1. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Chapter 45 Noninvasive Ventilation

2. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 2 Learning Objectives  Discuss the concept of noninvasive ventilation (NIV).  List the goals of and indications for NIV.  Select patients who should be managed with NIV.  List those factors that are predictive of success during NIV.

3. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 3 Learning Objectives (cont.)  Discuss patient interfaces, types of ventilators, and modes of ventilation used during NIV.  Discuss the initiation and management of NIV in the acute care setting.  List and discuss complications associated with NIV and their possible solutions.  Discuss the appropriate approach to the initial application of NIV.

4. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 4 Introduction to Noninvasive Ventilation  Abbreviated NPPV, NIPPV, or NIV  Supports ventilation without artificial airway  bag-mask provides the earliest example  Encompasses both ventilation and CPAP  Typically provided by nasal or oral mask

5. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 5 Introduction to Noninvasive Ventilation (cont.)  Use has increased due to:  Improved patient interfaces  Improved quality of NIV ventilators  NIV software available for critical care ventilators  Reports of success in literature

6. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 6 Types of Noninvasive Ventilation  Can be provided by a number of mechanisms  Pneumobelt  Rubber bladder strapped to abdomen  Bladder filling compresses abdominal contents pushing up diaphragm causing exhalation  Bladder deflation causes diaphragm to fall and inhalation occurs  Some patients prefer this while in wheelchair

7. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Pneumobelt 7

8. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 8  Negative-pressure ventilators (NPV)  Negative pressure around thorax causes pressure gradient across chest wall – inspiration occurs Iron lung: widely for polio epidemic (1920-1960s)  Surrounds entire body  Porta lung is a simplified, cheaper version Chest cuirass: seals around the chest  NPV fell from use with development of positive- pressure ventilation Types of Noninvasive Ventilation

9. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Noninvasive Ventilators 9

10. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 10 Types of Noninvasive Ventilation (cont.)

11. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 11 All of the following are goals for noninvasive ventilation, except? A.Avoid Intubation B.Improve mortality C.Maximize patient comfort D.Airway protection

12. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 12 Acute Care: COPD  Hypercapnic respiratory failure due to COPD is primary indication for NIV  Strong evidence of efficacy in reducing Need for intubation Hospital mortality and length of stay Complications  Standard of care for managing an acute exacerbation of COPD First-line therapy

13. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 13 Acute Care: Asthma & Cardiogenic Pulmonary Edema  Asthma and NIV  Some evidence of positive results Improved P/F ratio, PaCO 2, and pH Reduction intubation rates  Use remains controversial  Acute cardiogenic pulmonary edema:  Numerous studies show power of CPAP CPAP first-line therapy  NIV reserved for those with ventilatory failure

14. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 14 Acute Care: CAP & Hypoxemic Respiratory Failure  CAP and NIV  Only improves outcomes with COPD patients who develop pneumonia  Hypoxemic respiratory failure (P/F < 300)  First-line therapy for immunocompromised, awaiting transplant, and post lung resection  NIV very controversial for all other groups If used, note marked improvement in 1 to 2 hours or accept failure and intubate.  60% mortality noted if intubation is further delayed

15. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 15 Acute Care: Other Indications for NIV  DNI patients (do not intubate)  Only use if it makes patient more comfortable or to manage a reversible disorder  Postoperative use shows promise  Some evidence CPAP post abdominal surgery improves outcomes  NIV to facilitate weaning  Reserve for COPD and CHF patients  For other patient groups, NIV instead of reintubation worsened outcomes

16. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 16 Noninvasive ventilation may be used for a patient with a DNI (do not intubate) order, in all of the following situations, except: A.Make patient more comfortable B.Patient refuses artificial ventilation C.Managing a reversible disorder D.Manage obstructive sleep apnea

17. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 17 Chronic Care: Restrictive Thoracic Diseases  Indicated for patients: post polio, NMD, chest wall deformities, spinal injuries, and severe kyphoscoliosis  If evidence of nocturnal hypoventilation Hypersomnolence, morning headache, fatigue, dyspnea, cognitive dysfunction If present, use NIV to prevent chronic hypercapnia and associated hypoxemia  Helps by resting muscles, lowering CO 2, and improved compliance, FRC, and deadspace

18. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 18 Chronic Care of COPD Patients  Use is controversial  Consensus conference recommendation  Use for severe COPD with symptoms of nocturnal hypoventilation and one of the following PaCO 2 > 55 mm Hg PaCO 2 50 to 54 mm Hg with nocturnal desaturation Two hospital admissions for ventilatory failure

19. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 19 Hypoventilation  Associated with a number of diseases including central and obstructive sleep apnea and lung parenchymal diseases  Nasal CPAP is first-line therapy  NIV is recommended when other first-line therapies failed to alleviate hypoventilation

20. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 20 Patient Selection & Exclusion & Predictors of Success: NIV  Selection is generally established by signs and symptoms of respiratory distress (see Box 45-3).  Exclusion occurs once the need for ventilatory assistance has been established (see Box 45-4).  Predictors of success  Summarized in Box 45-5 but generally patients are not as sick and/or respond rapidly to NIV

21. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 21 All of the following are selection criteria for NIV patients in respiratory failure, except: A.Excessive use of accessory muscles B.Respiratory rate <25 breaths/min C.Paradoxical breathing D.Dyspnea

22. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 22 NIV Equipment: Patient Interfaces  Most common types  Nasal mask  Full-face mask (nasal-oral)  Mouthpiece  Less common  Total face mask (covers whole face)  Nasal pillows  helmet

23. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Face Masks 23

24. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Nasal Pillows 24

25. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 25 Patient Interfaces: Nasal Masks  Triangular in shape, only covers the nose  Made of hard, clear plastic with a cushion below for contact with face  A strap assembly holds mask on face.  Do not overtighten as may cause tissue necrosis

26. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Nasal Masks 26

27. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 27 Patient Interfaces: Nasal Masks (cont.)  Proper sizing  Reduces incidence of pressure sores and tissue necrosis  Reduces leaks  Increases patient comfort  Improves likelihood of long-term patient tolerance

28. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Nasal Masks 28

29. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 29 Patient Interfaces: Full-Face Masks  Interface of choice for patients with acute respiratory failure  >90% of this group should start with full-face mask  Designed for either  Noninvasive ventilators: entrainment valve that prevents asphyxia if ventilator fails  ICU ventilators: entrainment valve absent

30. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 30 Patient Interfaces: Full-Face Masks (cont.)  Disadvantages compared to nasal mask:  Increased deadspace, claustrophobia, risk of aspiration  Harder to talk and expectorate

31. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Full Face Mask 31

32. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 32 Noninvasive Ventilators  Most are electrically powered, blower driven, microprocessor controlled  Designed to work with small leak and compensate for that leak  Advantage: Patient ability to trigger and cycle properly in face of small to moderate leaks  Internal oxygen blender is desirable but often absent  hard to obtain >0.5 FIO 2

33. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Noninvasive Ventilators 33

34. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 34 Noninvasive Ventilators (cont.)  Typical modes  CPAP  Pressure support (PSV)  Pressure assist/control (P-A/C)  With PSV and P-A/C, machine is patient or time triggered, pressure limited, and flow or time cycled  Generate lower rates, pressures, and flows than ICU ventilators

35. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Noninvasive Ventilators 35

36. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 36 All of the following are types of NIV modes, except: A.CPAP B.PSV C.PRVC D.P-A/C

37. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 37 Critical Care Ventilators  Much more sophisticated, allow for precise oxygen control, high flows, pressures, etc  Inability to compensate for leaks is common  Often results in triggering and cycling issues PSV breaths end at set percent peak flow; if flow does not fall to set percent, may lock in inspiration Modern vents can adjust cycle off percent Time-cycling solves problem and improves patient comfort  Often causes lots of nuisance alarms  Use full-face mask to minimize leaks

38. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 38 Critical Care Ventilators  CPAP, PSV, and P-A/C have all have been used.  VC modes used but not recommended  Leaks can lead to hypoventilation  Various NIV packages now available on ICU ventilators; some will  Compensate for leaks  Allow audio alarm deactivation  Set maximum inspiratory time (great option)  No proven advantage of any mode

39. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Critical Care Ventilators 39

40. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 40 Humidification  Patients with symptoms of sneezing, nasal draining, nasal and oral dryness, and/or nasal obstruction benefit from humidity therapy  Heated humidity relieves many of above symptoms, thus improving patient compliance  Heat to about 30º C (patient comfort level).  As length of use is unpredictable, recommend use of humidification for all patients receiving NIV

41. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 41 Identifying Success or Failure of NIV  Success easy to identify  Improved ABGs: PaCO 2 decreases, pH increases, PaO 2 increases  Clinical improvement: decreased RR, VT increased, diminished accessory muscle use  Failure  If in 1 to 2 hours the above are not noted; move to intubation  Waiting too long can result in cardiac arrest

42. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 42 Adjusting NIV  Adjustments determined by patient presentation and ABGs  High PaCO 2 : Increase pressure ( V T ) or rate  Low PaCO 2 : Decrease pressure ( V T ) or rate Often rate is for backup only; if set in A/C may have above effects, but patient inspiratory efforts override ventilator setting  High PaO 2 : Decrease oxygen or PEEP  Low PaO 2 : Increase oxygen or PEEP When PEEP is adjusted, may alter pressure gradient and thus V T

43. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 43 Monitoring NIV  Must assess for  Leaks  Accessory muscle use  Ventilator synchrony and patient comfort  Improved vital signs and ABGs  If patient worsens on optimal setting, think immediate intubation  Particular attention must be paid to those with respiratory failure

44. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 44 Adverse Effects & Complications of NIV  Causes of NPPV failure include:  Mask-related problems  Flow-related problems  Large air leaks  Patient  ventilator asynchrony  Lack of improvement in gas exchange  See Table 45-2.  Major complications: aspiration, hypotension, and pneumothorax

45. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 45 All of the following are types problems which may occur with NIV, except: A.Mask-related problems B.Flow-related problems C.Large air leaks D.Improvement in gas exchange

46. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 46 Time and Costs of NIV  Success of NPPV is closely tied to time- intensive involvement of RT staff for  Mask fitting  Application  Adjustment of NIV settings  Patient education  Following initiation, time required (costs, also) should fall to reflect those required for invasive ventilation