Non invasive ventilation in COPD management.pptx

PPT on NIV in COPD

1. NIV in COPD Dr Subhajit Ghosh

2. Definition Non ‐ invasive ventilation (NIV) refers to the delivery of mechanical ventilation to the lungs using techniques that do not require an invasive artificial airway (ETT, TT)

3. Types of NIV Negative pressure NIV Main means of NIV during the 1st half of the 20th century Extensively used during polio epidemics Tank ventilator “iron lung” Cuirass, Jacket ventilator, Hayek oscillator Positive pressure NIV Positive pressure delivered through mask case CPAP & BiPAP

4. Negative Pressure Ventilation (NPV) Negative pressure ventilators apply a negative pressure intermittently around the patient’s body or chest wall The patient’s head (upper airway) is exposed to room air Negative pressure is applied intermittently to the thoracic area resulting in a pressure drop around the thorax This negative pressure is transmitted to the pleural space and alveoli creating a pressure gradient between the inside of the lungs and the mouth

5. Negative Pressure Ventilation (NPV)

6. NIV ‐ Advantages Non invasiveness Flexibility in initiating and removing mechanical ventilation Allows intermittent application Improves patient comfort Reduces the need for sedation Oral patency Preserves speech, swallowing and expectoration , reduces the need for nagastric tubes

7. Ad v a n t a g e s Avoid the resistive work imposed by the endotracheal tube Avoids the complications of endotracheal intubation Early (local trauma, aspiration) Late (injury to hypopharynx, larynx, and trachea, nosocomial infections) Reduces infectious complications ‐ pneumonia, sinusitis, sepsis Less cost

8. Mechanism of action Reduction in inspiratory muscle work and avoidance of respiratory muscle fatigue Tidal volume is increased CPAP counterbalances the inspiratory threshold work related to intrinsic PEEP. NIV improves respiratory system compliance by reversing microatelectasis of the lung Enhanced cardiovascular function – Afterload reduction d/t increased intrathoracic pressure

9. Pathophysiology of acute hypercapnia

10. Pathophysiology of acute hypoxemic respiratory failure

11. Disad v a n t a g e s System Slower correction of gas exchange abnormalities Increased initial time commitment Gastric distension (occurs in <2% patients) Mask Air leakage Transient hypoxemia from accidental removal Eye irritation Facial skin necrosis –most common complication Lack of airway access and protection Suctioning of secretions Aspiration

12. Levels of evidence A Multiple RCTs Recommended B Atleast one RCT Weaker evidence C Case series/reports Can be tried but with close monitoring

13. Indications Airway obstruction COPD (Evidence A) Facilitation of weaning in COPD (Evidence A) Asthma (B) Extubation failure in COPD (B) Cystic Fibrosis (C) OSA/obesity hypoventilation (C) Upper airway obstruction (C)

14. NIV & stable COPD NIV increasingly used in stable very severe COPD NIV+O 2 therapy – in selected patients with pronounced daytime hypercapnia Clear benefits in both survival & risk of hospital admission in patients with both COPD & OSA Global initiative for Chronic Obstructive Lung Disease(GOLD) update 2013

15. Cochrane Database Syst Rev. 2004;(3):CD004104.

16. Concludes Data from good quality RCTs show benefit of NIV as 1 st line intervention in addition to usual medical care to ARF 2° to an acute exacerbation of COPD in all suitable patients Use early in the course of respiratory failure and before severe ensues, as a means of reducing the likelihood of endotracheal intubation , treatment failure and mortality

17. NIV in COPD exacerbation Multiple RCTs support a success rate of 80‐ 85% Has been shown to improve respiratory acidosis ( pH & pCO 2 ) Respiratory rate, WOB, severity of breathlessness, complications like VAP, length of hospital stay (Evidence A) Mortality & intubation rates are reduced (Evidence A) GOLD update 2013

18. NIV in COPD exacerbation Indications for NIV – atleast one of the following Respiratory acidosis (pH<7.35 &/or PaCO 2 ) Severe dyspnea with clinical signs s/o respiratory muscle fatigue, increased WOB or both Use of respiratory accessory muscles Paradoxical motion of abdomen Intercostal retraction GOLD update 2013

19. NIV in AECOPD VBG vs. ABG T II Respiratory failure AECOPD Use of Bipap Lots of anecdotes Please ask questions!

20. ABG vs. VBG pH a-v difference = 0.04 VBG pH of 7.30, ‘true’ pH could be 7.26 to 7.34 pCO 2 a-v difference = 8.02 pvCO2 52, paCO 2 could be between 44 to 60

21. Can VBG replace ABG as part of initial assessment in AECOPD? Paired ABG-VBG samples in 234 patients with AECOPD in UK tertiary hospital Good agreement: pH H C O 3 • • • If SpO 2 > 80% then agreement OK with SaO 2 ABG sampling more painful and more attempts (!)

22. Flow chart

23. VBG vs. ABG VBG is an excellent screening tool – ~2/3rds of AECOPD in this population – nil further As soon as someone is sick (low pH) – they need a ABG

24. Respiratory failure Type 1 = failure of oxygen transfer Measurable gap between alveolar and capillary P O 2 Due to shunt through non-ventilated alveoli Type 2 = failure of ventilation i.e. not enough air reaching alveoli Not enough O 2 in Not enough CO 2 out

25. NIV B IPAP vs CPAP CPAP: inspiratory pressure = expiratory pressure NIV: Inspiratory pressure > expiratory pressure CPAP INDICATIONS: Acute pulmonary oedema Acute hypoxia pending intubation (can give FiO 2 =1) Acute hypoxia where intubation not indicated

26. NIV - Bipap Treatment of choice for persistent hypercapnic respiratory failure and acidosis (using ABG) – Not optimised with conventional medical therapy – i.e. CONTROLLED OXYGEN THERAPY NEBS ORAL STERODS ANTIBIOTICS (& the cause)

27. PaCO 2 is inversely proportional to minute volume (V E ) V E = TV x RR NIV treats mechanical respiratory failure, NOT the underlying cause NIV - Bipap

28. Acute Exacerbation COPD Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If PaO2 > 60 – reduce O2 & repeat ABG 30-60 mins If PaO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team / ICU Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? Perform ABG Type I PaO 2 < 60 PaCO 2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO 2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates Respiratory Failure? Screening VBG If pH <7.35 perform ABG

29. Acute Exacerbation COPD ite d i c al Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) Respiratory Failure? Perform ABG s level e f fort MAXIMUM MED -CONTROLLED -Salbutamol neb necessary) -Ipatropium nebu -Prednisolone 30 (hydrocortisone -Antibiotics* -Consider iv theo -Consider chest physio -Treat other causes of respiratory compromise (see above) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO 2 <8 PH < 7.35 and PCO 2 <6.0 PCO 2 > 6.0 Reduced consciou Reduced respiratory INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates ICAL THERAPY Treat the cause Maximum medical therapy OXYGEN THERAPY CONTROLLED OXYGEN THERAPY ulised 5mg (back to back if If paO2 > 8.0 – reduce O2 lised 500mcg QDS & repeat ABG 30-60 mins mg PO OD (7-14 days) If paO2 < 7.0, and still acute T II failure, desp ONLY if oral route not available controlled O2 therapy and maximal me therapy: phylines (care in CVS co-morbidity) - may require NIV Inform RHC Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion(s) CVS (failure / arrhythmia / ACS) PE GI Other – must have a cause

30. Acute Exacerbation COPD Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If PaO2 > 60 – reduce O2 & repeat ABG 30-60 mins If PaO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? Perform ABG Type I PaO 2 < 60 PaCO 2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO 2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates

31. Acute Exacerbation COPD Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If PaO2 > 60 – reduce O2 & repeat ABG 30-60 mins If PaO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? Perform ABG Type I PaO 2 < 60 PaCO 2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO 2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates

32. Acute Exacerbation COPD Inform RHC Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? el fort MAX I MU -CONTRO -Salbutam necessar -Ipatropiu -Prednisol (hydroco -Antibiotic -Consider -Consider chest physio -Treat other causes of respiratory compromise (see above) Respiratory Failure? Pneumothorax Pleural effusion Perform ABG CVS (failure/ arrhythmia / ACS) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO 2 <8 PH < 7.35 and PCO 2 <6.0 PCO 2 > 6.0 Reduced conscious lev Reduced respiratory ef INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates M MEDICAL THERAPY Treat the cause Maximum medical therapy LLED OXYGEN THERAPY CONTROLLED OXYGEN THERAPY ol nebulised 5mg (back to back if If paO2 > 8.0 – reduce O2 y) & repeat ABG 30-60 mins m nebulised 500mcg QDS one 30mg PO OD (7-14 days) If paO2 < 7.0, and still acute T II failure, despite rtisone ONLY if oral route not available controlled O2 therapy and maximal medical s* therapy: iv theophylines (care in CVS co-morbidity) - may require NIV MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available) -Antibiotics* -IV theophylines ?? (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise

33. Acute Exacerbation COPD Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If PaO2 > 60 – reduce O2 & repeat ABG 30-60 mins If PaO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? Perform ABG Type I PaO 2 < 60 PaCO 2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO 2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates

34. Acute Exacerbation COPD lure, xi ma l Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE nia? vel f fort MAX I MU -CONTR -Salbutam necessar -Ipatropiu -Predniso (hydroc -Antibioti -Conside -Consider chest physio -Treat other causes of respiratory compromise (see above) Respiratory Infective – bronchitis / pneumo Failure? Pneumothorax Pleural effusion Perform ABG CVS (failure/ arrhythmia / ACS) PE Other – must have a cause No respiratory Type I Acute Type 2 Warning signs: failure PO 2 <8 PH < 7.35 and PCO 2 <6.0 PCO 2 > 6.0 Reduced conscious le Reduced respiratory e INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates M MEDICAL THERAPY • Treat the cause • Maximum medical therapy OLLED OXYGEN THERAPY • CONTROLLED OXYGEN THERAPY ol nebulised 5mg (back to back if • If paO2 > 8.0 – reduce O2 y) • & repeat ABG 30-60 mins m nebulised 500mcg QDS • If paO2 < 7.0, and still acute T II fai lone 30mg PO OD (7-14 days) despite controlled O2 therapy and ma ortisone ONLY if oral route not available medical therapy: cs* r iv theophylines (care in CVS co-morbidity) • - may require NIV • Inform RHC ACUTE TII RESPIRATORY FAILURE Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If paO 2 > 60 – reduce O 2 & repeat ABG 30-60 mins If paO 2 < 50, and still acute T II failure, despite controlled O 2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU

35. Acute Exacerbation COPD , despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion ACS) e Respiratory Failure? us level ory effort MAXIMUM MEDIC -CONTROLLED O -Salbutamol nebuli necessary) -Ipatropium nebulis -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Perform ABG CVS (failure/ arrhythmia / PE Other – must have a caus No respiratory Type I Acute Type 2 Warning signs: failure PO 2 <8 PH < 7.35 and PCO 2 <6.0 PCO 2 > 6.0 Reduced conscio Reduced respirat INFORM ITU Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates AL THERAPY • Treat the cause • Maximum medical therapy XYGEN THERAPY • CONTROLLED OXYGEN THERAPY sed 5mg (back to back if • If paO2 > 8.0 – reduce O2 ed 500mcg QDS • & repeat ABG 30-60 mins • If paO2 < 7.0, and still acute T II failure Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU

36. Treat the cause Maximum medical therapy CONTROLLED OXYGEN THERAPY If paO2 > 60 – reduce O2 & repeat ABG 30-60 mins If paO2 < 50, and still acute T II failure, despite controlled O2 therapy and maximal medical therapy: - may require NIV Inform Resp Team Warning signs? INFORM ITU Why AECOPD? FIND A CAUSE Infective – bronchitis / pneumonia? Pneumothorax Pleural effusion CVS (failure/ arrhythmia / ACS) PE Other – must have a cause Respiratory Failure? Perform ABG Type I PaO 2 < 60 PaCO 2 < 45 Warning signs: Reduced conscious level Reduced respiratory effort INFORM ITU MAXIMUM MEDICAL THERAPY -CONTROLLED OXYGEN THERAPY -Salbutamol nebulised 5mg (back to back if necessary) -Ipatropium nebulised 500mcg QDS -Prednisolone 30mg PO OD (7-14 days) (hydrocortisone ONLY if oral route not available -Antibiotics* -Consider iv theophylines (care in CVS co-morbidity) -Consider chest physio -Treat other causes of respiratory compromise (see above) Acute Type 2 pH < 7.35 and PaCO 2 > 45 No respiratory failure Treat the cause Maximum medical therapy Repeat assessment / ABG if deteriorates Acute Exacerbation COPD

37. CO P D Known COPD. ED. V wheezy + SOB RR 35 pH 7.32 pO2 75 pCO2 57 Bic 22 BE –2 Sats 95%

38. CO P D Known COPD. ED. V wheezy + SOB RR 35 6 lts O 2 mask pH 7.32 pO 2 75 pCO 2 57 Bic 22 BE –2 Sats 95%

39. CO P D Known COPD. ED. V wheezy + SOB RR 35 6 lts O 2 mask pH 7.32 pO2 75 pCO2 57 Bic 22 BE –2 Sats 95% Acute T II Resp Failure Too much O 2 - 28% venturi mask

40. CO P D 6 lts O 2 mask pH 7.32 pO 2 75 pCO 2 57 Bic 22 BE –2 Sats 95% Known COPD. ED. V wheezy + SOB RR 35 28% O 2 pH 7.36 PO 2 54 pCO2 41 BIC 23 Sats 89%

41. CO P D 6 lts O 2 mask pH 7.32 pO 2 75 pCO 2 57 Bic 22 BE –2 Sats 95% Known COPD. ED. V wheezy + SOB RR 35 28% O 2 pH 7.36 PO 2 54 pCO2 41 BIC 23 Sats 89%

42. Controlled Oxygen 20% of pts acidotic on arrival will correct their pH to normal regardless of severity of initial acidosis [Plant. Thorax, 2000] But only when you treat the underlying cause for the respiratory failure

43. CO P D 28% O 2 pH 7.31 paO 2 56 paCO 2 66 BIC 30 Sats 88%

44. CO P D 28% O 2 pH 7.31 paO 2 56 paCO 2 66 BIC 30 Sats 88% Acute T II resp failure (acute on chronic) Optimal O 2 ? Optimal medical Rx ? NIV

45. 60c $3000

46. Rationale of NIV Increase in minute volume Reduction of work of breathing For AECOPD: – Prevents intubation [Nava, 2006; Kerran 2003, Plant 2000] – Reduces mortality [Nava, 2006; Kerran 2003, Plant 2000]

47. Indications Acute type 2 respiratory failure due to COPD Mild (7.31-7.35) / Moderate (7.25-7.3) / Severe (< 7.25) pH > 7.35 – NIV unhelpful [Kerran 2005]

48. Contra-indications: Cardiac or respiratory arrest Additional organ failure Inability to protect airway / clear secretions Bulbar weakness Misc: Facial surgery, injury Upper airway obstruction Undrained pneumothorax

49. Important riders No contra-indication absolute if NIV is ceiling measure For non-COPD T II RF critical care / resp / pulm phys team should be involved early

50. Persistently elevated CO 2 : Potential Causes Check chest expansion / air entry Maintenance of airway sputum retention ? Posture / conscious level Mask leak Check with hand around mask Consider full face mask Re-breathing Check at least 4cm EPAP Expiratory port Patient / ventilator synchronisation

51. Persistently elevated CO 2 : Potential Causes Check chest expansion / air entry Maintenance of airway sputum retention ? Posture / conscious level Mask leak Check with hand around mask Consider full face mask Re-breathing Check at least 4cm EPAP Expiratory port Patient / ventilator synchronisation Check pat i e nt C h e c k kit

52. Persistently elevated CO 2 : Ventilator adjustments ↑ IPAP Obese Poor chest wall or lung compliance ↓ EPAP to 4cm (unless suspect UA closure) If patient exhausted or ↓ RR consider mandatory (timed) mode, but.....

53. O 2 remains low despite ↓CO 2 ↑ FiO 2 (but same rules apply…) ↑ EPAP Re-consider the diagnosis

54. Sudden deterioration on NIV Pneumothorax PE Arrhythmias / MI Others…

55. Escalation of therapy Must be documented in every case ? Suitable for MV ? Resuscitation status If yes discuss with ITU on commencement of therapy if pH < 7.25 or otherwise indicated

56. Successful cases Responders: ventilated as much as possible in the first 24 hours Breaks should be given for food, physio, drugs Greater need for ventilation overnight

57. NIV failure Occurs in around 20% Various causes: Physiological deterioration / failure to improve Intolerance / agitation Patient’s wish to withdraw If no improvement within 1-2 hours, seek advice Admission pH <7.2 & 2 hrs a~er <7.2 – failure predicted (NEJM editorial 2004)

58. ‘Yorkshire NIV’ experience [Plant. Lancet 2000] pH >7.35 pH <7.35->7.3 pH <7.3 pH <7.2 NIV not indicated 80% will get better with conventional Rx NNT avoid ETT = 10 50% will deteriorate without NIV NIV improves survival 50% deteriorate Better hospital outcome & 1 year survival

59. ‘Yorkshire NIV’ experience [Plant. Lancet 2000] pH >7.35 pH <7.35->7.3 - - NIV not indicated 80% will get better x with conventional R - NNT avoid ETT = 10 pH <7.3 - 50% will deteriorate without NIV - NIV improves survival pH <7.2 50% deteriorate Better hospital outcome & 1 year survival NIV advised NIV strongly advised

60. Summary: AECOPD management At risk of T II resp failure? – Screening VBG ABG Find the cause CONTROLLED OXYGEN Give some time for nebs etc. to work (people used to survive before NIV!) We are too pessimistic about MV & COPD [Wildman, 2007]

61. Questions ?