1. NIV Dos & Don’t’s Dr Arvind Bhome M.D., F.A.A.R.C. Governor for India at ICRC of AARC

2. When to NIV? Dos: Definite consensus Indications AECOPD (Acute on Chronic ARF) Acute Congestive Heart Failure without Myocardial Infarction (ACPE) Immuno-compromised patients without severe Pulmonary Insufficiency Weaning COPD after Invasive MV (Difficult wean) Maybe with caution ? Don’t Acute Exacerbation of Bronchial Asthma (AEBA) with certain caveats (Hypocapnoeic & Eucapnoeic but not Hypercapnoeic & exhausted) CAP: Community Acquired Pneumonia without severe shunt Controversial ? Don’t Do Not Intubate patients: Pros & Cons. Pros: May provide relief of symptoms to terminally ill patients Cons: Patient must understand palliative nature in irreversible incurable disease. ARDS: Exception PF ratio >150 but <300 and single organ failure with no other contraindications.

3. Other conditions for “Maybe NIV” Neuromuscular Disorders Central Hypoventilation OHS OSA Extubation Failure Bronchiectasis CF Post-operative complications

4. AECOPD Rationale: Potentially reversible acute condition. Reduced need for intubation, length of stay, in-hospital mortality, VAP (intubation associated pneumonia).(?pH 7.2, PaCO2 >45 but <60) Don’t if Contraindications: Impending resp. arrest, agitated, confused, coma, unable to protect AW, profuse secretions, paradoxical breathing, haemo-dynamic instability, upper AW obstruction, facial deformity.

5. Additional exclusion criteria Untreated pneumothorax Unmotivated, uncooperative patient Other organ failure: e.g. Severe haemorrhage Upper GI surgery Irreversible conditions Brain injury unstable resp. drive

6. Review success at 1- 2hours Positive response to NIV indicators: RR reduced, PaCO2 reduced, pH corrected Comfortable patient, synchronous with NIV Secretions minimal No C/F of Pneumonia If no positive response (none of the above) Look for complications

7. Which complications of NIV? Failure to Ventilate: Inadequate volume, asynchrony. Inadequate volume: V T, ∆ P (I PAP -E PAP or PS –PEEP), Pressure rise time insufficient, flow cycling set ‘short’ reducing V T. Asynchrony: Comfort, triggering ease, rise time to pressure, flow cycling. Hypotension: If before NIV treat cause, if after check P PEAK. (Safety <20cmH2O) Aspiration risk or Aerophagia: Stroke, drug overdose; NG Tube(?) Claustrophobia: Skin & Eye irritation or Face wounds: Poor sleep, dry ENT, Sinus/Ear pain: NG tube applied to groove Flat surface applied on patient’s face Mask interface across beveled side

8. Terminate NIV, Intubate & Ventilate if Falling pH rising PaCO2 RR >30/min. Haemo-dynamic instability Inability to clear secretions SpO2 <90% Inability to tolerate interface Decreased level of consciousness

9. ACPE: Acute Cardiogenic Pulmonary Edema When Hypercapnoea is present: Checklist Hypotension is absent, no infarct. Conscious patient motivated cooperative Not too early not too late No LVEF criteria? LVEDP by echo Reduces need for intubation,mortality CPAP or NIV improves clinical outcome. 1.Masip J, Roque M, Sanchez B, et al: Noninvasive ventilation in acute cardiogenic pulmonary edema – systematic review and meta-analysis, JAMA, 294:3124-3130, 2005. 2.Rusterholtz T, Kempt J, Berton C, et al. Noninvasive pressure support ventilation with a face mask in patients with acute cardiogenic pulmonary edema (ACPE). Inten Care Med, 25:21-28, 1999.

10. Immuno-compromised patient Increased risk of infection, increases further (VAP) if intubated. AW damage avoided in Immuno-compromised patient Can be used if respiratory distress is moderate and no other contraindications Experienced teams may use in severe respiratory distress as well. Benefits outweigh risks.

11. Weaning from Invasive MV esp. COPD NIV superior to PSV for weaning as : Reduces weaning time, LOS, nosocomial pneumonia, and 60-day mortality rate. Nava S et al: Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease: a randomized, controlled trial, Ann Intern Med 128:721, 1998. COPD weaning : be cautious, cooperative patient, can maintain AW, can clear secretions, won’t aspirate Mehta S, Hill NS: Noninvasive ventilation, Am J Respir Crit Care Med 163:540, 2001.

12. When to NIV? Dos: Definite consensus Indications AECOPD (Acute on Chronic ARF) Acute Congestive Heart Failure without Myocardial Infarction (ACPE) Immuno-compromised patients without severe Pulmonary Insufficiency Weaning COPD after Invasive MV (Difficult wean) Maybe with caution ? Don’t Acute Exacerbation of Bronchial Asthma (AEBA) with certain caveats (Hypocapnoeic & Eucapnoeic but not Hypercapnoeic & exhausted) CAP: Community Acquired Pneumonia without severe shunt Controversial ? Don’t Do Not Intubate patients: Pros & Cons. Pros: May provide relief of symptoms to terminally ill patients Cons: Patient must understand palliative nature in irreversible incurable disease. ARDS: Exception PF ratio >150 but <300 and single organ failure with no other contraindications.

13. May be with caution.?Don’t. When? Acute Exacerbation of Bronchial Asthma (AEBA) with certain caveats (Hypocapnoeic & Eucapnoeic but not Hypercapnoeic & exhausted) Meduri GU et al: Noninvasive positive pressure ventilation in status asthmaticus, Chest 110:767, 1996. Strong advocate, intubation reduced oxygenation ventilation improved Body of evidence lacking. Repeatability poor My take study design & phenotyping poor. Hypocapnoeics perhaps won’t need it but may benefit. Eucapnoeics need it but may need intubation/invasion. Hypercapnoeics are too unstable to try Conclusion: Try in asthma only if you follow what I say!

14. May be with caution.?Don’t. When? CAP: Community Acquired Pneumonia without severe shunt Acute so potentially reversible Severe shunt means difficult to improve oxygenation May also have copious secretions and may aspirate if can’t cough them out due to the interface Potential for ALI/ARDS where NIV may delay invasion and lung protective ventilation for the baby lung

15. Controversial NIV - ? Don’t Do Not Intubate patients: Pros & Cons. Pros: May provide relief of symptoms to terminally ill patients Cons: Patient must understand palliative nature in irreversible incurable disease. Don’t give false hopes. Patient must understand that NIV is life support and not cure.

16. Controversial NIV - ? Don’t Only the mild forms worth giving a try NIV in ARDS is not evryone’s baby Needs good handle on ARDS physiology P/F ratio <150 strict no no. Above 300 no ARDS. Window of opportunity between 150 to 300. No window if Haemodynamics unstable, organ failure with compromised consciousness, secretions, bleeding possibilities. ? Single organ failure- Pulmonary ARDS. ?Try NIV. This phenotype has best chance of survival with lung protective strategy. Better results with Recruitment maneuvers. Small VT and liberal PEEP. More so if less chance of AKI.I rest my case! I hope Ram agrees!!

17. Other conditions for “Maybe NIV” Neuromuscular Disorders : Chronic stable Central Hypoventilation: Chronic stable OHS: Chronic stable OSA: Chronic stable Extubation Failure: Common sense NIV Bronchiectasis: Watch if PH & Chronic Cor CF: as above Post-operative complications: Prevention rather than cure.

18. One approach to learning NIV is learning by doing! Jesus said and I repeat love thy neighbour (not his wife!)

19. Any questions?