Non Invasive Ventilation - BiPAP & CPAP

Non-Invasive Ventilation

1. Non Invasive VentilationNon Invasive Ventilation
Shibu ChackoShibu Chacko

2. Non Invasive VentilationNon Invasive Ventilation

NIV – term favoured, bi levelNIV – term favoured, bi level

IPAP = acts as pressure support and IPAP = acts as pressure support and
increases patients respiratory effort by increases patients respiratory effort by
improving tidal volume and minute improving tidal volume and minute
ventilation.ventilation.

EPAP = used to splint airways open thus EPAP = used to splint airways open thus
improving gas exchange.improving gas exchange.

3. Aims of NIV treatmentAims of NIV treatment

To improve gas exchangeTo improve gas exchange

To reduce the work of breathing.To reduce the work of breathing.

To reduce shortness of breathTo reduce shortness of breath

To avoid the need for invasive ventilation. To avoid the need for invasive ventilation.

To reduce length of stayTo reduce length of stay

4. Criteria Criteria

NIV is indicated in patients with -NIV is indicated in patients with -
Type II Respiratory failure with a Type II Respiratory failure with a
pH 7.25 – 7.35pH 7.25 – 7.35

Patients with pH < 7.25 respond less well Patients with pH < 7.25 respond less well
and ideally managed in an ICU/HDU.and ideally managed in an ICU/HDU.

Patients who are severely hypoxic may be Patients who are severely hypoxic may be
more appropriately managed in ICU.more appropriately managed in ICU.

5. Clinical stateClinical state

Able to protect airwayAble to protect airway

Conscious and cooperativeConscious and cooperative

Haemodynamically stableHaemodynamically stable

Able to cough and clear secretionsAble to cough and clear secretions

6. Contra-indicationsContra-indications

Facial burns/ trauma/ recent facial or Facial burns/ trauma/ recent facial or
upper airways surgeryupper airways surgery

Vomiting/Copious respiratory secretions Vomiting/Copious respiratory secretions

Fixed upper airways obstructionFixed upper airways obstruction

Undrained pneumothoraxUndrained pneumothorax

Impaired level of consciousness Impaired level of consciousness

Unable to protect own airwayUnable to protect own airway

7. Factors to considerFactors to consider

Quality of life pre admissionQuality of life pre admission

Patient agreeable to trialling NIVPatient agreeable to trialling NIV

Ideally discussion with patient this Ideally discussion with patient this
treatment may not work.treatment may not work.

8. Oxygen TherapyOxygen Therapy

Dependant on patients clinical stateDependant on patients clinical state

Controlled (venturi) or low flow via nasal Controlled (venturi) or low flow via nasal
cannulacannula

%/ Flow rate dependant upon blood gas %/ Flow rate dependant upon blood gas
valuesvalues

May be enough to improve blood gases May be enough to improve blood gases
and prevent NIV use.and prevent NIV use.

9. PRIOR TO STARTING NIVPRIOR TO STARTING NIV

All patient fit for NIV treatment to be All patient fit for NIV treatment to be
transferred to Gundulph ward.transferred to Gundulph ward.

Decide what is maximum treatment, Decide what is maximum treatment,
ensure clearly documented.ensure clearly documented.

DNR form must be completed if pt is not DNR form must be completed if pt is not
for resuscitation.for resuscitation.

If for intubation then inform If for intubation then inform
Outreach/ICU/Site Outreach/ICU/Site

10. Equipment Equipment

Machine with trolleyMachine with trolley

Masks : full face, nasal, totalMasks : full face, nasal, total

Oxygen entrained via circuitOxygen entrained via circuit

Filters to be changed every 24 hoursFilters to be changed every 24 hours

Check lists, brief instruction on machine Check lists, brief instruction on machine
use in trolley.use in trolley.

Will run off battery Will run off battery

11. SETTINGSSETTINGS
Normally startedNormally started

IPAP = 10IPAP = 10

EPAP = 4EPAP = 4

Back up breaths = 10Back up breaths = 10

12. CARE FOR 1CARE FOR 1
STST
HOUR HOUR

Continuously monitor OContinuously monitor O2 2 SatsSats

Continuous ECG monitoringContinuous ECG monitoring

Observe patient neurological statusObserve patient neurological status

¼ hrly B/P and Pulse ¼ hrly B/P and Pulse

Visual obs of patients chest expansion and coordinationVisual obs of patients chest expansion and coordination
with ventilator with ventilator

Check mask is fitted well and as comfortable as possible Check mask is fitted well and as comfortable as possible
for patientfor patient

At the end of the first hour ABG’s to be checked and At the end of the first hour ABG’s to be checked and
settings altered if needed.settings altered if needed.

13. RememberRemember

Patient has to eat and drink!Patient has to eat and drink!

Medication Inhalers/nebsMedication Inhalers/nebs

PhysiotherapyPhysiotherapy

Will need a ten minute break every hourWill need a ten minute break every hour

Pressure areas Pressure areas

14. Oxygenation issuesOxygenation issues
By increasing EPAP / Oxygen flow will improve By increasing EPAP / Oxygen flow will improve
oxygenationoxygenation
EPAP 4 – 6 cm HEPAP 4 – 6 cm H22O. O.
Oxygen flow rates up to 10 lpm can be used Oxygen flow rates up to 10 lpm can be used
through circuitthrough circuit

15. Carbon dioxide issuesCarbon dioxide issues
To reduce PCOTo reduce PCO22 the patient tidal volume the patient tidal volume
needs increasing. This is done by needs increasing. This is done by
increasing IPAP.increasing IPAP.
IPAP 10 – 20 cm/HIPAP 10 – 20 cm/H22OO
Remembering to keep pressure difference Remembering to keep pressure difference
between IPAP and EPAP of at least 6between IPAP and EPAP of at least 6

16. Case study 1Case study 1
Blood gas 1Blood gas 1

pH pH 7.205 kpa7.205 kpa

PaCOPaCO227.23 kpa7.23 kpa

PaOPaO22 6.4 kpa6.4 kpa

HCOHCO33 18.118.1

SatsSats 69% 69%

Blood gas 1 hour NIVBlood gas 1 hour NIV

pHpH 7.18 kpa 7.18 kpa

PaCOPaCO227.1 kpa7.1 kpa

PaOPaO22 6.4 kpa6.4 kpa

HCOHCO33 19.819.8

SatsSats 78% 78%

SettingsSettings

IPAP 10, EPAP 4 IPAP 10, EPAP 4

5 lpm O25 lpm O2

17. No changes were madeNo changes were made

14 hours later abg !14 hours later abg !

pH pH 7.307 kpa7.307 kpa

PaCO2PaCO25.25 kpa5.25 kpa

PaO2PaO27.91 kpa7.91 kpa

HCO3HCO31919

Sats 90%Sats 90%

18. Case Study 2Case Study 2

Abg 1Abg 1

pH pH 7.27kpa7.27kpa

PaCOPaCO228.9 kpa8.9 kpa

PaOPaO228.0 kpa8.0 kpa

HCOHCO33 29.329.3

35% O35% O22

Abg 2Abg 2

pH pH 7.30 kpa7.30 kpa

PaCOPaCO228.0 kpa8.0 kpa

PaOPaO228.0 kpa8.0 kpa

HCOHCO3329 29

SettingsSettings

IPAP 14 EPAP 6IPAP 14 EPAP 6

2 lpm O2 lpm O22

19. 
Could increase or leave settingsCould increase or leave settings

20. On going care for NIV treatmentOn going care for NIV treatment

Continuously monitor OContinuously monitor O2 2 SatsSats

1 hrly B/P, Pulse and respiratory rate 1 hrly B/P, Pulse and respiratory rate

Visual obs of patients- chest expansion (equal) Visual obs of patients- chest expansion (equal)
co-coordinated with ventilator and ensure no co-coordinated with ventilator and ensure no
deterioration in patients mental state.deterioration in patients mental state.

Regularly reassure patientRegularly reassure patient

Re-check mask is fitted well and as comfortable Re-check mask is fitted well and as comfortable
as possible for patientas possible for patient

Observe patients face for pressure area Observe patients face for pressure area
breakdown.breakdown.

21. WEANINGWEANING
During the first 24hrs – as much as patient able to During the first 24hrs – as much as patient able to
tolerate. tolerate.
Day 2 – if stable off NIV for the morning (if not Day 2 – if stable off NIV for the morning (if not
continue as Day 1). continue as Day 1).
AfternoonAfternoon – 2hrs of NIV – 2hrs of NIV
NocteNocte- at least 6hrs treatment- at least 6hrs treatment
Day 3 – off NIV during day, may need treatment Day 3 – off NIV during day, may need treatment
over night.over night.
Day 4 – stop NIV Day 4 – stop NIV
ABG pre discharge as baselineABG pre discharge as baseline

22. WHAT IF NIV FAILSWHAT IF NIV FAILS

If after 6hrs of NIV treatment and adjusting settings there If after 6hrs of NIV treatment and adjusting settings there
is no improvement in the patients condition then the is no improvement in the patients condition then the
following should be considered.following should be considered.

Review by ICUReview by ICU as per management plan. as per management plan.

If not appropriate for ICUIf not appropriate for ICU
- stop NIV - stop NIV
- keep patient comfortable- keep patient comfortable
- consider, morphine, sedative such as - consider, morphine, sedative such as
Midazolam.Midazolam.
Allow the patient to die with dignity. Allow the patient to die with dignity.

23. Any QuestionsAny Questions
??