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Non invasiveventilation-rt
Non-invasive ventilation (NIV) delivers ventilatory support without an invasive artificial airway. It has benefits over invasive ventilation like preserving airway function and reducing risks. NIV is indicated for exacerbations of COPD, respiratory failure, cardiac pulmonary edema, and other conditions. Contraindications include coma, inability to protect airway. NIV includes CPAP, bilevel PAP and negative pressure devices. Settings are tailored to the condition but aim to reduce work of breathing and improve ventilation and oxygenation without overdistending the lungs. Response is monitored closely and NIV may be switched to invasive support if the patient deteriorates.
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Non invasiveventilation-rt
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- 2. What we aregoing to cover… What is NIV? Benefits of NIV Indications for NIV Contra-indications Types of NIV Case examples
- 3. What is Non-Invasive Ventilation(NIV) ‘Delivery of ventilatory support without the need for an invasive artificial airway’
- 4. BENEFITS OF NIV •provides greater flexibility in initiating and removing mechanical ventilation • Permits normal eating, drinking and communication with your patient • Preserves airway defense, speech, and swallowing mechanisms • Avoids the trauma associated with intubation and the complications associated with artificial airways • Reduces the risk of ventilator associated pneumonia (VAP) • Reduces the risk of ventilator induced lung injury associated with high ventilating pressures
- 5. Other Benefits ofUsing NIV • Reduces inspiratory muscle work and helps to avoid respiratory muscle fatigue that may lead to acute respiratory failure • Provides ventilatory assistance with greater comfort, convenience and less cost than invasive ventilation • Reduces requirements for heavy sedation • Reduces need for invasive monitoring
- 6. Indications Exacerbation ofCOPD with Respiratory acidosis Type II respiratory failure neuromuscular disease Pneumonia with respiratory acidosis
- 7. Indications Cardiogenic PulmonaryOedema Obstructive Sleep Apnoea Others (ARDS, post-op respiratory failure)
- 8. Contraindications for NIV Absolutecontraindications: Coma Respiratory arrest Any condition requiring immediate intubation Cardiac instability (shock+need for vasopressors, ventricular dysrhythmias, complicated AMI) GI bleeding – intractable emesis, uncontrolled bleeding
- 9. Contraindications for NIV Inability to protect airway impaired cough or swallowing poor clearance of secretions Status epilepticus Potential for upper airway obstruction Extensive head / neck tumors Any other tumor with extrinsic airway compromise
- 10. Candidates for NIV Patient cooperative (excludes agitated, comatose patients) Dyspnea (moderate to severe, shortness of breath/ agonal breathing) Tachypnea (rr> 24 /min) Increased work of breathing (accessory muscle use, pursed lip breathing) Hypercapnic respiratory acidosis (pH range 7.10 – 7.35) Hypoxemia (PaO2/FiO2 < 200 mm Hg,
- 11. Types of NIV Negative-Pressure Ventilation (Iron Lung) Continuous Positive Airway Pressure (CPAP) Bi-level Positive Airway Pressure (BiPAP)
- 12. Negative-Pressure Ventilation •Negative pressureventilators apply a negative pressure intermittently around the patient’s body or chest wall • The patient’s head (upper airway) is exposed to room air • An example of an NIV is the iron lung or tank ventilator
- 13. CPAP Continuous positivepressure applied to the airways Similar to use of PEEP Reduces work of breathing Improve ventilation to collapsed areas of lung Nasal or face mask
- 14. NIV machines CPAPmachine
- 15. CPAP CPAP ismost often used for two different clinical situations First, CPAP is a common therapeutic technique for treating patients with obstructive sleep apnea Second, CPAP is used in the acute care facility to help improve oxygenation, for example in patients with acute congestive heart failure .
- 16. CPAP Recruits lung units •improved V/Q matching > rapid correction of PaO2 • increased functional residual capacity • decreased respiratory rate and WOB Reduces airway resistance Improves hemodynamic in pulmonary edema • decreases venous return • decreases after load and increases cardiac index (in 50%) • decreases heart rate Average requirement: 10cmH2O
- 17. BIPAP Bi-Level pressuresupport Inspiratory Positive Airway Pressure (IPAP) & Expiratory PAP (EPAP) IPAP is the pressure support machine gives to help patients own inspiration Helps to reduce WOB and increase alveolar ventilation EPAP is essentially PEEP and help to prevent alveolar collapse
- 18. BIPAP IPAP=5-40 cm/H2OEPAP=4-20 Mode( S , S/T ) Improve ventilation depends to difference of IPAP & EPAP Nasal or face mask
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- 21. NIV masks Fullface mask
- 22. Methodology Initial ventilatorsettings: CPAP (EPAP) 4 cm H2O & PSV (IPAP) 5 cm H20. Mask is held gently on patient’s face. Increase the pressures until adequate Vt (7ml/kg), RR<25/mt, and patient comfortable. Titrate FiO2 to achieve SpO2>92%.((88-90% target for COPD pt.)) Keep peak pressure <25-30 cmH2O Head of the bed elevated (( 45 – 90º ))
- 23. Monitoring Response Physiological a) Continuousoximetry b) Exhaled tidal volume c) ABG should be obtained within12 hour and, as necessary, at 2 to 6 hour intervals. Objective a) Respiratory rate b) blood pressure c) pulse rate Subjective a) dyspnea b) comfort c) mental alertness
- 24. Monitoring….. Mask Fit, Comfort, Airleak, Secretions, Skin necrosis Respiratory muscle unloading Accessory muscle activity, paradoxical abdominal motion Abdomen Gastric distension
- 25. Criteria for TerminatingNIV and Switching to Invasive Mechanical Ventilation •Worsening pH and arterial partial pressure of carbon dioxide (PaCO2 ) •Tachypnea (over 30 breaths/min) •Hemodynamic instability •Oxygen saturation by pulse oximeter (SpO2 ) less than 90% •Decreased level of consciousnees •Inability to clear secretions •Inability to tolerate interface
- 26. Management Strategies COPD Main goal to decrease work of breathing (decreasing V/Q mismatch) and provide adequate ventilation Relatively low EPAP: 5-8cm H2O (assuming no obesity or sleep disordered breathing) Relatively moderate IPAP+EPAP: 10-14cm H2O Goal to have at least a 5cm H2O differential between EPAP and IPAP.
- 27. Management Strategies Ameta-analysis of 14 studies of NIV in COPD exacerb showed: mortality need for intubation pCO2, and resp. rate faster length of stay by 3.24 days complications of treatments
- 28. Management Strategies CHF Goal is to decrease work of breathing, decrease afterload and decrease overall static pressure Relatively moderate EPAP: 6-12 cm H2O Relatively low IPAP+EPAP: 12-18cm H2O Patient will benefit mostly with EPAP unless other concurrent disease ( COPD, Obesity- Hypoventilation)
- 29. Management Strategies Obesity-HypoventilationSyndrome Goal of therapy is to decrease work of breathing and increase ventilation EPAP: usually on the higher side; enough to overcome OSA and cardiopulmonary disease: ~10cmH2O.
- 30. Management Strategies Othercauses of respiratory failure Pneumonia/ARDS Cancer and respiratory failure Post-op management Settings depend on disease and other cardiopulmonary disease Most often used as a bridge to mechanical ventilation or for pts DNR/DNI Usually moderate settings: 8/4 or 12/7
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