1. นพ. ธรรมศักดิ์ ทวิช ศรี หน่วยเวชบำบัด วิกฤต ฝ่ายวิสัญญีวิทยา รพ. จุฬาลงกรณ์

2. The earliest known ventilators, developed during the late 19th century,were the ‘body or tank’ type

3. Noninvasive ventilation !!

4. CPAP, initially used for the treatment of acute pulmonary oedema, became popular in the 1980s for management of obstructive sleep apnoea CPAP, initially used for the treatment of acute pulmonary oedema, became popular in the 1980s for management of obstructive sleep apnoea

7. Noninvasive ventilation (NIV): a form of ventilatory support that avoids airway invasion  improved outcomes in certain types of acute respiratory failure (ARF)

8. The successful application of NIV requires the training & collaboration of an experienced ICU team, including intensivists, nurses, and respiratory therapists The successful application of NIV requires the training & collaboration of an experienced ICU team, including intensivists, nurses, and respiratory therapists

10. “NIV should be considered first-line therapy in the management of ARF caused by COPD exacerbations”

11. BMJ 2003;326:185–7

13. A trial of NIV can be considered in asthmatics who fail to respond adequately to initial bronchodilator therapy to improve air flow obstruction & decrease the work of breathing

14. CHEST 2003; 123:1018–1025

15. large randomized controlled trials (RCTs) are needed before recommending NIV use in status asthmaticus Cochrane Database Syst Rev 2005; 1:CD004360

16. Am J Respir Crit Care Med Vol 168. pp 70–76, 2003 a prospective, randomized, controlled trial in 43 mechanically ventilated patients who had failed a weaning trial for 3 consecutive days

17. Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

19. The probability of weaning success The cumulative survival probability Am J Respir Crit Care Med Vol 168. pp 70–76, 2003 NIV

20. Earlier extubation with NIV results in shorter mechanical ventilation & length of stay, less need for tracheotomy, lower incidence of complications, and improved survival Am J Respir Crit Care Med Vol 168. pp 70–76, 2003 Facilitating Extubation in COPD

22. The main physiologic benefit from NIV or CPAP in these patients is likely due to an increase in FRC that reopens collapsed alveoli & improves oxygenation Crit Care Med 2007; 35:2402–2407

23. increases lung compliance & reduces work of breathing increases lung compliance & reduces work of breathing

24. Anesthesiology 2005; 103:419–28 decrease afterload decrease preload & decreasing ventricular preload & afterload decreasing ventricular preload & afterload

25. JAMA. 2005;294:3124-3130 NIV reduces the need for intubation & mortality in patients with acute cardiogenic pulmonary edema. There are no significant differences in clinical outcomes when comparing CPAP vs NIPSV NIV reduces the need for intubation & mortality in patients with acute cardiogenic pulmonary edema. There are no significant differences in clinical outcomes when comparing CPAP vs NIPSV

26. JAMA. 2005;294:3124-3130

29. a cautious trial of NIV may be considered in patients with pneumonia deemed to be excellent candidates, but they need careful monitoring, because the risk of failure is high

30. AM J RESPIR CRIT CARE MED 1999;160:1585–1591

31. Relapse of pneumonia was the leading cause of death after hospital discharge, and relapse occurred in previously intubated patients with COPD AM J RESPIR CRIT CARE MED 1999;160:1585–1591

32. Studies on NIV to treat acute lung injury & ARDS have reported failure rates ranging from 50% to 80% Independent risk factors for NIV failure: severe hypoxemia, shock, & metabolic acidosis Independent risk factors for NIV failure: severe hypoxemia, shock, & metabolic acidosis

33. Crit Care Med 2007; 35:18–25 In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients SAPS II >34 & the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients SAPS II >34 & the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure PaO2/FIO2 >175

34. The data support NIV as the preferred initial ventilatory modality for these patients, to avoid intubation and its associated risks (reduced infectious complications)

35. JAMA. 2000;283:235-241

39. JAMA. 2005;293:589-595 Oxygen at an FiO2 of 0.5 plus a CPAP of 7.5 cmH 2 O Elective abdominal surgery & GA  extubated & underwent 1-hour screening test(PaO2/FiO2  300) 6 hours with oxygen through a Venturi mask at an FiO 2 of 0.5

40. JAMA. 2005;293:589-595 Patients who received oxygen plus CPAP had a lower intubation rate (1% vs 10%; P=.005; relative risk [RR], 0.099; 95% CI, 0.01-0.76)

41. JAMA. 2005;293:589-595 CPAP may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery

42. CPAP

48. Crit Care Med 2007; 35:2402–2407 A, multiple RCTs & meta-analyses B, more than one RCT, case control series, or cohort studies C, case series or conflicting data

50. Crit Care Med 2007; 35:2402–2407

51. When in doubt, a brief,cautious trial of NIV can be attempted, with plans to intubate if the patient fails to improve sufficiently When in doubt, a brief,cautious trial of NIV can be attempted, with plans to intubate if the patient fails to improve sufficiently

53. Selection of a properly fit & comfortable interface is critical to NIV success

55. face mask group nasal mask group

56. Leaks & Asynchrony

57. A process of balancing the ability to reduce work of breathing by providing an adequate level of pressure support (usually 8–10 cm H 2 O) against the discomfort & greater air leaking imposed by higher pressures

58. Am J Respir Crit Care Med 2005; 172:1112–1118 Dyspnea score assessment CPAP alone was unable to reduce inspiratory effort PEEP level of 10 cm H 2 O improved oxygenation highest level of PSV :greatest improvement in dyspnea both PSV settings reduced neuromuscular drive, unloaded the inspiratory muscles, & improved dyspnea

59. Crit Care Med 2007; 35:2402–2407 Monitoring of NIV for ARF Monitoring of NIV for ARF

60. 1.Consideration the etiology of the ARF & evidence for efficacy 2.Good candidates for NIV ? & no contraindications 3.Consideration of predictors of success & failure 4.Selection of an Interface & ventilator settings 5. Experience of caregivers Keys to success “ ขอบคุณ ครับ ”