1. NON-INVASIVE MV Good news It works !!!!!!! Warnings Not always Not for all Know the technique Be skilled

2. (from Vitacca M. et al. AJRCCM 2001; 164: 638-641) i-PSV and n-PSV delivered before and after extubation in patients not weaned Arterial Blood Gases i-PSV 7.38 59.1 206 n-PSV 7.38 61 210 pH PaCO 2 PaO 2 /FIO 2 T-tube 7.33 69 183

3. NIV INTERFACES TUBING MT NURSES LOCATION PATIENTS MONITORING

4. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

5. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

6. 60% Hypercapnic 55% Hypoxic

7. Conclusions: Use of NIV as the initial ventilation strategy for AECOPD varies across hospitals. Institutions with greater use of NIV have lower rate of IMV usage and better outcomes.

8. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

10. Appropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (from Vitacca M. et al. Chest 2000) Change (% of SB)

12. (from Vitacca M. et al. MACD 2004; 61: 81-85)

13. Assessment of Physiologic Variables and Subjective Comfort Under Different Levels of Pressure Support Ventilation* Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD; Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; and Enrico Clini, MD, FCCP† Chest 2004; 126: 851-59

14. Study protocol Time (min) SB (baseline) 10 V’ E, PTP 0 setting V’ E, PTP Pao, IE RANDOM of ventilators comfort

17. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

18. (from BTS Guideline Thorax 2002;57:192-211)

21. SVANTAGGI: non permette l’espettorazione, né l’alimentazione aumenta il rischio di aspirazione è altamente traumatica maschera facciale Punti critici 1- ponte nasale 2- lati della bocca 3- base inferiore del labbro 2 2 3 1 VANTAGGI: miglior controllo delle perdite pressioni più elevate N.B. La protesi dentaria va rimossa

22. maschera nasale Punti critici 1- ponte nasale 2- narici 3- base del naso verificare 4- pervietà delle cavità nasali 2 2 3 1 VANTAGGI: stabile, comfort maggiore bocca libera spazio morto ridotto svariati modelli SVANTAGGI: perdite d’aria dalla bocca maggior resistenza N.B. La protesi dentaria va conservata

23. Major problems with mask during NIV support Air leaks Side-effects Size

24. Side effects due to NPPV N=26 (compliant patients) (from Criner GJ. et al. Chest 1999;116:667-675) Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 %

26. MOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years) (from Teschler H. et al. ERJ 1999; 14: 1251-1257) PtcCO 2 (mmHg)Arousal Index (events h -1 ) p<0.001p<0.0002

29. Side effects due to NPPV N=26 (compliant patients) (from Criner GJ. et al. Chest 1999;116:667-675) Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 %

30. Tissue Necrosis Caused by an Improperly Fitting Mask

33. … However, a chinstrap was required to reduce oral leak in the majority of subjects using the nasal mask.

35. (CCM 2002; 30: 602-608)

36. (Crit Care Med 2002; 30: 602-608)

37. Conclusions: Helmet NPPV is feasible and can be used to treat COPD patients with acute exacerbation, but it does not improve CO2 elimination as efficiently as does FM NPPV.

38. CRITERI PER LA SCELTA DELLA MASCHERA Esperienza dell’équipe Considerazioni anatomiche Modalità di ventilazione Compliance e sensorio del paziente

39. (from BTS Guideline Thorax 2002;57:192-211)

40. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

42. In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification.

44. Crit Care Med 2002; 30:2515–2519

45. To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L*min -1

46. Respir Care 2004;49(3):270–275. CONCLUSIONS Delivered oxygen concentration during BiPAP is a complex interaction between the leak port type, the site of oxygen injection, the ventilator settings, and the oxygen flow. Because of this, it is important to continuously measure arterial oxygen saturation via pulse oximetry with patients in acute respiratory failure who are receiving noninvasive ventilation from a bi-level ventilator.