- NIV Definition ++ Noninvasive ventilation (NIV): is defined as a ventilatory mode that delivers a mechanical ventilatory support breath without use of an endotracheal tube or surgical airway, but using a tight-fitting face or nasal mask,. . . Cee * NiVisaclinical decision [4 * Respiratory failure in the ED is almost always—and most appropriately—a clinical diagnosis. * The decision to intubate and mechanically ventilate or to institute noninvasive ventilation support > is generally made purely on clinical grounds without delay for laboratory evaluation. Types of NIV Ci “it is of two types: CPAP & BiPAP. o CPAP does not directly increase tidal volume or minute ventilation. o In contrast, bilevel positive airway pressure (BiPAP) provides supplemental inspiratory tidal volume.Indications for the use of NIV Ci a NIVis commonly used for the treatment of respiratory failure from: * Absolute Indications: o Exacerbation of chronic obstructive airways disease (COPD). o Pulmonary oedema. o Respiratory failure in immunocompromised patients. E.g. AIDS, malignancy. 0 Weaning from conventional ventilation and prevention of need for reintubation in high risk patients. © Chest trauma. o Asthma. . . . * Relative Indications Q * Community acquired © Idiopathic Pulmonary Pneumonia Fibrosis. * Immunocompromised © Support during invasive patients with hypercapnic procedures i.e.. respiratory failure. Bronchoscopy © Asthma * Pneumocystis carinii © Rib fracture (Traumatic = renee with non penetrating 5 pee SE chest injury). Diseases. * Do-not - intubate status in terminal illness or malignancies.. . * Contra Indications im “Absolute: * Coma Cardiac arrest * Respiratory arrest Any condition requiring Intubation. * Non-compliant patient Relative Contraindications i Cardiac instability — Shock and need for pressor support Ventricular dysrhythmias Complicated acute myocardial infarction Gl bleeding (- intractable emesis and/or uncontrollable bleeding) o Inability to protect airway = Impaired cough or swallowing — Poor clearance of secretions — Depressed sensorium and lethargy Status epilepticus Potential for upper airway obstruction Extensive head and neck tumors Any other tumor with extrinsic airway compression ‘Angioedema or anaphylaxis causing airway compromise IGuidelines for providing NIV Ci “© Duration of treatment > Patients who benefit from NIV during the first 4 hours of treatment should receive NIV for as long as possible (a minimum of 6 hours) during the first 24 hours (Evidence A) > Treatment should last until the acute cause has resolved, commonly after about 3 days > When NIV is successful (pH>7.35,resolution of cause, normalization of RR) after 24 hrs/more >-plan weaning Protocol for initiation of NIV Ci v 1. Appropriately monitored location v 2. Patient in bed or chair sitting at > 30-degree angle ¥ 3A full-face mask should be used for the first 24 hours, followed by switching to a nasal mask if preferred by the patient (Evidence C) v 4.Encourage patient to hold mask v 5. Apply harness; avoid excessive strap tension v6 .Connect interface to ventilator tubing and turn on ventilator v 7. Check for air leaks, readjust straps as neededGuidelines for providing NIV Ci > 1.An initial IPAP of 10 cm H20 & EPAP of 4-5 cm H20 should be used (Evidence A). » 2.IPAP should be increased by 2-5 cm increments at a rate of approximately 5 cm H20 every 10mins, with a usual IPAP target of 20 cm H20 or until a therapeutic response is achieved or patient tolerability has been reached (Evidence A). > 3. 02 should be entrained into the circuit and the flow adjusted to SpO2 >88-92% (Evidence B) (BTS: NIV in COPD: management of acute type 2 respiratory failure) OXYGENATION AND HUMIDIFICATION i + Oxygen is titrated to achieve a desired oxygen saturation of 90% to 92%. v Use of oxygen blenders Y Adjusting liter flow delivered via oxygen tubing connected directly to the mask or ventilator circuit v Heated blow over vaporizer should be used if longer application intended.Bronchodilators Ci = Preferably administered off NIV = If necessary be entrained between the expiration port and face mask = Delivery of both oxygen and nebulized solutions is affected by NIV pressure settings (Evidence A) “+ If a nasogastric tube is in place, a fine bore tube is preferred to minimize mask leakage(Evidence C). Criteria for Terminating NIV and Switching te Mechanical ventilation > Worsening pH and PaCO2 > Tachypnea (over 30 bpm) > Hemodynamic instability > SpO2 < 90% » Decreased level of consciousness > Inability to clear secretions > Inability to tolerate interfaceWeaning strategy(A) Ci > 1. Continue NIV for 16 hours on day 2 > 2.Continue NIV for 12 hours on day 3 including 6-8 hours overnight use » 3.Discontinue NIV on day 4, unless continuation is clinically indicated. Assess ment import ee of NIVInterface for delivery of NIV Total face Mask Equally comfortable + Similar ~Application times ~Early NIV discontinuation rates Improvements in val signs and gas exchange Intubation and mortality rate.+ Nasal masks fi * Better tolerated than full face masks for longterm &chronic applic: ions * Less claustrophobia and discomfort and allow eating, conversation, and expectoration Nasal Masks Pressure over nasal bridge ~ forehead spacers —ultrathin silicon seals or heat-sensitive gels that minimize skin trauma * Problem- Air leakage through mouthCPAP Ci O Continuous positive airways pressure (CPAP) : implies application of a preset positive pressure throughout the respiratory cycle (i.e. inspiratory and expiratory phases) ina spontaneously breathing patient. CPAP Normal Respiration. CPAP: Provides static positive airway pressure throughout the respiratory cycle- both inspiration & expiration. * Facilitates inhalation by reducing pressure thresholds to initiate airflow.How CPAP works? Ci 1.CPAP splints the airway throughout the respiratory cycle, 2. Increases “* (FRC) the functional residual capacity of the lungs by holding airways open and preventing collapse. 3.Also causes the patient to breathe at higher lung volumes, making the lungs more compliant 4. Provides effective chest wall stabilization, 5. Improves ventilation-perfusion mismatch and thereby improves oxygenation. Benefits of CPAP ci 4.02 saturation Work of breathing ¥ cardiac workload by(% /ntrathoracic Pressure which will ) preload ).Use of CPAP i * 1.In the U.K., guidelines call for using CPAP with patients being weaned from ventilation; patients who are hypoxemic following extubation; or patients with a variety of acute conditions “who are hypoxic but not exhausted” (i.e., those who are ventilating themselves adequately). * 2.0SA ( obstructive sleep apnoea syndrome) OSA ( Obstructive Sleep Apnoe Ci * Sleep-disordered breathing (upper airway obstruction during sleep) occurs in around 20% of the adult population. It ranges from snoring to obstructive sleep apnoea (OSA), the latter being characterized by cessation of breathing for at least 10 s in the presence of inspiratory effort. * The incidence of clinically relevant OSA has been estimated to be around 22% in the general surgical population, with 70% of patients being undiagnosed at preoperative evaluation. * Patients with OSA are at increased risk of perioperative complications: including hypoxaemia, hypercapnoea, arrhythmias, myocardial ischaemia, delirium, and unplanned intensive care unit admissions.+ BiPAP( Bilevel Positive Airway Pressu Qi Q BIPAP: has two levels of continuous airway pressure. . IPAP: When the machine senses the patient's inspiratory flow starting to increase, it increases the inspiratory pressure applied, so that air flow is enhanced and the patient's own inspiratory tidal volume is augmented. EPAP. When the machine senses flow is slowing or stopped, it reduces the applied airway pressure so the patient has less work upon exhaling, but maintains a continuous positive expiratory pressure. BiPAP Ci ae TPAP (10) Pressure Sup} ie EPAP (5) “ TimeBiPAP Increases in inspiratory pressure are helpful to alleviate dyspnea * Increases in expiratory pressure are better to improve oxygenation BiPAP ee a Me eed LF)Ventilator settings Ci * IPAP/EPAP ~> start with 10/5 cm H20 (With a goal to achieve VT of 6-7ml/kg) * Increase IPAP > by 2cmH20 increments up to maximum 20-25 cm H20, if hypercapnia persists. Do not exceed 25cm H2O at any point of time. * Increase EPAP > by 2 CmH20 if hypoxia, maximum 10-15 cm H20. * Back up respiratory rate > 12-16/minute. * FIO2 > 1.0 to be adjusted to have SaO02 90% Which initial pressure settings to use fo ci BiPAP® spontaneous mode? Q Commonly the IPAP is set to 10 cmH,0 and the EPAP to 5cmH,0. o The response to these pressures should determine future changes. o Most machines can generate maximal pressures of 20-23 cmH,0. o If higher pressures are required leakage around the mask is usually a problem, and conventional invasive ventilation is indicated.What FiO, to choose? Ci + Choose an initial FiO, slightly higher to that what the patient received prior to NIV. > Adjust the FiO, to achieve an $aO, that you deem appropriate for their underlying disease. (Generally $a0, above 92% is acceptable). > Ifa patient is hypoxic while breathing 100% oxygen ona CPAP circuit, their hypoxia will not improve if they are placed onto a BiPAP circuit (in spite of the increased ventilatory assistance) because the FiO, will drop significantly. > Similarly if a patient starts to work harder on a BiPAP circuit they may become more hypoxic due to a drop in FiO, caused by increased gas flow through the breathing circuit. How to monitor the patient’s Ci response to NIV? * The most useful indicator is > How the patient feels. Patient compliance is the best indicator. (Patient should be able to tell you if feels better or worse). * Where available arterial blood gases (ABG) are useful to assess > changes in oxygenation and CO, clearance.Ci Predictor of Success of NIV With a trial of ventilation for 1-2 hours > Normally Leads to = Decrease in PaCO2 greater than 8 mm Hg = Increase in pH greater than 0.06 How to Predict failure? ci Q Again, this is largely based on how the patient feels and ABG results. “+ If the patient is getting increasingly tired, or their ABG deteriorating despite optimal settings, then they will probably need tracheal intubation and mechanical ventilation. “> It is important to recognize the failure to respond as soon as possible so that management may be planned before the patient collapses.Predictor of Failure Ci “+ Severity of illness: — Acidosis (pH <7.25) — Hypercapnia (>80 and pH <7.25) — (APACHE II) score higher than** 20.(Acute Physiology and Chronic Health Evaluation II) * Level of consciousness: — Neurologic score > 4 . (stuporous, arousal only after vigorous stimulation; inconsistently follows commands) — Encephalopathy score >3 .( major confusion, daytime sleepiness or agitation) — Glasgow Coma Scale score lower than < 8. “Failure to improve with 12-24 hours of NIV A ** BiPAP can only augment the patient's respiration; it should not be used as a primary form of ventilation. OThe tidal volume received by the patient depends upon: Y airway resistance, ¥ lung and chest wall compliance Y patient synchrony with machine, v and the absence of air leakage around the mask.Monitoring i > BP, RR, HR & rhythm, O2 saturation, Levei of conscious state. > Treatment tolerance. © Initially,@ 15 minutely for 1 hour, @30 minutely for 2 hours, @ 1 hourly for 2 hours, then 4 hourly » SPO2: Aiming for 94-98% (or 88-92% in COZ retainers). > ABGs > Prior to commencement, at 1 hour, within 1 hour of setting changed, then as clinically needed. Advantages of NIV Ci » Decreases incidence of Intubation. > Decreases Mortality. > Decreases ICU & Hospital Stay. > VAP can be avoided. > Intubation related complications can be avoided. > Cost effective.Complications Ci 1.Facial & Nasal pressure injury. * 2.Gastric distention * 3.Drying of mucous membranes of nose, nasal congestion & thick secretions. © 4.Aspiration of Gastric contents. * 5.General discomfort * 6.Claustrophobia Literature review Ci *%A 1995 study in the New England Journal of Medicine found> BiPAP reduced the need for endotracheal intubation, as well as hospital length of stay and mortality, in acutely ill COPD patients with a > PaO, less than 45 mm Hg, (pH) level less than 7.35, and (RR) greater than 30 breaths/minute. **A 2003 Cochrane review of studies with mostly COPD patients also found that BiPAP> J decreased mortality, incidence of ventilator-associated pneumonia, ICU and hospital length of stay, total duration ofStrong Evidence — Level A (multiple Ci controlled trials) * Acute hypercapnic COPD * Acute cardiogenic Pulmonary Oedema — most evidence for CPAP ¢ Immunocompromised patients + Less strong — Level B (single controlled trials, multiple case series) * Asthma * Community Acquired Pneumonia in COPD patients * Facilitation of weaning in COPD * Avoidance of extubation failure * Post Operative Respiratory Failure * Do not intubate patients Weak Evidence (few case series). ci ( No benefit in controlled trials) ¢ ARDS ¢ Community acquired pneumonia — non COPD * Cystic fibrosis ¢ Weaning — non COPD * OSA/ obesity hypoventilation ¢ TraumaNot indicated Cy o Acute deterioration in DILD. o Severe ARDS with multi organ failure. o Post op Upper airway, esophageal surgery. Present Status of NIV Hi * The application of mechanical ventilatory support through a mask in place of endotracheal intubation is becoming increasingly accepted and used in the emergency department & ICU settings.Summery Ci ¥ COPD is the most suitable condition for noninvasive ventilation. ¥ Noninvasive ventilation is most effective in patients with moderate-to-severe disease. v Hypercapnic respiratory acidosis may define the best responders (pH 7.20-7.30). — Noninvasive ventilation is also effective in patients with a pH of 7.35-7.30, but no added benefit is appreciated if the pH is greater than 7.35. — The lowest threshold of effectiveness is unknown, but success has been achieved with pH values as low as 7.10. ¥ Obtunded COPD patients can be treated, but the success rate is lower. ¥ Improvement after a 1- to 2-hour trial may predict success.