Recent Advance in Bipap Care Revised(1)

7/27/2019 Recent Advance in Bipap Care Revised(1)

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R e c e n t A d v a n c e i n

R e c e n t A d v a n c e i n R e c e n t A d v a n c e i n

R e c e n t A d v a n c e i n B i P A P

B i P A P B i P A P

B i P A P C a r e

C a r e C a r e

C a r e

R e c e n t A d v a n c e i n

R e c e n t A d v a n c e i n R e c e n t A d v a n c e i n

R e c e n t A d v a n c e i n B i P A P

B i P A P B i P A P

B i P A P C a r e

C a r e C a r e

C a r e

S p e a k e r : L e u n g K w o k C h e u n g

S p e a k e r : L e u n g K w o k C h e u n g S p e a k e r : L e u n g K w o k C h e u n g

S p e a k e r : L e u n g K w o k C h e u n g

A P N , I C U / P M H

A P N , I C U / P M H A P N , I C U / P M H

A P N , I C U / P M H

ContentContentContentContent

I n t r o d u c t i o n

B r e a t h i n g m o d e

I n d i c a t i o n

C o n t r a - i n d i c a t i o n

N u r s i n g c a r e o f N I V

C o m p l i c a t i o n

U p d a t e s o f N I V

N I V =

N

NN

N

o n

I

II

I

n v a s i v e

V

VV

V

e n t i l a t i o n

D e l i v e r y v e n t i l a t o r y s u p p o r t t h a t w i t h o u t t h e n e e d f o r

i n v a s i v e a r t i f i c i a l a i r w a y

N o n i n v a s i v e N e g a t i v e P r e s s u r e V e n t i l a t i o n

I r o n L u n g

N o n i n v a s i v e P o s i t i v e P r e s s u r e V e n t i l a t i o n

C P A P / B i P A P

IntroductionIntroductionIntroductionIntroduction

Wysocki M et al, Eur respir J 2001


1

s t

t r i a l o f N I V i n 1 9 3 0 s , a n d s u c c e s s f u l t r e a t m e n t

d o c u m e n t e d i n 1 9 6 0 s

D o e s n o t r e q u i r e a t r a c h e a l t u b e

R e q u i r e n a s a l , o r a l o r o r o n a s a l i n t e r f a c e a n d a d e v i c e

c a p a b l e o f d e l i v e r i n g g a s w i t h s u s t a i n e d h i g h - f l o w

a n d p o s i t i v e a i r p r e s s u r e .


A s i g n i f i c a n t i n c r e a s e i n u s e o f N I V o v e r t h e 8

A s i g n i f i c a n t i n c r e a s e i n u s e o f N I V o v e r t h e 8 A s i g n i f i c a n t i n c r e a s e i n u s e o f N I V o v e r t h e 8

A s i g n i f i c a n t i n c r e a s e i n u s e o f N I V o v e r t h e 8 -

--

- y e a r s s t u d y

y e a r s s t u d y y e a r s s t u d y

y e a r s s t u d y ....

Girou, E.2003

Implementing use ofNIV in patient withCOAD and CPEOutcome:1.improved survival2.reduction ofnosocomial infection.

Breathing modeBreathing modeBreathing modeBreathing mode

M o s t c o m m o n u s e N I V i n P M H

BiPAP Vision

C P A P

B i P A P

S m o d e

T m o d e

S / T m o d e


2/23

CPAPCPAPCPAPCPAP

C

CC

C

o n t i n u o u s

P

PP

P

o s i t i v e

A

AA

A

i r w a y

P

PP

P

r e s s u r e

S i n g l e l e v e l b r e a t h i n g m o d e

P a t i e n t b r e a t h e s a t a n e l e v a t e d p o s i t i v e p r e s s u r e

l e v e l

CPAPCPAPCPAPCPAP

T h e p u r p o s e i s t o k e e p t h e a i r w a y p a t e n t a n d

a l v e o l i o p e n f o r i m p r o v i n g o x y g e n a t i o n .

Positive pressure

Alveoli

BiPAPBiPAPBiPAPBiPAP

B i P A P = B i - l e v e l

P a t i e n t b r e a t h e s b e t w e e n 2 e l e v a t e d p o s i t i v e

p r e s s u r e l e v e l

I P A P

I P A P I P A P

I P A P ( I n s p i r a t o r y p o s i t i v e a i r w a y p r e s s u r e )

E P A P

E P A P E P A P

E P A P ( E x p i r a t o r y p o s i t i v e a i r w a y p r e s s u r e )

I P A P r e s e m b l e s P S ( p r e s s u r e s u p p o r t ) w h i c h h e l p s

t o e n h a n c e b r e a t h i n g e f f o r t

E P A P r e s e m b l e s C P A P / P E E P f o r k e e p i n g t h e

a l v e o l i o p e n

Lung VolumeLung VolumeLung VolumeLung Volume

EPAP

Tidal volume

Functional residue capacity

PEEP

Lung VolumeLung VolumeLung VolumeLung Volume

IPAP

EPAP

FRC

T

V

IPAPIPAPIPAPIPAP

t h e w o r k o f b r e a t h i n g r e s p i r a t o r y d i s t r e s s

u n l o a d s r e s p i r a t o r y m u s c l e s

I m p r o v e s r e s p i r a t o r y m u s c l e f u n c t i o n

a l v e o l a r v e n t i l a t i o n d e a d s p a c e v e n t i l a t i o n

r e s p i r a t o r y r a t e r e l a t e d t o a u t o P E E P

g a s e x c h a n g e

H y p o x e m i a a n d h y p e r c a p n i a

Antonelli M et al, Crit Care, 2000


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EPAPEPAPEPAPEPAP

g a s e x c h a n g e

a l v e o l a r r e c r u i t m e n t

c o r r e c t s h y p o x e m i a

F R C p r e v e n t a l v e o l a r c o l l a p s e i n e n d - e x p i r a t o r y p h a s e .

l u n g c o m p l i a n c e +

+ +

+ T V

r e s p i r a t o r y m u s c l e f x d y n a m i c h y p e r i n f l a t i o n

e f f o r t t o t r i g g e r v e n t i l a t o r .

E n h a n c e s t h e d e l i v e r y o f b r o n c h o d i l a t o r s t o d i s t a l

b r o n c h i a l t r e e

Antonelli M et al, Crit Care, 2000

BiPAP ModeBiPAP ModeBiPAP ModeBiPAP Mode

S

SS

S ( S p o n t a n e o u s )

F l o w s e n s o r s d e t e c t s p o n t a n e o u s i n s p i r a t o r y e f f o r t

t r i g g e r s I P A P

c y c l e s b a c k t o E P A P

T

TT

T ( T i m e d )

I P A P / E P A P c y c l i n g i s p u r e l y m a c h i n e - t r i g g e r e d , a t a s e t r a t e ,

t y p i c a l l y e x p r e s s e d i n b r e a t h s p e r m i n u t e ( B P M )

BiPAP ModeBiPAP ModeBiPAP ModeBiPAP Mode

S / T

S / TS / T

S / T ( S p o n t a n e o u s / T i m e d )

S i m i l a r S m o d e

t h e d e v i c e t r i g g e r s t o I P A P o n p a t i e n t i n s p i r a t o r y e f f o r t

a " b a c k u p " r a t e i s a l s o s e t t o e n s u r e t h a t p a t i e n t s s t i l l r e c e i v e a

m i n i m u m n u m b e r o f b r e a t h s p e r m i n u t e i f t h e y f a i l t o b r e a t h e

s p o n t a n e o u s l y

CPAP S S/T T

EPAP IPAP IPAP IPAP

EPAP EPAP EPAP

RR RR

I:E

How does NIV work?How does NIV work?How does NIV work?How does NIV work?

w o r k o f b r e a t h i n g ( W O B ) A v o i d r e s p i r a t o r y m u s c l e f a t i g u e

T V C P A P c o u n t e r b a l a n c e s t h e i n s p i r a t o r y t h r e s h o l d w o r k

r e l a t e d t o i n t r i n s i c P E E P

R e v e r s i n g m i c r o a t e l e c t a s i s o f l u n g

improve compliance

AdvantagesAdvantagesAdvantagesAdvantages

Significantly reduceinfection rate andVILI


I m p r o v e c l i n i c a l o u t c o m e s

e . g m o r b i d i t y , m o r t a l i t y , L O S , C o s t e f f e c t i v e

A v o i d c o m p l i c a t i o n s o f e n d o t r a c h e a l i n t u b a t i o n

E a r l y ( l o c a l t r a u m a , a s p i r a t i o n )

L a t e ( i n j u r y t o t h e t h e h y p o p h a r y n x , l a r y n x , a n d t r a c h e a ,

n o s o c o m i a l i n f e c t i o n s )

R e d u c e s t h e n e e d f o r s e d a t i o n

Antonelli M et al, Crit Car, 2000

VAP, LOS, Mortality


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M a i n t a i n O r a l p a t e n c y

p r e s e r v e s s p e e c h , s w a l l o w i n g , c o u g h

P a t i e n t c o m f o r t , a l s o p a r t i c i p a t e s i n d e c i s i o n m a k i n g ,

b e t t e r c o m m u n i c a t i o n w i t h h e a l t h c a r e p r o f e s s i o n a l .

Antonelli M et al, Crit Car, 2000

DisadvantagesDisadvantagesDisadvantagesDisadvantages

S y s t e m

I n c r e a s e d i n i t i a l t i m e c o m m i t m e n t

G a s t r i c d i s t e n s i o n ( o c c u r s i n < 2 % p a t i e n t s )

M a s k

A i r l e a k a g e

T r a n s i e n t h y p o x e m i a f r o m a c c i d e n t a l r e m o v a l

E y e i r r i t a t i o n

F a c i a l s k i n n e c r o s i s m o s t c o m m o n c o m p l i c a t i o n

L a c k o f a i r w a y a c c e s s a n d p r o t e c t i o n

D i f f i c u l t y i n s u c t i o n i n g o f s e c r e t i o n s

r i s k o f a s p i r a t i o n

IndicationIndicationIndicationIndication

S l e e p a p n e a s y n d r o m e

N e u r o m u s c u l a r d i s o r d e r s

C e n t r a l h y p o v e n t i l a t i o n s y n d r o m e

S e v e r e c h e s t d e f o r m i t i e s

I m m u n o s u p p r e s s i o n

C O P D

A c t u e C a r d i o g e n i c P u l m o n a r y E d e m a

H y p o x i c R e s p i r a t o r y F a i l u r e

P r o m o t e e a r l y e x t u b a t i o n

E x t u b a t i o n f a i l u r e

Commonindication inICU

ContraindicationContraindicationContraindicationContraindication

U n c o n s c i o u s p a t i e n t

R e q u i r e l a r g e a m o u n t o f s e d a t i o n

T e n d t o v o m i t

H a v e p o o r c o u g h o r g a g r e f l e x

U n c o o p e r a t i v e o r a g i t a t e d s t a t u s

H a v e p r e - e x i s t i n g p a t h o l o g i e s

P n e m o t h o r a x

P u l m o n a r y e m p h y s e m a

S e v e r e e p i s t a x i s

R e c e n t u p p e r a i r w a y o r u p p e r G I s u r g e r y


N u r s i n g c a r e o f N I V N u r s i n g c a r e o f N I V



N u r s i n g c a r e o f N I V N u r s i n g c a r e o f N I V


Ensure aEnsure aEnsure aEnsure a safesafesafesafe andandandand effectiveeffectiveeffectiveeffective NIV therapyNIV therapyNIV therapyNIV therapy

F a m i l i a r w i t h t h e i n t e r f a c e

F a m i l i a r w i t h t h e v e n t i l a t o r


5/23

InterfaceInterfaceInterfaceInterface

Nasal mask

Nasal prong

Nasal pillow

Facial mask

InterfaceInterfaceInterfaceInterface

Total face mask

Helmet

HelmetHelmetHelmetHelmet

Eating or drinking via preset pot

Facial mask vs Nasal maskFacial mask vs Nasal maskFacial mask vs Nasal maskFacial mask vs Nasal mask

Clinical Aspect Facial mask Nasalmask

Mouth leak and mouth breathing + -

Influence of dental status + -

Airway pressure + -

Dead space - +

Communication - +

Eating, drinking - +

Expectoration - +

Risk of aspiration - +

Comfort - +

Risk of gastric distention - +

Advantages (+) and disadvantages (-) of face and nasal mask

Helmet vs facial maskHelmet vs facial maskHelmet vs facial maskHelmet vs facial mask

Intensive Care Med. 2003:29 Crit Care Med. 2002:30; Chest. 200:126

R a r e c o m p l i c a t i o n s i n H e l m e t

S k i n n e c r o s i s

G a s t r i c d i s t e n t i o n


L O S , i n t u b a t i o n r a t e s , M o r t a l i t y r a t e

s i m i l a r

P a t i e n t t a i l o r m a k e s a n d m o r e

e x p e n s i v e

Total face maskTotal face maskTotal face maskTotal face maskM o s t c o m m o n u s e i n I C U


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Facial mask vs Total face maskFacial mask vs Total face maskFacial mask vs Total face maskFacial mask vs Total face mask

Outcome Facial mask(n=31)

Total mask(n=29)

Early NIV discontinuations 12 (38.0) 16 (55.2)

Failure to improve 7 (23.3) 5 (17.9)

Mask intolerance 5 (16.7) 11 (39.3)

Agitation 0 (0.0) 1 (3.6)

Copious secretions 2 (6.7) 0 (0.0)

Claustrophobia 3 (10.0) 5 (17.9)

Intubation rate 9 (29.0) 6 (20.7)

Mean LOS 19.2 (5-92) 10.9 (1-77)

Mortality 6 (19.4) 3 (10.3)

Facial mask vs Total face maskFacial mask vs Total face maskFacial mask vs Total face maskFacial mask vs Total face mask

W e a n i n g , i n t u b a t i o n r a t e ,

L O S , M o r t a l i t y

M e a n v i t a l s i g n s ( H R , R R ,

S a O 2 )

N O s i g n i f i c a n t d i f f e r e n c e s

b e t w e e n f a c i a l m a s k a n d

t o t a l f a c e m a s k

CHEST 2011; 139(5):10341041

Mask selectionMask selectionMask selectionMask selection

A v a i l a b i l i t y o f m a s k s i n y o u r u n i t

N I V v e n t i l a t o r t y p e

C o m f o r t v s E f f e c t i v e n e s s

P a t i e n t h e a d s h a p e a n d f a c e c o n t o u r

Mask Fitting Golden Rule:

All Noses AreAll Noses Are

Not CreatedNot Created

Equal!Equal!

How to fitting Total Face MaskHow to fitting Total Face MaskHow to fitting Total Face MaskHow to fitting Total Face Mask

P l a c e c h i n i n m a s k f i r s t

R o t a t e u p w a r d

I n t e r n a l s e a l i n g f l a p s h o u l d b e b e l o w t h e l o w e r l i p

L i g h t l y p r e s s a g a i n s t f a c e

S e c u r e h e a d g e a r s t r a p s

M i n i m a l t e n s i o n s h o u l d b e a p p l i e d

C o n n e c t c i r c u i t

CELKI

Mask Cleaning InstructionsMask Cleaning InstructionsMask Cleaning InstructionsMask Cleaning Instructions

E v e r y D a y

W a s h i n h o t s o a p y w a t e r

N o a l c o h o l o r l o t i o n s

D i s a s s e m b l y n o t n e c e s s a r y

A i r d r y

A l l e r g y t o M a s k M a t e r i a l

K n o w c o m p o s i t i o n o f m a s k

C h a n g e t o m a s k w i t h o t h e r m a t e r i a l

I r r i t a t i o n t o S k i n

S o a k i n h o t s o a p y w a t e r f o r o n e h o u r


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CELKI

Ten Tips For Mask UsageTen Tips For Mask UsageTen Tips For Mask UsageTen Tips For Mask Usage

1 . C l e a n f a c e a n d m a s k t h o r o u g h l y b e f o r e e a c h u s e .

2 . R e m o v e m a s k b y p u l l i n g o v e r h e a d o r u s e q u i c k r e l e a s e .

3 . M a r k t h e s t r a p s w i t h p e r m a n e n t m a r k e r w h e r e f a s t e n e d .

4 . T i g h t f i t i s n o t n e c e s s a r y . T h e m a s k c a n b e l o o s e a s l o n g a s a s e a l i s

m a i n t a i n e d .

( O v e r t i g h t e n i n g m a y c r e a t e f o l d s t h a t m a y r e s u l t i n l e a k s . )

5 . S t r a p s c a n b e a d j u s t e d t o p r e v e n t a i r l e a k s .

6 . S m a l l l e a k s a r e a c c e p t a b l e .

7 . E l i m i n a t e a l l l e a k s i n t o t h e e y e s .

8 . D o n o t o v e r t i g h t e n t h e h e a d g e a r .

9 . C h e c k f o r p r o p e r s i z i n g o f t h e m a s k a n d s p a c e r .

1 0 . D o n o t b l o c k t h e o p e n i n g s o n t h e e x h a l a t i o n d e v i c e .

AccessoriesAccessoriesAccessoriesAccessories

Entrainment valve

Whisper-Swivel + Whisper-Swivel II

Air entrainment valveAir entrainment valveAir entrainment valveAir entrainment valve

I n s p i r a t o r y v a l v e

K n i f e - e d g e s e a t , d i s c a n d s p r i n g

R e q u i r e s a v e r y s m a l l v e p r e s s u r e t o b e e x e r t e d t h e d i s c t o l i f t a l l o w i n g a i r t o b e e n t r a i n e d

Exhalation devicesExhalation devicesExhalation devicesExhalation devices

I n m a s k - F u l l f a c e m a s k

I n c i r c u i t

W h i s p e r - S w i v e l

W h i s p e r - S w i v e l I I

P l a t e a u e x p i r a t o r y v a l v e

B e t t e r r e m o v a l o f C O 2 i n

C O P D p a t i e n t

Exhalation devicesExhalation devicesExhalation devicesExhalation devices Exhalation devicesExhalation devicesExhalation devicesExhalation devices

D i f f e r e n t p o s i t i o n i n d i f f e r e n t t y p e o f m a s k s

L e s s r e b r e a t h e d C O 2 f o r m a s k w i t h e x h a l a t i o n

p o r t


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Minimum EPAP SettingMinimum EPAP SettingMinimum EPAP SettingMinimum EPAP Setting W h i s p e r S w i v e l / D i s p o s a b l e E x h a l a t i o n P o r t / B u i l t - i n

E x h a l a t i o n P o r t

E P A P s e t t i n g s o f 4 c m H 2 O s h o u l d b e u s e d

( i n s u r e C O 2 w a s h o u t a n d p r e v e n t b u i l d u p

)P l a t e a u V a l v e

A l e r t o n u s e o f P l a t e a u V a l v e w i t h E P A P s e t t i n g a b o v e 8

c m H 2 O

The blue diaphragm will be depressed

by high pressure level of EPAP in theexpiratory phase towards the valve capand hinder the CO2 washout from the

exhaust vent.

Using Bacteria FilterUsing Bacteria FilterUsing Bacteria FilterUsing Bacteria Filter

U s e a H I G H F l o w / L O W R e s i s t a n t F i l t e r

F i l t e r U s e i n t h e h o s p i t a l p r e v e n t c r o s s c o n t a m i n a t i o n

I f U s i n g a h e a t e d h u m i d i f i e r , t h e f i l t e r w i l l a l s o a c t a s a

b a r r i e r t o p r e v e n t w a t e r f r o m e n t e r i n g t h e u n i t

Bacteria filter

Nebulizer during NIVNebulizer during NIVNebulizer during NIVNebulizer during NIV

P l a c e N e b u l i z e r i n - l i n e a t t h e e n d o f h o s e u s i n g a T e e -

p i e c e a d a p t e r a n d m o u t h p i e c e

K e e p f l o w t o d r i v e N e b u l i z e r l e s s t h a n 1 5 L P M

M o s t N e b u l i z e r u s e 6 - 1 0 L P M

A l l o w p a t i e n t t o u s e B i P A P w / N e b u l i z e r a t W i l l

T a k e a c o u p l e o f b r e a t h s a t a t i m e f o l l o w e d b y s h o r t b r e a k

u n t i l p a t i e n t a d a p t s t o t r e a t m e n t

Humidification during NIVHumidification during NIVHumidification during NIVHumidification during NIV

H u m i d i f i c a t i o n n o t n o r m a l l y n e c e s s a r y , u n l e s s

D r y i n g o f n a s a l m u c o s a

A i r w a y r e s i s t a n c e

p o o r C o m p l i a n c e

H M E s i g n i f i c a n t l y

R e s i s t a n c e

C o m p l i a n c e

I m p a i r f u n c t i o n o f i n s p i r a t o r y a n d e x p i r a t o r y t r i g g e r s

Hess DR, Respir Care 2004

Ventilator settingVentilator settingVentilator settingVentilator setting Ventilator settingVentilator settingVentilator settingVentilator setting

IPAP

EPAP

Rate

FiO2

Mode

Tidal Volume

(Estimated exhaled tidalvolume) Minute Ventilation(Estimated)

Peak InspiratoryPressure


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Ventilator settingVentilator settingVentilator settingVentilator setting P a r a m e t e r s

C P A P : S i n g l e p r e s s u r e l e v e l

B i P A P : I P A P + E P A P , 2 p r e s s u r e l e v e l

D e t e r m i n e t h e l e v e l o f C P A P a n d E P A P

5 - 8 c m H 2 O

D e t e r m i n e t h e l e v e l o f I P A P

1 0 - 2 0 c m H 2 O

a c h i e v e T V 8 - 1 0 m l / k g

N o t r e c o m m e n d e d > 2 0 c m H 2 O o v e r c o m e e s o p h a g e a l p r e s s u r e

O x y g e n

G a s m i x i n g a n d l e a k i n g

F i O 2 > 0 . 5 i s d i f f i c u l t t o a c h i e v e e v e n

u s i n g m a x i m a l f l o w o f 1 5 L / m i n

B a c k u p R R + I : E r a t i o ( 1 : 2 , 1 : 3 )

Nursing careNursing careNursing careNursing care ---- monitoringmonitoringmonitoringmonitoring

C l i n i c a l a s s e s s m e n t

C h e s t w a l l m o v e m e n t

C o - o r d i n a t i o n o f r e s p i r a t o r y e f f o r t w i t h v e n t i l a t o r

A c c e s s o r y m u s c l e r e c r u i t m e n t

H R

R R

P a t i e n t c o m f o r t

M e n t a l s t a t u s

C o n t i n u e S p O 2

A B G M o n i t o r i n g : W i t h i n 1

s t

2 - 6 h r a f t e r s t a r t t o d e t e r m i n e

s u c c e s s , a n d a f t e r w a r d s w h e n i n d i c a t e d

MonitoringMonitoringMonitoringMonitoring ---- Ventilator functionVentilator functionVentilator functionVentilator function

IPAP

EPAP

Rate

Tidal Volume

Minute Ventilation

Peak InspiratoryPressure

AirLeak 60 L/min

Air leakAir leakAir leakAir leak

U n i v e r s a l l y a c c e p t e d t o h a v e s o m e a i r l e a k

M o n i t o r e d d e t e r m i n a n t o f s u c c e s s o f N I V

B i P A P c o m p e n s a t e s u p t o 6 0 L P M L e a k

M o u t h o r M a s k L e a k s < 2 5 L P M a r e O k


N a s a l m a s k

M o u t h l e a k d u e t o n a s a l r e s i s t a n c e a s a r e s u l t o f

u n i d i r e c t i o n a l f l o w .

M i n i m i z e d b y m o u t h c l o s u r e o r u s e c h i n s t r a p s

O r o - n a s a l m a s k s

A p p l i e d i n t h o s e i n r e s p i r a t o r y d i s t r e s s w i t h m o u t h b r e a t h i n g .

C o m f o r t F l a p w i l l h e l p s t o p l e a k s i n t o E y e s .

I f b o t h e r s o m e M o u t h L e a k s c o n t i n u e , u s e F u l l F a c e

M a s k .


C a u t i o n w i t h a i r l e a k o v e r ~ 6 0 L / m i n

Air leak enhances :

P r e v e n t i o n o f C O 2 r e t e n t i o n

t h e c h a n c e o f r e - b r e a t h i n g

But not excessive air leak!


10/23


S i g n i f i c a n t a i r l e a k f o r m o s t B i P A P i s 0 . 4 L / s e c a b o v e

i n t e n t i o n a l l e a k ( e x h a l a t i o n p o r t )

e f f e c t i v e n e s s o f v e n t i l a t i o n ( e x c e s s i v e a i r l e a k )

I n a b i l i t y t o m a i n t a i n o p t i m a l p r e s s u r e s

S l e e p f r a g m e n t a t i o n

I n a b i l i t y t o t r i g g e r v e n t i l a t o r

P r o l o n g e d i n s p i r a t o r y t i m e ( i n c r e a s e d t i m e t a k e n f o r f l o w

c o m p e n s a t i o n )

G r e a t e r o x y g e n c o n s u m p t i o n

Rabec CA et al, Arch Bronconeumol 2004

Air Leak Guidelines

0 - 6 lpm = Too tight

7 - 25 lpm = Just right

26 - 60 lpm = Adjust

> 60 lpm = Caution

MonitoringMonitoringMonitoringMonitoring

Alarm OverviewAlarm OverviewAlarm OverviewAlarm Overview

A l a r m s w a r n o f e v e n t s

A n e v e n t i s c o n d i t i o n / o c c u r r e n c e r e q u i r i n g c l i n i c a l

a w a r e n e s s / a c t i o n

E v e n t s a r e r e l a t e d t o :

T e c h n i c a l p e r f o r m a n c e o f v e n t i l a t o r

o r

C h a n g e i n p a t i e n t s c l i n i c a l c o n d i t i o n

t h a t v e n t i l a t o r c a n d e t e c t

Types of Vision System AlarmsTypes of Vision System AlarmsTypes of Vision System AlarmsTypes of Vision System Alarms

S y s t e m

P r e s e t b y m a n u f a c t u r e r

M o n i t o r t e c h n i c a l p e r f o r m a n c e o f v e n t i l a t o r

A d j u s t a b l e

M o n i t o r p a t i e n t s c l i n i c a l c o n d i t i o n t h a t c a n b e d e t e c t e d b y

v e n t i l a t o r w i t h a d j u s t a b l e a l a r m t o f a c i l i t a t e m o n i t o r i n g .

System AlarmsSystem AlarmsSystem AlarmsSystem Alarms

P r e s s u r e R e g u l a t i o n

L o w B a t t e r y f o r n e w m o d e l

P r o x i m a l P r e s s u r e L i n e D i s c o n n e c t i o n

O x y g e n F l o w

L o w L e a k

Low Internal Battery AlarmLow Internal Battery AlarmLow Internal Battery AlarmLow Internal Battery Alarm

L o I n t . B a t t . m e s s a g e i l l u m i n a t e s / a u d i b l e a l a r m

A l a r m a c t i v a t e s w h e n i n t e r n a l b a t t e r y v o l t a g e i s

l o w .

P l u g i n A C s u p p l y a n d s t a r t b a t t e r y c h a r g i n g .


11/23

Pressure Regulation AlarmPressure Regulation AlarmPressure Regulation AlarmPressure Regulation Alarm

A c t i v a t e d w h e n p r o x i m a l p r e s s u r e + / - 5 c m H

2

0 o f s e t

p r e s s u r e

P . R e g u l a t i o n m e s s a g e i l l u m i n a t e s / a u d i b l e a l a r m

V e n t i l a t o r s e n d s a v a i l a b l e f l o w t o a c h i e v e s e t p r e s s u r e

A u d i b l e s e l f c a n c e l s w h e n m e a s u r e d p r o x . p r e s s u r e

w i t h i n s p e c i f i c a t i o n .

Proximal Line Disconnect AlarmProximal Line Disconnect AlarmProximal Line Disconnect AlarmProximal Line Disconnect Alarm

A c t i v a t e d b y p r o x i m a l p r e s s u r e l i n e d i s c o n n e c t

P r o x . L i n e D i s c . m e s s a g e i l l u m i n a t e s / a u d i b l e

a l a r m .

P o s s i b l e c a u s e s

P o s s i b l e c a u s e s P o s s i b l e c a u s e s

P o s s i b l e c a u s e s :

P r e s s u r e l i n e d i s c o n n e c t i o n o r o b s t r u c t i o n .

Low Oxygen Flow AlarmLow Oxygen Flow AlarmLow Oxygen Flow AlarmLow Oxygen Flow Alarm

O

2

F l o w m e s s a g e i l l u m i n a t e s / a u d i b l e a l a r m .

P o s s i b l e c a u s e :

1 . I n s u f f i c i e n t o x y g e n s u p p l y p r e s s u r e .

2 . O b s t r u c t e d o x y g e n i n l e t f i l t e r

.

A u d i b l e s e l f c a n c e l s O

2

/ a i r r a t i o w i t h i n r a n g e f o r s e t

F I O

2

Low Flow AlarmLow Flow AlarmLow Flow AlarmLow Flow Alarm

A c t i v a t e d w h e n a v e r a g e b a s e l i n e f l o w d e c r e a s e s b y >

2 5 % o r 4 L / m i n , f o r a p e r i o d o f o n e m i n u t e

L o w F l o w m e s s a g e i l l u m i n a t e s / a u d i b l e a l a r m

A u d i b l e s e l f c a n c e l s w h e n b a s e l i n e f l o w r e t u r n s t o w i t h i n

r a n g e

A v e r a g e d b a s e l i n e l e a k c a l c u l a t e d w h e n :

U n i t i s t u r n e d o n a n d b e g i n s o p e r a t i o n

M o d e c h a n g e

L e a r n s o f t k e y s e l e c t e d b y u s e r

Adjustable AlarmsAdjustable AlarmsAdjustable AlarmsAdjustable Alarms

S t a n d a r d

H i g h P r e s s u r e

L o w P r e s s u r e w i t h L o w P r e s s u r e D e l a y c o n t r o l

A p n e a

O p t i o n a l

L o w R a t e

H i g h R a t e

L o w M i n u t e V e n t i l a t i o n

S e t a c c o r d i n g t o p r o x i m a l p r e s s u r e s

W a r n s o f e v e n t s o c c u r r i n g p r o x i m a l t o p a t i e n t

High Pressure AlarmHigh Pressure AlarmHigh Pressure AlarmHigh Pressure Alarm

A c t i v a t e d p r o x i m a l p r e s s u r e > h i g h p r e s s u r e l i m i t

f o r 0 . 5 s e c .

H i P

m e s s a g e i l l u m i n a t e s / a u d i b l e a l a r m .


P o s s i b l e c a u s e : P o s s i b l e c a u s e :


1 .

1 .1 .

1 . I n a p p r o p r i a t e a l a r m l i m i t s e t t i n g

I n a p p r o p r i a t e a l a r m l i m i t s e t t i n g I n a p p r o p r i a t e a l a r m l i m i t s e t t i n g

I n a p p r o p r i a t e a l a r m l i m i t s e t t i n g

2 .

2 .2 .

2 . P a t i e n t c o u g h i n g d u r i n g

P a t i e n t c o u g h i n g d u r i n g P a t i e n t c o u g h i n g d u r i n g

P a t i e n t c o u g h i n g d u r i n g i n s p i r a t o r y

i n s p i r a t o r y i n s p i r a t o r y

i n s p i r a t o r y c y c l e

c y c l e c y c l e

c y c l e .

V e n t i l a t o r i m m e d i a t e l y t e r m i n a t e s b r e a t h ( a d d e d

s a f e t y f e a t u r e )

A u d i b l e s e l f c a n c e l s i f p r o x i m a l p r e s s u r e < h i g h

p r e s s u r e l i m i t o n n e x t b r e a t h


12/23

Low Pressure AlarmLow Pressure AlarmLow Pressure AlarmLow Pressure Alarm

Proximal pressure < low pressure limit for settime delay

Lo P message illuminates/audible alarm. Possible cause:1. Large leak2. Patient and circuit disconnection.3. Patient inspiratory demand flow > machine delivered flow.

Audible self cancels if proximal pressure > lowpressure limit on next breath

Apnea AlarmApnea AlarmApnea AlarmApnea Alarm Activated if spontaneous trigger not detected within

set interval

Apnea message illuminates/ audible alarm. Possible causes:1. Patient not breathing, unable to trigger.2. Circuit may be disconnected.

v vv

Low Rate AlarmLow Rate AlarmLow Rate AlarmLow Rate Alarm Activated total respiratory rate < low rate BPM

limit

Lo RATE message illuminates/audible alarm Possible causes:1. decreased in RR2. Unable to trigger ventilator.3. Inappropriate alarm limit setting.

Audible self cancels total respiratory rate > lowrate BPM limit

High Rate AlarmHigh Rate AlarmHigh Rate AlarmHigh Rate Alarm Activated total respiratory rate > high rate BPM

limit

Hi RATE message illuminates/audible alarm Possible causes:1. Increase in patient breathing rate.2. Improperly set alarm limit.

Audible self cancels total respiratory rate s e t l o w

m i n u t e v e n t i l a t i o n l i m i t

Nursing care of NIVNursing care of NIVNursing care of NIVNursing care of NIV

M a i n t a i n a d e q u a t e o x y g e n a t i o n & v e n t i l a t i o n

M a i n t a i n a d e q u a t e o x y g e n a t i o n & v e n t i l a t i o n M a i n t a i n a d e q u a t e o x y g e n a t i o n & v e n t i l a t i o n

M a i n t a i n a d e q u a t e o x y g e n a t i o n & v e n t i l a t i o n

O b s e r v a t i o n

A B G , S p O 2

R e s p i r a t o r y r a t e & p a t t e r n

S i g n s o f e x h a u s t i o n o r r e s p i r a t o r y d i s t r e s s

S t a n d b y

B a g & m a s k

S u c t i o n

I n t u b a t i o n e q u i p m e n t

M e c h a n i c a l V e n t i l a t o r


13/23


R e d u c e p a t i e n t a n x i e t y & p h y s i c a l d i s c o m f o r t

A n x i e t y

E x p l a n a t i o n , r e a s s u r a n c e

P h y s i c a l d i s c o m f o r t

N a s a l a b r a s i o n

S k i n i r r i t a t i o n


D r y n e s s o f m u c o u s m e m b r a n e

G a s t r i c d i s t e n s i o n

M u s c l e c r a m p s


D e t e c t l i f e

D e t e c t l i f e D e t e c t l i f e

D e t e c t l i f e -

--

- t h r e a t e n i n g c o m p l i c a t i o n s

t h r e a t e n i n g c o m p l i c a t i o n s t h r e a t e n i n g c o m p l i c a t i o n s

t h r e a t e n i n g c o m p l i c a t i o n s

A s p i r a t i o n

C a r d i o - p u l m o n a r y c o m p l i c a t i o n s

D e c r e a s e i n c o n s c i o u s l e v e l

D e s a t u r a t i o n

Rare CxRare CxRare CxRare Cx

G a s t r i c d i s t e n s i o n

N o s o c o m i a l p n e u m o n i a

P n e u m o t h o r a x

P n e u m o n m e i d a s t i n u m

A i r e m b o l i s m s t r o k e

E s o p h a g e a l p e r f o r a t i o n

E s o p h a g o - p l e u r a l f i s t u l a

U p p e r a i r w a y o b s t r u c t i o n i n s p i r a t e d s e c r e t i o n

Hung SC et al , Eur Respir J, 1998; Hurst JR et al, Thorax, 2003; Hill NS, Resp Care 2000

When to discontinue NIV?When to discontinue NIV?When to discontinue NIV?When to discontinue NIV?

I n a b i l i t y t o t o l e r a t e t h e m a s k b e c a u s e o f

d i s c o m f o r t o r p a i n

I n a b i l i t y t o i m p r o v e g a s e x c h a n g e o r

d y s p n e a

N e e d f o r e n d o t r a c h e a l i n t u b a t i o n t o

m a n a g e s e c r e t i o n s o r p r o t e c t a i r w a y

H e m o d y n a m i c i n s t a b i l i t y

E C G i s c h e m i a / a r r h y t h m i a

F a i l u r e t o i m p r o v e m e n t a l s t a t u s i n t h o s e

w i t h C O 2 n a r c o s i s .

Gay, 2008

New model:BiPAPNew model:BiPAPNew model:BiPAPNew model:BiPAP---- V60V60V60V60 Bipap V60Bipap V60Bipap V60Bipap V60 ----additional modeadditional modeadditional modeadditional mode


14/23

Bipap V60: PC modeBipap V60: PC modeBipap V60: PC modeBipap V60: PC mode

T h e P C V ( p r e s s u r e c o n t r o l l e d v e n t i l a t i o n

T h e P C V ( p r e s s u r e c o n t r o l l e d v e n t i l a t i o n T h e P C V ( p r e s s u r e c o n t r o l l e d v e n t i l a t i o n

T h e P C V ( p r e s s u r e c o n t r o l l e d v e n t i l a t i o n )

))

)

-

--

- d e l i v e r s p r e s s u r e

d e l i v e r s p r e s s u r e d e l i v e r s p r e s s u r e

d e l i v e r s p r e s s u r e -

--

- c o n t r o l l e d m a n d a t o r y

c o n t r o l l e d m a n d a t o r y c o n t r o l l e d m a n d a t o r y

c o n t r o l l e d m a n d a t o r y

b r e a t h s , e i t h e r t r i g g e r e d b y t h e v e n t i l a t o r

b r e a t h s , e i t h e r t r i g g e r e d b y t h e v e n t i l a t o r b r e a t h s , e i t h e r t r i g g e r e d b y t h e v e n t i l a t o r

b r e a t h s , e i t h e r t r i g g e r e d b y t h e v e n t i l a t o r

( T i m e d ) o r t h e p a t i e n t ( s p o n t

( T i m e d ) o r t h e p a t i e n t ( s p o n t( T i m e d ) o r t h e p a t i e n t ( s p o n t

( T i m e d ) o r t h e p a t i e n t ( s p o n t

).

BipapBipapBipapBipap V60: Ramp timeV60: Ramp timeV60: Ramp timeV60: Ramp time

T h e R a m p t i m e

- h e l p s p a t i e n t a d a p t t o

v e n t i l a t i o n b y g r a d u a l l y

i n c r e a s i n g i n s p i r a t o r y ( I P A P )

a n d e x p i r a t o r y p r e s s u r e

( E P A P ) f r o m s u b t h e r a p e u t i c

t o u s e r - s e t i n t e r v a l .

BipapBipapBipapBipap V60: AVAPS modeV60: AVAPS modeV60: AVAPS modeV60: AVAPS mode(((( A v e r a g e v o l u m e

A v e r a g e v o l u m e A v e r a g e v o l u m e

A v e r a g e v o l u m e -

--

- a s s u r e d p r e s s u r e s u p p o r t )

a s s u r e d p r e s s u r e s u p p o r t ) a s s u r e d p r e s s u r e s u p p o r t )

a s s u r e d p r e s s u r e s u p p o r t )

A V A P S

A V A P S A V A P S

A V A P S

M a i n t a i n a t a r g e t t i d a l v o l u m e i n a

M a i n t a i n a t a r g e t t i d a l v o l u m e i n a M a i n t a i n a t a r g e t t i d a l v o l u m e i n a

M a i n t a i n a t a r g e t t i d a l v o l u m e i n a

p r e s s u r e l i m i t e d m o d e

p r e s s u r e l i m i t e d m o d e p r e s s u r e l i m i t e d m o d e

p r e s s u r e l i m i t e d m o d e

-

--

- I t a c h i e v e s t h e t a r g e t v o l u m e b y

I t a c h i e v e s t h e t a r g e t v o l u m e b y I t a c h i e v e s t h e t a r g e t v o l u m e b y

I t a c h i e v e s t h e t a r g e t v o l u m e b y

r e g u l a t i n g t h e p r e s s u r e

r e g u l a t i n g t h e p r e s s u r e r e g u l a t i n g t h e p r e s s u r e

r e g u l a t i n g t h e p r e s s u r e a p p l i e d .

a p p l i e d .a p p l i e d .

a p p l i e d .

* I f t h e c a l c u l a t e d t a r g e t p r e s s u r e i s o u t s i d e

* I f t h e c a l c u l a t e d t a r g e t p r e s s u r e i s o u t s i d e * I f t h e c a l c u l a t e d t a r g e t p r e s s u r e i s o u t s i d e

* I f t h e c a l c u l a t e d t a r g e t p r e s s u r e i s o u t s i d e

o f t h e m i n i m u m a n d m a x i m u m p r e s s u r e

o f t h e m i n i m u m a n d m a x i m u m p r e s s u r e o f t h e m i n i m u m a n d m a x i m u m p r e s s u r e

o f t h e m i n i m u m a n d m a x i m u m p r e s s u r e

r a n g e , t h e

r a n g e , t h e r a n g e , t h e

r a n g e , t h e t a r g e t v o l u m e

t a r g e t v o l u m e t a r g e t v o l u m e

t a r g e t v o l u m e w i l l n o t b e

w i l l n o t b e w i l l n o t b e

w i l l n o t b e

a c h i e v e d .

a c h i e v e d . a c h i e v e d .

a c h i e v e d .

Bipap V60 : CBipap V60 : CBipap V60 : CBipap V60 : C----flex for CPAPflex for CPAPflex for CPAPflex for CPAP

C P A P w i t h C

C P A P w i t h C C P A P w i t h C

C P A P w i t h C -

--

- F l e x

F l e x F l e x

F l e x

- o f f e r 3 l e v e l s o f f l o w

b a s e d e x p i r a t o r y

p r e s s u r e r e l i e f a t t h e

b e g i n n i n g o f e x h a l a t i o n .

- i m p r o v e d p a t i e n t

c o m f o r t a n d i m p r o v e d

s l e e p q u a l i t y

BipapBipapBipapBipap V60 for transportV60 for transportV60 for transportV60 for transport1 .

1 .1 .

1 . E n s u r e O 2 c y l i n d e r a r e f u l l .

E n s u r e O 2 c y l i n d e r a r e f u l l .E n s u r e O 2 c y l i n d e r a r e f u l l .

E n s u r e O 2 c y l i n d e r a r e f u l l .

2 .

2 .2 .

2 . W h e n e v e r p o s s i b l e , r e d u c e t h e

W h e n e v e r p o s s i b l e , r e d u c e t h e W h e n e v e r p o s s i b l e , r e d u c e t h e

W h e n e v e r p o s s i b l e , r e d u c e t h e

O 2 s e t t i n g b e f o r e t r a n s p o r t .

O 2 s e t t i n g b e f o r e t r a n s p o r t .O 2 s e t t i n g b e f o r e t r a n s p o r t .

O 2 s e t t i n g b e f o r e t r a n s p o r t .

3 .

3 .3 .

3 . M i n i m i z e a l l i n a d v e r t e n t l e a k

M i n i m i z e a l l i n a d v e r t e n t l e a k M i n i m i z e a l l i n a d v e r t e n t l e a k

M i n i m i z e a l l i n a d v e r t e n t l e a k

4 .

4 .4 .

4 . B e a w a r e O 2 i s r a p i d l y d e p l e t e d

B e a w a r e O 2 i s r a p i d l y d e p l e t e d B e a w a r e O 2 i s r a p i d l y d e p l e t e d

B e a w a r e O 2 i s r a p i d l y d e p l e t e d

a t h i g h l e a k r a t e .

a t h i g h l e a k r a t e .a t h i g h l e a k r a t e .

a t h i g h l e a k r a t e .

5 . E n s u r e f u l l y c h a r g e d b a c k u p

5 . E n s u r e f u l l y c h a r g e d b a c k u p 5 . E n s u r e f u l l y c h a r g e d b a c k u p

5 . E n s u r e f u l l y c h a r g e d b a c k u p

b a t t e r y p o w e r f o r

b a t t e r y p o w e r f o r b a t t e r y p o w e r f o r

b a t t e r y p o w e r f o r t r a n s p o r t

t r a n s p o r tt r a n s p o r t

t r a n s p o r t .

..

.

Oxygen depletion at various rate ofOxygen depletion at various rate ofOxygen depletion at various rate ofOxygen depletion at various rate of

leakleakleakleak


15/23

I s N I V e f f e c t i v e i n C O A D p a t i e n t ?

I s N I V e f f e c t i v e i n C O A D p a t i e n t ? I s N I V e f f e c t i v e i n C O A D p a t i e n t ?





COAD patient

Oxygen (N=20) NIV (N=19) P value

Intubation 7(35) 0 (0) 0.005

ICU Stay 2.72.0 1.20.4 0.006

LOS 7.9 4.1 8.78.3 0.68

Mortality 4 (20) 2 (10) 0.36

Bersten NEJM 1991; 325: 1825

COAD patient

Five centers in Europe NIV (N=43) Control (N=42)

Intubated 11 (26%) 31 (74%)

Hospital Stay 23 + 17 days 35 + 33 days

Mortality 4 (9%) 12 (29%)

Brochard NEJM 1995; 333:817

COAD patient

Chin Med J, 2005

MetaMetaMetaMeta----analysis NIVanalysis NIVanalysis NIVanalysis NIV

S u c c e s s r a t e 8 0 - 8 5 %

m o r t a l i t y + L O S s i g n i f i c a n t l y

i n t u b a t i o n r a t e s i g n i f i c a n t l y

N o s o c o m i a l i n f e c t i o n a n d p n e u m o n i a r a t e s i g n i f i c a n t l y

p H , P a C O 2 , r e d u c e s t h e s e v e r i t y o f b r e a t h l e s s n e s s i n

f i r s t 4 h r o f t r e a t m e n t

I n s u f f i c i e n t d a t a t o c o n f e r b e n e f i t o f N I P P V t o o t h e r

p a t i e n t s

K e e n e n C C M 1 9 9 7 ; 2 5 : 1 6 8 5 ; Girou JAMA 2000; 284; 2361;GOLD 2003

I s N I V e f f e c t i v e i n C O A D p a t i e n t ? I s N I V e f f e c t i v e i n C O A D p a t i e n t ? I s N I V e f f e c t i v e i n C O A D p a t i e n t ? I s N I V e f f e c t i v e i n C O A D p a t i e n t ?





16/23

I s N I V e f f e c t i v e i n A s t h m a p a t i e n t ?

I s N I V e f f e c t i v e i n A s t h m a p a t i e n t ? I s N I V e f f e c t i v e i n A s t h m a p a t i e n t ?





Asthma patientAsthma patientAsthma patientAsthma patient

A t o t a l o f 2 6 p a t i e n t s

c o m p l e t e d t h e s t u d y i n

t h e N P P V g r o u p .

s i g n i f i c a n t l y i m p r o v e d

a f t e r 4 0 m i n u t e s i n t h e

h i g h - p r e s s u r e g r o u p

c o m p a r e d w i t h t h a t i n

t h e c o n t r o l g r o u p

( p < 0 . 0 0 0 1 ) .

Soma et al., 2008

Asthma patientAsthma patientAsthma patientAsthma patient

Soroksky et al., 2003







I s N I V e f f e c t i v e i n C A P p a t i e n t

I s N I V e f f e c t i v e i n C A P p a t i e n t I s N I V e f f e c t i v e i n C A P p a t i e n t

I s N I V e f f e c t i v e i n C A P p a t i e n t ????I s N I V e f f e c t i v e i n C A P p a t i e n t I s N I V e f f e c t i v e i n C A P p a t i e n t I s N I V e f f e c t i v e i n C A P p a t i e n t I s N I V e f f e c t i v e i n C A P p a t i e n t ????

CAP patientCAP patientCAP patientCAP patient

Intubation rate

Antonelli et al., 2001


17/23

CAP patientCAP patientCAP patientCAP patient

S t u d y i n v o l v e d 6 4 s e v e r e C A P p a t i e n t

3 6 p a t i e n t s ( 5 6 % ) f a i l e d o n N I V

2 8 p a t i e n t s ( 4 3 % ) s u c c e e d e d

A l l p a t i e n t h a d l o w e r p H b e f o r e N I V

B U T n o s i g n i f i c a n t d a t a p r o v e n e f f e c t i v e n e s s o f N I V

o n C A P p a t i e n t

Guerin et al., 1997; Nourdine et al., 1999

I s N I V e f f e c t i v e i n C A P p a t i e n t ?

I s N I V e f f e c t i v e i n C A P p a t i e n t ? I s N I V e f f e c t i v e i n C A P p a t i e n t ?



I s N I V e f f e c t i v e i n C A P p a t i e n t ? I s N I V e f f e c t i v e i n C A P p a t i e n t ?


I s N I V e f f e c t i v e i n H y p o x i e m i a A R F I s N I V e f f e c t i v e i n H y p o x i e m i a A R F I s N I V e f f e c t i v e i n H y p o x i e m i a A R F I s N I V e f f e c t i v e i n H y p o x i e m i a A R F

p a t i e n t ?

p a t i e n t ? p a t i e n t ?

p a t i e n t ?

I s N I V e f f e c t i v e i n H y p o x i e m i a A R F

I s N I V e f f e c t i v e i n H y p o x i e m i a A R F I s N I V e f f e c t i v e i n H y p o x i e m i a A R F

I s N I V e f f e c t i v e i n H y p o x i e m i a A R F

p a t i e n t ?


p a t i e n t ?

Hypoxemic ARFHypoxemic ARFHypoxemic ARFHypoxemic ARF

Antonelli et al, 1998

COPD

Cardiogenic P. Edema

Acute Hypoventilation

Post-Extubation Failure

Hypoxemic Respiratory Failure

Hypoxemic ARFHypoxemic ARFHypoxemic ARFHypoxemic ARF

0.50.10.01 2 10 1001

Log Odds Ratio

Risk of Intubation rate in difference type of ARF

Antonelli el at, 1998

Hypoxemic ARFHypoxemic ARFHypoxemic ARFHypoxemic ARF Compare with baseline and NIV after2 Hrs

No difference PaCO2, pH Respiratory Rate

Does not support the routine use of NIV in allpatients with acute hypoxemic respiratory failure

Martin et al, 2000; Keenan et al, 2004


18/23

Is NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFpatient?patient?patient?patient?Is NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFIs NIV effective in Hypoxiemia ARFpatient?patient?patient?patient? Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?Is NIV effective in CPE patient?

Cardiogenic Pulmonary edema (CPE)Cardiogenic Pulmonary edema (CPE)Cardiogenic Pulmonary edema (CPE)Cardiogenic Pulmonary edema (CPE)

Effects of NIV on Mortality Effects of NIV on Intubation

Masip et al., 2005 Peter et al, 2006

CPECPECPECPE

O x y g e n a t i o n

n e e d f o r i n t u b a t i o n

m o r t a l i t y r a t e

H y p e r c a p n i a p a t i e n t s

m o r e r a p i d r e l i e f o f r e s p i r a t o r y d i s t r e s s

b e t t e r g a s e x c h a n g e

i n t u b a t i o n r a t e

Masip et al, 2005; Mehta, et al, 1997; Peter et al, 2006; Nava et al, 2003

I s N I V e f f e c t i v e i n C P E p a t i e n t ?

I s N I V e f f e c t i v e i n C P E p a t i e n t ? I s N I V e f f e c t i v e i n C P E p a t i e n t ?



I s N I V e f f e c t i v e i n C P E p a t i e n t ? I s N I V e f f e c t i v e i n C P E p a t i e n t ?


Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?Is NIV effective in Chest trauma patient?


19/23

Chest trauma patientChest trauma patientChest trauma patientChest trauma patient

R C T o f N I V v s I P P V

N o s o c o m i a l i n f e c t i o n

m o r t a l i t y

L o w e r P a O 2 i n f i r s t 2 d a y s

S a m e I C U s t a y

R C T o f N I V v s O 2 m a s k

L e s s i n t u b a t i o n r a t e

L O S s h o r t e r

S a m e s u r v i v a l

Gunduz et al., 2003; Hernandez et al., 2010

I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ?

I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ? I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ?

I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ?

I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ? I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ? I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ? I s N I V e f f e c t i v e i n C h e s t t r a u m a p a t i e n t ?

I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d

I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d


p a t i e n t ?


p a t i e n t ?


I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d


p a t i e n t ?


p a t i e n t ?

Immunosuppressed patientImmunosuppressed patientImmunosuppressed patientImmunosuppressed patient

E a r l y i n i t i a t i o n o f N I V i s a s s o c i a t e d w i t h s i g n i f i c a n t i n t u b a t i o n r a t e a n d s e r i o u s c o m p l i c a t i o n s a n d i m p r o v e d

L O S .

Conti et al., 1998; Hilber et al., 2004

I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d p a t i e n t ?

I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d p a t i e n t ? I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d p a t i e n t ?



I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d p a t i e n t ? I s N I V e f f e c t i v e i n I m m u n o s u p p r e s s e d p a t i e n t ?


I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ????I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ????


20/23

ARDS/ALI patientARDS/ALI patientARDS/ALI patientARDS/ALI patient

Not

significant

improved

Delclaux et al., 2000


Intubation rate

Antonelli et al., 2001


7 0 . 3 % f a i l e d o n N I V

1 9 p a t i e n t s s h o c k o r m e t a b o l i c a c i d o s i s .

m o r t a l i t y r a t e i n N I V

N I V s h o u l d b e t r i e d v e r y

c a u t i o u s l y o r n o t a t a l l i n

A R D S / A I L p a t i e n t s

Garpestad & Hill, 2006; Rana et al., 2006

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ? I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ? I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ? I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ?

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ?

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ? I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ?

I s N I V e f f e c t i v e i n A L I / A R D S p a t i e n t ?

Is NIV effective in postIs NIV effective in postIs NIV effective in postIs NIV effective in post----extubationextubationextubationextubationARF patient?ARF patient?ARF patient?ARF patient?Is NIV effective in postIs NIV effective in postIs NIV effective in postIs NIV effective in post----extubationextubationextubationextubation

ARF patient?ARF patient?ARF patient?ARF patient?

PostPostPostPost-

---extubation patientextubation patientextubation patientextubation patient

Does not improve outcome in patients whodevelop respiratory distress during the first 48

hours after extubationEsteban et al., 2004; Ferrer et al., 2006; Keenan et al., 2002


21/23

Is NIV effective in postIs NIV effective in postIs NIV effective in postIs NIV effective in post----extubationextubationextubationextubationARF patient?ARF patient?ARF patient?ARF patient?Is NIV effective in postIs NIV effective in postIs NIV effective in postIs NIV effective in post----extubationextubationextubationextubation

ARF patient?ARF patient?ARF patient?ARF patient?I s N I V e f f e c t i v e i n w e a n i n g

I s N I V e f f e c t i v e i n w e a n i n g I s N I V e f f e c t i v e i n w e a n i n g

I s N I V e f f e c t i v e i n w e a n i n g ????I s N I V e f f e c t i v e i n w e a n i n g I s N I V e f f e c t i v e i n w e a n i n g I s N I V e f f e c t i v e i n w e a n i n g I s N I V e f f e c t i v e i n w e a n i n g ????

WeaningWeaningWeaningWeaning

Ferrer et al., 2009

Duration/day

WeaningWeaningWeaningWeaning

1 1 R C T o f N I V v s I P P V

M o r t a l i t y

V A P

I C U s t a y

L O S

t o t a l d u r a t i o n M V s u p p o r t

U s e o f N I V f a c i l i t a t e w e a n i n g i n M V p a t i e n t s w i t h

p r e d o m i n a n t l y C O P D i s s i g n i f i c a n t b e n e f i t

Burns et al., 2006

I s N I V e f f e c t i v e i n w e a n i n g ?

I s N I V e f f e c t i v e i n w e a n i n g ? I s N I V e f f e c t i v e i n w e a n i n g ?



I s N I V e f f e c t i v e i n w e a n i n g ? I s N I V e f f e c t i v e i n w e a n i n g ?


Condition Suggestion LOE(Level of evidence)

COPD NIV A

Asthma More study C

CAP More study C

Hypoxemic ARF NIV depend on case A

CPE NIV A

Chest trauma More study B/C

Immunosuppesed ARF NIV A

ALI/ARDS Avoid NIV C

Post-operation ARF NIV but s til l more s tudy B

Post extubation ARF Avoid NIV C

Weaning from MV NIV A

SummarSummarSummarSummaryyyy

Keenan et al., 2011


22/23

Take Home messageTake Home messageTake Home messageTake Home message

N I V p r o v i d e s v e n t i l a t o r y s u p p o r t t o p a t i e n t b u t l e s s

c o m p l i c a t i o n s c o m p a r e d w i t h m e c h a n i c a l v e n t i l a t i o n .

P r o v i d e a s a f i r s t l i n e t h e r a p y i n a w i d e v a r i e t y o f

c o n d i t i o n s c a u s i n g r e s p i r a t o r y f a i l u r e .

U s e c a u t i o u s l y a n d d e p e n d o n c a s e

E a r l y i n i t i a t i o n o f N I V i s a s s o c i a t e d w i t h g o o d o u t c o m e i n

a p p r o p r i a t e l y s e l e c t e d i n d i v i d u a l s

References Alasdair G, Steve G, David E N, Moyra M, Fiona S, Jon N. Noninvasive Ventilation in Acute Cardiogenic

Pulmonary Edema ,The New England Journal of Medicine. Boston:Jul 10, 2008. Vol. 359, Iss. 2, p. 142-51

Ambrosino, N; Foglio, K; Rubini, F; Clini, E; Nava, S; Vitacca, M, Non-invasive mechanical ventilation inacute respiratory failure due to chronic obstructive pulmonary disease: correlates for success.Thorax.50(7):755-757, July 1995.

Ambrosino N & Vagheggini G. Noninvasive positive pressure ventilation in the acute care setting: where arewe? Eur Respir J , 2008; 31: 874-886.

American Thoracic Society, the European Respiratory Society, theEuropean Society of Intensive CareMedicine, and the Socitde Ranimation de Langue Franaise, and approved by the ATS. InternationalConsensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute

Respiratory Failure. Am. J. Respir. Crit. Care Med., Volume 163, Number 1, January 2001, 283-291 .

Andres E, Fernando FV, Niall DF et al., Noninvasive Positive-Pressure Ventilation for Respiratory Failure after

Extubation. N Engl J Med 2004;350: 2452-60.

Antonelli M, Conti G, Moro ML et al., Predictors of failure of noninvasive positive pressure ventialtion inpatients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med, 2001; 27: 1718-1728.

Antonelli M; Conti G; Bufi M; Costa MG; Lappa A; Rocco M; Gasparetto A; Meduri GU, Noninvasive ventilationfor treatment of acute respiratory failure in patients undergoing solid organ transplantation: a

randomized trial. JAMA. 283(2):235-41, 2000 Jan 12.

References Antonelli, M; Conti, G; Bufi, M; Costa, M; Lappa, A; Rocco, M; Gasparetto, A; Meduri, Gi,Noninvasive

Ventilation for Treatment of Acute Respiratory Failure in Patients Undergoing Solid Organ

Transplantation: A Randomized Trial. JAMA. 283(2):235-241, January 12, 2000.

Antonelli M, Conti G, Rocco M, et al: A comparison of noninvasive positive-pressure ventilation andconventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429,1998.

Antonelli M; Conti G; Rocco M; Bufi M; De Blasi RA; Vivino G; Gasparetto A; Meduri GU,A comparison ofnoninvasive positive-pressure ventilation and conventional mechanical ventilation in patients

with acute respiratory failure. New England Journal of Medicine. 339(7):429-35, 1998 Aug 13.

Bach, J.R. (2002). Noninvasive Mechanical ventilation. Hanley &Belgus, INC, Philadelphia.

BiPAP Vision Clinical Manual

Celikel T, Sungur M, Ceyhan B, Karakurt S: Comparison of noninvasive positive pressure ventilation withstandard medical therapy in hypercapnic acute respiratory failure. Chest 114:1636, 1998.

Cheung TM, Yam LY, So LK, et al: Effectiveness of noninvasive positive pressure ventilation in thetreatment of acute respiratory failure in severe acute respiratory syndrome. Chest 126:845, 2004.

Confalonieri M, Potena A, Carbone G, et al: Acute respiratory failure in patients with severe community-acquired pneumonia. Am J Respir Crit Care Med 160:1585, 1999.

References Conti G, Marino P, Cogliati A, et al: Noninvasive ventilation for the treatment of acute respiratory failure in

patients with hematologic malignancie s: a pilot study. Intensive Care Med 24:1283, 1998.

Conti G, Antonelli M, Navalesi P et al., Noninvasive vs conventional mechankical ventilation in patients withchronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial.Intensive Care Med, 2002; 28: 1701-1707.

Cuvelier A, Viacroze C, Benichou J et al., Dependency on mask ventilation after acute respiratory failure inthe intermediate care unit. Eur Respir J 2005, 26: 289-297.

Domenighetti G, Gayer R & Gentilini R. Noninvasive pressure support ventilation in non-COPD patients withacute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome.Intensive Care Med, 2002; 28: 1226-1232.

Esteban A, Frutos-Vivar F, Ferguson ND, et al: Noninvasive positive-pressure ventilation for respiratoryfailure after extubation. N Engl J Med 2004, 350:2452.

Ferrer M, Esquinas A, Leon M et al., Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure: ARandomized Clinical Tria l. Am J Respir Crit Care Med, 2003; 168: 1438-1444.

Ganesan R, Watts DK, Lestrud S. Noninvasive Mechanical Ventilation. Clin Ped Emerg Med, 2007; 8:139-144

Garpestad E & Hill NS. Noninvasive ventilation for acute lung injury: how often should we try, how often

should we fail? Critical Care, 2006; 10 ($): 147.


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References Guerin C, Girard R, Chemorin C, et al: Facial mask noninvasive mechanical ventilation reduces the incidence

of nosocomial pneumonia: a prospective epidemiological survey from a single ICU. Intensive Care Med23:1024, 1997.

Hilbert G, Gruson D, Vargas F, et al: Noninvasive ventilation inimmunosuppressed patients with pulmonaryinfiltrates, fever, and acute respiratory failure. N Engl J Med 344:481, 2001.

Hilbert G, Gruson D, Portel L, et al: Noninvasive pressure support ventilation in COPD patients with post-extubation hypercapnic respiratory insufficiency. Eur Respir J 11:1349, 1998.

Hilbert, G; Gruson, D; Vargas, F; Valentino, R; Gbikpi-Benissan, G; Dupon, M; Reiffers, J; Cardina ud, J,Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and

Acute Respiratory Failure.New England Journal of Medicine. 344(7):481-487, February 15, 2001.

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Recent Advance in Bipap Care Revised(1)