4. WHAT IS NON INVASIVE VENTILATIONWHAT IS NON INVASIVE VENTILATION????
“NIV is the delivery of mechanical ventilation to
the lungs using techniques that do not require an
endotracheal airway.”
5. WHERE TO USE NIV??
A) Acute respiratory failure
1. Hypercapnic acute respiratory failure
• Acute exacerbation of COPD
• Post extubation
• Weaning difficulties
• Chest wall deformities/ neuromuscular disease
• Cystic fibrosis
• Status asthmaticus
• Acute respiratory failure in obesity hypoventilation
INDICATIONS
9. WHY TO USE NIV ?? (Advantages)WHY TO USE NIV ?? (Advantages)
1) Noninvasiveness
Avoids the complications of endotracheal intubation
- Early (local trauma, aspiration)
- Late (injury to the the hypopharynx, larynx, and
trachea, nosocomial infections)
2 ) Ease of application
- Easy to implement
- Easy to remove
10. 3) Allows intermittent application
4) Can be used in non ICU settings
5) Improves patient comfort
6) Reduces the need for sedation
7) Oral patency (preserves speech,
swallowing, and cough)
11. Disadvantages of NIVDisadvantages of NIV
1.System
– Increased initial time commitment,
– Gastric distension
– manpower consuming
2.Mask
- Air leakage
- Eye irritation
- Facial skin necrosis/ulcers
3.Lack of airway access and protection
- Suctioning of secretions
12. WHAT IS THE SELECTION CRITERIA ??WHAT IS THE SELECTION CRITERIA ??
A) ACUTE RESPIRATORY FAILURE
Atleast 2 of the following criteria must be
present
1. Respiratory distress with dyspnoea
2. Use of accessory muscles of respiration
3. Abdominal paradox
4. Respiratory rate > 24/min
5. ABG shows pH< 7.35 or PaCO2 >45 mmHg
or PaO2/FiO2 <200
13. B) CHRONIC RESPIRATORY
FAILURE( OBSTRUCTIVE LUNG
DISEASE)
1. Fatigue, Hypersomnalence, dyspnea
2. ABG shows Ph<7.35. Paco2>55 mmHg
3. Oxygen saturation <88% for >10 min
despite O2 supplementation
14. C) THORACIC RESTRICTIVE/CEREBRAL
HYPOVENTILATION DISEASES
1. Fatigue, morning headache, hypersomnalence,
nightmares, enuresis, dyspnea
2. ABG shows PaCo2 >45 mmHg
3. Nocturnal SaO2 <90% for more than 5 minutes
sustained
Eg: Muscular dystrophy
Multiple sclerosis
Amyotrophic lateral scloresis
Kyphpscoliosis
15. WHAT TO SEE BEFORE STARTING NIV ??WHAT TO SEE BEFORE STARTING NIV ??
• Cardiac or respiratory arrest
• Nonrespiratory organ failure
Severe encephalopathy (eg, GCS <10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac arrhythmia
• Facial or neurological surgery, trauma, or deformity
• Upper airway obstruction
• Inability to cooperate/protect airway
• Inability to clear secretions
• High risk for aspiration
16. WHAT EQUIPMENTS ARE REQUIRED FOR NIV???WHAT EQUIPMENTS ARE REQUIRED FOR NIV???
17. • PORTABLE NIV MACHINES
– Advantages
• Portability
• Ease of use
– Disadvantages
• Cannot develop pressures >30cm H2O
• Lack of sophisticated alarm systems, battery backup
• CRITICAL CARE VENTILATORS
18. PRESSURE MODES
Better tolerated than
volume‐cycled vents
– Constant positive airway
pressure(CPAP)
– Bilevel or biphasic
positive airway pressure
(BiPAP)
– Pressure support
ventilation(PSV)
VOLUME MODES
Initial tidal volumes
range from 10 to 15 mL/kg
– Control
– Assist control
– Proportional assist control
WHAT ARE THE MODES OF NIV ??WHAT ARE THE MODES OF NIV ??
25. WHAT IS INTERFACE??
“The device that makes physical contact between
the patient and the ventilator is termed the
Interface.”
• Interfaces should be comfortable,
offer a good seal,
minimize leak,
limit dead space
28. Anatomic Landmarks for
Nasal Mask Fit
• Anatomic LandmarksAnatomic Landmarks
a)a) Sides of noseSides of nose
b)b) Bridge of noseBridge of nose
(caution)(caution)
c)c) Above the lipAbove the lip
Foam “bridges” that attach to the end of the mask and rest on the
forehead help reduce pressure on the bridge of the nose.
Nasal template to size.
29.
30. Full Face Masks
• Most often successful in the critically ill patient
Full Face Mask
Entrainment
valve
Adjustable
Forehead Support
Ball and
Socket Clip
Double-foam
cushion
Pressure
pick-off
port
31. Fitting Full Face Mask
• Landmarks
a) Below the lower lip
with mouth open
b) Corners of the
mouth
c) Just below the
junction of nasal
bone and cartilage
1
a
b
c
b
35. 1. Appropriately monitored location, oximetry, respiratory impedance, vital signs as clinically indicated
2. Patient in bed at >30 angle
3. Select ventilator
4. Select interface, check fit
5. Connect interface to ventilator tubing and turn on ventilator, hold the mask initialy
6. Apply headgear; avoid excessive strap tension (one or two fingers under strap)
7. Start with low pressure in spontaneously triggered mode with backup rate; pressure limited: 8 to 10
cm H2O inspiratory pressure; 4 to 5 cm H2O expiratory pressure; PS 5-6 cm of H2O. CPAP is 5 cm of
H2O
8. Gradually increase inspiratory pressure IPAP should be increased by 2–3 cm increments at a rate of
approximately every 10 mins, with a usual IPAP target of 20 cm H2O (10 to 20 cm H2O) as tolerated to
achieve alleviation of dyspnea, decreased respiratory rate, increased tidal volume (if being monitored),
and good patient-ventilator synchrony
9. Provide O2 supplementation as need to keep O2 sat >90 percent
10. Check for air leaks, readjust straps as needed
11. Add humidifier as indicated
12. Monitor blood gases (1 Hour)
38. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??
39. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??
Goals
40. HOW TO WEAN FROM NIV??HOW TO WEAN FROM NIV??
No NO
Continue with
NPPV therapy
Continue with
NPPV therapy
Does
patient meet
weaning
guidelines? Clinically stable
RR < 24
HR < 110
pH > 7.35
SpO2 >90%
on< 50% If patient status does
not improved consider
intubation
NO
YES
Restart NPPV at
previous settings
Restart NPPV at
previous settings
YES
Trial off NPPV with
supplemental
oxygen
Trial off NPPV with
supplemental
oxygen
Slowly titrate IPAP
downward in decrements
of 2-3 cm H2O
Slowly titrate IPAP
downward in decrements
of 2-3 cm H2O
Does
patient demonstrate
clinical evidence
of respiratory
distress?
Discontinue NPPV and place on
supplemental oxygen
41. •Worsening pH and arterial partial pressure of carbon
dioxide (PaCO2 )
•Tachypnea (over 30 breaths/min)
•Hemodynamic instability
•Oxygen saturation by pulse oximeter (SpO2 ) less than 90%
•Decreased level of consciousnees
•Inability to clear secretions
•Inability to tolerate interface
WHEN TO TERMINATE NIV AND SWITCH TOWHEN TO TERMINATE NIV AND SWITCH TO
INVASIVE MECHANICAL VENTILATION??INVASIVE MECHANICAL VENTILATION??
Call for
help !!
42.
43. Claustrophobia
1. Try using a nasal interface or,
2. Try using a total face mask, or
3. Try mild sedation (use caution).
Gastric Insufflation (Aerophagia) and Gastric Distention
1. Excessive pressure or air swallowing can cause
air gastric inflation (insufflation) and gastric
distention
2. Use pressures less than 20 to 25 cm H2O
44. Use of Nasogastric Tubes
1.The tube increases leaking around the mask
2.The tube itself blocks a nasal passage
3.Compression of tube against the skin by the mask
may increase risk of skin breakdown
NG tube applied to groove
Flat surface applied on patient’s
face
Mask interface across beveled
side
NG Sealing PadNG Sealing Pad
45. Eye Irritation
1. Eye irritation may result from air blowing in the eye
2. Be sure mask fit is appropriate
3. Spacers used on the forehead or the bridge of the
nose
4. Readjust headgear straps
46. Skin Problems Due to Interface
1. Pressure lesions (skin
breakdown, necrosis) if mask
is to tight or left on for
extended periods of time
2. Use of skin dressings
Possible Solutions to Skin Irritation
1.Use the least amount of pressure to fit the mask that
still prevents excessive leaks
2.Use spacers
3.Alternate devices to reduce skin breakdown
4.Use a skin barrier lotion and/or topical corticosteroids
47. Nasal or Oral Dryness, Nasal Congestion, Mucus
Plugging
When these problems occur, possible solutions include
the following:
1. Add or increase humidification
2. Irrigate nasal passages with a saline spray
3. Use topical decongestants or steroids
48. Hypotension
1. If hypotension was present prior to therapy,
treat the cause
2. Be sure ventilating pressures are not excessively
high (peak pressures < 20 cm H20)
1.Maintain a policy of selecting patients appropriately
for NPPV patients who can protect their own airway
Risk of Aspiration
Notes de l'éditeur
This slide shows some of the nasal masks and their components. (Respironics, Inc.)
Use the sizing gauge to select the appropriate size mask.
Place the bottom portion of the mask below the lower lip while the mouth is slightly open. The mask should cover the mouth entirely.
The major function of the lung is to get oxygen into the body and carbon dioxide out
There are two currently used forms of weaning from NPPV. The first method is a combination of weaning the ventilatory support and taking the patient off for incremental periods of spontaneous breathing through the day or over the course of a few days. During the trial periods, the patient should be placed on supplemental oxygen equal to their previous FIO2 setting. Some patients with chronic respiratory failure may continue to require long term nocturnal ventilatory support.
The second method of weaning involves a gradual reduction in the levels of ventilatory support and FIO2. The oxygen is weaned to less than 50% keeping the SpO2 greater than 90%. Then the IPAP is gradually titrated downward in decrements of 2-3 cmH2O until reaching 5 cm H2O or the EPAP level. Whatever weaning method is used, noninvasive ventilation should be restarted if a patient manifests signs of fatigue and clinical evidence of respiratory distress appear. Restart patient on their previous NPPV settings. Monitoring respiratory rate, tidal volumes, and Ti/Tot are good indicators of the patient’s response to the weaning process. When the noninvasive pressure is removed, the patient should be placed on supplemental oxygen. (From Respiratory Care 49: 72, 2004.
A number of complications arise when using NPPV. Some are related to the gas flow and pressures. Some are associated with the interface. Problems with the interface device accounts for a majority of the problems associated with noninvasive ventilation. Some of the various problems and complications of NPPV will be reviewed in the next few slides. In addition, possible solutions will be recommended.
Some people become very claustrophobic when anything is place over their face or head.
The prophylactic use of a nasogartric tube in patients receiving NPPV is controversial. The NG tube can, itself, increase the risk of leaks, block the airway and increase the risk of pressure sores.
Eye irritation and conjunctivitis can be caused by gas blowing into the eyes or from aerosolized medications being directed at the eyes. Readjustment of the mask and headgear can often correct eye irritation and dryness.
This photograph illustrates necrosis of the skin at the bridge of the nose. Keep in mind that damage to the cartilage and skin of the nose can result in permanent damage.
Nasal and/or oral drying, nasal congestion and mucus plugging can occur if the inhaled air is too dry and when flows and pressures are high. Using a nasal saline spray, and adding or increasing humidification can help.
If the patient is hypotensive prior to beginning ventilation, the cause of the hypotension needs to be corrected. For example, if the patient is dehydrated and thus hypotensive they may need fluids.