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Non-Invasive Ventilation

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Presentation on theme: "Non-Invasive Ventilation"— Presentation transcript:

1 Non-Invasive Ventilation
Arjun Srinivasan, Mahadevan & Pattabhiraman Pulmonology Associates KMCH

2 Agenda Definition & mechanism of action Indications
When, who, where, what & how ? Technical aspects Weaning off NIV Complications

Non-invasive ventilation (NIV) refers to a form of assisted ventilation that involves provision of ventilatory support without endotracheal intubation (ETI)

4 CPAP vs. NIV CPAP NIV Pressure greater than atm applied to proximal airway throughout resp cycle Splints airway Increases lung volume Raises intrathoracic pressures Does not offload resp muscles Greater pressure applied during inspiration over and above the baseline CPAP Unloads resp muscles Can provide complete resp support

5 NIV – how it works Decreasing work of breathing
Off loading of resp muscles & decreasing fatigue Preventing wide swings in intrathoracic pressure Decreasing afterload to heart Preventing complications of IMV Intubation & MV Loss of airway defenses Post extubation issues

6 NIV Whom to initiate ? Acute Chronic COPD Pulmonary edema
Immunocompromised patients Weaning from mechanical Neuromuscular weakness Bronchial asthma ARDS Do not intubate – pts Other indications Chronic

7 What is expected of NIV ?

8 NIV in COPD exacerbation
COPD exacerbation is a perfect indication for NIV use Excellent candidates for partial respiratory support Offloads respiratory muscles & prevents dynamic hyperinflation Gives time for the bronchodilators & steroids to take effect Supports till balance of respiratory system is restored

9 First study on COPD exacerbation
Pressure support ventilation by face mask leads to: Reduced need for intubation Duration of mechanical ventilation Duration of ICU stay LIMITATIONS OF STUDY Used historical controls Not randomized controlled trial Bochard et al., 1990 NEJM

10 First RCT Compared NIV (n =30)with conventional therapy (n = 30):Equal number received bronchodilators, corticosteroids and antibiotics therapy Within first hour NIV patients had greater improvement in pCO2 and dyspnea score Mortality of 10% in NIV group as compare to 30 % in control group Bott et al, Lancet 1993

11 Risk of treatment failure in seven studies of NPPV as an adjunct to usual medical care
0.5 1 1.5 2 2.5 3 Avdeev et al 1998 Barbe et al 1996 Bott et al 1993 Brochard et al 1995 Celikel et Dikensoy et al 2002 Plant et al 2000 Total (95% CI) NPPV Usual Medical Care 0.17 0.36 6.60 0.38 0.58 0.51 0.63 0.51 BMJ 2003;;326:1-5

12 BMJ 2003;;326:1-5 Risk of treatment failure in seven studies of NPPV as an adjunct to usual medical care

13 Risk of endotracheal intubation in eight trials of NPPV as an adjunct to usual medical care
0.14 1 2 3 4 5 6 Avdeev et al 1998 Barbe et al 1996 Bott et al 1993 Brochard et al 1995 Celikel et al 1998 Dikensoy et al 2002 Kramer et al 1995 Plant et al 2000 Total (95% CI) NPPV Usual medical Care 0.29 0.35 0.42 0.62 0.50 0.20 0.56

14 BMJ 2003;;326:1-5 Risk of endotracheal intubation in eight trials of NPPV as an adjunct to usual medical care

15 Mortality in seven studies of NPPV as an adjunct to usual medical care
0.33 1 2 3 4 5 6 7 8 9 10 Avdeev et al 1998 Barbe et al 1996 Bott et al 1993 Brochard et al 1995 Celikel et al 1998 Dikensoy et al 2002 Plant et al 2000 Total (95% CI) 0.50 0.33 0.33 0.33 0.50 0.41

16 Mortality in seven studies of NPPV as an adjunct to usual medical care
BMJ 2003;;326:1-5 Mortality in seven studies of NPPV as an adjunct to usual medical care

17 Role of NIV in COPD exacerbation
Established beyond doubt that NIV decreases Failure Intubation (NNT 4) Mortality (NNT 10) Chandra et al. analyzed healthcare utilization between and concluded that patients who get intubated after failed NIV had higher mortality Increasing use of NIV in difficult to ventilate patients Continuation of NIV despite lack of early improvement

18 NIV in cardiogenic pulmonary edema
Robust data supporting use of NIV in CPE Cochrane review of 21 trials and 1071 subjects showed NIV Decreases intubation (NNT 8) Decreases in hospital mortality (NNT 13) Does not increase risk of MI Winck et al, reviewed 7 studies comparing NIV vs. CPAP and showed both were equally efficient even in patients with hypercapnea

19 NIV in extubation NIV as a tool for facilitating extubation and weaning off ventilator NIV post extubation for preventing respiratory failure for patients at risk NIV as a treatment for established extubation failure

20 NIV in weaning Latest review included 16 trials involving 994 patients with COPD & mixed populations They analysed effect on Weaning failure VAP Mortality

21 Effect on weaning failure

22 Effect on VAP

23 Effect on mortality

24 NIV for preventing weaning failure in at risk group
Patients of hypercapneic respiratory failure including COPD, neuromuscular dis orders NIV post extubation as per protocol to prevent weaning failure Studies have shown significant benefit with NIV in these sub- groups

25 NIV in established extubation failure
2 trials till date have looked at NIV in established extubation failure Both have not shown any benefit in Re intubation rate ICU mortality

26 NIV in post operative patients
Main aim in post operative patients is Prevent acute respiratory failure Treat acute respiratory failure and prevent intubation 29 studies identified in a recent review Significant heterogeneity in the type of surgery, patient co morbidities & outcome measurements Take home point is despite lack of RCT NIV improved blood gas & prevents hypoxemia in most cases

27 Summarizing role in weaning
Definite role in weaning COPD patients Preventing re-intubation in high risk group No evidence to support its use in established weaning failure Should be considered in post operative period for preventing & treating respiratory failure

28 Immunocompromised patients
NIV plays a vital role in management of these patients Intubation is associated with significant morbidity & mortality 2 RCTs & several observational studies have been consistent in demonstrating NIV Improves oxygenation Reduces intubation Reduces mortality

29 NIV in ARDS Area of intense debate & no consensus
Studies & systematic reviews have shown May decrease intubation rates, ICU stay in select sub-groups who show early response High rates of failure Disturbingly patients who get intubated after failed NIV have higher mortality Use with caution / not at all When in doubt, intubate

30 NIV in asthma Data is scarce in Asthma
Early studies showed no clear benefit Recent study from PGI showed better lung function with lower bronchodilator requirements with NIV Likely to remain this way as with modern therapy established respiratory failure requiring ventilatory support is very rare

31 NIV in do not intubate NIV is being increasingly used in these patients especially in wards Recent studies have shown Up to 43 % of these patients survive to discharge Depends on primary etiology COPD & CCF fare better Better sensorium / ability to clear secretions have better outcome Post exubation failure, hypoxemic respiratory failure & end stage cancers patients fare poorly

32 NIV in DNI- guidelines Goals
NIV in patients without any restrictions to other life supporting treatments NIV in patients refusing endotracheal intubation NIV as the only support (TLC group) Need to discuss goals clearly & get consent from relatives Unclear issues Whether actually provides comfort ? Or Just prolongs the dying process ?

33 NIV in chest trauma Recent systematic review of 9 studies showed in
In blunt trauma chest without ALI, NIV Reduces intubation Hypoxemia ICU stay Mortality With established ALI Controversial with no good data

34 NIV for pre-oxygenation
2 RCTs have evaluated 3-5 mins of NIV as compared to routine preoxygenation before intubation NIV associated with Higher SpO2 immediately after & at 5 mins Higher lung volumes Especially in morbidly obese patients

35 NIV in OHS Acute exacerbation patients fare similarly if not better than COPD patients with hypercapneic respiratory failure They they get intubated, will need NIV immediately post extubation These patients need continuance of care with home NIV Can have late NIV failures because of non compliance

36 NIV facilitated FOB Patient receives NIV (10/5) by full face 100% FiO2 for 5 minutes preceding procedure Patient’s vitals & SpO2 are continuously monitored

37 NIV facilitated FOB Bronchoscope is introduced through“dual axis swivel” adapter of a catheter mount This is done after patient is adequately oxygenated

38 NIV facilitated FOB 2 % lidocaine gel for lubrication & local anesthesia Mask is replaced after nasal entry of bronchoscope Tight apposition to ensure no leak Vitals are continuously monitored

39 NIV facilitated FOB BAL - wedging scope against approprite segment (3-5 alliquots of ~ 50 ml NS) TBLB – after decreasing CPAP to 0 & PS = 10 cms NIV continued for 30 mins post procedure

40 Mechanism of action of NIV
Splinting of upper airway & increasing cross sectional area Counteracting the PEEPi created due to obstruction caused by bronchoscope Ability to provide FiO2 of 1 Recruitment of collapsed alveoli- thereby reducing shunt fraction & increasing FRC Decreases WOB

41 Evidence…

42 Author (Year) Study No. of patients Age ± SD Gender M:F NIV setting NIV duration Bronchoscopic procedure Complications Antonelli et al(3) (1996) Prospective observational 8 40 ± 14 years CPAP-4 PSV-17 FiO2-1 10 minutes before FOB and 90 minutes after the procedure BAL Two patients died after 5 & 7 days of FOB due to underlying disease Maitre et al (2002) Randomized controlled study 30 With CPAP-15 Without CPAP-15 58 (35-78) 57 (26-83) 15:4 15:5 CPAP titrated in incremental steps of 2.5 cm H2O up to 7.5 cm 5 minutes before FOB and 30 minutes after the procedure Bronchial biopsy Eight patients required intubation, 7 in the O2 group and 1 in CPAP group Antonelli et al (2002) 26 13-NIV 13-O2 supplement by venturi mask NIV - 52 ± 20 years O ± 10 years 8:8 in both groups PSV-15 to 17 FiO2-0.9 10 minutes before FOB and 30 minutes after the procedure 4 in NIV 7 in O2 died of underlying illness No procedural complications Antonelli et al (2003) 4 60.25 years PSV-10 to 20 PEEP- 8 to 14 FiO2-0.7to 0.9 Before and during FOB and 30 minute after procedure One patient died after 48 hours due to underlying disease Heunks et al (2010) 12 64.25 years 6:6 PSV-10 PEEP- 6 20 minutes before FOB until SpO2 > FiO2 0.4 Worsening hypoxemia during procedure in 1 patient requiring temporary withdrawal of FOB Scala et al (2010) Prospective case-control study NIV-15 CMV-15 NIV-80 ± 5 CMV-80 ± 5 12:3 9:6 PSV-10 to 25 PEEP- 5 Before FOB until clinical improvement with gradual reduction of PSV None related to the procedure

43 Respir Care. 2012 Mar 13. [Epub ahead of print]
Bronchoscopic Lung Biopsy Using Noninvasive Ventilatory Support: Case Series and Review of Literature of NIV-assisted Bronchoscopy. Agarwal R, Khan A, Aggarwal AN, Gupta D. Abstract RESULTS: Six patients with a mean (SD) age of 44.5 (11.6) years were included in the study. The median (IQR) PaO₂/FiO₂ ratio prior to lung biopsy was ( ) and the median (IQR) IPAP/EPAP used was 14 (12-15)/5 cm H₂O. FOB was well tolerated and all patients maintained SpO₂ >92% during the procedure. One patient required endotracheal intubation due to hemoptysis. A definite diagnosis was obtained in five of the six patients. A repeat procedure was performed in one patient, which again yielded no diagnosis. No other periprocedural complications were encountered. CONCLUSIONS: NIV-assisted BLB is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.

44 Monitoring during NIV Subjective and objective parameters
First 2hrs - intense monitoring Next 8hrs - close monitoring… There after - routine monitoring Even if parameters were borderline at start of NIV, early change / improvement predicts success of NIV This is the most important aspect of NIV First few hours predict the outcome of the patient

45 Monitoring during NIV … Look at patient, ventilator, interface, bed side monitor, ABG … Patient - Comfort, conscious level Chest expansion Accessory muscles Synchrony … Interfaces - leak, tightness … Trigger, volume delivered, cycling … HR, RR, SpO2, BP … ABG - pCO2, pH, pO2 at base line, 1-2hrs after, then based on response

46 Trouble shooting Potential issues Solutions
Leak Agitation / asynchrony Hypoxia Hypercarbia Check mask fit/ strap position/ tubings / ? Chin strap Talk to patient / adjust settings / sedation /analgesia Adjust ventilator / FiO2/ intubate

47 Potential indicators of success in NIV
… Synchronous breathing … Intact dentition … Younger age … Lower acuity of illness … Able to cooperate … Less secretions … Better compliance … Improvements in gas … Better neurologic score … Less air leak … PaCO mmHg … pH exchange and heart respiratory rates within first 2 hours

48 Situations where NIV is likely to fail
Hypercapnic failure Hypoxemic failure GCS < 11 RR > 35/min PH < 7.25 APACHE > 29 Asynchrony Agitation / intolerance Edentulous / excessive leak No initial improvement Diagnosis of ARDS / pneumonia Age > 40 SBP < 90 Metabolic acidosis PH < 7.25 Low PO2/ FiO2 Simplified APS II > 34 Failure of PO2 / FiO2 to improve above 175 by 1st hour

49 Weaning patients from NIV
No specific protocol Pts of COPD would require at least 24 hours to stabilise NIV is usually removed as per patient’s request for feeding/facial hygiene Re – attached as deemed necessary Attempt gradual decrease in IPAP / EPAP & discontinue when patient tolerates

50 Complications of NIV Failure is the most serious complication
Most dreaded complication is failure to recognize NIV failure early leading to delay in intubation Studies have shown that this can lead to increased mortality especially when used in situations where NIV is used without strong evidence

51 Complications of NIV Principles of mechanical ventilation. 3e

52 Summary & conclusions NIV is an important tool in the hands of RT & intensivist Provides a level of respiratory support in emergency / wards unimaginable otherwise Has changed the way we manage COPD exacerbations Needs careful monitoring during initial hours A tool which needs to be used wisely for us to reap the benefits

53 Thank you Questions ?

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