkin irritationRhinitis / aerophagiaDiscomfort
4323138
%
Tissue Necrosis Caused by Tissue Necrosis Caused by an Improperly Fitting Maskan Improperly Fitting Mask
… However, a chinstrap was required to reduce oral leak in the majority of subjects using the nasal mask.
(CCM 2002; 30: 602-608)
(Crit Care Med 2002; 30: 602-608)
Conclusions: Helmet NPPV is feasible and can be used to treat COPD patients with acute exacerbation, but it does not improve CO2 elimination as efficiently as does FM NPPV.
CRITERI PER LA SCELTA DELLA
MASCHERA
Esperienza dell’équipe
Considerazioni anatomiche
Modalità di ventilazione
Compliance e sensorio del
paziente
(from BTS Guideline Thorax 2002;57:192-211)
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification.
Crit Care Med 2002; 30:2515–2519
To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L*min-1
Respir Care 2004;49(3):270–275.
CONCLUSIONS Delivered oxygen concentration during BiPAP is a complex interaction between the leak port type, the site of oxygen injection, the ventilator settings, and the oxygen flow.Because of this, it is important to continuously measure arterial oxygen saturation via pulse oximetrywith patients in acute respiratory failure who are receiving noninvasive ventilation from a bi-level ventilator.