1. Non-invasive ventilation – setting up a service Andrew Bentley Critical Care & Chest Medicine North Manchester General Hospital

2. Setting up an acute non-invasive ventilation service NIV Why? Where? When?How? Who?

3. NIV Mortality Length of of stay stay Cost effectiveness effectiveness Need for for intubation intubation Acute Non-invasive ventilation Why? Why? Cost effectiveness of ward based NIV for acute exacerbations Of COPD: economic analysis of randomised controlled trial. PK Plant, JL Owen, S Parrott, MW Elliott. BMJ 2003;326:956-959

4. Respiratory failure in acute COPD - role of non-invasive ventilation Increase in elastic and resistive forces Tissue acidosis worsens respiratory muscle function Lung hyperinflation respiratory muscles at maximum capacity Improvement in gas exchange Improvement in gas exchange Reduced work of breathing Reduced work of breathing Unloading of inspiratory muscles Unloading of inspiratory muscles In-hospital mortality is 20-40% despite selective use of mechanical ventilation In-hospital mortality is 20-40% despite selective use of mechanical ventilation

5. Bott et al, Lancet 1993;341:1555-1557

6. Brochard et al, Lancet 1995;333:817-822 N=85

7. Brochard et al, NEJM 1995;333:817-822 P<0.05 n=32

8. Brochard et al, NEJM 1995;333:817-822 Hospital stay No. of patients

9. Brochard et al, NEJM 1995;333:817-822 Endotracheal intubation No. of patients

10. Kramer et al, Am J Resp Crit Care Med 1995;151:1799-1806 N=31

11. NIV Acute hypercapnic hypercapnicCOPD Pneumonia Heart failure failure? ? Acute Non-invasive ventilation Who? Who?

12. Non-invasive ventilation – patient groups COPD COPD Reduced mortality Reduced mortality Reduced morbidity related to endotracheal intubation Reduced morbidity related to endotracheal intubation Reduced ICU admissions Reduced ICU admissions Reduced hospital length of stay Reduced hospital length of stay Acute Respiratory failure Acute Respiratory failure Acute pneumonia & ARDS Post surgery Solid organ transplant Immunosuppressed with pulmonary infiltrates Haematological malignancy Antonelli et al. NEJM 1998;339:429- 435 Antonelli et al. JAMA 2000;283:235- 241 Hilbert et al. NEJM 2001;344:481-487 Confalonieri et al. AmJRespCritCareMed1999;160:1585- 1591

13. Acute non-invasive Ventilation in COPD - predictors of poor outcome Low pH Low pH Pneumonia (consolidation) on CXR Pneumonia (consolidation) on CXR Low body weight Low body weight Bronchiectasis (excessive secretions) Bronchiectasis (excessive secretions) Poor neurological status Poor neurological status Ambrosino et al, Thorax 1995;50:755-757 Simonds et al, Thorax 1995;50:595-596

14. NIV Equipment Protocols Monitoring Training Acute Non-invasive ventilation How? How?

15. Non-invasive ventilation at NMGH 1996 – Medical HDU 1996 – Medical HDU Sullivan ST VPAPs Sullivan ST VPAPs Non-invasive monitoring Non-invasive monitoring Entrained supplemental oxygen via mask Entrained supplemental oxygen via mask Respiratory physio led service Respiratory physio led service 1999 – 12 bedded medical & surgical HDU 1999 – 12 bedded medical & surgical HDU Vision BiPAPs Vision BiPAPs Invasive monitoring Invasive monitoring Nurse led service Nurse led service Protocol driven (for acute hypercapnic COPD) Protocol driven (for acute hypercapnic COPD) Automatic referral to chest consultant Automatic referral to chest consultant

16. Non-invasive modalities of positive pressure ventilation in acute exacerbations of COPD Non-invasive pressure support ventilation (NPSV) vs NIPPV (assist-control) Non-invasive pressure support ventilation (NPSV) vs NIPPV (assist-control) Success rate (NPSV 87.5%; NIPPV 77%) Success rate (NPSV 87.5%; NIPPV 77%) Compliance score (NPSV 4 vs NIPPV 3, p<0.02) Compliance score (NPSV 4 vs NIPPV 3, p<0.02) Reduced work of breathing assist control>NPSV Reduced work of breathing assist control>NPSV Patient comfort NPSV>assist control Patient comfort NPSV>assist control IPAP v IPAP +EPAP v CPAP v volume cycled NIPPV IPAP v IPAP +EPAP v CPAP v volume cycled NIPPV No difference between Pressure support, CPAP & volume cycled NIPPV No difference between Pressure support, CPAP & volume cycled NIPPV No advantage conferred by EPAP No advantage conferred by EPAP Vitacca et al, Int Care Med 1993;19:450-455 Meecham-Jones et al, Thorax 1994;49:1222-1224 Girault et al, Chest 1997;111:1639-1648

17. Non-invasive ventilation at NMGH Documented resuscitation and ICU admission status. Documented resuscitation and ICU admission status. Medical treatment: Medical treatment: Controlled oxygen therapy Nebulised bronchodilators Antibiotics IV aminophylline Systemic corticosteroids Inclusion criteria Inclusion criteria pH <7.36 pH <7.36 pCO 2 > 45 mmHg pCO 2 > 45 mmHg pO 2 < 60 mmHg pO 2 < 60 mmHg Exclusion criteria Exclusion criteria Hypotension Hypotension Primary metabolic acidosis Primary metabolic acidosis Untreated pneumothorax Untreated pneumothorax Compromised airway Compromised airway NIPPV to be considered if: NIPPV to be considered if: No improvement in oxygenation and the same or deteriorating pH after 2 hours of medical therapy. No improvement in oxygenation and the same or deteriorating pH after 2 hours of medical therapy. Improvement in oxygenation but same or worsening pH after 2 hours of medical therapy. Improvement in oxygenation but same or worsening pH after 2 hours of medical therapy. Obvious clinical deterioration. Obvious clinical deterioration.

18. Acute Non-invasive ventilation Standard medical treatment Standard medical treatment Controlled oxygen (SaO 2 85-90%) Controlled oxygen (SaO 2 85-90%) Nebulised salbutamol 5mg every 4-6 hours Nebulised salbutamol 5mg every 4-6 hours Nebulised ipratroprium 500µg 6 hourly Nebulised ipratroprium 500µg 6 hourly Prednisolone 30mg daily for minimum of 5 days Prednisolone 30mg daily for minimum of 5 days Antibiotic agent Antibiotic agent NIV NIV BiPAP through face mask or nasal mask IPAP 10cm H 2 O, increased to 20 cm H 2 O EPAP 5 cm H 2 O Target duration first day 24 hours, second day 16 hours, third day 8 hours, fourth day discontinued Oxygen in circuit to maintain SaO 2 85-90% Plant PK, Owen JL, Elliott MW. Early use of NIV for acute exacerbations Of COPD on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000;355:1931-1935

19. Acute Non-invasive ventilation Training Training On the job, self directed, protocol driven Locally organised sessions & study days Company organised Courses – national & international Eg. ERS School courses 2004: NIPPV June 10-12 th Pisa, Italy

20. Acute Non-invasive ventilation Training requirements Training requirements Understanding rationale for assisted ventilation Understanding rationale for assisted ventilation Mask & headgear assembly Mask & headgear assembly Ventilator circuit assembly Ventilator circuit assembly Theory of operation & adjusting ventilation to desired outcome Theory of operation & adjusting ventilation to desired outcome Cleaning & general maintenance Cleaning & general maintenance Problem solving, recognise serious situations and act accordingly Problem solving, recognise serious situations and act accordingly General overall acceptance that technique works General overall acceptance that technique works

21. Acute non-invasive ventilation Monitoring Monitoring Pulse oximetry NIBP Peripheral venous access Arterial blood gas sampling ECG Capillary gases Arterial lines

22. NIV Early Protocols AppropriatenessLater Demand Acute Non-invasive ventilation When? When?

23. NIV A&E/MEU ICU Ward HDU Acute Non-invasive ventilation Where? Where?

24. Acute hypercapnic exacerbations of COPD in A&E Little advantage of NIV over conventional therapy Little advantage of NIV over conventional therapy Barbe et al. EurRespJ 1996;9:1240-1245 Wood et al. Chest 1998;113:1339-1346 1 year prevalence study of acute COPD 1 year prevalence study of acute COPD exacerbations in Leeds A&E departments (n=954) 25% acidotic on arrival to A&E and 25% of these 25% acidotic on arrival to A&E and 25% of these had corrected pH on arrival to ward Relationship between PaO 2 on arrival and Relationship between PaO 2 on arrival and presence of respiratory acidosis Plant et al. Thorax 2000;55:550-554

25. Non-invasive ventilation - Location of provision of service YONIV study (Plant et al, Lancet 2000;355:1931- 1935) YONIV study (Plant et al, Lancet 2000;355:1931- 1935) NIV can be applied successfully outside of ICU/HDU setting NIV can be applied successfully outside of ICU/HDU setting Outcome not as good as in HDU setting if pH<7.30 Outcome not as good as in HDU setting if pH<7.30 Outside of ICU cost efficacy related to prevention of ICU admission Outside of ICU cost efficacy related to prevention of ICU admission Training, patient throughput, skill retention – single location (Doherty et al, Thorax 1998;53:863-866) Training, patient throughput, skill retention – single location (Doherty et al, Thorax 1998;53:863-866) 1998 – acute NIV service (48% hospitals) 1998 – acute NIV service (48% hospitals) Ward (40%), HDU (12%), ICU (13%) Ward (40%), HDU (12%), ICU (13%) Acute Respiratory Care Units Acute Respiratory Care Units NHS Modernisation Agency (Critical Care Programme) weaning & long term ventilation (April 2002) NHS Modernisation Agency (Critical Care Programme) weaning & long term ventilation (April 2002)

26. Acute non-invasive ventilation Where - factors to consider Where - factors to consider Location of staff with training & expertise Location of staff with training & expertise Adequate staff available over 24 hour period Adequate staff available over 24 hour period Rapid access to endotracheal intubation and invasive mechanical ventilation Rapid access to endotracheal intubation and invasive mechanical ventilation Severity of respiratory failure and liklihood of success Severity of respiratory failure and liklihood of success Facilities for monitoring Facilities for monitoring

27. Non-invasive ventilation on HDU at NMGH Audit of practice 1999 Audit of practice 1999 “Uncontrolled “ oxygen therapy prior to arrival in A+E. “Uncontrolled “ oxygen therapy prior to arrival in A+E. Poor documentation Poor documentation High mortality despite treatment (45%) High mortality despite treatment (45%) Low pH on admission (mean pH <7.20) Low pH on admission (mean pH <7.20) Multiple comorbid factors as predictors of poor outcome Multiple comorbid factors as predictors of poor outcome

28. Appropriate for NIPPV n = 69 NIPPV institutedn = 43 (62%) NIPPV not institutedn = 26 (38%) Recovered with medical therapy n = 14 (20%) Admitted to ICUn = 1 (1.5%) Contraindication to NIPPVn = 2 (3%) No documentation / unclearn = 9 (13%) Non-invasive ventilation on HDU at NMGH Audit March 2000 –March 2001 Audit March 2000 –March 2001

29. Findings: NIPPV instituted43 Resuscitation state documented15 (35%) Maximal medical treatment26 (60%) 2 nd blood gas not documented11 (25%) Documentation of termination of NIPPV: weaned1 not tolerated9 hypotension2 ICU1 Unclear30 Outcome of NIPPV: - Survived with no re-admission to date:14 (33%) - Re-admission within study time period: 9 (21%) - Death same admission: 20 (46%) - HDU / Ward19 - ICU 1 Non-invasive ventilation on HDU at NMGH

30. Interrogating KSM, James Wheeler,March 5 th 2003 “The Washington Times” recently published a method for the efficient interrogation of Al Quaeda suspect Khalid Shaikh Mohammed, suggested by the president of the Freedom Research Foundation. This involved ventilation by nasal mask of a paralysed subject, with the ventilator turned off to provide transient suffocation whenever the interrogator was dissatisfied.” Summerfield D. BMJ 2003;326:773-774