1. Non-invasive ventilation
Lijun Ding
23 Jan 2018
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2. Learning objectives What is NIV The difference between CPAP and BiPAP
The indication of the use of NIV
Complication of NIV application
Patient monitoring and safety
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3. What is NIV? ‘NIV refers to the provision of ventilatory
support through the patient’s upper airway using a mask or a similar device.
This technique is distinguished from those which bypass the upper airway with a tracheal tube, laryngeal mask, or tracheostomy and therefore are considered as invasive.’
Continuous positive airway pressure (CPAP)
Bilevel positive airways pressure (BiPAP)
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5. CPAP mechanism 1 2 3 Blow a stream of air to keep airway open
Maintain a continuous positive pressure throughput the respiratory cycle 2
Keep alveoli open for gas exchange at end of expiration 3
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6. Effectiveness of CPAP Increase functional residual capacity (FRC)
reduce the WOB.
Alveoli recruitment, increase gas exchange, improve V/Q match and oxygenation
Re-expand fluid filled alveoli
Does not affect tidal volume

7. Indication for CPAP Type 1 respiratory failure (PaO 2 <8 KPa)
Acute cardiogenic pulmonary oedema
Atelectasis (collapsed lungs)
Obstructive sleep apnoea

8. BiPAP mechanism 1 2 3 Bilevel positive airway pressure: IPAP & EPAP
IPAP (higher pressure) gives inspiratory support to augment tidal volume 2
EPAP (lower pressure) prevents alveoli closure at expiratory phase
EPAP= CPAP= PEEP 3
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9. Effectiveness of BiPAP
Increase in tidal volume assists CO2 clearance
Inspiratory support reduce WOB
EPAP
Keeps alveoli open on expiration
Increases lung volume, functional residual capacity (FRC)
Improves alveolar gas exchange
Improves oxygenation
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10. Indication for BiPAP
Type 2 respiratory failure (Hypercapnia PaCO 2 >6.1KPa even SpO 2 is normal)
Exacerbation of COPD
Acute cardiogenic pulmonary oedema
Weaning from mechanical ventilation
Post extubation

11. Setting
IPAP
cmH2O, increase to target pressure as tolerated by the patient
EPAP
4 – 5 cmH2O, can be increased to cmH2O
The pressure between IPAP and EPAP is pressure support . Be aware when adjusting ventilation setting to maintain tidal volume
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12. Microsoft Engineering Excellence
Contraindication
Respiratory arrest , Apnoea
Vomiting, bowel obstruction
Cardio-respiratory instability, SBP <90mmHg, severe hypoxaemia, respiratory acidosis
Uncooperative patient (claustrophobia , anxious, agitation)
Recent facial, oesophageal or gastric surgery
Craniofacial trauma or burns
Inability to protect airway (High aspiration risk )
Excessive secretion and unable to manage secretion
Reduced level of consciousness
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13. Complications Pressure sore Air leak Dry eyes
Gastro distension, vomiting and aspiration
Hypotension
Increased ICP
Secretion drying / retention
Difficulty in communication
Reduce in oral intake
Anxiety
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14. Patient monitoring
Keep reassessing A and B, repeat ABG minutes after application
Alarms setting
Looking for improvement after 1-2 hrs (no more than 4 hrs)
Always be prepared for intubation (NIV may fail, need management plan)
Need to recognise sings of failing (escalation when required)

15. Signs of failure
Unable to tolerate mask or failure of coordination with the ventilator
Development of new symptoms or complications such as pneumothorax, excessive sputum retention, nasal bridge erosion
Failure to improve in arterial blood gas
Respiratory acidosis worsening
Deterioration in patient's condition
CVS instability
reduced mental status
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16. Patient care Appropriate masks Avoid high airway pressures
Gastric distension/aspiration
PUP
Sinus pain
Communication issues (psychological support)
Humidification/NEBS
Hydration and nutrition
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17. References
Branson, R. (2013) ‘The Scientific Basis for Postoperative Respiratory Care’, Respiratory Care, 58 (11), pp
British Thoracic Society (2002) ‘Non-invasive ventilation in acute respiratory failure’, Thorax ,57(3) , pp
British Thoracic Society (2017) ‘BTS guideline for oxygen use in adults in healthcare and emergency settings, Thorax, 72, pp.i1–i90. doi: /thoraxjnl m.
Burns, K., et al. (2014) ‘Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review’, Canadian Medical Association Journal, 186(3). pp. E112-E122. doi: / CD pub3.
Chang, D. (2014) Clinical Application of Mechanical Ventilation. 4th edn. New York: Delmar Health Care.
Esmond, G. and Mikelsons, C. (2009) Non-invasive respiratory support techniques: Oxygen therapy, Non-invasive ventilation and CPAP. Chichester: Wiley-Blackwell.
Jaber, S., Chanques, G. and Jung, B. (2010) ‘Postoperative non-invasive ventilation’, Anaesthesiology, 112 (2), pp
McNeill, G. and Glossop, A. (2012) ‘Clinical applications of non-invasive ventilation in critical care’, Continuing Education in Anaesthesia, Critical Care & Pain, 12(1), pp doi: /bjaceaccp/mkr047.
Ornico, S.R., et al. (2013) ‘ ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial’, Critical Care, 17:R39. doi: /cc12549
Vital, F., Ladeira, M. and Atallah, Á. (2013) ‘Non-invasive positive pressure ventilation (CPAP or Bilevel NPPV) for cardiogenic pulmonary oedema (Review)’, Cochrane Database of Systematic Reviews, 5. doi: / CD pub3.
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Cover best practices.

18. Microsoft Engineering Excellence
Any Questions?
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