King Ventilation

8/18/2019 King Ventilation

1/51

““Bi-Level and Non-invasiveBi-Level and Non-invasiveIntermittent Postive PressureIntermittent Postive Pressure

VentilationVentilation”.”.M.A . KingM.A . King

Respiratory Support & SleepRespiratory Support & SleepCentre,Centre,

Papworth Hospital, Cambrige,Papworth Hospital, Cambrige,

C!" #R$, %KC!" #R$, %K


2/51

Bi-level and NIPPVBi-level and NIPPV

olumetri' me'hani'al (entilationolumetri' me'hani'al (entilationis usually reser(e )or theis usually reser(e )or the

un'ons'ious patient an isun'ons'ious patient an iseli(ere by an enotra'heal tube.eli(ere by an enotra'heal tube.

*on+in(asi(e ntermittent Positi(e*on+in(asi(e ntermittent Positi(e

Pressure entilation is eli(ere byPressure entilation is eli(ere bya mas-.a mas-.

Bi-level and NIPPVBi-level and NIPPV


3/51

PlanPlan

A(oi mentioning CPAP an !i+e(el in /SA 0A(oi mentioning CPAP an !i+e(el in /SA 0 1o'us in non+in(asi(e (entilatory support.1o'us in non+in(asi(e (entilatory support.

2hat is (entilatory )ailure32hat is (entilatory )ailure3 2ho nees this treatment32ho nees this treatment3 2hat o the ma'hines o32hat o the ma'hines o3 2hat are the out'omes32hat are the out'omes3 4is'usion4is'usion 55 4o Sleep 6e'hnologists nee to be in(ol(e4o Sleep 6e'hnologists nee to be in(ol(e

in these treatments3in these treatments3


4/51

6e'hnologi'al e(elopments sin'e the 6e'hnologi'al e(elopments sin'e the

in(ention o) CPAPin(ention o) CPAP

/SA

CPAP

/SA with lungproblems

!i+e(el

entilatoryinsu7'ien'y

entilatory1ailure

!i+e(el Bi-Level

Pressuresupport(entilators

Pressuresupport(entilators

89#: 899; 899

<

=89#

:

>;;; =89#

:


5/51

entilatory 1ailure.entilatory 1ailure.

ung 1un'tion ? entilation an gas e@'hangeung 1un'tion ? entilation an gas e@'hange

Minute entilation is a )un'tion o)Minute entilation is a )un'tion o) respiratoryres

piratory

raterate an tial (olumean tial (olume

entilatory 1ailureentilator

y 1ailure 'auses a rise in C/> an'auses a rise in C/> an

rop in />rop in />

as $@'hange Brespiratory )ailure 'ausesas $@'hange Brespiratory )ailure 'auseshypo@ia alonehypo@ia alone


6/51

““Pump” 1ailurePump” 1ailure..

Respiratory 'ontrol 'entres.Respiratory 'ontrol 'entres.

*eurologi'al system B *er(es an*eurologi'al system B *er(es ansynapsessynapses

Mus'leMus'le

Me'hani's B 6hora'i' 'age.Me'hani's B 6hora'i' 'age.

R$S6RC6$ $*6A6/RD 4$1$C6R$S6RC6$ $*6A6/RD 4$1$C6


7/51

Restri'ti(e e)e't.Restri'ti(e e)e't.

Small lungs in aSmall lungs in a

rigi 'hest 'age.rigi 'hest 'age.

*ormal lungs whi'h*ormal lungs whi'h'an not be'an not be

[email protected]@pane.

ung me'hani'sung me'hani's

are altere anare altere an

e7'ien'ey lost.e7'ien'ey lost.


8/51

entilatory Pump.entilatory Pump.

Cerebral cortex

Brainstem

Respiratory muscles

Ventilation

Airflow resistance

Restrictive lung defect.Chemoreceptors

Mechanoreceptors

2AK$

Sleep-wake

Minute (entilation ?M


9/51


10/51

Respiratory Mus'leRespiratory Mus'le

2ea-ness2ea-ness

Begin AJRCCM !!" #$ %%&%!


11/51

MVreduced

6

RR

Control

wor-

Hyper'apnoea

Hypo@ia

Bhypersomnia

Prolonge hypo(entilationE or F e(ents BAH,4esats, Arousals, 2AS/,poor sleep ar'hite'ture.

A'iosis

VentilatoryFailure

Musclefatigue

Progressive andinsidious

pump


12/51

MVreduced

6

RR

Control

wor-

Hyper'apnoea

Hypo@ia

Prolonge hypo(entilationE or F e(ents BAH,4esats, Arousals, 2AS/,poor sleep ar'hite'ture.

A'iosis

VentilatoryFailure

Neuro-Muscleinsult

Acute

CVA

Trauma

Neuro’disease

Infectio

n


13/51

/besity epiemi' hits $urope Bnot/besity epiemi' hits $urope Bnot

1ran'e.1ran'e.


14/51

*o'turnal (entilatory*o'turnal (entilatory

insu7'ien'yinsu7'ien'y Reu'e tial (olume an reu'eReu'e tial (olume an reu'e

)reGuen'y.)reGuen'y.

Reu'e minute (olume ?Reu'e minute (olume ?hyper'apnoea an [email protected]'apnoea an hypo@ia.


15/51

ni'ations )or *PP.ni'ations )or *PP.

entilatory pump )ailure.entilatory pump )ailure.

Chroni' or a'ute.Chroni' or a'ute.

Reu'e M, hypo@ia withReu'e M, hypo@ia with

hyper'apnoea.hyper'apnoea.

( potential for normal gas exchange –( potential for normal gas exchange –

single system failure).single system failure).


16/51

Assessment.Assessment.

Arterial bloo gases BA!s.Arterial bloo gases BA!s.

/(ernight o@imetry an C/>/(ernight o@imetry an C/>

ung 1un'tion.B (olumes an mus'leung 1un'tion.B (olumes an mus'le

strengthstrength

Mei'al e@am B 'ario+(as'ularMei'al e@am B 'ario+(as'ular

A! an" sleep stages have little A! an" sleep stages have little

"iagnostic or prognostic value"iagnostic or prognostic value..


17/51

Simple o(ernight [email protected] o(ernight o@imetry.


18/51

2hat o the ma'hines o32hat o the ma'hines o3


19/51

*on+in(asi(e (entilation+*on+in(asi(e (entilation+

obe'ti(esobe'ti(es8.8. mpro(e al(eolar (entilation &mpro(e al(eolar (entilation &

[email protected]@ygenation.

>.>. Reu'tion o) wor- o) breathing.Reu'tion o) wor- o) breathing.

".". Airway support.Airway support.


20/51

/be'ti(e5mpro(e al(eolar/be'ti(e5mpro(e al(eolar

(entilation & o@ygenation.(entilation & o@ygenation.

6he physiologi'al me'hanism is 6he physiologi'al me'hanism is

'omple@ & epenent upon the'omple@ & epenent upon the

pathologyIisease me'hanism.pathologyIisease me'hanism.

8.8. pa/>?JBPb+S2P@pa/>?JBPb+S2P@1i/>1i/>+PaC/>IRL+PaC/>IRL

>.>. n'reasen'rease 6ial (olume 6ial (olume anan raterate ??

minute entilation.minute entilation.


21/51

2or- o) breathing2or- o) breathing

Wor increases!"en F#C reducedor !"en TV $ VC


22/51

2or- o) breathing2or- o) breathing2hen 1RC an lung 'omplian'e are reu'e more wor- is

reGuire to inate the lung. !y applying P$$P, the lung(olume at the en o) e@halation is in'rease. 6he alreaypartially inate lung reGuires less pressure an energy thanbe)ore )or )ull ination

6


23/51

1i/> & impro(e M B 6 & RR1i/> & impro(e M B 6 & RR

6

RR

Ti

6e

1i/>

r'o


24/51

Me'hani'al entilatoryMe'hani'al entilatory

SupportSupportn(asi(e F eno+tra'heal tube.n(asi(e F eno+tra'heal tube.

*on+ in(asi(e (entilation*on+ in(asi(e (entilation B*.B*.

*egati(e Pressure **egati(e Pressure *

Positi(e Pressure * NPositi(e Pressure * N


25/51

*egati(e Pressure * pre'ees*egati(e Pressure * pre'ees

positi(e pressure (entilation by 8;;positi(e pressure (entilation by 8;;

years.years. ++ Patient lays insie a rigi 'yliner with ne'- anPatient lays insie a rigi 'yliner with ne'- an

hea outsie 'yliner.hea outsie 'yliner. A (a'uum pump 'reates a negati(e pressure withinA (a'uum pump 'reates a negati(e pressure within

the 'hamber Boutsie o) 'hestthe 'hamber Boutsie o) 'hest + this 'auses e@pansion o) the patientOs 'hest. 6his+ this 'auses e@pansion o) the patientOs 'hest. 6his'hange in 'hest geometry reu'es intrapulmonary'hange in 'hest geometry reu'es intrapulmonarypressure an ambient air ows into the lungs.pressure an ambient air ows into the lungs.

2hen the (a'uum ens, the negati(e pressure2hen the (a'uum ens, the negati(e pressureapplie to the 'hest rops to ero, an the elasti'applie to the 'hest rops to ero, an the elasti're'oil o) the 'hest an lungs results in passi(ere'oil o) the 'hest an lungs results in passi([email protected]@halation.

Pump F Austable rate an austable negati(ePump F Austable rate an austable negati(epressure.pressure.


26/51

ron lung.ron lung.


27/51


28/51

imitations o) *egati(eimitations o) *egati(e

Pressure *Pressure * %nsupporte upper airway+%nsupporte upper airway+

obstru'tion inu'e with highobstru'tion inu'e with high

transluminal pressure graients.transluminal pressure graients. Can reu'e 'aria' /P anCan reu'e 'aria' /P an

peripheral oeema.peripheral oeema.

C/*6R/$4 (entilation.C/*6R/$4 (entilation. imite te'hnologies.imite te'hnologies.


29/51


30/51

Positi(ePositi(e PressurePressure **

8. 4eli(ery o) positi(e pressure to lungs8. 4eli(ery o) positi(e pressure to lungs

without intubationwithout intubation..

>. 4eli(ery o) air is>. 4eli(ery o) air is patient 'ontrollepatient 'ontrolle Bwith ma'hine ba'- up eli(ery.Bwith ma'hine ba'- up eli(ery.

". Air is eli(ere". Air is eli(ere (ia a nasal mas-(ia a nasal mas- oror

oro+naso mas- B )ull )a'e mas-.oro+naso mas- B )ull )a'e mas-.

*PP*PP


31/51

*omen'lature o) Positi(e pressure systems*omen'lature o) Positi(e pressure systems CPAPCPAP !i+le(el!i+le(el NIPPVNIPPV PAPPAP $PAP$PAP

P$$PP$$P entilating F pea- pressure Bentilating F pea- pressure Bpressurepressure

supportsupport 6riggers + Cy'ling 6riggers + Cy'ling 6i. 6e, I$ ratio 6i. 6e, I$ ratio Moe S, S6, 6Moe S, S6, 6 Rise 6imeRise 6ime

RampsRamps


32/51

1i/>, tial (olume & rate.1i/>, tial (olume & rate.

1i/> F1i/> F room air >;.#Q, )a'ility to aroom air >;.#Q, )a'ility to ao@ygen. /> Q not measure.o@ygen. /> Q not measure.

6 6 FF Patient 'ontrolle breath enhan'ePatient 'ontrolle breath enhan'eby eli(ery o) air to a targetby eli(ery o) air to a target pressurepressurele(el.le(el. Misse breaths re'ognise.Misse breaths re'ognise.

RR+RR+ apnoeaapnoea re'ognise.re'ognise. !a'- up rate!a'- up rate..

eli(ere.eli(ere. #achypnea#achypnea reu'e byreu'e by'ontrol'ontrol o)o) inspiratory timeinspiratory time anan e@piratory time.e@piratory time.


33/51

mpro(e al(eolar (entilation &mpro(e al(eolar (entilation &

[email protected]@ygenation.

6he physiologi'al me'hanism is 6he physiologi'al me'hanism is

epenent upon theepenent upon the

pathologyIisease me'hanism.pathologyIisease me'hanism.

pa/>?JBPb+S2P@pa/>?JBPb+S2P@1i/>1i/>+PaC/>IRL+PaC/>IRL

n'reasen'rease 6ial (olume 6ial (olume anan raterate ??

minute entilation.minute entilation.


34/51

!asi' summary!asi' summary

6rigger le(el 6rigger le(el? spontaneous patient eort to? spontaneous patient eort totrigger a ma'hine “breath”.trigger a ma'hine “breath”.

PAPPAP ? e@pans the lungs more.? e@pans the lungs more. $PAP$PAP ? supports small airways an allows? supports small airways an allows

)or P$$P.)or P$$P. P$$PP$$P? in'reases the (olume hel in the? in'reases the (olume hel in the

lungs a)ter passi(e re'oil. Hols open al(eolilungs a)ter passi(e re'oil. Hols open al(eoli& impro(es gas e@'hange.Reu'es wor-.& impro(es gas e@'hange.Reu'es wor-.

6 or ba'- up rate+ 6 or ba'- up rate+ ensures ma'hine breathsensures ma'hine breathsi) the patient oes not trigger.i) the patient oes not trigger.StatusIprogress measure with C/> & />StatusIprogress measure with C/> & />

measurementsmeasurements


35/51

1i/> & impro(e M B 6 & RR1i/> & impro(e M B 6 & RR

6

RR

Ti

6e

1i/>

r'o


36/51

!i+le(el!i+le(el

6e'hnology has e(elope )rom CPAP o(er 6e'hnology has e(elope )rom CPAP o(erse(eral years.se(eral years.

Splints upper airway.Splints upper airway. Supplements Spontaneous breathing,Supplements Spontaneous breathing,

syn'hronisation,syn'hronisation, impro(es 'om)ortimpro(es 'om)ort.. Reu'es wor- o) breathing.Reu'es wor- o) breathing.

6ime. Misse breaths eli(ere. 6ime. Misse breaths eli(ere.

Range o) )eatures an settings ae in re'entRange o) )eatures an settings ae in re'enttimes. Alarms F essentially a (entilator.*PPtimes. Alarms F essentially a (entilator.*PP


37/51

i il% i til t


38/51

%nre'ognise (entilatory%nre'ognise (entilatory

insu7'ien'y leas to biginsu7'ien'y leas to big

problemsproblems


39/51

Problems with Home no'turnalProblems with Home no'turnal

** Cost o) (entilator.Cost o) (entilator. Choi'e o) (entilator+ lo'-e settings.Choi'e o) (entilator+ lo'-e settings.

Mas- problems.Mas- problems. Complian'e B nights an hrs useComplian'e B nights an hrs use *ee to monitor e7'a'y an share*ee to monitor e7'a'y an share

mei'al 'are with lo'al o'tor.mei'al 'are with lo'al o'tor. Rare iseases, physi'al isability,Rare iseases, physi'al isability,

mental isability, agitation, poor sleep.mental isability, agitation, poor sleep.


40/51

Clini'al /ut'omes &Clini'al /ut'omes &

obser(ational stuies.obser(ational stuies.

PhysiologyPhysiology F A!s, 6'C/>, Sp/>.F A!s, 6'C/>, Sp/>.

ung 1un'tion.ung 1un'tion.

Psg F AH little (alue. 2AS/ an betterPsg F AH little (alue. 2AS/ an better

sleep.sleep.

Luality o) i)eLuality o) i)e F A'ti(ities o) i(ing.F A'ti(ities o) i(ing.

Health 'are utilityHealth 'are utility B'ostB'ost

Sur(i(alSur(i(al


41/51

Post *


42/51

Mean o(ernight o@imetry be)ore an a)ter *Mean o(ernight o@imetry be)ore an a)ter *

elective Post exacerbation

Mode of Referral

70.0

75.0

80.0

85.0

90.0

95.0

100.0 Sleep Study

Baseline

Mean O

!isc"ar#e

Mean O


43/51

* 5 2a-e A!s in Myotoni'* 5 2a-e A!s in Myotoni'

4ystrophy4ystrophy

Nugent C"est %&&%'%' ()*-(+(

*umerous publi'ations5 * in*umerous publi'ations5 * in


44/51

*umerous publi'ations5 * in*umerous publi'ations5 * in

Restri'ti(e lung an neuromus'ularRestri'ti(e lung an neuromus'ular

iseaseisease

*o prospe'ti(e ranomise*o prospe'ti(e ranomise

'ontrolle trials'ontrolle trials

Multiple 'ase series an >Multiple 'ase series an >

withrawal trials all showing similarwithrawal trials all showing similartreatment ee'tstreatment ee'ts


45/51

Shoul * be use inShoul * be use in

C/P4C/P433


46/51

UK: 30000 !"P# deat$s ea%$ &ear

' B& (0(0 !"P# is )redi%ted to *e t$e t$ird *i++est ,iller in t$e

orld and ill *e res)onsi*le or t$e deat$s o over si/ million

)eo)le

' !"P# is a maor %ause o medi%al admissions )arti%ular in

inter. 308355 emer+en%& $os)ital admissions )er &ear.

' " t$ose t$at are admitted to $os)ital or !"P# 1 in 10 ill

die in $os)ital one in t$ree ill die it$in si/ mont$s and 23

ill die it$in telve mont$s o t$eir admission to $os)ital

$00%000 patients dia#nosed &it" 'OP! in t"e ()


47/51

'oc"rane Syste*atic Revie&No%turnal NIPPV or at least 3 mont$s in

$&)er%a)ni% )atients it$ sta*le !"P# $ad no

%onsistent %lini%all& or statisti%all& si+nii%ant

ee%t on lun+ un%tion +as e/%$an+e res)irator&

mus%le stren+t$ slee) ei%ien%& or e/er%ise

toleran%e.4$e small sam)le sies o t$ese studies

)re%ludes a deinite %on%lusion re+ardin+ t$e

ee%ts o NIPPV in !"P#.

6ore eviden%e is reuired.


48/51

SummarySummary !i e(el is neee )or some /SA patients.!i e(el is neee )or some /SA patients.

!i+e(el ma'hines ha(e some )eatures o)!i+e(el ma'hines ha(e some )eatures o)

pressure support (entilators but may not bepressure support (entilators but may not be

appropriate )or all patients.appropriate )or all patients. entilatory 1ailure is 'ommon in someentilatory 1ailure is 'ommon in some

iseases.iseases.

ong term * is more ee'ti(e )or someong term * is more ee'ti(e )or some

patient groups than others.patient groups than others. Potential )orPotential )or ramati' in'reaseramati' in'rease o) /besityo) /besity

Hypopnoea Synrome a'ross $urope.Hypopnoea Synrome a'ross $urope.


49/51

Shoul Psg te'hnologists beShoul Psg te'hnologists be

in(ol(e in * ser(i'es3in(ol(e in * ser(i'es3

*o'turnal Bsleep relate entilatory*o'turnal Bsleep relate entilatory

insu7'ien'y.insu7'ien'y. 4iagnosti's. Btype o) abnormality4iagnosti's. Btype o) abnormality entilatory 1ailure is not etermineentilatory 1ailure is not etermine

by e(ents BAHby e(ents BAH 6reatment F mei'al spe'iality. 6reatment F mei'al spe'iality. /ut'omes. Be7'a'y o) */ut'omes. Be7'a'y o) *


50/51

s our spe'iality le bys our spe'iality le by

te'hnologies 3te'hnologies 3

CPAP

B/SA is one o)#: sleepisorers

Ventilator

y Failure

Bi-levelmac"ines

3


51/51

$Guipment by isorer B )ew patients with /SA$Guipment by isorer B )ew patients with /SA

e(elop entilatory )ailuree(elop entilatory )ailure Papworth,Cambrige,Sept >;;Papworth,Cambrige,Sept >;;

CPAP$,)&,

B/SA is one o)#: sleep

isorers

Ventilatory

Failure $ ,)

Bi-levelmac"ines usedfor ./A and in

0 C.P1

King Ventilation

Documents

Transcript of King Ventilation