Noninvasive ventilation
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Transcript of Noninvasive ventilation
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The earliest known ventilators, developed during the late 19th century,were the ‘body or tank’ type
Noninvasive ventilation !!
CPAP, initially used for the treatment ofacute pulmonary
oedema, became popular in the 1980s for management of
obstructive sleep apnoea
CPAP, initially used for the treatment ofacute pulmonary
oedema, became popular in the 1980s for management of
obstructive sleep apnoea
Noninvasive ventilation (NIV): a form of ventilatory support that avoids airway invasion improved outcomes in certain types
of acute respiratory failure (ARF)
The successful application of NIV requires the training & collaboration of an experienced ICU team, including intensivists, nurses, and respiratory therapists
The successful application of NIV requires the training & collaboration of an experienced ICU team, including intensivists, nurses, and respiratory therapists
“NIV should be considered first-line therapy in the
management of ARF caused by COPD exacerbations”
BMJ 2003;326:185–7
BMJ 2003;326:185–7
A trial of NIV can be considered in asthmatics who fail torespond adequately to initial bronchodilator therapy to improve air flow obstruction &decrease the work of breathing
CHEST 2003; 123:1018–1025
large randomized controlled trials (RCTs) are needed before recommending NIV use in status asthmaticus
Cochrane Database Syst Rev 2005; 1:CD004360
Am J Respir Crit Care Med Vol 168. pp 70–76, 2003
a prospective, randomized, controlled trial in 43 mechanically ventilated patients who had failed a weaning trial for 3 consecutive days
Am J Respir Crit Care Med Vol 168. pp 70–76, 2003
Am J Respir Crit Care Med Vol 168. pp 70–76, 2003
The probabilityof weaning success
The cumulative survival probability
Am J Respir Crit Care Med Vol 168. pp 70–76, 2003
NIVNIV
Earlier extubation with NIV results in shorter mechanicalventilation & length of stay, less need for tracheotomy, lower incidence of complications, and improved survival
Am J Respir Crit Care Med Vol 168. pp 70–76, 2003
Facilitating Extubation in Facilitating Extubation in COPDCOPD
Facilitating Extubation in Facilitating Extubation in COPDCOPD
The main physiologic benefit from NIV or CPAP in these patients is likely due to an increase in FRC that reopens collapsed alveoli & improves oxygenation
Crit Care Med 2007 352402; :2407–
increases lung compliance &reduces work of breathing
increases lung compliance &reduces work of breathing
Anesthesiology 2005; 103:419–28
decrease afterload
decrease preload &
decreasing ventricular
preload & afterload
decreasing ventricular
preload & afterload
JAMA. 2005;294:3124-3130
NIV reduces the need for intubation & mortality in patients with acute cardiogenic pulmonary edema.
There are no significant differences in clinical outcomes when comparingCPAP vs NIPSV
NIV reduces the need for intubation & mortality in patients with acute cardiogenic pulmonary edema.
There are no significant differences in clinical outcomes when comparingCPAP vs NIPSV
JAMA. 2005;294:3124-3130
JAMA. 2005;294:3124-3130
JAMA. 2005;294:3124-3130
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
AM J RESPIR CRIT CARE MED 1999;160:1585–1591
Relapse of pneumonia was the leading cause of death after hospital discharge, and relapse
occurredin previously intubated patients with COPD
AM J RESPIR CRIT CARE MED 1999;160:1585–1591
Studies on NIV to treat acute lung injury & ARDS have reported failure rates ranging from 50% to 80%Independent risk factors for NIV failure: severe hypoxemia, shock, & metabolic acidosis
Independent risk factors for NIV failure: severe hypoxemia, shock, & metabolic acidosis
Crit Care Med 2007; 35:18–25
In expert centers, NPPV applied as first-line interventionin ARDS avoided intubation in 54% of treated patients
SAPS II >34 & the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure
In expert centers, NPPV applied as first-line interventionin ARDS avoided intubation in 54% of treated patients
SAPS II >34 & the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure
PaO2/FIO2 >175
The data support NIV as the preferred initial ventilatory modality for these patients, to avoid intubation and itsassociated risks (reduced infectious complications)
JAMA. 2000;283:235-241
JAMA. 2000;283:235-241
JAMA. 2000;283:235-241
JAMA. 2005;293:589-595
Oxygen at an FiO2 of Oxygen at an FiO2 of 0.5 plus a CPAP of 0.5 plus a CPAP of 7.5 cmH7.5 cmH22OO
Elective abdominal surgery & GA extubated & underwent 1-hour screening test(PaO2/FiO2 300)
6 hours with oxygen 6 hours with oxygen through a Venturi through a Venturi mask at an FiOmask at an FiO22 of of 0.50.5
JAMA. 2005;293:589-595
Patients who received oxygen plus CPAP had a lower intubation rate (1% vs 10%; P=.005; relative risk [RR], 0.099; 95% CI, 0.01-0.76)
JAMA. 2005;293:589-595
CPAP may decrease the incidence of endotrachealintubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery
CPAP
Crit Care Med 2007 352402; :2407–
A, multiple RCTs & meta-analyses B, more than one RCT, case control series, or cohort studies C, case series or conflicting data
Crit Care Med 2007 352402; :2407–
When in doubt, a brief,cautious trial of NIV
can be attempted,with plans to intubate if the
patient fails to improve sufficiently
When in doubt, a brief,cautious trial of NIV
can be attempted,with plans to intubate if the
patient fails to improve sufficiently
Selection of a properly fit & comfortable interface iscritical to NIV success
face mask group
nasal mask group
Leaks &Asynchrony
A process of balancing the ability to reduce work of breathing byproviding an adequate level of pressure support (usually 8–10 cm H2O) against the discomfort & greater air leaking imposed by higher pressures
Am J Respir Crit Care Med 2005; 172:1112–1118
Dyspnea score assessment
CPAP alone wasunable to reduce inspiratory effort
PEEP level of 10 cmH2O improved oxygenation
highest level of PSV :greatest improvementin dyspnea
both PSV settings reduced
neuromuscular drive, unloaded the inspiratory
muscles, & improveddyspnea
Crit Care Med 2007 352402; :2407–
Monitoring of
NIV for ARF
1.Consideration the etiology of the ARF & evidence for efficacy 2.Good candidates for NIV ? & no contraindications3.Consideration of predictors of success & failure 4.Selection of an Interface & ventilator settings5. Experience of caregivers
Keys to success
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