Are You Optimizing Every Bilevel Breath? Jim Eddins, RRT

Objectives Discuss the basics of non-invasive ventilation and the benefits of using NIV Discuss features that improve bilevel tolerance Determine the most effective bilevel settings based on disease state

Consider Using NIV When … Use NIV Obstructive events persist at 15 cm H 2 O Respirations are characterized by CSA, CSR or CompSA Patient has a history of ventilatory insufficiency Patient is not tolerating high pressure settings or is complaining of inability to exhale, despite expiratory pressure relief feature

Utilizing Pressures Effectively Increase IPAP to achieve: Adequate tidal volume Respiratory rate (RR) < 25 bpm Decrease work of breathingReduction in PaCO2 Increase EPAP to: Overcome obstruction in the upper airways Improve oxygenationCounterbalance PEEPi

Breath Cycle on Bilevel Patient Flow Delivered Pressure IPAP EPAP Exhalation Trigger Cycle Inhalation Pressure support ( P)

The Problem with Asynchrony Asynchrony ↑Accessory Muscle Use ↑ WOB ↑ Discomfort, ↓ Compliance Ineffective Treatment

How Can Inspiratory Time Controls Help Increase Compliance? IPAP EPAP Ti Max Ti Min Breath cycle 0 Rise Time

Rise Time Problem: Patient describes “Pressure is too STRONG!” Solution: Increase rise time

Maximum Inspiratory Time Problem: Patient requires longer expiratory time (i.e. COPD) Solution: Best option – Shorten inspiratory time Additional options – Select higher cycle sensitivity, Select faster rise time

Minimum Inspiratory Time Problem: Patient’s inspiratory effort is weak (i.e. restrictive disease)/can’t sustain adequate inspiration Solution: Best option – Increase/prolong Ti Min Second option – Select lower cycle sensitivity

Trigger & Cycle Sensitivities Very HighQuick to trigger2.4 L/min HighMore sensitive4 L/min MedDefault6 L/min LowLess sensitive10 L/min Very LowSlow to trigger15 L/min Very HighQuick to cycle 50% of peak flow HighMore sensitive35% MedDefault25% LowLess sensitive15% Very LowSlow to cycle8% Adjustable Trigger Sensitivity Patient Flow EPAP Adjustable Cycle Sensitivity Patient Flow EPAP

Cycling for COPD Patients Increased inflammation and mucus Slower inspiratory flow rates Delayed cycling to expiration Less time for exhalation Increased air trapping (PEEPi) Increased trigger delay and trigger workload Increased missed triggers Increased work of breathing

COPD Bilevel S Devices (E0470) COPD Overlap syndrome Diseases TiControl Rise time Ti Max Ti Min Trigger sensitivity Cycle sensitivity Tools to assist with ventilation and comfort

Synchrony Insight - Ti Min Premature cycling creates asynchrony Occurs in restrictive patients Lungs physically restricted Paralysis or muscles deteriorated Gentile, Respiratory Care, 2011 “However, premature cycling may also have detrimental effects on patient-ventilator synchrony. Premature cycling is simply when the ventilator terminates the breath while the patient requires a long inspiratory period.”

Restrictive Disease Bilevel ST Device (E0471) ALS Muscular dystrophy Diseases TiControl Rise time Ti Max Ti Min Trigger sensitivity Cycle sensitivity Tools to assist with ventilation and comfort

Clinical Parameters Subjective Dyspnea Comfort Mental status Ventilatory pattern Accessory muscle use Synchrony with VPAP Objective Vitals (RR, HR, BP) Leak Tidal volume Oximetry ABGs

Conclusion There are multiple benefits to using NIV, particularly in patients with chronic hypoventilation There are additional features on some devices that modify pressure waveforms and work to improve bilevel tolerance