1. Noninvasive Oxygenation and Ventilation

2. Goals of noninvasive measures
Either short term or long term support of pulmonary function
Short Term
Hospital NC
BiPAP for acute respiratory distress
Long Term
Home O2 for chronic COPDers
CPAP for Obesity Hypoventilation Syndrome or OSA

3. What goal for oxygen? COPDers Non-COPDers Between 88 and 95%
PaO2 >= 60
Non-COPDers
>= 92%
PaO2 > 60

4. O2 Saturation vs. PaO2 40-50-60 to 70-80-90 rule PaO2 O2 Sat 40 70 50

5. Types of NIV
Nasal Cannula
Venti-Mask
Non-rebreathers
BiLevel
CPAP

6. Non-Invasive Oxygenation: Achieved FiO2

7. Venti-Mask colors

8. Non-Rebreather versus Partial Non-rebreather

9. Non-Invasive Ventilation
BiLevel
CPAP (not discussed)

10. Advantages to Noninvasive Ventilation
No internal traumatic complications
Decreased infections
Less interference with communication and swallowing
Less need for sedation

11. Indications Well established Weaker indications COPD exacerbation
Weaning in COPD patients
Acute cardiogenic pulmonary edema
Immunocompromised patients
DNI patients
Weaker indications
Asthma exacerbations
Cystic fibrosis
Hypoxemic respiratory failure
Extubation failure

12. NIV and COPD RCTs have shown
20-50% reduced intubation rate
Improved RR, dyspnea and gas exchange
Decreased length of stay
Lowered mortality
Intubated COPD patients who have failed T “piece” trials
Should be able to breath without assistance for 5 minutes
Can tolerate levels of pressure generated by NIV
Should not be “difficult” intubations

13. NIV and Asthma Physiological Rationale Limited evidence
Decrease work of breathing
Improve exchange
Limited evidence
No consistent recommendations for trial of NIV in patients failing standard therapy

14. Acute Cardiogenic Pulmonary Edema
Physiology
Recruits “flooded” alveoli
Reduces preload and afterload
RCTs have shown that BiPAP/CPAP can
Improve dyspnea and oxygenation
Lowers intubation rate
Reduced intubation
Reduced LOS
Reduced mortality

15. Immunocompromised Patients
Mechanical ventilation in these patients have a high risk of
Nosocomial infection (VAP) and septicemia
Fatal airway hemorrhage caused by thrombocytopenia and platelet dysfunction
NIV begun in these patients before respiratory failure becomes severe may halve mortality
Greatest benefit with early initiation and single-organ failure

16. Post-op Patients
CPAP reduces intubation in patients after abdominal surgery (reduces atelectasis)
NIV improves outcomes in hypoxemic respiratory failure after lung resection

17. Predictors of NIV success in acute respiratory distress
Cooperative patient
Intact neurological function
Good synchrony with ventilator
APACHE score <29
pH > 7.25
Intact dentition
Air leaking well-controlled
Able to control secretions

18. Selection guidelines for use of NIV in acute respiratory distress
Appropriate diagnosis with potential reversibility over hours to days
Ascertain need for ventilatory assistance
Moderate to severe respiratory distress
Tachypnea (>24/min for COPD, >30/min for hypoxemia
Accessory muscle use or abdominal paradox
Blood gas abnormality
pH < 7.35, PaCO2 > 45 or PaO2/FiO2 < 200

19. Contraindications for NIV
Respiratory arrest/Cardiac arrest
Medically unstable (hemodynamically unstable, arrythmias, cardiogenic shock/MI, GIB, ABG pH < 7.1)
Unable to protect airway (bulbar dysfunction, AMS)
Excessive secretions
Uncooperative or agitated
Unable to fit mask (facial trauma/surgery)
Recent upper airway or GI surgery

20. BiLevel – What is it? IPAP (Inspiratory Positive Airway Pressure)
Excess pressure to move air into lungs
EPAP(Expiratory Positive Airway Pressure)
Increased minimum lung pressure maintained to increase alveolar recruitment
PS (Pressure Support)
PS = IPAP - EPAP

21. BiLevel – Setting?
IPAP
Usually 8-12 cm H2O
EPAP
Usually 4-5 cm H2O

22. BiLevel - Recheck
A baseline ABG should be done during initial episode of respiratory distress
Patient should be followed-up in 1-2 hours depending on condition after BiLevel NIV is placed

23. BiLevel – Recheck Criteria
Objective
Compare repeat ABG to baseline
PaO2/FiO2 should be > 150 after 1st hour
Gas Exchange: Oximetry, PaCO2, pH
RR, HR, BP, cough strength and ability to raise secretions should be improved
Subjective
Comfort/Discomfort
Feeling of dyspnea
Ventilatory Function
Synchrony
Tidal Volume
Airleaks
Wave form

24. BiLevel - Complications