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Non-Invasive Ventilation Update on ICU Applications

and Outcomes

Rachael Ali-Permell, BS, RT, RRT-NPS, ACCS, AE-C

Manager Respiratory Therapy Department Bayhealth Milford Memorial Hospital, Delaware

Faculty

Quinones Healthcare Seminars, LLC  

History

With the introduction of nasal CPAP to treat obstructive sleep apnea in the early 1980s, NIPPV rapidly displaced negative-pressure ventilation as the treatment of choice for chronic respiratory failure in patients with neuromuscular and chest wall deformities

The past 12 years, noninvasive ventilation has moved from the outpatient to the inpatient setting, where it is used to treat acute respiratory failure.

*  Utilization highly variable among hospitals, regions, and countries

*  Used extensively in Europe, with use increasing over time Noninvasive ventilation (NIV) use exceeds 80% of patients in some European ICUs

*  Used less in Canada and United States (20-50%; some areas 0%) Attributed to (1) unfamiliarity of physicians and other staff and (2) lack of proper equipment

*  Inaccurate perception of increased time commitment *  Practice guidelines increase usage of noninvasive

ventilation

Utilization of noninvasive ventilation

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*  Demonstrated to be cost-effective in patient management Savings of more than $3000

*  Even greater cost savings if patients managed in a non-ICU setting

*  Avoids costs of endotracheal intubation and mechanical ventilation *  Shorter ICU and hospital stays

*  Eliminates costs associated with infectious complications - Episodes of ventilator-associated pneumonia reduced by more than half.

Cost-analysis of noninvasive ventilation    

“Hospital-acquired infections kill 99,000 Americans each year.”

“That’s equivalent of a jumbo jet full of passengers crashing every other day.¹” 35,967 Deaths Annually from Hospital-Acquired Pneumonia²

1www.safepatientproject.org 2Nicolau et al. “Redefing Success for VAP: 360-Degree approach”, JMCP June 2009, Vol. 15, No. 5

*  Reducing the time patients spend on mechanical ventilation (MV) may decrease the risk of several serious complications.

*  One major challenge in the ICU is VAP (ventilator-associated pneumonia). Between 10% and 20% of patients receiving >48 hours of mechanical ventilation will develop VAP.

*  The strongest evidence for use of non-invasive ventilation (NIV) is in patients with respiratory failure secondary to either chronic obstructive pulmonary disease or cardiogenic pulmonary edema.

*  NIV is emerging as an alternative to MV in a number of different clinical situations.

*  When NIV is commenced outside critical care, a defined plan should already be in place if NIV is unsuccessful.

*  NIV should not delay intubation and MV in those patients who fail to respond to or deteriorate on NIV.

Key points  

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Absolute contraindications: *  Need for urgent endotracheal intubation *  Decreased level of consciousness *  Excess respiratory secretions and risk of vomiting and aspiration Poor

clearance of secretions *  Past facial surgery precluding mask fitting *  Potential for upper airway obstruction Extensive head and neck tumors *  Any other tumor with extrinsic airway compression *  Angioedema or anaphylaxis causing airway compromise

Relative contraindications: *  Hemodynamic instability Shock and need for pressor support *  Ventricular dysrhythmias *  Complicated acute myocardial infarction *  Severe hypoxia and/0r hypercapnia, PaO2/FiO2 ratio of <200mmHg, PaCO2>

60mmHg. *  Poor patient cooperation *  Lack of trained or experienced staff

*  Exacerbations increase the work of breathing *  Increasing hyperinflation with decreased diaphragmatic excursion and

strength

*  Increasing intrinsic positive end-expiratory pressure (PEEP), ineffective or inadequate tidal volume generation, respiratory patterns, and increased respiratory rate.

*  Noninvasive ventilation *  Effectively unloads the respiratory muscles

*  Increasing tidal volume *  Decreasing the respiratory rate

*  Decreasing the diaphragmatic work of breathing

which translates to an improvement in oxygenation, a reduction in hypercapnia, and an improvement in dyspnea.

*  Application (compared with endotracheal intubation) a. Easy to implement

b. Easy to remove

c. Allows intermittent application

*  Improves patient comfort

*  Reduces the need for sedation

*  Oral patency (preserves speech, swallowing, and cough, reduces the need for nasoenteric tubes)

*  Avoid the resistive work imposed by the endotracheal tube

*  Avoids the complications of endotracheal intubation *  Early (local trauma, aspiration) *  Late (injury to the hypopharynx, larynx, and trachea, nosocomial infections)

Advantages of NIV

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1.System *  Slower correction of gas exchange abnormalities

*  Increased initial time commitment

*  Gastric distension (occurs in <2% patients)(NG tube placed)

2.Mask *  Air leakage

*  Transient hypoxemia from accidental removal

*  Eye irritation

*  Facial skin necrosis –most common complication. 3.Lack of airway access and protection *  Suctioning of secretions

*  aspiration

Disadvantages of NIV

First 30 min. of NPPV is labor intensive. Bedside presence of a

respiratory therapist or nurse familiar with this therapy is essential.

Providing reassurance and adequate explanation

Be ready to intubate and start on invasive ventilation.

Important!!!  

Humidification during NIV

No humidification: drying of nasal mucosa and oropharynx; increased airway resistance; decreased compliance. A heated humidifier should be used when the duration of application is anticipated to be more than a few hours

*  HME lessens the efficacy of NIV *  Only pass-over humidifiers should be used

 

Intensive  Care  Med.  2002;28  

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Uses of NIV

1.  COPD. Acute exacerbation. 2.  Cardiogenic pulmonary edema/CHF

3.  Obesity Hypoventilation Syndrome

4.  Sleep Disordered Breathing

5.  Neuromuscular Disease

6.  Bronchial asthma

7.  Post extubation RF/

8.  Accelerate weaning.

9.  Pneumonia/ARDS

Criteria 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.

CPAP  constant flow of pressurized air that works to maintain an open airway, no difference in the pressures when breathing in or out. BIPAP "bilevel" component refers to the fact that there are in fact two pressures, which the machine is able to alternate between. a higher pressure when breathing in, and a lower one when breathing out. This allows you to breathe out against a slightly lower pressure.    AVAPS (Average Volume Assured Pressure Support) Maintains a target tidal volume in a pressure limited mode. It provides extra assurance similar to a volume limited mode with the safety of a pressure limited mode.

*  Which  patients  benefit  from  AVAPS?    *  Patients who develop chronic hypoventilation may find this mode

more comfortable and effective . Neuromuscular, COPD, and obesity hypoventilation patients.

Modes on BIPAP

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CPAP with C-Flex offers three levels of flow-based expiratory pressure relief. This option leads to improved sleep quality and patient comfort, adding greater flexibility and improved treatment acceptance.

PPV (proportional pressure ventilation) delivers pressure and flow in proportion to the patient’s effort, enabling the patient to more efficiently adjust their breathing to meet their changing requirements. Proportional assist modes have been shown to lower peak pressures as compared to pressure support and may improve patient comfort. Patient comfort leads to therapy compliance, which may improve the success of noninvasive ventilation.

Modes on BIPAP

*  CPAP start at(EPAP) 8-10cm H2O *  BiPAP start with an IPAP of 12-15cmH2O, and EPAP of 4-7cm H2O. *  Based on current evidence pressures should not exceed 25cm H2O at any point

regardless of the mode of NIV being used.

In order to maintain the pressures, it is important to achieve a good seal with the NIV mask.

*  Mask is held gently on patient’s face. *  Increase the pressures until adequate Vt (7ml/kg), RR<25/m, and

patient comfortable. *  Titrate FiO2 to achieve SpO2>90%. *  Keep peak pressure <25-30 cm *  Head of the bed elevated

Initial Settings  

Once noninvasive ventilation is initiated, patients should be closely monitored in a critical care unit or a step-down unit until they are sufficiently stable to be moved to a regular medical floor. The aim of monitoring Relief of symptoms, reduced work of breathing, improved or stable gas exchange, good patient-ventilator synchrony, and patient comfort A drop in the respiratory rate with improved oxygen saturation or improving pH with a lower PaCO2, reduce heart rate, within the first 1 to 2 hours indicates a successful outcome. The absence of these favorable signs indicates a poor response to noninvasive ventilation

MONITORING

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*  failures may relate to asynchrony. *  The NIV failure rate (need for intubation) may be as high as 40%. *  Good NIV tolerance has been associated with success of NIV, and

improved comfort has been associated with better synchrony. *  In one study, a high rate of asynchrony occurred in 43% of subjects

during NIV.

*  Patient-ventilator asynchrony during NIV is related to the underlying disease process and the presence of leaks.

Solution *  reducing the leak related to the interface and using a ventilator with good

leak compensation should reduce the rate of asynchrony.

Hess DR . Patient-ventilator interaction during noninvasive ventilation. Respir Care 2011;56(2):153-165; discussion 165-167.

How to Address Asynchrony?

Physiological a) Continuous oximetry b) Exhaled tidal volume

c) ABG should be obtained within 1 hour and, as necessary, at 2 to 6 hour intervals.

Objective a) Respiratory rate b) blood pressure c) pulse rate Subjective a) dyspnea b) comfort c) mental alertness

Response  

COPD 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 rate—is reduced

GOLD  2003  

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An arterial blood gas (ABG) sample typically shows that the patient has low oxygen levels (hypoxia) and high carbon dioxide levels (hypercapnia) The CO2 will be greater than 45, sometimes 60 or higher, and the bicarb will be greater than 30. The pH will be normal.

v  There have been several important meta-analyses regarding the use of NIV in COPD. Show that NIV is of value in treating acute exacerbations of COPD.1

v  Study patients have decreased: v  Hospital mortality v  Intubation rates v  Length of stay

v  Economic evaluation noted a cost savings of $3244 for each patient treated with NIV vs. mechanical ventilation.

NIV should be applied as soon as indicated to achieve maximum benefit. In one study, the success rate was 93% when NIV was used early in the course of hospital treatment, while the success rate was only 63% when standard medical therapy was used before NIV.2 Crit Care Med 2000;28:2094-2102.(Meta-analysis and economic evaluation of treatment)1 Chest 1998;114:1636-1642. (Randomized, prospective; 30 adult patients)2

Non-Invasive Ventilation and COPD

A systematic review and meta-analyses of noninvasive ventilation and weaning in about 500 patients (mostly COPD patients) *  RESULTS: ~The use of noninvasive ventilation reduced mortality rates by 45%, ~Ventilator-associated pneumonia rates by 71% ~Duration of ICU stay by 6.27 days ~Hospital days by 7.19 days (10.8-3.58 d) Compared with a conventional weaning approach. The duration of endotracheal intubation was reduced by 7.81 days as was the need for tracheostomy. However, reintubation rates were not decreased. A more recent report suggests that hypercapnic patients may do better if treated with noninvasive ventilation following extubation.

NIV  and  weaning  

Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. Aug 12 2009.

*  NIV is used as both a rescue therapy and a preventative measure in recently extubated patients, thought to be high risk for reintubation to reduce the need for a period of further MV.

*  Prolonged endotracheal intubation is uncomfortable, increases the risk of VAP, and increases the risk of tracheal damage

*  Airway protection/secretion clearance capabilities must be present. *  Postextubation respiratory insufficiency requiring reintubation can occur in more than 20% of

patients In quasi-randomized controlled trials done to evaluate the evidence for extubation with immediate application of NIV, compared with continued invasive weaning.

NIV was associated with: Reduced mortality, lower rates of ventilator-associated pneumonia (VAP), fewer ICU and hospital days, shorter total duration of ventilation, and shorter duration of invasive ventilation. *  The authors concluded that use of NIV to allow earlier extubation should be used in patients with

COPD in a highly monitored environment.

Burns et al, Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev 2010(8):CD004127.

NIV Post-Extubation in critical care

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CHF

*  Respiratory failure in CHF is related to a combination of: ~ pulmonary vascular congestion, interstitial edema, and alveolar fluid accumulation. ~ Leading initially to hypoxemic respiratory failure

~ CHF patients who further deteriorate manifest hypercapnia respiratory failure. Goal is to recruits alveoli, increases functional residual capacity, and allows breathing on the more compliant portion of the lung's pressure-volume curve, thereby decreasing the work of breathing, improving ventilation-perfusion relationships, and eventually correcting hypoxemia and hypercapnia.

Positive intrathoracic pressure also decreases preload and left ventricular afterload, and decrease overall static pressure. *  Relatively moderate EPAP: 6-12 cm H2O

*  Relatively low IPAP+EPAP: 12-18cm H2O *  Patient will benefit mostly with EPAP unless other concurrent disease ( COPD,

Obesity-Hypoventilation)

*  Typical starting point: BiPAP 10/6

*  Meta-­‐analyses  do  suggest  a  benefit  with  CPAP,  with  a  risk  reduction  in  intubation  of  60%  and  a  decrease  in  mortality  rate  of  47%.  

Immunocompromised patients who develop acute respiratory failure often require respiratory support. In such patients, endotracheal intubation is associated with substantial mortality. Study: to compare NIV with standard treatment using supplemental oxygen administration to avoid endotracheal intubation in recipients of solid organ transplantation with acute hypoxemic respiratory failure. Patients: Of 238 patients who underwent solid organ transplantation from December 1995 to October 1997, 51 were treated for acute respiratory failure. Of these, 40 were eligible and 20 were randomized to each group. Criteria for eligibility : Acute respiratory distress; a respiratory rate greater than 35/min, a ratio of the PaO2 to the fraction of inspired oxygen (FIO2) (PaO2:FIO2) of less than 200 while the patient was breathing oxygen through a Venturi mask; and active contraction of the accessory muscles of respiration or paradoxical abdominal motion.

RESULTS: The 2 groups were similar at study entry.

*  Within the first hour of treatment, 14 patients (70%) in the NIV group, and 5 patients (25%) in the standard treatment group improved their ratio of the PaO2 to the fraction of inspired oxygen (FIO2).

*  Over time, a sustained improvement in PaO2 to FIO2 was noted in 12 patients (60%) in the NIV group, and in 5 patients (25%)

*  The use of NIV was associated with a significant reduction in the rate of endotracheal intubation (20% vs 70%), rate of fatal complications (20% vs 50%), length of stay in the intensive care unit by survivors (mean [SD] days, 5.5 vs 9), and intensive care unit mortality (20% vs 50%).

CONCLUSIONS: These results indicate that transplantation programs should consider NIV in the treatment of selected recipients of transplantation with acute respiratory failure.

Antonelli et al..  JAMA.  2000;283(2):235-­‐241.  

Immunocompromised Patients

*  Goal of therapy is to decrease work of breathing and increase ventilation

*  EPAP: usually on the higher side; enough to overcome OSA and cardiopulmonary disease: ~10cmH2O, more for bigger individuals

*  IPAP+EPAP: at least a 4cm H2O differential

*  Need to adjust according to ventilation requirements; may benefit from back up rate

*  Restores sleep quality and daytime vigilance and reduces cardiovascular morbidity

*  NIV suppresses respiratory events during sleep, normalizes sleep structure

Obesity-Hypoventilation Syndrome

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The use of NIV is controversial in most studies that have addressed in this patient population.

*  Zhan et Noninvasive  ventilation  in  severe  hypoxemic  respiratory  failure:  a  randomized  clinical  trial.  Am  J  Respir  Crit  Care  Med  2003;168(12):  1438-­‐1444.

enrolled 40 subjects who did not have indications for immediate endotracheal intubation with mild ARDS. subjects were randomly allocated to receive either NIV or oxygen.

Results: NIV was associated with a lower breathing frequency and improved PaO2/FIO2 over time, and the proportion

of patients requiring intubation was significantly lower in the subjects receiving NIV.

*  Ferrer et al; Early  use  of  noninvasive  positive  pressure  ventilation  for  acute  lung  injury:  a  multicenter  randomized  controlled  trial.  Crit  Care  Med  2012;40(2):  455-­‐460.  

randomized 105 subjects with severe hypoxemic respiratory failure to receive either NIV or high FIO2

The respiratory-failure etiologies were mostly pneumonia and cardiogenic pulmonary edema, but there were 15 subjects with ARDS.

Results: NIV prevented intubation, reduced the incidence of septic shock, and improved survival.

*  Agarwal et al Outcomes  of  noninvasive  ventilation  in  acute  hypoxemic  respiratory    failure  in  a  respiratory  intensive  care  unit  in  north  India.  Respir  Care  2009;54(12):1679-­‐1687.

In a prospective observational study, evaluated the role of NIV for hypoxic respiratory failure. Subjects were classified into 2 groups: ARDS and other causes.

Results: reported that 12 of the 21 ARDS subjects needed intubation, versus 7 of the 19 in the other group.

ARDS  

*  DNI (Do- Not-Intubate) *  CMO (comfort measures only)

 *  NIV may be applied to Restore pre-admission health status without using treatments and

techniques the patient has elected against (eg, Intubation) *  Delay death if the patient so desires, to give, for instance, a geographically distant family

member enough time to travel to the hospital to be at the patient’s side before death *  To allow the patient to be transferred home to die *  To give the patient enough time to settle personal or financial matter. *  Maximize comfort and minimize pain and other discomforts, including adverse effects of

treatments. The clinician’s role is to try to meet the patient’s needs so that the final hours or days of life are as comfortable as possible.

DNI and CMO patients

*  Rotate types of interfaces *  Proper tightening

*  Skin and mask hygiene

*  Nasal-forehead spacer

*  Adjustable forehead pad

*  Cushioning between mask and face

*  Barrier tape between mask and face

How to Reduce the Risk of Skin Damage During Noninvasive Ventilation

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Efficacy of Nasal and Oronasal mask

lowering PaC02 and avoiding intubation is similar in the acute setting. a recent randomized study Shows, patients tolerated the full facemask better because of reduced air leakage through the mouth. Selection of a comfortable mask that fits properly is key to the success of noninvasive ventilation. The full facemask should be tried first in the acute setting, and if possible, The mask straps are then tightened with the least tension necessary to avoid excessive air leakage. Study by Ontario Practice

For acute NIV applications, 85.5% of respondents used an oronasal mask (covering the nose and mouth) at least 30% of the time. Fewer respondents used nasal masks (41.7%) or total face masks (covering the entire face; 18.6%)  Disclosures Crit Care Med. 2005;33(7):1477-1483

NIV is under utilized, despite the robust evidence. NIV should be part of the treatment regiment that a medical practitioner has at his or her disposal when caring for patients with acute respiratory failure. Increased utilization requires that clinicians view it as superior to invasive ventilation, that it is perceived as compatible with existing approaches to mechanical ventilation, and that it is not too difficult to apply. Barriers to NIV use include lack of awareness of the evidence, lack of agreement with the evidence and lack of self-efficacy.

Conclusion

1.  Corrado A, Gorini M, Melej R, et al. Iron lung versus mask ventilation in acute exacerbation of COPD: a randomized crossover study. Intensive Care Med. Apr 2009;35(4):648-55. [Medline].

2.  Ozsancak A, Sidhom S, Liesching TN, Howard W, Hill NS. EVALUATION OF THE TOTAL FACE MASKTM FOR NONINVASIVE VENTILATION TO TREAT ACUTE RESPIRATORY FAILURE. Chest. Feb 17 2011;[

3.  Brochard L, Isabey D, Piquet J, et al. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med. Nov 29 1990;323(22):1523-30. [Medline].

4.  Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. Sep 28 1995;333(13):817-22. [Medline].

5.  Plant PK, Owen JL, Parrott S, Elliott MW. Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised controlled trial. BMJ. May 3 2003;326(7396):956. [Medline].

6.  Keenan SP, Sinuff T, Cook DJ, Hill NS. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med. Jun 3 2003;138(11):861-70. [

7.  Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. Jan 25 2003;326(7382):185. [Medline].

8.  Confalonieri M, Garuti G, Cattaruzza MS, et al. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. Feb 2005;25(2):348-55. [Medline].

9.  Diaz GG, Alcaraz AC, Talavera JC, et al. Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failure. Chest. Mar 2005;127(3):952-60.

10. Scala R, Naldi M, Archinucci I, Coniglio G, Nava S. Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness. Chest. Sep 2005;128(3):1657-66. [Medline].

11. Girou E, Brun-Buisson C, Taille S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. Dec 10 2003;290(22):2985-91. [Medline].

12. Girou E, Schortgen F, Delclaux C, et al. Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. JAMA. Nov 8 2000;284(18):2361-7.

13.  [Guideline] Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. National Guideline Clearinghouse. 2008.

14. Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. May 21 2009;338:b1574. [Medline]. [Full Text].

15. Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. Aug 12 2009.

16. Dean R Hess Noninvasive Ventilation for Acute Respiratory Failure; Respiratory Care June 1, 2013 vol. 58 no. 6 950-972

References

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Thank You !

Questions?