Non-invasive Ventilation

What is NIV? Non-Invasive Positive Pressure Ventilation (NPPV) refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar device NIV should be available 24 hours a day in hospitals admitting patients in acute hypercapnic respiratory failure (British Thoracic Society, 2002) Different types of NIV include High Flow Oxygen Therapy (HFT), Continuous Positive Airway Pressure (CPAP), pressure controlled ventilation (more commonly known as BiPAP) and volume controlled ventilation (not often used in children)

When to use NIV May be used for both acute and chronic respiratory problems May be used both at home and in the hospital setting In an acute setting, the commencement of therapy is usually dictated by the patient’s work of breathing, blood gases and oxygen requirements Chronic use will be dictated by sleep studies and individual need and condition

Conditions that NIV is commonly used for Acute conditions Bronchiolitis Pertussis Pneumonia Chronic conditions Central Hypoventilation Duchenne’s muscular dystrophy SMA (Spinal Muscular Atrophy) Tracheomalacia and bronchomalacia

What does NIV do? Used to overcome mechanical problems with the airway,lungs or chest wall Rest fatigued inspiratory muscles Support upper airway collapse To regulate gas exchange Normalise CO2 levels Treat acidosis Increase oxygenation and reverse hypoxia To increase lung volume Treat hypoxemic respiratory failure Prevent/treat atelectasis Increase PEEP Optimise work of breathing

Types of NIV used at JR High flow oxygen therapy Optiflow Vapotherm This delivers a flow of warmed gas that exceeds the patients respiratory demand so facilitating flushing of the dead space of the upper airway. CPAP is not provided however it is thought that a 5-8cmH2O pressure may be acheived in some patients.

Types of NIV used at JR Advantages of HFT Patient compliance will be similar to that as when using nasal cannula oxygen therapy. Minimal risk of pressure areas developing. Disadvantages of HFT Gases need to be humidified to body temperature with 100% relative humidity therefore requiring the equipment to facilitate this.

Types of NIV used at JR Continuous positive airway pressure (CPAP) CPAP drivers including SiPAP V60 and Trilogy NIPPY This provides positive airway pressure throughout the breathing cycle, restoring functional residual capacity to prevent collapse and lessen work of breathing

Types of NIV used at JR Advantages of CPAP Can be used for spontaneously breathing patients Disadvantages of CPAP Compliance may be poor Patient must have an intact respiratory drive as there is no backup rate Increased risk of pressure areas developing Specialist equipment needs to be used to deliver the pressure and monitor it adequately

Types of NIV used at JR BiPAP V60 AND Trilogy NIPPY This provides positive pressure throughout the breathing cycle with a higher pressure delivered during inspiration This results in reduced work of breathing and improvement in tidal volume and CO2 removal

Types of NIV used at JR Advantages Improves work of breathing so decreasing respiratory effort Most equipment will support spontaneously breathing patients as well as delivering breaths for patients that are having apnoeas Disadvantages Compliance may be poor Increased risk of pressure areas developing Specialist equipment needs to be used to deliver the pressure and monitor it adequately

Terminology EPAP/CPAP/PEEP IPAP/PIP iT/Ti Backup rate Expiratory positive airway pressure Continuous positive airway pressure Positive end expiratory pressure IPAP/PIP Inspiratory positive airway pressure Positive inspiratory pressure iT/Ti Inspiratory time Backup rate Tidal volume/TV/VTi/VTe Minute volume/MV/Min vent MAP Mean airway pressure

Contraindications Craniofacial trauma or burns Basal skull fractures Recent facial, oesophageal or gastric surgery Uncooperative patient Consider whether NIV is the best option

Care of a child on NIV Consent Child and family support/education Pressure area care NGT IVI Secretion clearance

Any questions?

Time for NIV