NON INVASIVE VENTILATION

Definition: NIV is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway Definition: NIV is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway

Types: o negative pressure NIV Main means of NIV during the 1 st half of the 20 th century Main means of NIV during the 1 st half of the 20 th century o positive pressure NIV resurgence in the early 1980s due to the development of nasal CPAP resurgence in the early 1980s due to the development of nasal CPAP

Why the interest in NIV The desire to avoid complications of invasive ventilation Complications related to the process of intubation and mechanical ventilation Complications related to the process of intubation and mechanical ventilation Aspiration Aspiration Trauma Trauma Arrythmias and hypotension Arrythmias and hypotension barotrauma barotrauma Complications caused by loss of airway defense mechanisms Complications caused by loss of airway defense mechanisms Direct conduit to lower airway chronic bacterial colonization Direct conduit to lower airway chronic bacterial colonization The desire to avoid complications of invasive ventilation Complications related to the process of intubation and mechanical ventilation Aspiration Trauma Arrythmias and hypotension barotrauma Complications caused by loss of airway defense mechanisms Direct conduit to lower airway chronic bacterial colonization

Complication that occur after removal of ETT Complication that occur after removal of ETT Hoarseness, sore throat, cough Hoarseness, sore throat, cough Sputum production Sputum production Upper airway obstruction Upper airway obstruction hemoptysis hemoptysis From the patients point of view From the patients point of view Discomfort Discomfort Decreased ability to eat and communicate Decreased ability to eat and communicate Complication that occur after removal of ETT Hoarseness, sore throat, cough Sputum production Upper airway obstruction hemoptysis From the patients point of view Discomfort Decreased ability to eat and communicate

Advantages of NIV Leaves upper airway intact Leaves upper airway intact Preserve airway defense mechanisms Preserve airway defense mechanisms Allows patient to eat, drink, verbalize and expectorate Allows patient to eat, drink, verbalize and expectorate Enhance comfort, convenience and portability Enhance comfort, convenience and portability Less cost Less cost Leaves upper airway intact Preserve airway defense mechanisms Allows patient to eat, drink, verbalize and expectorate Enhance comfort, convenience and portability Less cost

InterfacesInterfaces Devices that connect the ventilators tubing to the face allowing pressurized gas to enter into upper airway Devices that connect the ventilators tubing to the face allowing pressurized gas to enter into upper airway

Nasal Cone shaped clear plastic device with soft cuff Cone shaped clear plastic device with soft cuff Multiple sizes and shapes Multiple sizes and shapes Chronic application Chronic application Better tolerated by patients with claustrophobia Better tolerated by patients with claustrophobia Exert pressure over the bridge of the nose Exert pressure over the bridge of the nose

Avoided by Avoided by o Fore head spacer o Nasal mask with gel seal o Mini-masks o Custom-molded individualized masks o Thin plastic flap o Nasal pillows (pledgets directed to the nostrils) Avoided by Avoided by o Fore head spacer o Nasal mask with gel seal o Mini-masks o Custom-molded individualized masks o Thin plastic flap o Nasal pillows (pledgets directed to the nostrils)

Oronasal ( full face mask) Preferred Preferred o in acute settings o for patients with copious air leaking through the mouth o For edentulous patients Interferes with speech, eating and expectoration Interferes with speech, eating and expectoration Increase risk of aspiration, rebreathing Increase risk of aspiration, rebreathing Increase likelihood of claustrophobic reaction Increase likelihood of claustrophobic reaction Total face mask (hockey goalies mask) Total face mask (hockey goalies mask) Oronasal ( full face mask) Preferred Preferred o in acute settings o for patients with copious air leaking through the mouth o For edentulous patients Interferes with speech, eating and expectoration Interferes with speech, eating and expectoration Increase risk of aspiration, rebreathing Increase risk of aspiration, rebreathing Increase likelihood of claustrophobic reaction Increase likelihood of claustrophobic reaction Total face mask (hockey goalies mask) Total face mask (hockey goalies mask)

Mouth pieces Provides NIPPV to patients with chronic respiratory failure Provides NIPPV to patients with chronic respiratory failure Simple inexpensive Simple inexpensive Nasal air leaking decrease its efficacy Nasal air leaking decrease its efficacy o Managed by increasing ventilators tidal volume o Occluding nostrils with cotton pledgets or nose clips

Ventilators for NIPPV CPAP Delivers constant pressure during both inspiration and expiration Delivers constant pressure during both inspiration and expiration Increase functional residual capacity Increase functional residual capacity Improve lung compliance Improve lung compliance Open collapsed alveoli Open collapsed alveoli Improve oxygenation Improve oxygenation Decrease work of breathing Decrease work of breathing Decrease left ventricular transmural pressure, afterload and COP Decrease left ventricular transmural pressure, afterload and COP Simple, small and cheap portable units are available Simple, small and cheap portable units are availableCPAP Delivers constant pressure during both inspiration and expiration Delivers constant pressure during both inspiration and expiration Increase functional residual capacity Increase functional residual capacity Improve lung compliance Improve lung compliance Open collapsed alveoli Open collapsed alveoli Improve oxygenation Improve oxygenation Decrease work of breathing Decrease work of breathing Decrease left ventricular transmural pressure, afterload and COP Decrease left ventricular transmural pressure, afterload and COP Simple, small and cheap portable units are available Simple, small and cheap portable units are available

Pressure limited ventilators PCV PCV Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E ratio Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E ratio Permits patient triggering with a back up rate Permits patient triggering with a back up rate PSV PSV Assist spontaneous breathing Assist spontaneous breathing Peak inspiratory and expiratory pressures are selected Peak inspiratory and expiratory pressures are selected Close matching with patients spontaneous breathing Close matching with patients spontaneous breathing Allow patient to control rate and inspiratory duration Allow patient to control rate and inspiratory duration Portable devices (bilevel devices) Portable devices (bilevel devices) Pressure limited ventilators PCV PCV Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E ratio Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E ratio Permits patient triggering with a back up rate Permits patient triggering with a back up rate PSV PSV Assist spontaneous breathing Assist spontaneous breathing Peak inspiratory and expiratory pressures are selected Peak inspiratory and expiratory pressures are selected Close matching with patients spontaneous breathing Close matching with patients spontaneous breathing Allow patient to control rate and inspiratory duration Allow patient to control rate and inspiratory duration Portable devices (bilevel devices) Portable devices (bilevel devices)

Volume limited ventilators V t is usually set higher (10 15ml/kg ) V t is usually set higher (10 15ml/kg ) Usually set in the A/C mode, RR set slightly below the patients rate Usually set in the A/C mode, RR set slightly below the patients rate Portable devices are more convenient, cheap, have more sophisticated alarm system, generate high pressure Portable devices are more convenient, cheap, have more sophisticated alarm system, generate high pressure Volume limited ventilators V t is usually set higher (10 15ml/kg ) V t is usually set higher (10 15ml/kg ) Usually set in the A/C mode, RR set slightly below the patients rate Usually set in the A/C mode, RR set slightly below the patients rate Portable devices are more convenient, cheap, have more sophisticated alarm system, generate high pressure Portable devices are more convenient, cheap, have more sophisticated alarm system, generate high pressure

Proportional assisted ventilation (PAV) Targets and respond rapidly patients effort ( inspiratory flow and volume) Targets and respond rapidly patients effort ( inspiratory flow and volume) Able to select the proportion of breathing work that is to be assisted Able to select the proportion of breathing work that is to be assisted

Negative pressure ventilation Intermittently apply a sub atmospheric pressure to the chest wall and upper abdomen Intermittently apply a sub atmospheric pressure to the chest wall and upper abdomen Efficiency depends on chest wall and abdomen compliance and surface area over which negative pressure is applied Efficiency depends on chest wall and abdomen compliance and surface area over which negative pressure is applied

E.g. E.g. Tank ventilator Tank ventilator Cuirass Cuirass Wrap Wrap Shell Shell Iron lung Iron lung Rocking belt and pneumobelt (work by displacing abdominal viscera) Rocking belt and pneumobelt (work by displacing abdominal viscera)

Goals of NIV Short term (acute) Relieve symptoms Relieve symptoms Reduce work of breathing Reduce work of breathing Improve or stabilize gas exchange Improve or stabilize gas exchange Good patient-ventilator synchrony Good patient-ventilator synchrony Optimize patient comfort Optimize patient comfort Avoid intubation Avoid intubation Minimize risk Minimize risk Short term (acute) Relieve symptoms Relieve symptoms Reduce work of breathing Reduce work of breathing Improve or stabilize gas exchange Improve or stabilize gas exchange Good patient-ventilator synchrony Good patient-ventilator synchrony Optimize patient comfort Optimize patient comfort Avoid intubation Avoid intubation Minimize risk Minimize risk Long term (chronic) Improve sleep duration and quality Enhance functional status Prolong survival Maximize quality of life Long term (chronic) Improve sleep duration and quality Enhance functional status Prolong survival Maximize quality of life

PROTOCOL FOR INITIATION OF NIV 1. Appropriately monitored location 2. Patient in bed or chair sitting at > 30-degree angle 3. Select and fit interface 4. Select ventilator 5. Apply headgear; avoid excessive strap tension 6. encourage patient to hold mask 7. Connect interface to ventilator tubing and turn on ventilator 1. Appropriately monitored location 2. Patient in bed or chair sitting at > 30-degree angle 3. Select and fit interface 4. Select ventilator 5. Apply headgear; avoid excessive strap tension 6. encourage patient to hold mask 7. Connect interface to ventilator tubing and turn on ventilator

8. Start with low pressures/volumes in spontaneously triggered mode with backup rate; pressure-limited: 8 to 12 cm H2O inspiratory; 3 to 5 cm H2O expiratory, volume-limited: 10 ml/kg 9. Gradually increase inspiratory pressure (10 to 20 cm H2O) or tidal volume (10 to 15 ml/kg) as tolerated to achieve alleviation of dyspnea, decreased respiratory rate, increased tidal volume, and good patient-ventilator synchrony 10. Provide O2 supplementation as needed to keep O2 sat > 90%

PROTOCOL FOR INITIATION OF NIV 11. Check for air leaks, readjust straps as needed 12. Add humidifier as indicated 13. Consider mild sedation (i.e., intravenously administered lorazepam 0.5 g) in agitated patients 14. Encouragement, reassurance, and frequent checks and adjustments as needed 15. Monitor occasional blood gases (within 1 to 2 h and then as needed) 11. Check for air leaks, readjust straps as needed 12. Add humidifier as indicated 13. Consider mild sedation (i.e., intravenously administered lorazepam 0.5 g) in agitated patients 14. Encouragement, reassurance, and frequent checks and adjustments as needed 15. Monitor occasional blood gases (within 1 to 2 h and then as needed)

MonitoringMonitoring Subjective responses o Bed side observation o Ask about discomfort related to the mask or airflow Physiologic response o RR, HR o Patient breath in synchrony with the ventilator o accessory muscle activity and abdominal paradox o Monitor air leaks and V t Gas exchange o Continuous oximetry o Occasional ABG Subjective responses o Bed side observation o Ask about discomfort related to the mask or airflow Physiologic response o RR, HR o Patient breath in synchrony with the ventilator o accessory muscle activity and abdominal paradox o Monitor air leaks and V t Gas exchange o Continuous oximetry o Occasional ABG

Uses of NIV Respiratory failure Respiratory failure Hypercapnic respiratory failure Obstructive diseases Obstructive diseases Restrictive diseases Restrictive diseases Hypoxic respiratory failure Acute pulmonary edema Acute pulmonary edema Acute pneumonia Acute pneumonia ARDS ARDS Trauma Trauma Respiratory failure Respiratory failure Hypercapnic respiratory failure Obstructive diseases Obstructive diseases Restrictive diseases Restrictive diseases Hypoxic respiratory failure Acute pulmonary edema Acute pulmonary edema Acute pneumonia Acute pneumonia ARDS ARDS Trauma Trauma

Imunocomprimized patients Imunocomprimized patients Avoid ETT infectious and hemorrhagic complications Avoid ETT infectious and hemorrhagic complications Morbidly obese patients Morbidly obese patients used in obstructive sleep apnea used in obstructive sleep apnea Do not intubate patients Do not intubate patients ETT is contraindicated or postpond ETT is contraindicated or postpond Refuse intubation Refuse intubation Post operative patients Post operative patients Avoid reintubation if RF develops Avoid reintubation if RF develops Improve gas exchange and pulmonary function Improve gas exchange and pulmonary function Weaning and extubation Weaning and extubation Before meeting extubation criteria Before meeting extubation criteria Imunocomprimized patients Imunocomprimized patients Avoid ETT infectious and hemorrhagic complications Avoid ETT infectious and hemorrhagic complications Morbidly obese patients Morbidly obese patients used in obstructive sleep apnea used in obstructive sleep apnea Do not intubate patients Do not intubate patients ETT is contraindicated or postpond ETT is contraindicated or postpond Refuse intubation Refuse intubation Post operative patients Post operative patients Avoid reintubation if RF develops Avoid reintubation if RF develops Improve gas exchange and pulmonary function Improve gas exchange and pulmonary function Weaning and extubation Weaning and extubation Before meeting extubation criteria Before meeting extubation criteria

Adverse effects and complications of NIV Mask related Nasal pain Nasal pain Nasal bridge erythema and ulceration Nasal bridge erythema and ulceration Ventilator air flow or pressure complications Conjunctival irritation Conjunctival irritation Sinus or ear pain Sinus or ear pain Nasal or oral dryness Nasal or oral dryness Nasal congestion or discharge Nasal congestion or discharge Gastric insufflation Gastric insufflation Mask related Nasal pain Nasal pain Nasal bridge erythema and ulceration Nasal bridge erythema and ulceration Ventilator air flow or pressure complications Conjunctival irritation Conjunctival irritation Sinus or ear pain Sinus or ear pain Nasal or oral dryness Nasal or oral dryness Nasal congestion or discharge Nasal congestion or discharge Gastric insufflation Gastric insufflation

Failure of NIV Mask intolerance Mask intolerance Failure to improve ventilation Failure to improve ventilation Claustrophobia Claustrophobia Sensation of excessive air pressure Sensation of excessive air pressure Patient-ventilator asynchrony Patient-ventilator asynchronyMI Specially with BIPAP Specially with BIPAP Failure of NIV Mask intolerance Mask intolerance Failure to improve ventilation Failure to improve ventilation Claustrophobia Claustrophobia Sensation of excessive air pressure Sensation of excessive air pressure Patient-ventilator asynchrony Patient-ventilator asynchronyMI Specially with BIPAP Specially with BIPAP

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