Hess, NIV

How to Maximize Noninvasive Ventilation Dean R. Hess PhD RRT Associate Professor of Anesthesia Harvard Medical School Assistant Director of Respiratory Care Massachusetts General Hospital Editor in Chief Respiratory Care

NIV versus CPAP

clinician skills

NIV Success patient selection

equipment selection

Mask CPAP y Obstructive sleep apnea y Cardiogenic pulmonary edema y Treat post-operative atelectasis

CPAP = EPAP = PEEP No ventilation assistance with CPAP

CPAP for Post-Op Hypoxemia

y Acute hypoxemic respiratory failure?

CPAP for Hypoxemic Respiratory Failure

y Patients who developed hypoxemia after

y Patients received O2 or O2 + mask CPAP

major abdominal surgery received CPAP or oxygen alone y Oxygenation improved more rapidly for CPAP y Lower intubation rate (1% vs 10%), lower pneumonia rate (2% vs 10%), and fewer ICU days (1.4 vs 2.6 d) with CPAP

y After 1 hr, symptoms and PaO2/FIO2

Squadrone, JAMA 2005; 293:589

improved with CPAP y No difference in intubation rate or mortality y Higher number of adverse events in patients receiving CPAP

Delclaux et al, JAMA 2000; 284:2352

Hess, NIV

Evidence for NIV COPD Exacerbation

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Cardiogenic pulmonary edema Prevent extubation/decannulation failure

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Transplantation, immunocompromise

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Neuromuscular disease

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Obesity hypoventilation syndrome

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Acute hypoxemic respiratory failure

? ?

Do not intubate/Do not Resuscitate Failed extubation

y 14 studies included in the review y Decreased risk of intubation: NNT 4 y Lower mortality with NIV: NNT 10

Picot, Cochrane Database of Systematic Reviews 2008

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Respiratory failure following lung resection

Asthma

COPD Exacerbation

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Cardiogenic Pulmonary Edema y Decreased intubation:

CPAP - NNT 9 NIV - NNT 14 y Reduced mortality CPAP - NNT 6 NIV - NNT 8 y No difference between CPAP and NIV y No additional harm (acute MI) with NIV Vital, Cochrane Database of Systematic Reviews 2008

Congestive Heart Failure

Sleep-disordered breathing common in patients with congestive heart failure. Sharma, Med Clin N Am 2010;94:447

Sharma, Med Clin N Am 2010;94:447

Hess, NIV

Post-Extubation NIV y Earlier extubation; extubate directly to NIV { {

Nava, Ann Intern Med 1998;128:721 Ferrer, Am J Respir Crit Care Med 2003;168:70

Chest 2010;137:1033

y Prevent extubation failure in patients at risk;

extubate directly to NIV { {

Nava, Crit Care Med 2005;33:2465 Ferrer, Am J Respir Crit Care Med 2006;173:164

y Rescue failed extubation; evidence does not

support { {

Chest 1996;110:1566

Keenan, JAMA 2002;287:3238 Esteban, N Engl J Med 2004;350:2452

Hypoxemic Respiratory Failure y NIV decreased the need for intubation and

ICU mortality y Diagnoses included pneumonia, cardiogenic

pulmonary edema, thoracic trauma, ARDS, severe asthma, and postoperative respiratory failure Ferrer, Am J Respir Crit Care Med 2003; 168:1438

The literature does not support the routine use of NIV in all patients with acute hypoxemic respiratory failure. Keenan, Crit Care Med 2004; 32:2516

NIV Following Lung Resection

y 32.7% received NIV. y 47/55 patients (85.4%) who received NIV ultimately

required invasive ventilation.

JAMA 2009;302:1872

Auriant, Am J Respir Crit Care Med 2001;164:1231

Hess, NIV

NIV for Acute Asthma y 52 immunosuppressed patients with

y ED RCT of 30 patients with severe asthma

hypoxemic acute respiratory failure y NIV every 3 hrs for at least 45 min y Fewer patients in the NIV group than in the standard-treatment group required endotracheal intubation (12 vs. 20), died in the ICU (10 vs 18), or died in the hospital (13 vs 21)

y NIV group had more rapid improvement in

FEV1 and reduced hospital admission

Soroksky, Chest 2003; 123:1018

N Engl J Med 2001;344:481

Respir Care 2010;55: 536

Crit Care Med 2005;33:1976

Obesity Hypoventilation Syndrome

NIV for Restrictive Lung Disease y Chest wall deformity { Kyphoscoliosis { Post-thoracoplasty for tuberculosis y Slowly progressive

neuromuscular disorders { { { {

The results of this study support long-term NIV as an effective and well tolerated treatment of OHS whether initiated in the acute or chronic setting. Priou, Chest 2010

{ {

Postpolio syndrome High spinal cord injury Spinal muscular atrophy Slowly progressive muscular dystrophies Multiple sclerosis Bilateral diaphragm paralysis

y More rapidly progressive

neuromuscular disorders { {

Duchenne muscular dystrophy Amyotrophic lateral sclerosis

y Rapidly progressive

neuromuscular disorders { {

Guillain-Barré syndrome Myasthenia gravis

Hess, NIV

Patient Selection for NIV

When to Stop y Lack of improvement within 1-2 hrs

Step 1: Patient needs ventilation yRespiratory distress yRespiratory acidosis yTachypnea yDiagnosis that responds well to NIV (e.g., COPD, CPE)

Step 2: No exclusions for NIV yAirway protection yUnable to fit mask yUncooperative patient yPatient wishes

y Patient intolerance of therapy y Adverse effects: hypotension y Patient wishes

When to Transfer to ICU y Failure of NIV y Mask intolerance y Better monitoring

Choice of Interface y The internal volume of masks had no short-term effect on

gas exchange, minute ventilation, or effort (Crit Care Med 2009; 37:939)

y Nasal versus oronasal mask: failure more often with nasal oronasal

nasal

pillows

mask (Crit Care Med 2009; 37:124)

Start with oronasal mask for acute respiratory failure

y Nasal versus oronasal mask: oronasal mask better

total face

mouthpiece

helmet

tolerated (Crit Care Med 2003; 31:468) y Nasal mask versus oronasal mask versus nasal pillows: nasal mask better tolerated; PaCO2 lower with oronasal and pillows (Crit Care Med 2000; 28:1785) y Oronasal mask versus mouthpiece: tolerance better and less staff time required for mask (Anaesthesia 2006; 61:20)

Mouth Leak y Decreased comfort

Skin Breakdown y Use correctly fitted mask

y Less effective ventilation y Ineffective trigger/cycle y NIV failure (Soo Hoo 1994, Fraticelli 2009) y Increased nasal resistance (Richards 1996) y Upper airway drying (De Araujo 2000)

y Try different interface; rotate interfaces y Adjust headgear

y Disrupted sleep (Meyer 1997; Tescheler 1999)

Oronasal mask; coaching? Chin strap?

y Duoderm

photo courtesy Dr. Nick Hill

Hess, NIV

Ventilators for NIV

Ventilators for NIV Ventilators for NIV are typically pressure support devices: IPAP EPAP PS = IPAP - EPAP Trigger Pressure vs volume (PCV vs PSV vs PAV)

Rise time Cycle Back-up rate

Rebreathing: • Increase EPAP level ≥4 cm H2O • Increase leak in system • Fixed leak in mask rather than hose • Titrate O2 into mask rather than hose

Inhaled Bronchodilators leak mask

y Remove patient from ventilator and administer bronchodilator by nebulizer or MDI (Mukhopadhyay, J Crit Care 2009;24:474.e1) y Administer nebulizer or MDI/spacer inline

blower & pressure controller

single hose Hess, J Aerosol Med 2007; 20:S85 Iosson, N Engl J Med 2006; 354:e8

Managing Asynchrony y Trigger dys-synchrony { Leaks { Auto-PEEP { High

levels of support

y Flow dys-synchrony { Rise

time

y Cycle dys-synchrony { Leaks { High

levels of support

Hess, NIV

Practical Application

Practical Application

y Select appropriate patient

y Silence alarms; choose low settings

y Choose a ventilator capable of meeting

y Initiate NIV while holding mask in place

patient needs (usually pressure ventilation) y Choose interface; avoid mask that is too large y Explain therapy to the patient

y Secure mask, avoid tight fit y Titrate pressure support (IPAP) to

patient comfort

Practical Application y Titrate FIO2 to SpO2 > 90% y Avoid PIP > 20 cm H2O y Titrate PEEP/EPAP/CPAP per trigger effort and SpO2 y Coach and reassure patient; make

adjustments per patient compliance

Complications y Leaks y Mask discomfort and facial soreness y Eye irritation y Sinus congestion y Oronasal drying y Patient-ventilator dyssynchrony y Gastric insufflation y Hemodynamic compromise

(Complications are usually minor)

Cough Assist

clinician skills

NIV Success patient selection

equipment selection