Presentation on theme: "“Bi-Level and Non-invasive Intermittent Postive Pressure Ventilation”."— Presentation transcript:
1“Bi-Level and Non-invasive Intermittent Postive Pressure Ventilation”. M.A . KingRespiratory Support & Sleep Centre,Papworth Hospital, Cambridge,CB3 8RE, UK
2Bi-level and NIPPVVolumetric mechanical ventilation is usually reserved for the unconscious patient and is delivered by an endotracheal tube.Non-invasive Intermittent Positive Pressure Ventilation is delivered by a mask.Bi-level and NIPPV
3Plan Avoid mentioning CPAP and Bi-Level in OSA ! Focus in non-invasive ventilatory support.What is ventilatory failure?Who needs this treatment?What do the machines do?What are the outcomes?Discusion: Do Sleep Technologists need to be involved in these treatments?
4Technological developments since the invention of CPAP Ventilatory insufficiencyVentilatory FailureOSA with lung problemsOSABi-LevelBi-LevelBi-LevelCPAPPressure support ventilatorsPressure support ventilators198719901995<19872000<1987
5Ventilatory Failure. Lung Function = Ventilation and gas exchange Minute Ventilation is a function of respiratory rate and tidal volumeVentilatory Failure causes a rise in CO2 and drop in O2Gas Exchange (respiratory) failure causes hypoxia alone
6“Pump” Failure. Respiratory control centres. Neurological system ( Nerves and synapses)MuscleMechanics ( Thoracic cage).RESTRICTIVE VENTILATORY DEFECT
7Restrictive defect. Small lungs in a rigid chest cage. Normal lungs which can not be expanded.Lung mechanics are altered and efficiencey lost.
14Nocturnal ventilatory insufficiency Reduced tidal volume and reduced frequency.Reduced minute volume = hypercapnoea and hypoxia.
15Indications for NIPPV. Ventilatory pump failure. Chronic or acute. Reduced MV, hypoxia with hypercapnoea.( potential for normal gas exchange – single system failure).
16Assessment. Arterial blood gases (ABGs). Overnight oximetry and CO2 Lung Function.( volumes and muscle strength)Medical exam ( cardio-vascular)AHI and sleep stages have little diagnostic or prognostic value.
19Non-invasive ventilation- objectives Improve alveolar ventilation & oxygenation.Reduction of work of breathing.Airway support.
20Objective:Improve alveolar ventilation & oxygenation. The physiological mechanism is complex & dependent upon the pathology/disease mechanism.paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQIncreased Tidal volume and rate = minute Ventilation.
21Work of breathingWork increases when FRC reduced or when TV = VC
22Work of breathingWhen FRC and lung compliance are reduced more work is required to inflate the lung. By applying PEEP, the lung volume at the end of exhalation is increased. The already partially inflated lung requires less pressure and energy than before for full inflationTV
25Negative Pressure NIV precedes positive pressure ventilation by 100 years. - Patient lays inside a rigid cylinder with neck and head outside cylinder.A vacuum pump creates a negative pressure within the chamber (outside of chest)- this causes expansion of the patient's chest. This change in chest geometry reduces intrapulmonary pressure and ambient air flows into the lungs.When the vacuum ends, the negative pressure applied to the chest drops to zero, and the elastic recoil of the chest and lungs results in passive exhalation.Pump – Adjustable rate and adjustable negative pressure.
28Limitations of Negative Pressure NIV Unsupported upper airway- obstruction induced with high transluminal pressure gradients.Can reduce cardiac OP and peripheral oedema.CONTROLLED ventilation.Limited technologies.
30Positive Pressure NIV NIPPV 1. Delivery of positive pressure to lungs without intubation.2. Delivery of air is patient controlled (with machine back up delivery).3. Air is delivered via a nasal mask or oro-naso mask ( full face mask).NIPPV
31Nomenclature of Positive pressure systems CPAPBi-levelNIPPVIPAPEPAPPEEPVentilating – peak pressure (pressure support)Triggers - CyclingTi. Te, I/E ratioMode S, ST, TRise TimeRamps
32FiO2, tidal volume & rate.FiO2 – room air 20.8%, facility to add oxygen. O2 % not measured.TV – Patient controlled breath enhanced by delivery of air to a target pressure level. Missed breaths recognised.RR- apnoea recognised. Back up rate. delivered. Tachypnea reduced by control of inspiratory time and expiratory time.
33Improved alveolar ventilation & oxygenation. The physiological mechanism is dependent upon the pathology/disease mechanism.paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQIncreased Tidal volume and rate = minute Ventilation.
34Status/progress measured with CO2 & O2 measurements Basic summaryTrigger level= spontaneous patient effort to trigger a machine “breath”.IPAP = expands the lungs more.EPAP = supports small airways and allows for PEEP.PEEP= increases the volume held in the lungs after passive recoil. Holds open alveoli & improves gas exchange.Reduces work.T or back up rate- ensures machine breaths if the patient does not trigger.Status/progress measured with CO2 & O2 measurements
36Bi-level Technology has developed from CPAP over several years. Splints upper airway.Supplements Spontaneous breathing, synchronisation, improves comfort.Reduces work of breathing.Time. Missed breaths delivered.Range of features and settings added in recent times. Alarms – essentially a ventilator.NIPPV
38Unrecognised ventilatory insufficiency leads to big problems
39Problems with Home nocturnal NIV Cost of ventilator.Choice of ventilator- locked settings.Mask problems.Compliance ( nights and hrs used)Need to monitor efficacy and share medical care with local doctor.Rare diseases, physical disability, mental disability, agitation, poor sleep.
40Clinical Outcomes & observational studies. Physiology – ABGs, TcCO2, SpO2.Lung Function.Psg – AHI little value. WASO and better sleep.Quality of Life – Activities of Living.Health care utility (cost)Survival
42Mean overnight oximetry before and after NIV electivePost exacerbationMode of Referral70.075.080.085.090.095.0100.0Sleep StudyBaselineMean O2Discharge
43NIV : Wake ABGs in Myotonic Dystrophy Nugent Chest
44No prospective randomised controlled trials Numerous publications: NIV in Restrictive lung and neuromuscular diseaseNo prospective randomised controlled trialsMultiple case series and 2 withdrawal trials all showing similar treatment effects
46UK: 30,000 COPD deaths each year 600,000 patients diagnosed with COPD in the UKUK: 30,000 COPD deaths each year· By 2020 COPD is predicted to be the third biggest killer in the world and will be responsible for the deaths of over six million people· COPD is a major cause of medical admissions, particular in winter. 308,355 emergency hospital admissions per year.· Of those that are admitted to hospital for COPD, 1 in 10 will die in hospital, one in three will die within six months, and 43% will die within twelve months of their admission to hospital
47Cochrane Systematic Review Nocturnal NIPPV for at least 3 months in hypercapnic patients with stable COPD had no consistent clinically or statistically significant effect on lung function, gas exchange, respiratory muscle strength, sleep efficiency or exercise tolerance.The small sample sizes of these studies precludes a definite conclusion regarding the effects of NIPPV in COPD.More evidence is required.
48Summary Bi Level is needed for some OSA patients. Bi-Level machines have some features of pressure support ventilators but may not be appropriate for all patients.Ventilatory Failure is common in some diseases.Long term NIV is more effective for some patient groups than others.Potential for dramatic increase of Obesity Hypopnoea Syndrome across Europe.
49Should Psg technologists be involved in NIV services? Nocturnal (sleep related) Ventilatory insufficiency.Diagnostics. (type of abnormality)Ventilatory Failure is not determined by events (AHI)Treatment – medical speciality.Outcomes. (efficacy of NIV)
50Is our speciality led by technologies ? Bi-level machinesCPAP(OSA is one of 87 sleep disorders)Ventilatory Failure?
51Equipment by disorder ( few patients with OSA develop Ventilatory failure) Papworth,Cambridge,Sept 2006Bi-level machines used for OSA and in 78 COPDCPAP=3503(OSA is one of 87 sleep disorders)Ventilatory Failure = 385