1. Noninvasive Positive Pressure Ventilation (NIV) Dr. Samir Sahu, Intensivist, Intensivist, Kalinga Hospital, Bhubaneswar.

2. Aim of Ventilation To support the overloaded ventilatory pump To support the overloaded ventilatory pump To improve arterial blood gases & pH To improve arterial blood gases & pH To relieve dyspnea & unload the respiratory muscles To relieve dyspnea & unload the respiratory muscles To buy time for the patient until the causes of exacerbation are resolved by medical therapy To buy time for the patient until the causes of exacerbation are resolved by medical therapy

3. NIV Noninvasive Ventilation means augmenting Alveolar Ventilation without endotracheal tube or tracheostomy tube. Noninvasive Ventilation means augmenting Alveolar Ventilation without endotracheal tube or tracheostomy tube. It consists of a Nasal or a Facial Mask It consists of a Nasal or a Facial Mask It can be used in the Casualty, ICU, Ward for Acute RF or at Home for Chronic RF. It can be used in the Casualty, ICU, Ward for Acute RF or at Home for Chronic RF. Avoids intubation & VAP Avoids intubation & VAP

4. Indication for Noninvasive Ventilatory Support Depends on Severity of Exacerbation Severity of Exacerbation Severity of Respiratory Acidosis Severity of Respiratory Acidosis Timing of Intervention Timing of Intervention Patient Characteristics Patient Characteristics Skill of the Team Skill of the Team Available monitoring facilities Available monitoring facilities

5. Indications of NIV Hypercapnic Acute Respiratory Failure Acute exacerbation of COPD Acute exacerbation of COPD Thoracic Wall Deformities Thoracic Wall Deformities Neuromuscular Diseases Neuromuscular Diseases Weaning Weaning Hypoxaemic Acute Respiratory Failure Cardiogenic Pulmonary Oedema Cardiogenic Pulmonary Oedema Chronic Respiratory Failure Polio,TB,NMD,KS,COPD,Bronchiectasis. Polio,TB,NMD,KS,COPD,Bronchiectasis.

6. Indications of NIV

7. NIV in AE of COPD A meta-analysis of 15 trials found that adding NPPV to standard care reduced rates of endotracheal intubation, length of hospital stay & in-hospital mortality rates in patients with severe exacerbations. (Worsening dyspnoea, increase in sputum purulence, increase in sputum volume) A meta-analysis of 15 trials found that adding NPPV to standard care reduced rates of endotracheal intubation, length of hospital stay & in-hospital mortality rates in patients with severe exacerbations. (Worsening dyspnoea, increase in sputum purulence, increase in sputum volume) Keenan et al;Ann Intern Med. 2003 Keenan et al;Ann Intern Med. 2003

8. COPD Acute exacerbation (pH 45 Acute exacerbation (pH 45 Mild exacerbations (pH>7.35) may not benefit Keenan et al, 2003 Mild exacerbations (pH>7.35) may not benefit Keenan et al, 2003 Can be used in ICU/HDU/Wards, Patients with severe exacerbations (pH<7.3) are better managed in the ICU Can be used in ICU/HDU/Wards, Patients with severe exacerbations (pH<7.3) are better managed in the ICU

9. COPD Recent studies demonstrate that outcomes of severe COPD exacerbations are no worse if treated with NIV than with endotracheal intubation, indicating that an initial trial with NIV is not deleterious, even in severely ill COPD patients. Recent studies demonstrate that outcomes of severe COPD exacerbations are no worse if treated with NIV than with endotracheal intubation, indicating that an initial trial with NIV is not deleterious, even in severely ill COPD patients. Scala R et al, Chest 2005 Conti G et al, Intensive Care Med 2002

10. COPD – Practice points All AE-COPD should have ABG on presentation besides clinical examination All AE-COPD should have ABG on presentation besides clinical examination NIV preferably started in ICU NIV preferably started in ICU Patients closely monitored during first 1-2 hours Patients closely monitored during first 1-2 hours ABG should be repeated at end of 1-4 hrs ABG should be repeated at end of 1-4 hrs NIV should be given almost continuously in first 24 hours except during feeding. Later on duration can be reduced depending on clinical condition & physiological parameter(SpO2,ABG) NIV should be given almost continuously in first 24 hours except during feeding. Later on duration can be reduced depending on clinical condition & physiological parameter(SpO2,ABG)

11. Neuromuscular Disease/ Chest wall Deformity NIV is recommended when they present in Acute-on chronic respiratory failure NIV is recommended when they present in Acute-on chronic respiratory failure

12. Acute Asthma Not recommended for routine use in Asthma exacerbation Not recommended for routine use in Asthma exacerbation NIV may be tried in ICU in patients of Acute Severe Asthma who fail to respond quickly to medical treatment & have no contraindication NIV may be tried in ICU in patients of Acute Severe Asthma who fail to respond quickly to medical treatment & have no contraindication Patients should be monitored closely and intubated promptly if there is no improvement in the first hour or two, because these patients can deteriorate rapidly. Patients should be monitored closely and intubated promptly if there is no improvement in the first hour or two, because these patients can deteriorate rapidly.

13. Obstructive Sleep Apnea CPAP/NIV is recommended for Obstructive Sleep Apnea presenting as acute respiratory failure CPAP/NIV is recommended for Obstructive Sleep Apnea presenting as acute respiratory failure NIV is recommended for patients of Obesity Hypoventilation Syndrome with acute respiratory failure NIV is recommended for patients of Obesity Hypoventilation Syndrome with acute respiratory failure

14. Interstitial Lung Diseases NIV is not recommended for Interstitial Lung Disease with acute or chronic respiratory failure NIV is not recommended for Interstitial Lung Disease with acute or chronic respiratory failure

15. Cardiogenic Pulmonary Edema CPAP/NIV are recommended in addition to standard medical treatment in cardiogenic pulmonary edema CPAP/NIV are recommended in addition to standard medical treatment in cardiogenic pulmonary edema CPAP/NIV are equally effective in cardiogenic pulmonary edema CPAP/NIV are equally effective in cardiogenic pulmonary edema NIV is preferable in patients associated with hypercapnic respiratory failure NIV is preferable in patients associated with hypercapnic respiratory failure

16. Cardiogenic Pulmonary Edema The main physiologic benefit from NIV or CPAP in these patients is likely due to an increase in functional residual capacity that reopens collapsed alveoli and improves oxygenation. This also increases lung compliance and reduces work of breathing. The increased intrathoracic pressure also can improve cardiac performance by decreasing ventricular preload and afterload. The main physiologic benefit from NIV or CPAP in these patients is likely due to an increase in functional residual capacity that reopens collapsed alveoli and improves oxygenation. This also increases lung compliance and reduces work of breathing. The increased intrathoracic pressure also can improve cardiac performance by decreasing ventricular preload and afterload.

17. Immunosupressed Patients NIV is recommended early in the course of hypoxic respiratory failure in immunocompromised patients, particularly in those with hematological malignancies NIV is recommended early in the course of hypoxic respiratory failure in immunocompromised patients, particularly in those with hematological malignancies NIV as the preferred initial ventilatory modality for these patients (solid organ & bone marrow transplants, HIV) to avoid intubation and its associated risks. NIV as the preferred initial ventilatory modality for these patients (solid organ & bone marrow transplants, HIV) to avoid intubation and its associated risks.

18. Lung Resection/Abdominal Surgery NIV may be used in patients who develop respiratory failure after lung resection or abdominal surgery NIV may be used in patients who develop respiratory failure after lung resection or abdominal surgery

19. Severe Community Acquired Pneumonia NIV may be used in the ICU with caution in selected patients with community acquired pneumonia particularly in those associated with COPD NIV may be used in the ICU with caution in selected patients with community acquired pneumonia particularly in those associated with COPD A cautious trial of NIV may be considered in patients with pneumonia deemed to be excellent candidates, but they need careful monitoring, because the risk of failure is high. A cautious trial of NIV may be considered in patients with pneumonia deemed to be excellent candidates, but they need careful monitoring, because the risk of failure is high.

20. ARDS NIV may be used with great caution in cases of Acute Lung Injury & that too only in ICU. NIV may be used with great caution in cases of Acute Lung Injury & that too only in ICU. Reserved for hemodynamically stable patient who can be closely monitored in an ICU where facilities for invasive ventilation are present Reserved for hemodynamically stable patient who can be closely monitored in an ICU where facilities for invasive ventilation are present

21. ARDS Independent risk factors for NIV failure include severe hypoxemia, shock, and metabolic acidosis. Independent risk factors for NIV failure include severe hypoxemia, shock, and metabolic acidosis. Those with > 2 organ failures, hemodynamic instability, or encephalopathy were excluded Those with > 2 organ failures, hemodynamic instability, or encephalopathy were excluded Predictors of NIV failure were Simplified Acute Physiology Score II > 34 and Pao2/Fio2 ≤ 175 after the first hour of therapy. Predictors of NIV failure were Simplified Acute Physiology Score II > 34 and Pao2/Fio2 ≤ 175 after the first hour of therapy. NIV cannot be recommended as routine therapy for ALI/ARDS, a cautious trial in highly selected patients with a Simplified Acute Physiology Score II ≤ 34 and readiness to promptly intubate if oxygenation fails to improve sufficiently within the first hour. NIV cannot be recommended as routine therapy for ALI/ARDS, a cautious trial in highly selected patients with a Simplified Acute Physiology Score II ≤ 34 and readiness to promptly intubate if oxygenation fails to improve sufficiently within the first hour. Rana S. Crit Care 2006, Antonelli M. Crit Care Med 2007 Rana S. Crit Care 2006, Antonelli M. Crit Care Med 2007

22. Trauma CPAP/NIV can be recommended for hemodynamically stable patients of chest trauma with flail chest CPAP/NIV can be recommended for hemodynamically stable patients of chest trauma with flail chest

23. Palliative Care & Do not Intubate Patients NIV offers an effective, comfortable & dignified method of supporting patients with end stage disease & acute respiratory failure NIV offers an effective, comfortable & dignified method of supporting patients with end stage disease & acute respiratory failure If the patient and/or family desire prolonged survival, then use should be reserved primarily for COPD and congestive heart failure patients. If the patient and/or family desire prolonged survival, then use should be reserved primarily for COPD and congestive heart failure patients. On the other hand, if the goal is to palliate, to relieve dyspnea, or to delay death so that affairs can be settled, then NIV can be used for these as well as other diagnoses. On the other hand, if the goal is to palliate, to relieve dyspnea, or to delay death so that affairs can be settled, then NIV can be used for these as well as other diagnoses. However, it should be reassessed frequently and stopped if the goal of palliation is not being met. However, it should be reassessed frequently and stopped if the goal of palliation is not being met.

24. Hypoxemic Respiratory Failure Practice Points Preferably Full-face mask during acute phase Preferably Full-face mask during acute phase Preferably ICU Ventilator as a high FiO2 can be administered Preferably ICU Ventilator as a high FiO2 can be administered Pressure support with PEEP with fast rise time high inspiratory flow to compensate for air leaks Pressure support with PEEP with fast rise time high inspiratory flow to compensate for air leaks NIV should be discontinued if no improvement in gas exchange & dyspnea, significant mouth leak, severe mask intolerance, no improvement in mental status in 30 min in a agitated hypoxemic patient NIV should be discontinued if no improvement in gas exchange & dyspnea, significant mouth leak, severe mask intolerance, no improvement in mental status in 30 min in a agitated hypoxemic patient

25. Postextubation Respiratory Failure Support the use of NIV in patients at high risk of extubation failure, particularly if they have COPD, congestive heart failure, and/or hypercapnia. However, early indiscriminate use in all patients with risk factors is discouraged. Patients with extubation failure treated with NIV should be monitored closely and delays in needed intubation avoided Support the use of NIV in patients at high risk of extubation failure, particularly if they have COPD, congestive heart failure, and/or hypercapnia. However, early indiscriminate use in all patients with risk factors is discouraged. Patients with extubation failure treated with NIV should be monitored closely and delays in needed intubation avoided

26. Facilitating Extubation in COPD Patients intubated for hypercapnic respiratory failure due to COPD who fail spontaneous breathing trials should be considered for a trial of extubation to NIV. This approach should be reserved for patients who are good candidates for NIV in other respects and who are able to tolerate levels of pressure support easily administered via mask (i.e., ≤ 15 cm H2O). In addition, they should not have been a difficult intubation. Patients intubated for hypercapnic respiratory failure due to COPD who fail spontaneous breathing trials should be considered for a trial of extubation to NIV. This approach should be reserved for patients who are good candidates for NIV in other respects and who are able to tolerate levels of pressure support easily administered via mask (i.e., ≤ 15 cm H2O). In addition, they should not have been a difficult intubation.

27. Ventilation in COPD Non Invasive Ventilation Non Invasive Ventilation Invasive Ventilation as rescue intervention Invasive Ventilation as rescue intervention Invasive Ventilation as first choice Invasive Ventilation as first choice NIV to speed up liberation from ventilation NIV to speed up liberation from ventilation

28. Weaning – Practice Points SBT after at least 48hrs of stabilization with invasive ventilation SBT after at least 48hrs of stabilization with invasive ventilation If SBT successful – extubate If SBT successful – extubate If SBT fails then stabilize patient with full support on MV for 1 hr If SBT fails then stabilize patient with full support on MV for 1 hr After stabilization extubate & start NIV After stabilization extubate & start NIV Initially apply NIV continuously(22-24hrs) with discontinuation for feeding, expectoration Initially apply NIV continuously(22-24hrs) with discontinuation for feeding, expectoration Gradually reduce time on NIV as per patients improvement Gradually reduce time on NIV as per patients improvement

29. Preoxygenation Before Intubation Critically ill patients with hypoxic respiratory failure are at high risk of oxygen desaturations during intubation. A recent RCT of such patients showed that preoxygenation with NIV before intubation resulted in improved oxygen saturation during and after intubation and decreased the incidence of oxygen desaturations below 80% during intubation. This approach is promising but should be further studied before routine use can be recommended. Critically ill patients with hypoxic respiratory failure are at high risk of oxygen desaturations during intubation. A recent RCT of such patients showed that preoxygenation with NIV before intubation resulted in improved oxygen saturation during and after intubation and decreased the incidence of oxygen desaturations below 80% during intubation. This approach is promising but should be further studied before routine use can be recommended. Baillard C. Am J Respir Crit Care Med 2006

30. Fiberoptic Bronchoscopy

31. Selection Criteria for NPPV Acute Respiratory Failure Respiratory Distress Respiratory Distress (moderate to severe dyspnoea, use of accessory muscles, abdominal paradox) (moderate to severe dyspnoea, use of accessory muscles, abdominal paradox) Respiratory Rate (>25/min hypercapnic, >30 hypoxemic) Respiratory Rate (>25/min hypercapnic, >30 hypoxemic) pH 45mm Hg pH 45mm Hg Any 2 of the above PaO 2 <60mm Hg (SpO 2 <90%), P/F <200 PaO 2 <60mm Hg (SpO 2 <90%), P/F <200

32. Exclusion Criteria for NIV Cardiac or Respiratory Arrest Cardiac or Respiratory Arrest Haemodynamic Instability - Hypotension Haemodynamic Instability - Hypotension Cannot protect airways - Coma, secretions Cannot protect airways - Coma, secretions Craniofacial Trauma (unable to fit mask) Craniofacial Trauma (unable to fit mask) Life threatening hypoxia Life threatening hypoxia Copious secretions Copious secretions Severe GI symptoms (vomiting, obstruction, recent upper GI & airway surgery)) Severe GI symptoms (vomiting, obstruction, recent upper GI & airway surgery)) More than 2 organ failure More than 2 organ failure Extreme Obesity Extreme Obesity Agitated or Uncooperative Agitated or Uncooperative

33. NIV - Apparatus Bilevel Pressure Support Ventilator Bilevel Pressure Support Ventilator (portable)/ ICU Ventilator (portable)/ ICU Ventilator Silicon Bubble cushion Nasal mask Silicon Bubble cushion Nasal mask Silicon Full Face mask (better in acute RF) Silicon Full Face mask (better in acute RF) Interface is crucial to success of NIV Interface is crucial to success of NIV Head gear Head gear Oxygen supplementation Oxygen supplementation

34. Equipment Pressure preset is now the predominant mode used in NIV Pressure preset is now the predominant mode used in NIV EPAP – flushes dead space CO2, helps alveolar recruitment, stabilizes upper airway during sleep EPAP – flushes dead space CO2, helps alveolar recruitment, stabilizes upper airway during sleep Trigger – flow trigger is better Trigger – flow trigger is better Cycling – Inspiratory time 1-0.8sec Cycling – Inspiratory time 1-0.8sec

35. NIV Masks

36. Nasal Mask Full Face Mask

37. Nasal Pillows

38. Initiation of NIV Appropriately monitored location(SpO 2, Vitals) Appropriately monitored location(SpO 2, Vitals) Patient > 30 o angle Patient > 30 o angle Select Interface (mask), Select Ventilator Select Interface (mask), Select Ventilator Apply Headgear,Connect interface to ventilator tubing & turn on ventilator Apply Headgear,Connect interface to ventilator tubing & turn on ventilator Start IPAP 8-12 & EPAP 3-5 cm H 2 O Start IPAP 8-12 & EPAP 3-5 cm H 2 O Gradually increase IPAP(10-20) to alleviate dyspnea, decrease RR (IPAP-EPAP>4) Gradually increase IPAP(10-20) to alleviate dyspnea, decrease RR (IPAP-EPAP>4) Obese or OSA patients require higher EPAP Obese or OSA patients require higher EPAP Provide O 2 supplementation to keep O 2 >90% Provide O 2 supplementation to keep O 2 >90% Check for air leaks, readjust straps as needed Check for air leaks, readjust straps as needed

39. Continuation of NIV ABG at initiation & after 2hrs ABG at initiation & after 2hrs If PCO 2 decreases, pH increases & SpO 2 is maintained continue treatment If PCO 2 decreases, pH increases & SpO 2 is maintained continue treatment Consider reduction in duration of NPPV Consider reduction in duration of NPPV Light diet to avoid nausea & vomiting Light diet to avoid nausea & vomiting Continue other medication Continue other medication The first few hours are Labour intensive Motivation, training,& dedication leads to success

40. Predictors of success of NPPV Younger age Younger age Lower acuity of illness (APACHE score) Lower acuity of illness (APACHE score) Able to cooperate; better neurologic score Able to cooperate; better neurologic score Able to coordinate breathing with ventilator Able to coordinate breathing with ventilator Less air leak; intact dentition Less air leak; intact dentition Less severe Hypercarbia (PCO 2 >45, 45,<92) Less severe Acidemia (pH 7.10) Less severe Acidemia (pH 7.10) Improvements in gas exchange,HR,RR within 1-4 hours Improvements in gas exchange,HR,RR within 1-4 hours

41. Predictors of Failure - COPD Air leaking Air leaking Apache II >29 Apache II >29 Asynchrony Asynchrony Copious secretions Copious secretions GCS <11 GCS <11 Lack of compliance & tolerance Lack of compliance & tolerance pH < 7.25 pH < 7.25 Respiratory rate >35/min Respiratory rate >35/min

42. Predictors of Failure – Hypoxemic Respiratory Failure ALI/ARDS ALI/ARDS SAPS >35 SAPS >35 Metabolic Acidosis Metabolic Acidosis P/F <146 (<175 in ARDS) after 1 hr NIV P/F <146 (<175 in ARDS) after 1 hr NIV Pneumonia Pneumonia Severe hypoxemia Severe hypoxemia Shock Shock

43. Failure Early Failure – 1-3 hrs Early Failure – 1-3 hrs Late Failure – subsequent failure during hospital stay (>48hrs) Late Failure – subsequent failure during hospital stay (>48hrs) 20% of COPD AE experience a new episode of Res. Failure. Mortality is 91% with continued NIV compared to 52.6% in those who are intubated & ventilated 20% of COPD AE experience a new episode of Res. Failure. Mortality is 91% with continued NIV compared to 52.6% in those who are intubated & ventilated Mechanical Ventilation allow the patient to improve sufficiently to take advantage of NIV which was ineffective earlier Mechanical Ventilation allow the patient to improve sufficiently to take advantage of NIV which was ineffective earlier

44. Predictors of NIV FAILURE At admission – At admission – GCS <11 Apache II >29 RR >35/min pH <7.25 >50% if any 3 & 82% if all 4 2hr after NIV – 75% any 3 & 99% if all 4 2hr after NIV – 75% any 3 & 99% if all 4

45. What the Literature says Early Failure – (1-3hrs) Early Failure – (1-3hrs) Late Failure – (>48hrs) – 10-20% Late Failure – (>48hrs) – 10-20% Failure Rate – 5-40% Failure Rate – 5-40% Second episode of ARF(same admn) – 20% (more severe disease) Second episode of ARF(same admn) – 20% (more severe disease) Readmission after 1 year – 80% Readmission after 1 year – 80% Life threatening – 63% Death – 49%

46. Monitoring of NIV Subjective - Mask comfort - Tolerance of ventilator settings - Respiratory distress Subjective - Mask comfort - Tolerance of ventilator settings - Respiratory distress Physical findings – Respiratory rate – Other vital signs – Accessory muscle use – Abdominal paradox Physical findings – Respiratory rate – Other vital signs – Accessory muscle use – Abdominal paradox Ventilator parameters – Air leaking – Adequacy of Pressure support – Adequacy of PEEP – Tidal volume 5-7 ml/kg – Patient-ventilator synchrony Ventilator parameters – Air leaking – Adequacy of Pressure support – Adequacy of PEEP – Tidal volume 5-7 ml/kg – Patient-ventilator synchrony

47. NIV Monitoring Gas Exchange – Continuous oximetry until stable – ABGs baseline & 1-2 hrs, then as indicated Gas Exchange – Continuous oximetry until stable – ABGs baseline & 1-2 hrs, then as indicated Location – Usually ICU to start – General Ward if stable – Depends on monitoring needs of patient & monitoring capabilities Location – Usually ICU to start – General Ward if stable – Depends on monitoring needs of patient & monitoring capabilities

48. Complications of NIV Air Leaks Air Leaks Nasal/Oral dryness Nasal/Oral dryness Mask discomfort Mask discomfort Gastric distention Gastric distention Failure to Ventilate Failure to Ventilate

49. Survival using long-term NPPV

50. Selection Criteria for NPPV Chronic Respiratory Failure - COPD Failure of standard medical therapy (bronchodilators & LTOT) Failure of standard medical therapy (bronchodilators & LTOT) Fatigue, Dyspnea, morning headache,etc Fatigue, Dyspnea, morning headache,etc (Symptomatic Diurnal Respiratory Failure) (Symptomatic Diurnal Respiratory Failure) PaCO 2 > 55 mm Hg PaCO 2 > 55 mm Hg PaCO 2 50-55 mm Hg with Nocturnal desaturation PaCO 2 50-55 mm Hg with Nocturnal desaturation

51. NPPV in Chronic RF in COPD 2yr multicentric RCT in 122 patients Slightly decreased trend to PaCO 2 reten. Slightly decreased trend to PaCO 2 reten. Improved Dyspnoea & Health related quality of life Improved Dyspnoea & Health related quality of life Further work required for frequency & severity of exacerbations Further work required for frequency & severity of exacerbations Clini et al, Eur Res J 2002 Clini et al, Eur Res J 2002

52. NPPV - Diagnosis COPD - 125 COPD - 125 + pneumonia - 17 + pneumonia - 17 + A Renal F - 5 + A Renal F - 5 + CAD - 5 + CAD - 5 + Sepsis - 3 + Sepsis - 3 + CVA - 3 + CVA - 3 + Pericard E - 1 + Pericard E - 1 + Trauma - 1 + Trauma - 1 + OHS - 1 + OHS - 1 TB sequalae - 16 TB sequalae - 16 TB sequelae - 16 TB sequelae - 16 Bronchiectasis - 2 Bronchiectasis - 2 Kyphoscoliosis - 1 Kyphoscoliosis - 1 CRF/ARF -12 CRF/ARF -12 Obstructive S A – 9 Obstructive S A – 9 Pulmonary Oed. 66 Pulmonary Oed. 66 Bronchial Asthma-2 Bronchial Asthma-2 Collapse Lung - 1 Collapse Lung - 1 Pulm. Embolism - 2 Pulm. Embolism - 2 ARDS - 5 ARDS - 5 Pneumonia - 3 Pneumonia - 3

53. NPPV 1999- 2004 200520062007Total Hypercapnic74253740136 Hypoxic35224730 Wean6261114

54. Place of NPPV 1999- 2004 200520062007Total ICU79304488241 HDU34172448 Ward10124

55. THANK YOU