Non Invasive Ventilation Update

Dean R. Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care Noninvasive Ventilation: Update 2010

NIV versus CPAP CPAP = EPAP = PEEP No ventilation assistance with CPAP

Mask CPAP ,[object Object],[object Object],[object Object],[object Object]

Evidence for NIV COPD Exacerbations ★★★★★ Acute cardiogenic pulmonary edema ★★★★ Prevent extubation failure ★★★ Transplantation, immunocompromise ★★ Respiratory failure following lung resection ★ Acute hypoxemic respiratory failure ? Asthma ? Do not intubate/Do not Resuscitate ★ /− Failed extubation −

COPD Exacerbation ,[object Object],[object Object],[object Object],Picot, Cochrane Database of Systematic Reviews 2008

Cardiogenic Pulmonary Edema ,[object Object],[object Object],[object Object],[object Object],Vital, Cochrane Database of Systematic Reviews 2008

Post-Extubation NIV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hypoxemic Respiratory Failure ,[object Object],[object Object],Ferrer, Am J Respir Crit Care Med 2003; 168:1438 The literature does not support the routine use of NIV in all patients with acute hypoxemic respiratory failure. Keenan, Crit Care Med 2004; 32:2516

NIV for Acute Asthma ,[object Object],[object Object],Soroksky, Chest 2003; 123:1018

[object Object],[object Object],[object Object],N Engl J Med 2001;344:481

Nosocomial Pneumonia NIV compared with invasive mechanical ventilation patients assigned to NIV or invasive mechanical ventilation patients assigned to NIV or standard therapy Hess, Respir Care 2005;50:924

Patient Selection for NIV ,[object Object],[object Object],[object Object],[object Object],Step 1: Patient needs mechanical ventilation

Exclusions for NIV ,[object Object],[object Object],[object Object],[object Object],Step 2: No exclusions for NIV

When to Stop ,[object Object],[object Object],[object Object],[object Object],When to Transfer to ICU ,[object Object],[object Object],[object Object]

Is NIV Appropriate? Is NIV NOT Appropriate? When To Stop?

The Interface ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

nasal total face oronasal pillows mouthpiece helmet

Choice of Interface ,[object Object],[object Object],[object Object],[object Object],[object Object]

Mouth Leak ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Oronasal mask; coaching?; chin strap?

Skin Breakdown ,[object Object],[object Object],[object Object],[object Object],photo courtesy Dr. Nick Hill

Ventilators for NIV ,[object Object],Trigger Pressure vs volume (PCV vs PSV vs PAV) Rise time Cycle Back-up rate

AVAPS: Average Volume Assured Pressure Support ,[object Object],[object Object],[object Object]

blower & pressure controller single hose leak ,[object Object],[object Object],[object Object],[object Object],[object Object],mask

Inhaled Bronchodilators ,[object Object],[object Object],Hess, J Aerosol Med 2007; 20:S85 Iosson, N Engl J Med 2006; 354:e8

Managing Dys-Synchrony ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Practical Application ,[object Object],[object Object],[object Object],[object Object]

Complications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(Complications are usually minor)

NIV Success clinician skills equipment selection patient selection

Non Invasive Ventilation Update

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Notes de l'éditeur