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Agenda DDefinition & mechanism of action IIndications WWhen, who, where, what & how ? TTechnical aspects WWeaning off NIV CComplications.

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Presentation on theme: "Agenda DDefinition & mechanism of action IIndications WWhen, who, where, what & how ? TTechnical aspects WWeaning off NIV CComplications."— Presentation transcript:

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2 Agenda DDefinition & mechanism of action IIndications WWhen, who, where, what & how ? TTechnical aspects WWeaning off NIV CComplications

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

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

5 NIV – how it worksNIV – 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  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 ?What is expected of NIV ?

8 NIV in COPD exacerbationNIV 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 RCTFirst 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 pCO 2 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 BMJ 2003;;326:1-5

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

13 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 Risk of endotracheal intubation in eight trials of NPPV as an adjunct to usual medical care

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

15 Mortality in seven studies of NPPV as an adjunct to usual medical care 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) NPPV Usual medical care

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

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 extubationNIV 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 weaningNIV 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 failureEffect on weaning failure

22 Effect on VAPEffect on VAP

23 Effect on mortalityEffect 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 ARDSNIV 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 asthmaNIV 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 intubateNIV 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- guidelinesNIV 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 traumaNIV 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-oxygenationNIV 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 OHSNIV 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 FOBNIV 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 FOBNIV 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 FOBNIV 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 FOBNIV 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 FiO 2 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 settingNIV duration Bronchoscopi c procedure Complications Antonel li et al(3) (1996)3 Prospective observational 8 40 ± 14 years CPAP-4 PSV-17 FiO 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 (35- 78) 57 (26- 83) 15:4 15:5 CPAP titrated in incremental steps of 2.5 cm H 2 O up to 7.5 cm 5 minutes before FOB and 30 minutes after the procedure BAL Bronchial biopsy Eight patients required intubation, 7 in the O 2 group and 1 in CPAP group Antonel li et al (2002) Randomized controlled study NIV 13-O 2 supplement by venturi mask NIV - 52 ± 20 years O ± 10 years 8:8 in both groups CPAP-4 PSV-15 to 17 FiO minutes before FOB and 30 minutes after the procedure BAL 4 in NIV 7 in O2 died of underlying illness No procedural complications Antonel li et al (2003) Prospective observational years PSV-10 to 20 PEEP- 8 to 14 FiO to 0.9 Before and during FOB and 30 minute after procedure BAL One patient died after 48 hours due to underlying disease Heunks et al (2010) Prospective observational years 6:6 PSV-10 PEEP- 6 FiO minutes before FOB until SpO 2 > FiO BAL 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 FiO 2 -1 Before FOB until clinical improvement with gradual reduction of PSV BALNone related to the procedure

43 Respir Care.Respir Care Mar 13. [Epub ahead of print] Bronchoscopic Lung Biopsy Using Noninvasive Ventilatory Support: Case Series and Review of Literature of NIV-assisted Bronchoscopy. Agarwal RAgarwal R, Khan A, Aggarwal AN, Gupta D.Khan AAggarwal ANGupta D Abstract RESULTS: Six patients with a mean (SD) age of 44.5 (11.6) years were included in the study. The median (IQR) PaO ₂ /FiO ₂ ratio prior to lung biopsy was ( ) and the median (IQR) IPAP/EPAP used was 14 (12-15)/5 cm H ₂ O. FOB was well tolerated and all patients maintained SpO ₂ >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 NIVMonitoring 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 shootingTrouble shooting Potential issues 1.Leak 2.Agitation / asynchrony 3.Hypoxia 4.Hypercarbia Solutions 1.Check mask fit/ strap position/ tubings / ? Chin strap 2.Talk to patient / adjust settings / sedation /analgesia 3.Adjust ventilator / FiO2/ intubate 4.Adjust ventilator / FiO2/ intubate

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

48 Situations where NIV is likely to fail Hypercapnic failure  GCS < 11  RR > 35/min  PH < 7.25  APACHE > 29  Asynchrony  Agitation / intolerance  Edentulous / excessive leak  No initial improvement Hypoxemic failure  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 1 st hour

49 Weaning patients from NIVWeaning 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 NIVComplications 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 NIVComplications of NIV Principles of mechanical ventilation. 3e

52 Summary & conclusionsSummary & 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

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