Niv(non invasive ventilation) aiims ppt

NIV (non invasive ventilation) basics

1. Non-Invasive V entilation Presenter : Dr. Mohammad Tabish Moderator : Dr. Timitrov Preceptors: Dr. Manish Soneja Dr. Animesh Ray

2. Overview History Types of ventilators and modes of NIV Interfaces Indications & Contraindications How to start and Monitor Advantage, disadvantages and complications NIV in different clinical conditions Conclusion

3. History Initially negative pressure ventilators (Tank & cuirass ventilators) were used for ventilating large number of victims of polio during acute illness Drinker-Shaw’s Iron Lung 1928

4. The copenhagen polio outbreak 1952

5. History In 1981 Sullivan and colleague -continuous positive airway pressure(CPAP) for obstructive sleep apnea (OSA ) BiPAP was developed in mid 1990's This was followed by improvements in the interface and establishment of role of NIV in patients of COPD American Journal of Respiratory and Critical Care Medicine Volume 191 Number 10 | May 15 2015

6. Definition Non-invasive ventilation is a technique of providing ventilation without the use of an artificial airway (endotracheal intubation or tracheostomy) ARFC Consensus Conference: non-invasive positive pressure ventilation: consensus statement, Respir Care 42:362,

7. Types ventilators for NIV Conventional ICU ventilators Portable NIV ventilators Separate inspiratory and expiratory tubing Non vented mask is used Precise and high FiO2 Better monitoring and alarm system Has single limb tube Requires vented mask Less precision

8. Basic settings and graphics EPAP IPAP Trigger Cycle Inspiratory time Back up ventilation Types of breath

9. What causes the breath to begin ? TRIGGER: Initiation of a new breath (start inspiration) MACHINE: Time PATIENT: Flow Pressure Trigger

10. Cycle CYCLE: Change over from inspiration to expiration (end inspiration) What causes the breath to end ? MACHINE : Time PATIENT : Flow

11. Patient cycling 100% 25% Flow V s time P ressure V s time

12. 3. Breath type Spontaneous Breaths Ventilator Breaths Spontaneous Patient triggered Patient cycled Mandatory Machine triggered Machine cycled Assisted Patient triggered Machine cycled Supported Patient triggered Patient cycled PRESSURE / TIME PRESSURE / TIME FLOW / TIME PRESSURE/ TIME FLOW / TIME PRESSURE/ TIME FLOW / TIME

13. Different Modes 1. Controlled or timed mode (T) -No patient effort -Machine provide full ventilator support

14. 2.Assist control or spontaneous timed (S/T) -Mainly provide support in response to patient effort -Provide backup safety rate also

15. 3)Assist or spontaneous mode (S) -Provide ventilator support in response to breathing effort only -No backup rate

16. Pressure Flow Volume S pontanous mode ventilation Cycle = Flow Trigger = Patient Breaths: Supportive

17. Continuous positive airway pressure – CPAP P rovides a positive airway pressure during entire spontaneous breath CPAP = EPAP

18. BIPAP - Bilevel positive airway pressure Other term- bilevel , VPAP (variable positive airway pressure) and duo Sets two pressures above the atmospheric pressure Higher inspiratory positive airway pressure( IPAP ) Lower expiratory positive airway pressure ( EPAP )

19. BIPAP

20. Pressure curve during BiPAP +6 -3 + 3 + 3 +12

21. Mechanism of action NIV Positive end expiratory pressure Unloads respiratory muscles Decrease work of breathing Increase FRC by recruitment of lungs Decreases preload and afterload Offsets auto-PEEP Improves compliance Improves oxygenation Unloading of respiratory muscles Improves cardiac output Inspiratory pressure support

22. AUTO PEEP  + 8 EPAP - 0 Patient effort required  -10 cm H2O AUTO PEEP  + 8 SET TRIGGER -2 cm H2O EPAP - 6 Patient effort required  -4cm H2O SET TRIGGER -2 cm H2O AUTO PEEP and EPAP

23. Interfaces Devices that connect ventilator and tubing to the face Types – Nasal mask – Nasal pillow – Oro-nasal mask – Full face mask – Helmet Interfaces should be comfortable, offer a good seal , minimize leak, and limit dead space

24. Nasal Masks Covers only nose Less claustrophobia and discomfort – allow eating , conversation and expectoration Better tolerated than full face masks P roblem –air leakage through mouth

25. Nasal Pillows Consists of two small cushions fit under the nose

26. Nasal Pillows Advantages Disadvantages 1.Allows – 1.Air leaks speaking drinking 2.Nasal irritation coughing 2.Absence of nasal or facial skin damages

27. Vented oro -nasal mask

28. Non-vented oro-nasal mask

29. Full face mask

30. Full Face Masks Advantages Disadvantages 1.Better control of mouth leaks 1. Difficulty in speaking and coughing 2.Little cooperation required 2 . High risk of aspiration 3.Better for mouth breather 3. Claustrophobia

31. NIV helmet Covers the whole head and all or part of neck No immediate contact with face

32. NIV helmet Advantages Disadvantages 1. Minimum air leak 1. Rebreathing 2. Little cooperation 2. Axillary skin required damage 3. Absence of nasal or facial skin damage

33. Indications Acute setting AECOPD with type2 respiratory failure Obesity hypoventilation syndrome with acute on chronic type2 respiratory failure Acute cardiogenic pulmonary edema Immunocompromised with pneumonia Rochwerg et al. Official ERS/ATS clinical practice guidelines : noninvasive ventilation for acute respiratory failure. Eur Respir J 2017

34. Indications Acute setting Mild ARDS under close monitoring Post operative respiratory failure Weaning As palliative therapy Rochwerg et al. Official ERS/ATS clinical practice guidelines : noninvasive ventilation for acute respiratory failure. Eur Respir J 2017

35. Indications Chronic setting Home NIV for COPD OSA Obesity hypoventilation syndrome Neuromuscular disorder, chest wall deformity Rochwerg et al. Official ERS/ATS clinical practice guidelines : noninvasive ventilation for acute respiratory failure. Eur Respir J 2017

36. Contraindications Need for an emergent intubation Hemodynamic instability, cardiorespiratory arrest Inability to co-operate/protect airway/clear secretions Severely impaired consciousness (GCS <10) Non respiratory organ failure that is acutely life threatening Facial surgery /trauma Prolonged MV anticipated Rochwerg et al. Official ERS/ATS c linical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017

37. Application of NIV in portable ventilators Choose correct interface Explain therapy and its benefit and outcome Set spontaneous (S) or S/T mode Start with IPAP of 6-8cmH20 , EPAP2-4 cmH2o IPAP-EPAP should be 4 cmH2o Administer O2 at 2 lit/min NIV guidines ISCCM 2006

38. Hold interface with hand over his face , do not fix it Increase EPAP by 1-2 cm increments till all his inspiratory efforts are able to trigger the ventilators EPAP usually titrated to 4 to 6cm A djust Ti max to approx 1 sec, set up backup rate Increase IPAP- 1-2 cm H2O up to maximum pressure which patient can tolerate Now Secure interface Increase O2 to target spo2 of 88 to 92%

39. Application of NIV in standard ICU ventilator Choose correct interface Explain therapy and its benefit and outcome choose mode- pressure support or pressure control silent ventilator alarms, keep FiO2 minimum Inspiratory PS 5-6 cm H20 , PEEP 2 cmH20 NIV guidines ISCCM 2006

40. Hold interface with hand over his face , do not fix it Increase PEEP by 1-2 cm increments till all his inspiratory efforts are able to trigger the ventilators PEEP usually titrated to 5-10 A djust Ti max to approx 1 sec, set up backup rate Increase Insp. pressure - 1-2 cm H2O up to maximum pressure which patient can tolerate Now Secure interface Increase Fio2 to target spo2 of 88 to 92%

41. M onitoring Subjective responses Bed side observation Ask about discomfort related to the mask or airflow Physiologic response ↓ RR, ↓ HR, BP, continuous ECG Level of consciousness ↓ accessory muscle activity and abdominal paradox Monitor air leaks and Vt

42. M onitoring Patient machine synchrony Chest wall movement, air leak Gas exchange Continuous spo2 monitoring ABG after ½ to 1 hr of initiation and 1 hr after every subsequent change in setting Every 4 hr till patient is stable

43. Criteria for switching to invasive mechanical ventilation Worsening pH and PaCO2 Tachypnea (over 30 bpm ) Hemodynamic instability SpO2 < 90 % Decreased level of consciousness Inability to clear secretions Inability to tolerate interface

44. Complications Corrective actions Mask discomfort Excessive leak around mask Pressure sores Nasal or oral dryness A e rophagia /gastric distention Aspiration Mucus plugging Hypotension Check mask for correct size & fit Minimize headgear tension Change to different mask Use wound care dressing Add or increase humidification Irrigate nasal passage with saline Use lowest effective pressure for adequate Vt Use simethicone agents Make sure patient able to protect airway Ensure adequate hydration Ensure adequate humidification Avoid excessive O2 flow(>20 l/min) Avoid excessive high PEEP

45. Sedation with NIV Sedation should only be used with close monitoring Infused sedative /anxiolytic only in ICU Agitated /distressed on NIV (iv morphine 2.5-5 mg (+/- benzodiazepine) may improve tolerance of NIV) A Craig Davidson AC et al.thorax 2016;ii1-ii35

46. Application of NIV with COPD Patients

47. NIV in COPD exacerbation Multiple RCTs support a success rate of 80 ‐ 85 % Mortality & intubation rates are reduced (Evidence A) GOLD updat e 201 7

48. NIV in COPD exacerbation Respiratory acidosis (pH<7.35 &/or PaCO2 >45mmHg ) Severe dyspnea with clinical signs s/o respiratory muscle fatigue Use of respiratory accessory muscles Paradoxical motion of abdomen Intercostal retraction Persistent hypoxemia despite supplemental oxygen therapy GOLD updat e 201 7

49. NIV in acute cardiogenic pulmonary edema CPAP/ BIPAP recommended in addition to standard medical treatment in cases of cardiogenic pulmonary edema. (Level 1) CPAP & BIPAP equally effective in cardiogenic pulmonary edema (Level I). BIPAP is preferable in patients associated with hypercapnic respiratory failure. ( Level II ) NIV guidlines for acute respiratory failure,Indian Society Of Critical care Medicine(ISCCM) 2006

50. Chronic respiratory failure (Obstructive lung disease) As chronic home NIV Stable very severe COPD Excessive daytime hypercapnia Recent hospitalization Concurrent OSA GOLD update 2017

51. NIV in ARDS NIV may be used with great caution in cases of Acute Lung Injury and that too only in ICU (Level III) Reserved for hemodynamically stable patient who can be closely monitored in an ICU NIV in CAP NIV may be used in the ICU with caution in selected patients with community acquired pneumonia particularly in those with associated COPD (Level II) NIV guidelines for acute respiratory failure , Indian Society Of Critical care Medicine(ISCCM) 2006

52. Cystic fibrosis NIV may be helpful as rescue therapy to support acute respiratory failure in cystic fibrosis, providing a bridge to lung transplantation (Level II) Improvement in hypoxemia but not in hypercapnia ILD NIV is not recommended for interstitial lung disease with acute on chronic respiratory failure. (Level III) NIV guidlines for acute respiratory failure,Indian Society Of Critical care Medicine(ISCCM) 2006

53. NIV for weaning Weaning in uncomplicated COPD who fail a trial of spontaneous breathing. (Level II) Not recommended postextubation respiratory failure in non-COPD cases . It may, however, be used in COPD patients. (Level III) R outinely after extubation for reducing incidence of respiratory failure and reintubation rate is not recommended . (Level II) C an be recommended in after extubation who have a high risk of developing respiratory failure and reintubation (age>65 yrs , APACHE II>12 at the time of extubation , cardiac failure at time of intubation). (Level I) NIV guidlines for acute respiratory failure,Indian Society Of Critical care Medicine(ISCCM) 2006

54. NIV in Asthma GINA 2018 update Evidence regarding the role of NIV in asthma is weak If NIV is tried, the patient should be monitored closely (Evidence D ) It should not be attempted in agitated patients , and patients should not be sedated in order to receive NIV (Evidence D)

55. Immunocompromised patients Multiple RCTs support whenever possible, NIV should be tried first in immunocompromised patients with hypoxemic RF (Level 1) Trauma C an be recommended for hemodynamically stable patients of chest trauma with flail chest (Level II) Post- op RF After lung resection or abdominal surgery ( levelII ) NIV guidlines for acute respiratory failure,Indian Society Of Critical care Medicine(ISCCM) 2006

56. Which of the following statements concerning mask is/are true ? Masks covering mouth and nose are more effective in improving blood gases than nasal masks in acute respiratory failure Oro nasal masks are better tolerated than nasal masks in acute respiratory failure Nasal masks are the first choice for NIV in acute respiratory failure Mask switching is not recommended in the first 24 hr of NIV in acute respiratory failure

57. Fitting Orofacial Mask Landmarks Below the lower lip with mouth open Corners of the mouth Just below the junction of nasal bone and cartilage Sizes S- Small (8-9cm) M- Medium (9-10cm) L- Large (10-11cm) 1 a b c b

58. Nasal Mask Fit Anatomic Landmarks Sides of nose Bridge of nose (caution) Above the lip

59. Interfaces of choice Oro nasal Total face Helmet Nasal Mask Nasal prongs Mouth piece Acute setting Claustrophobic Home NIV Frequent Expectoration High level of noise Abnormal facial anatomy

60. Mouth piece Micro CPAP

61. 2) Which of the following statements concerning interface-related pressure ulcers in NIV is/ are true? a. Pressure ulcers occur more often with oro nasal than nasal masks b. A helmet cannot create pressure ulcers c . The use of skin protective dressings can reduce the incidence of pressure ulcers d . The most important strategy to prevent mask- related pressure ulcers is rotation of different masks

62. 3 ) A 55 yr old male k/c/o COPD presents in emergency with acute onset shortness of breath for last 2 days and decrease in sensorium since last 4 hrs O/E GCS- 8/15, tachypneic , tachycardic , BP- 110/80 mmHg ABG : pH- 7.27, Pco2- 72, Po2 – 64 mmHg, Hco3- 30 How will you manage? Intubate and ventilate with PPV Start on BIPAP therapy using portable ventilator Start on NIV using ICU ventilator using orofacial mask Start on high flow Oxygen therapy

63. 4 ) A 58 yr old smoker presents with an exacerbation of his COPD to the emergency department. O/E- Tachypnoeic (respiratory rate 32 per min) Initial ABG on room air pH - 7.28, PaO2- 50 mmHg , PaCO2- 58 mmHg. He is started on nebulized bronchodilators , steroids, antibiotics, and NIV with a facial mask and a ventilator in the emergency department . He synchronises well with the ventilator, his respiratory rate decreases to 23 per min after 1 h, ABG: pH 7.32, PaO2 64 mmHg and PaCO2 50 mmHg, and the patient feels better.

64. He is transferred to a HDU and NIV is restarted with a smaller ventilator. The patient is doing well on the ventilator. There is no significant air leak, no signs of auto-positive end-expiratory pressure, patient ventilator asynchrony or pneumothorax, but the next arterial blood gas shows a pH of 7.29, PaO2 60 mmHg and PaCO2 of 65 mmHg . What is the most appropriate next step? a . Continue the patient on oxygen only b. Repeat the arterial blood gas analysis c. Check the equipment used (ventilator, circuit and mask) d. Intubate the patient immediately e. Change to a nasal mask

65. Carbon dioxide rebreathing

66. Carbon dioxide rebreathing Circuit- open single limb circuit or a closed double-limb circuit. Single limb circuit- requires a vented mask or a non vented mask with exhalation valve A closed double limb circuit is used with a non vented mask Exhalation port should never be obstructed intentionally to reduce leakage C olours on the mask or the mask elbow B lue colour represents non vented masks Clear entrainment elbow for vented masks

67. 5 ) A 45 year old female k/c/o severe obstructive sleep apnea , on CPAP therapy for last 3 months presents to sleep clinic with complaints dryness of mouth and throat. What will you advise? Reassurance and continue the same I ncrease daily intake of fluids Use mouth lubricants Use a humidifier

68. Dryness of mucosa and humidification Oral and nasal dryness or a blocked nose are frequent complaints -occurrence rate of 10–50% Air leaking through the mouth or around the mask, but even without an air leak Treatment Topical nasal application of saline, hyaluronic acid, steroids, decongestants or antihistamines , and regular mouth care Addition of heat/moisture exchangers and an external heated humidifier to the circuit. Decrease dryness and enhance comfort and tolerance of mask ventilation It is also recommended to avoid thickened and tenacious secretions. Humidifier is not routinely recommeded

69. NIV has an important role in the management of acute respiratory failure Careful Patient selection, explanation, Close observation & monitoring are critical for success of NIV Selection of a comfortable interface is the key to success Low GCS is not a contraindication for NIV in Acute exacerbration of COPD NIV shoudn’t be attempted in patient who has indication for endotracheal intubation Take home messages

70. THANK YOU

71. ERS/ATS 2016 guidelines