Part II: Introduction to Part II: Introduction to Noninvasive Positive Pressure Noninvasive Positive Pressure Ventilation in the Acute Care Ventilation in the Acute Care SettingSetting

By: Susan P. Pilbeam, MS, RRT, FAARC

John D. Hiser, MEd, RRT, FAARC

Ray Ritz, BS, RRT, FAARC

American Association for Respiratory Care

December, 2006

Benefits of Using NPPVBenefits of Using NPPV

NPPV provides greater flexibility in initiating and removing mechanical ventilation

Permits normal eating, drinking and communication with your patient

Preserves airway defense, speech, and swallowing mechanisms

Benefits of Using NPPV Benefits of Using NPPV Compared to Invasive Compared to Invasive VentilationVentilation

Avoids the trauma associated with intubation and the complications associated with artificial airways

Reduces the risk of ventilator associated pneumonia (VAP)

Reduces the risk of ventilator induced lung injury associated with high ventilating pressures

Other Benefits of Using Other Benefits of Using NPPVNPPV Reduces inspiratory muscle work and

helps to avoid respiratory muscle fatigue that may lead to acute respiratory failure

Provides ventilatory assistance with greater comfort, convenience and less cost than invasive ventilation

Reduces requirements for heavy sedation

Reduces need for invasive monitoring

Additional Benefits of NPPV Additional Benefits of NPPV in the Acute Care Settingin the Acute Care Setting

Preserves the ability to communicate

Enhances patient comfort

Examples of Patient Problems Examples of Patient Problems that may Benefit from NPPV in that may Benefit from NPPV in the Acute Care Setting the Acute Care Setting Acute Exacerbation of COPD

Hypoxemic Respiratory Failure/ARDS

Community Acquired Pneumonia (CAP)

Asthma

Immunocompromised States

Acute Cardiogenic Pulmonary Edema (CPE) - when hypercapnia is present.

Additional Examples of Disorders Additional Examples of Disorders in which NIPPV by Nasal or Face in which NIPPV by Nasal or Face Mask has been UsedMask has been Used Neuromuscular disorders

Central alveolar hypoventilation

Cystic fibrosis

Bronchiectasis

Postoperative complications

Postextubation failure in difficult-to-wean patients

Do-not-intubate patients

First Step: Selection Criteria First Step: Selection Criteria for Patients in the Acute Care for Patients in the Acute Care Setting Setting Consider the patient's diagnosis, clinical

characteristics and the risk of failure of the procedure

Applying NPPV too early may be unnecessary for patients with mild respiratory distress

On the other hand, applying NPPV when a patient has already deteriorated to severe respiratory failure may potentially delay life-saving intubation and ventilation

Establishing the Need for Establishing the Need for VentilationVentilation

Signs and Symptoms of Distress in the Adult – Tachypnea (respiratory rate >24

breaths/min)– Accessory muscle use, and

paradoxical breathing – ABG results:

• pH < 7.35 and PaCO2 > 45 mm Hg, or

• PaO2/FiO2 < 200

Patient Medical HistoryPatient Medical History

The underlying patient disorder must be taken into account

For example, does the patient have acute respiratory failure with a history of COPD. Or, does the patient have acute congestive heart failure with an elevated CO2?

Next exclusionary criteria must be evaluated

Second Step: Second Step: Exclusionary CriteriaExclusionary Criteria Respiratory arrest (apnea) or the need for

immediate intubation

Unable to protect the airway (impaired cough or swallowing)

Excessive secretions

Hemodynamic instability

Agitated and confused patients

Paradoxical breathing

Upper airway obstruction

Additional Exclusionary Additional Exclusionary CriteriaCriteria

Facial deformities or conditions that prevent mask fit, e.g. facial burns, severe facial trauma, craniofacial surgery, fixed anatomic abnormalities of the nasopharynx

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Additional Exclusionary Additional Exclusionary CriteriaCriteria

Untreated pneumothorax

Uncooperative or unmotivated patients

Brain injury with unstable respiratory drive

Other major organ involvement – for example, severe hemorrhaging

Recent esophageal or gastric surgery (relative contraindication)

Finally, irreversibility of disorder

NPPV InitiatedNPPV Initiated

Once the patients signs and symptoms are evaluated,

And the underlying disorder is considered,

And finally exclusionary criteria are eliminated,

Then NPPV may be justified IFIF the acute respiratory failure is likely to resolve in a few days.

InterfacesInterfaces

A variety of interfaces can be used to provide NPPV

This section will focus on those devices used in the acute care setting

Nasal MasksNasal Masks

Thin flexible &

bridge material

Dual density

foam bridge forehead

support

Dual flap cushion

360 swivel

standard elbow

Respironics Contour Deluxe™ Mask

Fitting Nasal MasksFitting Nasal Masks

Nasal fitting template

Choose the smallest mask without obstructing the nostrils

Courtesy of Respironics

Anatomic Landmarks for Anatomic Landmarks for Nasal Mask FitNasal Mask Fit

Anatomic Anatomic LandmarksLandmarks

a)a)Sides of noseSides of nose

b)b)Bridge of nose Bridge of nose (caution)(caution)

c)c) Above the lipAbove the lip

Courtesy of Respironics

Nasal Mask FitNasal Mask Fit

Top of the mask: placed just above the junction of the nasal bone and the cartilage (dorsum of the nasal bridge)

The fit should be not pinch the nose at the side

The lower part of the mask fits just above the upper lip

A common error is to pick a mask that is too large

Nasal Mask Fit (continued)Nasal Mask Fit (continued)

Foam “bridges” that attach to the end of the mask and rest on the forehead help reduce pressure on the bridge of the nose

Advantages of Nasal MasksAdvantages of Nasal Masks

Less risk of aspiration

Enhanced secretion clearance

Less claustrophobia

Easier speech

Less dead space

Disadvantages of Nasal Disadvantages of Nasal MasksMasks

Mouth leak

Less effectiveness with nasal obstruction

Nasal irritation and rhinorrhea

Mouth dryness

Full Face MasksFull Face Masks

Most often successful in the critically ill patient

Respironics PerformaTrak® Full Face Mask

Entrainment valve

AdjustableForehead Support

Ball and Socket Clip

Double-foam cushion

Pressure pick-off port

Mask Fitting is EssentialMask Fitting is Essential

A full face mask surrounds the nose and mouth and rests below the lower lip

Using a template can give an estimate of the appropriate mask size

Courtesy of Respironics, Inc.

Fitting Full Face MaskFitting Full Face Mask

Landmarks

a) Below the lower lip with mouth open

b) Corners of the mouth

c) Just below the junction of nasal bone and cartilage

1

Courtesy of Respironics, Inc

a

b

c

b

Full Face MasksFull Face Masks

It should fit even if the patient’s mouth is slightly open

Be sure the mask fits well and does not leak excessively, particularly not into the eyes

Minimizing LeaksMinimizing Leaks

Sometimes leaks are caused by the mask not being correctly seated on the face

Some leaks can even be caused by excessive tension of the head straps. Minimize headgear tension (1-2 fingers should fit between head straps and face)

In patients without a full set of teeth, using a full face or total face mask can help minimize leaks

Advantages and Advantages and Disadvantages of Oronasal Disadvantages of Oronasal or Full Face Masks or Full Face Masks More effective for dyspneic patients

Disadvantages:

– Increased dead space

– Difficulty in maintenance of adequate seal

– Increased risk of facial pressure sores

– Claustrophobia

More Disadvantages More Disadvantages of Full Face Masksof Full Face Masks

Increased risk of aspiration

More difficulty with speech

Inability to eat with mask in place

More difficulty with secretion clearance

Possible asphyxiation with ventilator malfunction

Nasal Pillows or Nasal Nasal Pillows or Nasal CushionsCushions

Pillow Cushion

Nasal Cushion

Nasal Pillows to seal nares

Respironics Comfort Lite Nasal Mask

Nasal Pillows or Nasal Nasal Pillows or Nasal Cushions (continued)Cushions (continued) Suitable for

patients with

– Claustrophobia

– Skin sensitivities

– Need for visibility

Respironics Comfort Lite Nasal Mask

Fitting Nasal Pillows or Fitting Nasal Pillows or Nasal CushionsNasal Cushions

Using the plastic sizing gauge, insert each size into the nostril

Choose the size that best seals the nostril

Courtesy of Respironics, Inc.

Total Face MaskTotal Face Mask

Interface selection– Total face

mask– Mouthpiece

Respironics Total Face Mask

Mouthpiece/Lip Seal Mouthpiece/Lip Seal

Mouth pieces with or without lip seals can also be used for an interface

Their use is generally restricted to patients who are ventilator-dependent (chronic conditions)

Some mouthpieces are used with nose clips

Some patients use custom-made oral appliances for ventilation

Mask Selection GuideMask Selection Guide

NPPV- Masks With LeaksNPPV- Masks With Leaks

Vented masks require a vent for exhalation and use only one corrugated tube to connect to the ventilator

Respironics BiPAP Vision ® Noninvasive Ventilator with a Nasal Mask

NPPV – Masks Without LeaksNPPV – Masks Without Leaks

Non-vented masks have both inspiratory and expiratory lines

Exhaled volumes, flows and pressures can be monitored Respironics Esprit Critical Care

Ventilator with PerformaTrak SE Full Face Mask

Tips on Initiating NPPV Tips on Initiating NPPV VentilationVentilation

Essential elements are staff competence and patient compliance

Have a variety of masks available to ensure a proper fit.

Change mask if the patient’s facial contours change, for example if facial edema develops

Tips on Initiating NPPV Tips on Initiating NPPV Ventilation, (continued)Ventilation, (continued)

Let the patient breath through the mask before connecting the system in order to reduce anxiety (Perhaps allow the patient to hold the mask.)

If the patient is claustrophobic, try a nasal mask (Make sure patient has their mouth closed or a chin strap may be needed) Courtesy of Respironics, Inc.

Tips on Initiating NPPV Tips on Initiating NPPV Ventilation, (continued)Ventilation, (continued)

Place patient in an upright or sitting position

Carefully explain the NPPV procedure to the patient including goals and potential complications

Example NPPV SettingsExample NPPV Settings

Common IPAP orders – 8 to 12 cm H2O– Adjust to change tidal volume

Typical EPAP setting– 4 cm H2O – Increase to improve oxygenation

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20

10

0

IPAP = 12

EPAP = 4

PS = 8

Initial Ventilator SettingsInitial Ventilator Settings

Progressively increase the pressure until the ordered pressures are achieved

Then assess patient– Patient’s adaptability and comfort– Acceptable tidal volumes

– SpO2 and vital signs

Completing NPPV SetupCompleting NPPV Setup

Determine desired FIO2

Set back-up rate

Begin ventilation, coaching the patient until the patient becomes comfortable

Monitor SpO2 and adjust FIO2 to maintain O2 saturation > 90%

Monitor HR and respiratory rate

Steps For Initiating NPPVSteps For Initiating NPPV

Secure the mask to the patient – Avoid excessive tightening of the

straps. Attach the interface to the ventilator (1-2 fingers space)

Titrate IPAP, EPAP, inspiratory rise time, sensitivity (patient trigger), flow cycle, exhaled tidal volume, and synchrony with the ventilator

Steps For Initiating NPPVSteps For Initiating NPPV

Avoid peak pressures > 20 to 25 cm H20

Check for leaks and readjust the mask and head straps if necessary (It is essential to minimize leaks)

Small leaks are compensated by most ventilators

Allowing a small leak may avoid an excessively tight fit and possibly reduce the risk of skin breakdown

Monitoring the Leak SizeMonitoring the Leak Size

0-6 L/min = Mask may be too tight

7-25 L/min = Just right

26-60 L/min

= Adjust mask and monitor

> 60 L/min = Caution

Air Leak Guidelines for Vision BiPAP Noninvasive Ventilator

Note: Leak compensation for noninvasive ventilation in critical care ventilators varies and could be as low as 20 L/min. Therefore, management of smaller leaks is required.

Predictors of Success with Predictors of Success with NPPVNPPV

Positive initial response to NPPV within 1-2 hours– Correction of pH– Decreased respiratory rate

– Reduced PaCO2

Synchronous breathing efforts with ventilator

Lower quantity of secretions

Absence of pneumonia

Complications or Problems Complications or Problems Associated with NPPV Associated with NPPV

Failure to Ventilate – Failure to Ventilate – Inadequate VolumeInadequate Volume

Tidal volume is inadequate for patient

Check ventilating pressures to be sure the Delta P is sufficient for the patient [DP = IPAP – EPAP or PS – PEEP]

Be sure the rise time to pressure is sufficient

Be sure the flow-cycle criteria is not too “short”, thus compromising volume delivery

Failure to Ventilate –Failure to Ventilate –Lack of SynchronyLack of Synchrony

Patient and ventilator are not synchronous.

Check the sensitivity. Is it easy for the patient to trigger a breath?

Check the rise time to full pressure. Does it meet the patient’s flow demand?

Check the flow-cycle criteria during PSV. Make sure it is set appropriate for the patient. (see section III of this teaching module)

HypotensionHypotension

If hypotension was present prior to therapy, treat the cause

 If hypotension resulted after initiating NPPV, be sure ventilating pressures are not excessively high (peak pressures < 20 cm H20)

Risk of AspirationRisk of Aspiration

The risk of aspiration exists in some patients

Maintain a policy of selecting patients appropriately for NPPV patients who can protect their own airway

Examples of patients who may not be able to protect their airways: – Stroke victims, and individuals with a drug

overdose. In these examples, an endotracheal tube should be inserted to protect the airway

ClaustrophobiaClaustrophobia

Try using a nasal interface or,

Try using a total face mask, or

Try mild sedation (use caution).

Gastric Insufflation Gastric Insufflation (Aerophagia) and Gastric (Aerophagia) and Gastric DistentionDistention

Excessive pressure or air swallowing can cause air gastric inflation (insufflation) and gastric distention

Use pressures less than 20 to 25 cm H2O

Use simethicone (anti-flatulent) agent

Use of Nasogastric TubesUse of Nasogastric Tubes

Use of nasogastric tubes to take air from the stomach is controversial

The tube increases leaking around the mask

The tube itself blocks a nasal passage

Compression of tube against the skin by the mask may increase risk of skin breakdown

Possible Solution with Possible Solution with Nasogastric TubesNasogastric Tubes

If an NG tube must be used, one possible solution is to use an interface between the tube and the skin and mask

Respironics NG Sealing Pad ImageRespironics NG Sealing Pad Image

NG tube applied to groove

Flat surface applied on patient’s face

Mask interface across beveled side

Eye IrritationEye Irritation

Eye irritation may result from air blowing in the eye

Be sure mask fit is appropriate

Spacers used on the forehead or the bridge of the nose, depending on the type of mask, may need to be adjusted

Readjust headgear straps

Skin Problems Due to Skin Problems Due to Interface Devices Interface Devices

Skin irritation or rashes may occur due to pressure from a mask, frictional irritation between the skin and mask or due to allergies to the mask material

Facial discomfort or pain can also occur

Possible Solutions to Possible Solutions to Skin IrritationSkin Irritation

Use the least amount of pressure to fit the mask that still prevents excessive leaks

Use spacers

Alternate devices to reduce skin breakdown

Use a skin barrier lotion and/or topical corticosteroids

Skin Problems Due to Skin Problems Due to Interface DevicesInterface Devices

Pressure lesions (skin breakdown, necrosis) if mask is to tight or left on for extended periods of time

Use of Duodenum or Restore (skin dressings)

Poor Sleep QualityPoor Sleep Quality

Inability to sleep well can be due to many causes such as anxiety, frequent disruptions of the patient at night during normal sleeping hours, discomfort caused by the mask or ventilating pressures

Using an appropriate medication to reduce anxiety, and promote sleep may be appropriate

Be sure the patient is able to protect their airway and is not likely to aspirate

Nasal or Oral Dryness, Nasal Nasal or Oral Dryness, Nasal Congestion, Mucus PluggingCongestion, Mucus Plugging

When these problems occur, possible solutions include the following:– Add or increase humidification– Reduce leaks– Irrigate nasal passages with a saline

spray

Nasal or Oral Dryness, Nasal Nasal or Oral Dryness, Nasal Congestion, Mucus PluggingCongestion, Mucus Plugging

Use topical decongestants or steroids

Perform oral and/or nasal hygiene

If nasal mask is in use, use a chin strap to keep mouth closed or change to full face mask

Sinus or Ear PainSinus or Ear Pain

High inspiratory pressures may affect the ear and sinuses

Use lower inspiratory pressure to help reduce ear and sinus pain

Tight fitting masks may also put pressure on the nose and upper face and may affect sinus pressure and sinus drainage

Criteria for Termination of Criteria for Termination of NPPV for Invasive Ventilation NPPV for Invasive Ventilation

Worsening pH and PaCO2

Tachynpnea (> 30 breaths/min)

Hemodynamic instability

SpO2 < 90%

Decreased level of consciousness

Inability to clear secretions

And inability to tolerate interfaces

Predictors of Success with Predictors of Success with NPPV NPPV

Higher level of consciousness

Younger age

Lower severity of illness; no co-morbidities

Less severe gas exchange (pH < 7.35, > 7.10; PaCO2 < 92 mm Hg)

Minimal air leakage around the interface

Dentition intact

WeaningWeaning

If NPPV is successful, the patient may only require support for 2 to 3 days or less

Currently there is no specific procedure for weaning from mechanical ventilation

Trials of NPPV as tolerated

Weaning AlgorithmWeaning Algorithm

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NOContinue with NPPV therapyContinue with NPPV therapy

Does patient meet

weaning guidelines? Clinically stable

RR < 24 HR < 110 pH > 7.35 SpO2 >90% on< 50% If patient status does

not improved consider intubation

NO

YES

Restart NPPV at previous settings

Restart NPPV at previous settings

YES

Trial off NPPV with supplemental oxygen

Trial off NPPV with supplemental oxygen

Slowly titrate IPAP downward in decrements of 2-3 cm H2O

Slowly titrate IPAP downward in decrements of 2-3 cm H2O

Does patient demonstrate

clinical evidence of respiratory

distress?

Discontinue NPPV and place on supplemental oxygen

Section SummarySection Summary

This section has reviewed initiating NPPV, the interfaces used in NPPV, complications and problems along with possible solutions, and weaning from NPPV