Module 2.5 Invasive & Non-Invasive Ventilation

Basic Principles of Critical Care

1. INVASIVE AND NONINVASIVE VENTILATION Gradian Health Systems Basic Principles of Critical Care RESPIRATORY SYSTEM

2. Disclaimer Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications regarding medical care and clinical service delivery. The tables, checklists, and other clinical documents referenced in this training have not been validated in all settings. These documents are intended to serve as examples only. We recognize that all clinical training content and activities must be customized to meet the needs of each facility and its clinical staff, factoring in available resources, practitioner skill level, and other environmental considerations. For any questions regarding the contents or applications of this training, please contact Gradian Health Systems : 40 W 25 th St, 6 th Floor New York, NY 10010 USA [phone] [email protected]

3. Module 2 Gradian Health Systems Basics Principles of Critical Care Respiratory System

4. Module 2: Respiratory System MODULE OVERVIEW Lesson 1 I Respiratory System Anatomy and Physiology Lesson 2 I Oxygen Therapy Lesson 3 I Evaluation of the Respiratory System Lesson 4 I Airway Equipment and Management Lesson 5 I Invasive and Non-invasive Ventilation Lesson 6 I Basics of Mechanical Ventilation Lesson 7 I Ventilator Modes and Settings Lesson 8 I Ventilation Complications Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

5. Components of the Gradian CCV System Lesson 5: Invasive and Non-invasive Ventilation Lesson Objectives Differentiate between invasive and non-invasive ventilation Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

6. Components of the Gradian CCV System Lesson 5: Invasive and Non-invasive Ventilation Key Concepts Invasive ventilation Non-invasive ventilation (NIV) Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

7. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Definitions of Key Terms Positive pressure ventilation I refers to the movement of air into the airway using positive pressure Noninvasive ventilation I refers to ventilatory support provided without the use of an invasive airway (e.g. supraglottic device, ETT, tracheostomy), i.e. with the use of a nasal or face mask Invasive ventilation I refers to ventilatory support provided with the use of an invasive airway (e.g. supraglottic device, ETT, tracheostomy) Hypoxemic respiratory failure I AKA respiratory failure type I; characterized by low oxygen levels (PaO 2 <60mmHg) and normal or low PaCO 2 Hypercapnic respiratory failure I AKA respiratory failure type II; characterized by high PaO 2 levels (PaCO 2 > 50mmHg) Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

8. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Noninvasive Ventilation (NIV) Indications Acute hypercapnic ventilatory failure (e.g. acute exacerbations of COPD, asthma) Post-extubation period Cardiogenic pulmonary edema – used in addition to other measures Hypoxemic respiratory failure Obstructive sleep apnea Patients who may not need intubation but admitted to the HDU to support respiratory system Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

9. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Noninvasive Ventilation (NIV) Contraindications Cardiac or respiratory arrest Coma or altered mental status (confusion, agitation) Inability to protect the airway Airway obstruction Staff inexperience Vomiting Trauma to the face and neck Hypotension Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

10. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Noninvasive Ventilation (NIV) Complications Claustrophobia Aspiration – this is increased with air swallowing Inability to talk or eat Trauma – pressure sores, abrasions Hypotension –occurs if the pressure settings are so high such that venous return is impaired Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

11. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Types of NIV Continuous positive airway pressure ventilation (CPAP) Bilevel positive airway pressure ventilation (BiPAP)   CPAP Provides positive pressure throughout the respiratory cycle (inspiration and expiration). Airways remain open, reducing the work of breathing and improving oxygenation.   BiPAP Provides different pressures in inspiration and expiration. Inspiratory pressure ( iPAP ) is usually higher than expiratory pressure ( ePAP ). Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

12. Components of the Gradian CCV System Invasive and Non-invasive Ventilation NIV Preparation Be familiar with equipment and ventilator Ensure mask fits appropriately on patients face Seek patient consent Explain how to breathe through the mask and allow them to practice and become comfortable with the use Set the machine to allow for comfort and escalate gradually to the desired setting while evaluating patient’s synchronization with the machine Ensure constant monitoring of the patient (ECG, SpO 2 , RR, ABG) Consider antiemetic, if patient is nauseous Have a plan in case of NIV failure or if patient deteriorates Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

13. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Invasive Ventilation This is what most people refer to as mechanical ventilation (MV). The components of MV include the ventilator, oxygen source, and the artificial airway tubes – standard ETTs and tracheostomy tubes This section is intended to be introductory. Ventilators and ventilation will be covered in more detail during the next lesson. Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

14. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Indications for Mechanical Ventilation (MV) Cardiorespiratory arrest Tachypnea Respiratory failure Goals of MV Based on the indications for mechanical ventilation and broadly classified as: Support of the respiratory system – relief of respiratory distress, decrease work of breathing and muscle fatigue Improve gaseous exchange Protect the airway from complications of mechanical ventilation Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

15. Components of the Gradian CCV System Invasive and Non-invasive Ventilation MV Complications Hypotension due to reduction in cardiac output Ventilator associated lung injury (VALI) Barotrauma: injury due to high pressures Volutrauma : injury due to high volume Oxygen toxicity Aspiration GI bleeding due to stress ulcers Ventilator associated pneumonia (VAP) Deep venous thrombosis Trauma associated with endotracheal intubation – laryngeal injury and stenosis, tracheal stenosis Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

16. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Weaning From Mechanical Ventilation Ventilation, when not required, can be life threatening so should be discontinued as early as possible. It takes up considerable ICU staff time. There are two components of weaning: discontinuation of ventilation and removal of the airway. Weaning should be attempted when the following conditions are met: Every day in the morning we should assess patient for weaning by daily screening and spontaneous breathing tests (SBTs): • Alert, cooperative patient • Acute phase of disease process has resolved • Acceptable pattern and depth of spontaneous breathing Patient coughs when suction catheter is passed, entacting gag reflex Patient not receiving any vasopressor or sedative infusion drip Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

17. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Weaning from Mechanical Ventilation Successful weaning takes place in three stages: Patient is gradually removed from the ventilator Patient is removed from the tube Patient is removed from oxygen Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

18. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Weaning from Mechanical Ventilation Weaning should be done within the shortest time possible but with consideration for patient safety. The decision should be based on physiological, rather than mechanical, point of view. The patient’s clinical status is the key determinant factor and weaning should be started when the patient is recovering from the acute stage and when the primary need for ventilator support has been addressed. To achieve greater success there should be collaboration between the physician, respiratory therapist, and the nurse to aid in conservation of the patient’s strength, efficient use of resources, and to maximize outcomes. Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

19. Components of the Gradian CCV System Invasive and Non-invasive Ventilation Care Related to Weaning Prepare for weaning from the beginning of mechanical ventilation. Patient should be reassured that the use of a ventilator is temporary Remain with the patient during weaning as they are not attached to the ventilator alarms and may be unable to summon for help Patient deterioration may go unnoticed. Weaning should not be attempted at night until prolonged day time periods of spontaneous breathing are well established – staff patient ratio is important Assess status of blood gasses Reduce oxygen concentration gradually Provide psychological support for the patient Maintain IPC at all times Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation