Non-invasive ventilation - BiPAP

1. Non-invasive ventilation - bipap

2. What we will cover... Definition Why do we use NIV? Indications for BiPAP use Contraindications to use Patient selection Set up Monitoring Escalation Duration of treatment Weaning Palliation Clinical scenarios

3. AIM To gain a more in depth knowledge of BiPAP and it’s clinical indications

4. Objectives To state the definition of NIV To list 3 clinical indications to commence BiPAP To list 3 contraindications for its use To discuss patient selection considerations To be able to correctly describe set up To be able to give clear instructions on monitoring To be able to relay that an escalation plan should be documented at commencement

5. Definition Non invasive ventilation – ‘the provision of ventilatory support through the patient’s upper airway using a mask or similar device’. CPAP – continuous positive airway pressure BiPAP – bilevel positive airway pressure.

6. Why use? NIV in T2RF in COPD - reduction in mortality ~50% Reduces intubation rates in COPD pts with decompensated respiratory acidosis Reduction in need for ICU admission and reduced hospital costs compared to standard medical therapy

7. Clinical Indications Acute exacerbation of COPD Persistent respiratory acidosis : PaCO2 > 6kPa, 7.26 < pH <7.35 - despite immediate maximal standard medical treatment on controlled oxygen therapy for no more than one hour

8. Clinical Indications Standard medical therapy : Controlled oxygen to maintain SaO2 88-92% Nebulised salbutamol 2.5 – 5mg Nebulised ipratropium 0.5 mg Prednisolone 30 mg Antibiotics (when indicated)

9. Clinical Indications Acute / acute on chronic hypercapnic respiratory failure - chest wall deformity / neuromuscular disease. Decompensated OSA ( esp if respiratory acidosis) ? A cute exacerbation of bronchiectasis ARDS / postoperative, post-transplantation respiratory failure Weaning from invasive ventilation ?Heart failure / pneumonia

10. Contraindications Facial burns / trauma / recent facial or upper airway surgery Vomiting Fixed upper airway obstruction Undrained pneumothorax Upper gastrointestinal surgery Inability to protect the airway Copious respiratory secretions Life threatening hypoxaemia Haemodynamically unstable requiring inotropes / pressors (unless in a critical care unit) Severe co-morbidity Confusion / agitation Bowel obstruction Patient declines treatment

11. Selecting Patient Place in one of 5 groups: Immediate intubation and ventilation Suitable for NIV and escalation to ICU / intubation if required Suitable for NIV but not suitable for escalation Not suitable for NIV but for full active management Palliative care most appropriate

12. Selecting Patient Premorbid state Severity of physiological disturbance Reversibility of acute illness Presence of relative contraindications Patients wishes (if possible)

13. Selecting Patient Inclusion criteria Sick but not moribund Able to protect airway Conscious and cooperative No excessive respiratory secretions Potential for recovery to quality of life acceptable to the patient Patient’s wishes considered

14. Set Up Decision to start – CT2 or above Patient consent Trained staff Initial settings IPAP – 10 cms H2O 2-5cms increments 5cms every 10 mins target 20 cms or until therapeutic response achieved / pt tolerability reached EPAP – 4-5 cms H20. Oxygen (when required) – sats 88 – 92 %

15. Monitoring Continuous sats , cardiac monitoring (first 12 hours) RR, HR, BP and GCS ABGs – minimum 1, 4 and 12 hours (1 hour after further changes) Management plan – within first 4 hours of NIV – ?intubation Compliance with NIV, patient-ventilator synchrony and mask comfort – KEY FACTORS IN DETERMINING OUTCOME! Appropriately trained staff

16. Escalation Management plan in event of NIV failure should be made at outset! Uncertainty / not for escalation - discuss with a consultant E scalation appropriate – discuss with ICU team early (ideally intubate first 4 hours) In late NIV failure (>48 hours) intubation is mx of choice

17. Treatment Duration B enefit during first hours - NIV for as long as possible during first 24 hours Tx should last until the acute cause has resolved, commonly 2 – 3 days If NIV successful (pH> 7.35, resolution of underlying cause and sx , RR normalized) – appropriate to start weaning

18. Weaning Tx reduction – daytime periods first After withdrawal in the day, a further night of NIV is recommended Documentation of weaning strategy in nursing and medical records

19. Palliation When NIV failed, not for escalation – need proactive approach to palliation

20. Key Points NIV works! – evidence based Indicated in AECOPD – respiratory acidosis (PaCO2>6kPa, pH<7.35 , >7.26) despite 1 hour medical therapy Select your patients with thought! Ensure no contraindications Think of long term plan when starting

21. Clinical Scenarios...

22. Case 1 67 yo man with known moderate to severe COPD Multiple admissions with IECOPD, no ITU admissions 3/7 hx of productive cough, increasing SOB & wheeze ABG (on non rebreathe mask put on by ambulance): pH 7.28, pCO2 9.1, pO2 58 HCO3 29.2, BE -2, lactate 1.9 MANAGEMENT?

23. M anagement Salbutamol neb 2.5–5 mg Ipratroprium neb 500μg Prednisolone 30mg PO or hydrocortisone 200mg IV (for minimum of 5 days) Antibiotic (if evidence of infection) CXR Consider IV aminophylline Most importantly controlled oxygen

24. ABG after 1 hour Initial ABG (100% non re-breathe mask) ABG at 1 hour (28% venturi mask) pH 7.28 7.37 pO2 58 26.5 pCO2 9.1 8.1 HCO3 29.2 32 BE -2 -1.5 Sats 98 88

25. Case 1 67 yo man with known moderate to severe COPD Multiple admissions with IECOPD, no ITU admissions 3/7 hx of productive cough, increasing SOB & wheeze ABG (on non rebreathe mask put on by ambulance): pH 7.28, pCO2 9.1, pO2 58 HCO3 29.2, BE -2, lactate 1.9 Initial management as before

26. ABG after 1 hour Initial ABG (100% non rebreathe) ABG at 1 hour (28% venturi ) pH 7.28 7.21 pO2 58 26.2 pCO2 9.1 11.3 HCO3 29.2 28 BE -2 Sats 98 86 What now?

27. NIV NIV should be considered in all patients with an acute exacerbation of COPD in whom a: r espiratory acidosis (pH <7.35, PaCO2 > 6kPa) persists despite immediate maximum standard medical treatment on controlled oxygen therapy for no more than 1 hour

28. Starting NIV NIV started at EPAP 4cm H 2 0 (improves O2) IPAP 10cm H 2 0 (reduces PCO2) O2 level to maintain 88-92% sats Titrate up to therapeutic setting over 1 hour  IPAP by 2–5cm increments at ~ 5cm H 2 0/10 mins , with usual target of 20 cm H 2 0 or until therapeutic response achieved or patient tolerability reached Within 1 hour, IPAP target of 18-22cm H 2

29. ABG 2 hours post starting NIV Initial ABG (100% non rebreathe) ABG at 1 hour (28% venturi ) ABG 2 hrs post starting NIV pH 7.28 7.21 7.36 pO2 58 26.2 18.1 pCO2 9.1 11.3 7.2 HCO3 29.2 28 24 BE -2 Sats 98 86 90 What now?

30. Markers of improvement ABG at 2 hours showing improved pH & decreasing pCO2 What next? If no longer acidotic and pCO2 normalising then don’t stop immediately! Remain on present settings, repeat ABG in 4-6hrs Need to wean down the B iPAP over several days – e.g. D1 24hr, D2 16hr, D3 8hr then stop

31. ALTERNATIVELY…ABG 2 hours post starting NIV… Initial ABG (100% non rebreathe) ABG at 1 hour (28% venturi ) ABG 2 hrs post starting NIV pH 7.28 7.21 7.15 pO2 58 26.2 23.1 pCO2 9.1 11.3 13.5 HCO3 29.2 28 27 BE -2 Sats 98 86 82 What now?

32. Failure to improve Still acidotic & pCO2 not improving despite therapeutic settings I s this person an ITU candidate? Consider if development of complication E.g. pneumothorax, mucus plugging, aspiration pneumonia Poor fitting mask, tubing disconnection

33. Case 3 57 yo lady with IHD and severe LV dysfunction Acute onset SOB 2 hours previously Brought to resus – wheezy ++, accessory muscle use ++, RR 40 ABG: pH 7.23, pCO2 7.9, pO2 7.1, lactate 3.8, HCO3 18 on 15L non-rebreathe mask Likely diagnosis? Management?

34. Cardiogenic pulmonary oedema Management: O2, morphine, furosemide, GTN CPAP Reduces preload and afterload through positive intrathoracic pressure, increases SV, decreases HR Standard is not BiPAP Studies show does improve pH/pCO2/HR/RR/SOB and intubation rate BUT possible increased MI rate ( Mehta S et al, Crit Care Med 1997; 25:620-628)

35. Summary Acute exacerbation of COPD F irstly 1 hour of maximum standard medical treatment ABG at 1 hour If NIV started then ABG at 1-2 hours Slow wean down of NIV if improvement Consider complications/ITU if deterioration BiPAP not standard for pulmonary oedema

36. References Mehta S, Jay GD, Woolard RH, Hipona RA, Connolly EM, Cimini DM, Drinkwine JH, Hill NS. “Randomized , prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema” Critical Care Medicine 1997; 25 :620–628 http://www.brit-thoracic.org.uk “Non -invasive ventilation in chronic obstructive pulmonary disorder: management of acute type 2 respiratory failure” RCP/BTS Concise guideline, October 2008 “NIPPV Non-Invasive Ventilation in Acute Respiratory Failure” British Thoracic Society Standards of Care Committee; Thorax 2002; 57:192- 211 “The Use of Non-Invasive Ventilation in the management of patients with chronic obstructive pulmonary disease admitted to hospital with acute type II respiratory failure (with particular reference to Bilevel positive pressure ventilation )” British Thoracic Society/Royal College of Physicians London/Intensive Care Society guideline, October 2008 Lightowler JV, Wedzicha JA, Elliott MW et al; “Non - invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta- analysis .” BMJ 2003 ; 326 :185–7. Ram FSF, Picot J, Lighthowler J et al. “Non -invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease.” Cochrane Database Syst Rev 2004 ; 3 .