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8/6/2019 Non Invasive Ventilation Conference
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Non Invasive VentilationNon Invasive VentilationNon Invasive VentilationNon Invasive Ventilation
Dr.Balamugesh, MD, DM,
Dept. of Pulmonary Medicine,Christian Medical College,
Vellore.
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Definition..Definition..
Noninvasive ventilation is the delivery of
ventilatory support without the need for an
invasive artificial airway
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How does NIV work?How does NIV work?
Reduction in inspiratory muscle workand avoidance of respiratory musclefatigue
Tidal volume is increased CPAP counterbalances the inspiratory
threshold work related to intrinsicPEEP.
NIV improves respiratory systemcompliance by reversingmicroatelectasis of the lung.
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Advantages ofNIVAdvantag
es ofNIV
Noninvasiveness
Application (compared with endotracheal intubation)
a.Easy to implement b. Easy to remove Allows
intermittent application
Improves patient comfort
Reduces the need for sedationOral patency (preserves speech, swallowing, and
cough, reduces the need for nasoenteric tubes)
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Avoid the resistive work imposed by the
endotracheal tube
Avoids the complications of endotracheal
intubation
Early (local trauma, aspiration)
Late (injury to the the hypopharynx, larynx, andtrachea, nosocomial infections)
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Disadvantages ofNIVDisadvantages ofNIV
1.System
Slower correction of gas exchange abnormalities
Increased initial time commitment
Gastric distension (occurs in
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3.Lack of airway access and protection
Suctioning of secretions
aspiration
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Location of NIVLocation of NIV
NIV can be administered in the emergencydepartment, intermediate care unit, or generalrespiratory ward
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Who can administer NIV?Who can administer NIV?
by physicians, nurses, or respiratory caretherapists,
depends on staff experience and availabilityof resources for monitoring, and managingcomplications
For the first few hours, one-to-one monitoringby a skilled and experienced nurse,
respiratory therapist, or physician ismandatory.
Immediate access to staff skilled in invasiveairway management.
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InterfaceInterface
Nasal masks
less dead space
less claustrophobia
allow for expectoration
vomiting and oral intake
vocalize
facial mask
dyspnoeic patients
are usually mouthbreathers
More dead space
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Mask: orofacial vs nasalMask: orofacial vs nasal
similar with regard toimproving vital signs and gas
exchange and avoidingintubation
nasal mask was less well
tolerated mainly due togreater air leakagethrough mouth Crit Care Med. 2003 Feb;31
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Helmet vs facial
mask
Helmet vs facial
mask
Complications (skin necrosis,
gastric distension, and eye
irritation) were fewer with
helmet
allowed prolonged continuous
application ofNIV
Length of stay in ICU,intubation rates, mortality
similar
Intensive Care Med. 2003;29 CritCare Med. 2002;30
Chest. 2004;126
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Position of exhalation port and mask design
affect CO2 rebreath
ing during NIV
Position of exhalation port and mask design
affect CO2 rebreath
ing during NIV
facial mask with exhalation port within the
mask compared with port in the ventilatorcircuit
smallest mask volume
less rebreathed CO2
inspiratory load
Crit Care Med. 2003 Aug;31
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Humidification during NIVHumidification during NIV
No humidification: drying of nasal mucosa;
increased airway resistance; decreased
compliance.
HME lessens the efficacy ofNIV
Only pass-over humidifiers should be
used
Intensive Care Med. 2002;28
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Aerosol bronchodilator delivery during NIVAerosol bronchodilator delivery during NIV
optimum nebulizer position: between the leak port and
patient connection
Optimum ventilator settings: high inspiratory pressure
and low expiratory pressure.
Optimum RR 20/mt. Rather than 10/mt. 25% of salbutamol dose may be delivered
Crit Care Med. 2002 Nov;30
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Desirable to deliver the aerosolizedbronchodilator without removing the
patient from NIV ? aerosol delivery in systems in which
the leak port is in the mask or in which aleak port of different design
? Nebulizer was maintained in thevertical position
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Uses of NIVUses of NIV1. COPD. Acute exacerbation/domiciliary.
2. Cardiogenic pulmonary edema.
3. Bronchial asthma
4. Post extubation RF
5. Hasten weaning.
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COPD EXACERBATION: NIVCOPD EXACERBATION: NIV success rates of 80-85%
increases pH, reduces PaCO2, reduces
the severity of breathlessness in first 4 h
of treatment
decreases the length of hospital stay
Mortality, intubation rateis reduced
GOLD 2003
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CRITERIA FOR NIV IN ACUTE
EXACERBATION OF COPD
CRITERIA FOR NIV IN ACUTE
EXACERBATION OF COPD GOLD 2005
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Cardiogenic Pulmonary edema.Cardiogenic Pulmonary edema. sufficiently high level evidence to favor the
use of CPAP,
there is insufficient evidence to recommend
the use of BiPAP, probably the exception
being patients with hypercapnic CPE.
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MethodologyMethodology
Initial ventilator settings: CPAP (EPAP) 2 cmH2O & PSV (IPAP) 5 cm H20.
Mask is held gently on patients face. Increase the pressures until adequate Vt
(7ml/kg), RR90%. Keep peak pressure
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MonitoringMonitoring
ResponsePhysiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG should be obtained with 1 hour and, asnecessary, at 2 to 6 hour intervals.
Objective a) Respiratory rateb) blood pressure
c) pulse rate
Subjectivea) dyspneab) comfort
c) mental alertness
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Monitoring..Monitoring..Mask
Fit, Comfort, Air leak, Secretions, Skin necrosis
Respiratory muscle unloading
Accessory muscle activity, paradoxical
abdominal motion
Abdomen
Gastric distension
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First 30 min. of NPPV is labor intensive.
Bedside presence of a
respiratory therapist or nurse
familiar with this mode is essential.Providing reassurance and adequate explanation
Be ready to intubate andstart on invasive
ventilation.
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Criteria to discontinue NIVCriteria to discontinue NIV Inability to tolerate the mask because of discomfort or
pain
Inability to improve gas exchange or dyspnea Need for endotracheal intubation to manage secretions
or protect airway
Hemodynamic instability
ECG ischemia/arrhythmia Failure to improve mental status in those with CO2
narcosis.
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Eur Respir J 2002; 20:
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