non invasive ventilation conference

8/6/2019 Non Invasive Ventilation Conference

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Non Invasive VentilationNon Invasive VentilationNon Invasive VentilationNon Invasive Ventilation

Dr.Balamugesh, MD, DM,

Dept. of Pulmonary Medicine,Christian Medical College,

Vellore.


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Definition..Definition..

Noninvasive ventilation is the delivery of

ventilatory support without the need for an

invasive artificial airway


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How does NIV work?How does NIV work?

Reduction in inspiratory muscle workand avoidance of respiratory musclefatigue

Tidal volume is increased CPAP counterbalances the inspiratory

threshold work related to intrinsicPEEP.

NIV improves respiratory systemcompliance by reversingmicroatelectasis of the lung.


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Advantages ofNIVAdvantag

es ofNIV

Noninvasiveness

Application (compared with endotracheal intubation)

a.Easy to implement b. Easy to remove Allows

intermittent application

Improves patient comfort

Reduces the need for sedationOral patency (preserves speech, swallowing, and

cough, reduces the need for nasoenteric tubes)


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Avoid the resistive work imposed by the

endotracheal tube

Avoids the complications of endotracheal

intubation

Early (local trauma, aspiration)

Late (injury to the the hypopharynx, larynx, andtrachea, nosocomial infections)


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Disadvantages ofNIVDisadvantages ofNIV

1.System

Slower correction of gas exchange abnormalities

Increased initial time commitment

Gastric distension (occurs in


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3.Lack of airway access and protection

Suctioning of secretions

aspiration


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Location of NIVLocation of NIV

NIV can be administered in the emergencydepartment, intermediate care unit, or generalrespiratory ward


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Who can administer NIV?Who can administer NIV?

by physicians, nurses, or respiratory caretherapists,

depends on staff experience and availabilityof resources for monitoring, and managingcomplications

For the first few hours, one-to-one monitoringby a skilled and experienced nurse,

respiratory therapist, or physician ismandatory.

Immediate access to staff skilled in invasiveairway management.


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InterfaceInterface

Nasal masks

less dead space

less claustrophobia

allow for expectoration

vomiting and oral intake

vocalize

facial mask

dyspnoeic patients

are usually mouthbreathers

More dead space


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Mask: orofacial vs nasalMask: orofacial vs nasal

similar with regard toimproving vital signs and gas

exchange and avoidingintubation

nasal mask was less well

tolerated mainly due togreater air leakagethrough mouth Crit Care Med. 2003 Feb;31


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Helmet vs facial

mask

Helmet vs facial

mask

Complications (skin necrosis,

gastric distension, and eye

irritation) were fewer with

helmet

allowed prolonged continuous

application ofNIV

Length of stay in ICU,intubation rates, mortality

similar

Intensive Care Med. 2003;29 CritCare Med. 2002;30

Chest. 2004;126


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Position of exhalation port and mask design

affect CO2 rebreath

ing during NIV

Position of exhalation port and mask design

affect CO2 rebreath

ing during NIV

facial mask with exhalation port within the

mask compared with port in the ventilatorcircuit

smallest mask volume

less rebreathed CO2

inspiratory load

Crit Care Med. 2003 Aug;31


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Humidification during NIVHumidification during NIV

No humidification: drying of nasal mucosa;

increased airway resistance; decreased

compliance.

HME lessens the efficacy ofNIV

Only pass-over humidifiers should be

used

Intensive Care Med. 2002;28


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Aerosol bronchodilator delivery during NIVAerosol bronchodilator delivery during NIV

optimum nebulizer position: between the leak port and

patient connection

Optimum ventilator settings: high inspiratory pressure

and low expiratory pressure.

Optimum RR 20/mt. Rather than 10/mt. 25% of salbutamol dose may be delivered

Crit Care Med. 2002 Nov;30


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Desirable to deliver the aerosolizedbronchodilator without removing the

patient from NIV ? aerosol delivery in systems in which

the leak port is in the mask or in which aleak port of different design

? Nebulizer was maintained in thevertical position


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Uses of NIVUses of NIV1. COPD. Acute exacerbation/domiciliary.

2. Cardiogenic pulmonary edema.

3. Bronchial asthma

4. Post extubation RF

5. Hasten weaning.


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COPD EXACERBATION: NIVCOPD EXACERBATION: NIV success rates of 80-85%

increases pH, reduces PaCO2, reduces

the severity of breathlessness in first 4 h

of treatment

decreases the length of hospital stay

Mortality, intubation rateis reduced

GOLD 2003


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CRITERIA FOR NIV IN ACUTE

EXACERBATION OF COPD

CRITERIA FOR NIV IN ACUTE

EXACERBATION OF COPD GOLD 2005


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Cardiogenic Pulmonary edema.Cardiogenic Pulmonary edema. sufficiently high level evidence to favor the

use of CPAP,

there is insufficient evidence to recommend

the use of BiPAP, probably the exception

being patients with hypercapnic CPE.


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MethodologyMethodology

Initial ventilator settings: CPAP (EPAP) 2 cmH2O & PSV (IPAP) 5 cm H20.

Mask is held gently on patients face. Increase the pressures until adequate Vt

(7ml/kg), RR90%. Keep peak pressure


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MonitoringMonitoring

ResponsePhysiological a) Continuous oximetry

b) Exhaled tidal volume

c) ABG should be obtained with 1 hour and, asnecessary, at 2 to 6 hour intervals.

Objective a) Respiratory rateb) blood pressure

c) pulse rate

Subjectivea) dyspneab) comfort

c) mental alertness


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Monitoring..Monitoring..Mask

Fit, Comfort, Air leak, Secretions, Skin necrosis

Respiratory muscle unloading

Accessory muscle activity, paradoxical

abdominal motion

Abdomen

Gastric distension


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First 30 min. of NPPV is labor intensive.

Bedside presence of a

respiratory therapist or nurse

familiar with this mode is essential.Providing reassurance and adequate explanation

Be ready to intubate andstart on invasive

ventilation.


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Criteria to discontinue NIVCriteria to discontinue NIV Inability to tolerate the mask because of discomfort or

pain

Inability to improve gas exchange or dyspnea Need for endotracheal intubation to manage secretions

or protect airway

Hemodynamic instability

ECG ischemia/arrhythmia Failure to improve mental status in those with CO2

narcosis.


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Eur Respir J 2002; 20:

non invasive ventilation conference

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