1. Part IV: Application of NPPV and CPAP in Specific Disorders By: Susan P. Pilbeam, MS, RRT, FAARC John D. Hiser, MEd, RRT, FAARC Ray Ritz, BS, RRT, FAARC American Association for Respiratory Care December, 2006

2. Outline Use of NPPV in patients with acute-on-chronic respiratory failure, acute asthma Use of NPPV in patients with acute-on-chronic respiratory failure, acute asthma Use of NPPV in immunocompromised patients. Use of NPPV in immunocompromised patients. Use of CPAP in patients with acute congestive heart failure without myocardial infarction Use of CPAP in patients with acute congestive heart failure without myocardial infarction Use of NPPV in patients with do-not-intubate directives Use of NPPV in patients with do-not-intubate directives Use of NPPV to facilitate weaning from invasive ventilation Use of NPPV to facilitate weaning from invasive ventilation

3. Use of NPPV in patients with acute-on-chronic respiratory failure. NPPV is strongly recommended for patients with chronic COPD who are experiencing worsening of their condition NPPV is strongly recommended for patients with chronic COPD who are experiencing worsening of their condition This is true as long as the individual patient does NOT have any exclusionary criteria (See Part II) This is true as long as the individual patient does NOT have any exclusionary criteria (See Part II) Numerous studies support the use of NPPV in this patient group Numerous studies support the use of NPPV in this patient group

4. Use of NPPV in patients with acute-on- chronic respiratory failure. In this patient group, NPPV can result in: Reduced need for intubation Reduced need for intubation Reduced in-hospital mortality Reduced in-hospital mortality Reduced length of stay Reduced length of stay Results in fewer complications associated with an artificial airway and invasive ventilation (example, ventilator associated pneumonia) Results in fewer complications associated with an artificial airway and invasive ventilation (example, ventilator associated pneumonia)

5. NPPV in Acute Asthma More studies are needed to to determine if NPPV is an effective treatment for patients with acute asthma More studies are needed to to determine if NPPV is an effective treatment for patients with acute asthma Available studies suggest that NPPV in this patient group may improve oxygenation and ventilation Available studies suggest that NPPV in this patient group may improve oxygenation and ventilation Intubation rate may also be reduced in this group Intubation rate may also be reduced in this group

6. Immunocompromised Patients Immunocompromised patients are at increased risk of infection Immunocompromised patients are at increased risk of infection This patient group can benefit from NPPV because it helps avoid intubation This patient group can benefit from NPPV because it helps avoid intubation Airway damage during intubation and the risk of ventilator associated pneumonia are two problems that are avoided if NPPV can be used Airway damage during intubation and the risk of ventilator associated pneumonia are two problems that are avoided if NPPV can be used

7. Immunocompromised Patients In immunocompromised patients with moderate to severe respiratory distress, NPPV may be used if no other contraindications (exclusionary criteria) exist In immunocompromised patients with moderate to severe respiratory distress, NPPV may be used if no other contraindications (exclusionary criteria) exist

8. Use of NPPV or CPAP in patients with acute congestive heart failure In patients with acute cardiogenic pulmonary edema, NPPV reduces the intubation rate In patients with acute cardiogenic pulmonary edema, NPPV reduces the intubation rate It also reduces the mortality rate. It also reduces the mortality rate. Evidence is good that either CPAP by mask or NPPV improves clinical outcomes in this patient group 1 Evidence is good that either CPAP by mask or NPPV improves clinical outcomes in this patient group 1

9. Use of NPPV in Patients with Do-Not- Intubate Directives Use of NPPV in patients with “do-not-intubate” directives is controversial Use of NPPV in patients with “do-not-intubate” directives is controversial These patients typically have irreversible and terminal disease These patients typically have irreversible and terminal disease Patients must understand NPPV cannot cure them Patients must understand NPPV cannot cure them NPPV is a form of life support and may provide relief of symptoms of respiratory distress NPPV is a form of life support and may provide relief of symptoms of respiratory distress

10. NPPV to Facilitate Weaning In patients with chronic respiratory failure who are invasively ventilated, NPPV may facilitate weaning In patients with chronic respiratory failure who are invasively ventilated, NPPV may facilitate weaning In this patient group, NPPV, compared to invasive PSV, reduced the following: In this patient group, NPPV, compared to invasive PSV, reduced the following: Weaning time Weaning time Length of stay in ICU Length of stay in ICU Nosocomial pneumonia Nosocomial pneumonia 60-day mortality rate 60-day mortality rate

11. NPPV to Facilitate Weaning In patients with COPD who are difficult to wean from invasive ventilation, caution must be used In patients with COPD who are difficult to wean from invasive ventilation, caution must be used The patient must be willing to cooperate. The patient must be willing to cooperate. The patient must be able to maintain their airway without risk of aspiration The patient must be able to maintain their airway without risk of aspiration The patient must be able to clear secretions The patient must be able to clear secretions

12. Section Summary NPPV has been shown to be beneficial to the following patient groups NPPV has been shown to be beneficial to the following patient groups Acute-on-chronic respiratory failure (e.g. exascerbation of COPD) Acute-on-chronic respiratory failure (e.g. exascerbation of COPD) Patients with acute asthma Patients with acute asthma Acute congestive heart failure (not caused by an acute myocardial infarction) Acute congestive heart failure (not caused by an acute myocardial infarction) Patients who are immunocompromised Patients who are immunocompromised To facilitate weaning from invasive ventilation in difficult to wean patients with COPD To facilitate weaning from invasive ventilation in difficult to wean patients with COPD