Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting By:...
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Transcript of Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting By:...
Part II: Introduction to Part II: Introduction to Noninvasive Positive Pressure Noninvasive Positive Pressure Ventilation in the Acute Care Ventilation in the Acute Care SettingSetting
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
Benefits of Using NPPVBenefits of Using NPPV
NPPV provides greater flexibility in initiating and removing mechanical ventilation
Permits normal eating, drinking and communication with your patient
Preserves airway defense, speech, and swallowing mechanisms
Benefits of Using NPPV Benefits of Using NPPV Compared to Invasive Compared to Invasive VentilationVentilation
Avoids the trauma associated with intubation and the complications associated with artificial airways
Reduces the risk of ventilator associated pneumonia (VAP)
Reduces the risk of ventilator induced lung injury associated with high ventilating pressures
Other Benefits of Using Other Benefits of Using NPPVNPPV Reduces inspiratory muscle work and
helps to avoid respiratory muscle fatigue that may lead to acute respiratory failure
Provides ventilatory assistance with greater comfort, convenience and less cost than invasive ventilation
Reduces requirements for heavy sedation
Reduces need for invasive monitoring
Additional Benefits of NPPV Additional Benefits of NPPV in the Acute Care Settingin the Acute Care Setting
Preserves the ability to communicate
Enhances patient comfort
Examples of Patient Problems Examples of Patient Problems that may Benefit from NPPV in that may Benefit from NPPV in the Acute Care Setting the Acute Care Setting Acute Exacerbation of COPD
Hypoxemic Respiratory Failure/ARDS
Community Acquired Pneumonia (CAP)
Asthma
Immunocompromised States
Acute Cardiogenic Pulmonary Edema (CPE) - when hypercapnia is present.
Additional Examples of Disorders Additional Examples of Disorders in which NIPPV by Nasal or Face in which NIPPV by Nasal or Face Mask has been UsedMask has been Used Neuromuscular disorders
Central alveolar hypoventilation
Cystic fibrosis
Bronchiectasis
Postoperative complications
Postextubation failure in difficult-to-wean patients
Do-not-intubate patients
First Step: Selection Criteria First Step: Selection Criteria for Patients in the Acute Care for Patients in the Acute Care Setting Setting Consider the patient's diagnosis, clinical
characteristics and the risk of failure of the procedure
Applying NPPV too early may be unnecessary for patients with mild respiratory distress
On the other hand, applying NPPV when a patient has already deteriorated to severe respiratory failure may potentially delay life-saving intubation and ventilation
Establishing the Need for Establishing the Need for VentilationVentilation
Signs and Symptoms of Distress in the Adult – Tachypnea (respiratory rate >24
breaths/min)– Accessory muscle use, and
paradoxical breathing – ABG results:
• pH < 7.35 and PaCO2 > 45 mm Hg, or
• PaO2/FiO2 < 200
Patient Medical HistoryPatient Medical History
The underlying patient disorder must be taken into account
For example, does the patient have acute respiratory failure with a history of COPD. Or, does the patient have acute congestive heart failure with an elevated CO2?
Next exclusionary criteria must be evaluated
Second Step: Second Step: Exclusionary CriteriaExclusionary Criteria Respiratory arrest (apnea) or the need for
immediate intubation
Unable to protect the airway (impaired cough or swallowing)
Excessive secretions
Hemodynamic instability
Agitated and confused patients
Paradoxical breathing
Upper airway obstruction
Additional Exclusionary Additional Exclusionary CriteriaCriteria
Facial deformities or conditions that prevent mask fit, e.g. facial burns, severe facial trauma, craniofacial surgery, fixed anatomic abnormalities of the nasopharynx
J Crit Care 2004 Vol. 19:82-91
Additional Exclusionary Additional Exclusionary CriteriaCriteria
Untreated pneumothorax
Uncooperative or unmotivated patients
Brain injury with unstable respiratory drive
Other major organ involvement – for example, severe hemorrhaging
Recent esophageal or gastric surgery (relative contraindication)
Finally, irreversibility of disorder
NPPV InitiatedNPPV Initiated
Once the patients signs and symptoms are evaluated,
And the underlying disorder is considered,
And finally exclusionary criteria are eliminated,
Then NPPV may be justified IFIF the acute respiratory failure is likely to resolve in a few days.
InterfacesInterfaces
A variety of interfaces can be used to provide NPPV
This section will focus on those devices used in the acute care setting
Nasal MasksNasal Masks
Thin flexible &
bridge material
Dual density
foam bridge forehead
support
Dual flap cushion
360 swivel
standard elbow
Respironics Contour Deluxe™ Mask
Fitting Nasal MasksFitting Nasal Masks
Nasal fitting template
Choose the smallest mask without obstructing the nostrils
Courtesy of Respironics
Anatomic Landmarks for Anatomic Landmarks for Nasal Mask FitNasal Mask Fit
Anatomic Anatomic LandmarksLandmarks
a)a)Sides of noseSides of nose
b)b)Bridge of nose Bridge of nose (caution)(caution)
c)c) Above the lipAbove the lip
Courtesy of Respironics
Nasal Mask FitNasal Mask Fit
Top of the mask: placed just above the junction of the nasal bone and the cartilage (dorsum of the nasal bridge)
The fit should be not pinch the nose at the side
The lower part of the mask fits just above the upper lip
A common error is to pick a mask that is too large
Nasal Mask Fit (continued)Nasal Mask Fit (continued)
Foam “bridges” that attach to the end of the mask and rest on the forehead help reduce pressure on the bridge of the nose
Advantages of Nasal MasksAdvantages of Nasal Masks
Less risk of aspiration
Enhanced secretion clearance
Less claustrophobia
Easier speech
Less dead space
Disadvantages of Nasal Disadvantages of Nasal MasksMasks
Mouth leak
Less effectiveness with nasal obstruction
Nasal irritation and rhinorrhea
Mouth dryness
Full Face MasksFull Face Masks
Most often successful in the critically ill patient
Respironics PerformaTrak® Full Face Mask
Entrainment valve
AdjustableForehead Support
Ball and Socket Clip
Double-foam cushion
Pressure pick-off port
Mask Fitting is EssentialMask Fitting is Essential
A full face mask surrounds the nose and mouth and rests below the lower lip
Using a template can give an estimate of the appropriate mask size
Courtesy of Respironics, Inc.
Fitting Full Face MaskFitting Full Face Mask
Landmarks
a) Below the lower lip with mouth open
b) Corners of the mouth
c) Just below the junction of nasal bone and cartilage
1
Courtesy of Respironics, Inc
a
b
c
b
Full Face MasksFull Face Masks
It should fit even if the patient’s mouth is slightly open
Be sure the mask fits well and does not leak excessively, particularly not into the eyes
Minimizing LeaksMinimizing Leaks
Sometimes leaks are caused by the mask not being correctly seated on the face
Some leaks can even be caused by excessive tension of the head straps. Minimize headgear tension (1-2 fingers should fit between head straps and face)
In patients without a full set of teeth, using a full face or total face mask can help minimize leaks
Advantages and Advantages and Disadvantages of Oronasal Disadvantages of Oronasal or Full Face Masks or Full Face Masks More effective for dyspneic patients
Disadvantages:
– Increased dead space
– Difficulty in maintenance of adequate seal
– Increased risk of facial pressure sores
– Claustrophobia
More Disadvantages More Disadvantages of Full Face Masksof Full Face Masks
Increased risk of aspiration
More difficulty with speech
Inability to eat with mask in place
More difficulty with secretion clearance
Possible asphyxiation with ventilator malfunction
Nasal Pillows or Nasal Nasal Pillows or Nasal CushionsCushions
Pillow Cushion
Nasal Cushion
Nasal Pillows to seal nares
Respironics Comfort Lite Nasal Mask
Nasal Pillows or Nasal Nasal Pillows or Nasal Cushions (continued)Cushions (continued) Suitable for
patients with
– Claustrophobia
– Skin sensitivities
– Need for visibility
Respironics Comfort Lite Nasal Mask
Fitting Nasal Pillows or Fitting Nasal Pillows or Nasal CushionsNasal Cushions
Using the plastic sizing gauge, insert each size into the nostril
Choose the size that best seals the nostril
Courtesy of Respironics, Inc.
Total Face MaskTotal Face Mask
Interface selection– Total face
mask– Mouthpiece
Respironics Total Face Mask
Mouthpiece/Lip Seal Mouthpiece/Lip Seal
Mouth pieces with or without lip seals can also be used for an interface
Their use is generally restricted to patients who are ventilator-dependent (chronic conditions)
Some mouthpieces are used with nose clips
Some patients use custom-made oral appliances for ventilation
Mask Selection GuideMask Selection Guide
NPPV- Masks With LeaksNPPV- Masks With Leaks
Vented masks require a vent for exhalation and use only one corrugated tube to connect to the ventilator
Respironics BiPAP Vision ® Noninvasive Ventilator with a Nasal Mask
NPPV – Masks Without LeaksNPPV – Masks Without Leaks
Non-vented masks have both inspiratory and expiratory lines
Exhaled volumes, flows and pressures can be monitored Respironics Esprit Critical Care
Ventilator with PerformaTrak SE Full Face Mask
Tips on Initiating NPPV Tips on Initiating NPPV VentilationVentilation
Essential elements are staff competence and patient compliance
Have a variety of masks available to ensure a proper fit.
Change mask if the patient’s facial contours change, for example if facial edema develops
Tips on Initiating NPPV Tips on Initiating NPPV Ventilation, (continued)Ventilation, (continued)
Let the patient breath through the mask before connecting the system in order to reduce anxiety (Perhaps allow the patient to hold the mask.)
If the patient is claustrophobic, try a nasal mask (Make sure patient has their mouth closed or a chin strap may be needed) Courtesy of Respironics, Inc.
Tips on Initiating NPPV Tips on Initiating NPPV Ventilation, (continued)Ventilation, (continued)
Place patient in an upright or sitting position
Carefully explain the NPPV procedure to the patient including goals and potential complications
Example NPPV SettingsExample NPPV Settings
Common IPAP orders – 8 to 12 cm H2O– Adjust to change tidal volume
Typical EPAP setting– 4 cm H2O – Increase to improve oxygenation
Respir Care 2004;49(1):72-87
20
10
0
IPAP = 12
EPAP = 4
PS = 8
Initial Ventilator SettingsInitial Ventilator Settings
Progressively increase the pressure until the ordered pressures are achieved
Then assess patient– Patient’s adaptability and comfort– Acceptable tidal volumes
– SpO2 and vital signs
Completing NPPV SetupCompleting NPPV Setup
Determine desired FIO2
Set back-up rate
Begin ventilation, coaching the patient until the patient becomes comfortable
Monitor SpO2 and adjust FIO2 to maintain O2 saturation > 90%
Monitor HR and respiratory rate
Steps For Initiating NPPVSteps For Initiating NPPV
Secure the mask to the patient – Avoid excessive tightening of the
straps. Attach the interface to the ventilator (1-2 fingers space)
Titrate IPAP, EPAP, inspiratory rise time, sensitivity (patient trigger), flow cycle, exhaled tidal volume, and synchrony with the ventilator
Steps For Initiating NPPVSteps For Initiating NPPV
Avoid peak pressures > 20 to 25 cm H20
Check for leaks and readjust the mask and head straps if necessary (It is essential to minimize leaks)
Small leaks are compensated by most ventilators
Allowing a small leak may avoid an excessively tight fit and possibly reduce the risk of skin breakdown
Monitoring the Leak SizeMonitoring the Leak Size
0-6 L/min = Mask may be too tight
7-25 L/min = Just right
26-60 L/min
= Adjust mask and monitor
> 60 L/min = Caution
Air Leak Guidelines for Vision BiPAP Noninvasive Ventilator
Note: Leak compensation for noninvasive ventilation in critical care ventilators varies and could be as low as 20 L/min. Therefore, management of smaller leaks is required.
Predictors of Success with Predictors of Success with NPPVNPPV
Positive initial response to NPPV within 1-2 hours– Correction of pH– Decreased respiratory rate
– Reduced PaCO2
Synchronous breathing efforts with ventilator
Lower quantity of secretions
Absence of pneumonia
Complications or Problems Complications or Problems Associated with NPPV Associated with NPPV
Failure to Ventilate – Failure to Ventilate – Inadequate VolumeInadequate Volume
Tidal volume is inadequate for patient
Check ventilating pressures to be sure the Delta P is sufficient for the patient [DP = IPAP – EPAP or PS – PEEP]
Be sure the rise time to pressure is sufficient
Be sure the flow-cycle criteria is not too “short”, thus compromising volume delivery
Failure to Ventilate –Failure to Ventilate –Lack of SynchronyLack of Synchrony
Patient and ventilator are not synchronous.
Check the sensitivity. Is it easy for the patient to trigger a breath?
Check the rise time to full pressure. Does it meet the patient’s flow demand?
Check the flow-cycle criteria during PSV. Make sure it is set appropriate for the patient. (see section III of this teaching module)
HypotensionHypotension
If hypotension was present prior to therapy, treat the cause
If hypotension resulted after initiating NPPV, be sure ventilating pressures are not excessively high (peak pressures < 20 cm H20)
Risk of AspirationRisk of Aspiration
The risk of aspiration exists in some patients
Maintain a policy of selecting patients appropriately for NPPV patients who can protect their own airway
Examples of patients who may not be able to protect their airways: – Stroke victims, and individuals with a drug
overdose. In these examples, an endotracheal tube should be inserted to protect the airway
ClaustrophobiaClaustrophobia
Try using a nasal interface or,
Try using a total face mask, or
Try mild sedation (use caution).
Gastric Insufflation Gastric Insufflation (Aerophagia) and Gastric (Aerophagia) and Gastric DistentionDistention
Excessive pressure or air swallowing can cause air gastric inflation (insufflation) and gastric distention
Use pressures less than 20 to 25 cm H2O
Use simethicone (anti-flatulent) agent
Use of Nasogastric TubesUse of Nasogastric Tubes
Use of nasogastric tubes to take air from the stomach is controversial
The tube increases leaking around the mask
The tube itself blocks a nasal passage
Compression of tube against the skin by the mask may increase risk of skin breakdown
Possible Solution with Possible Solution with Nasogastric TubesNasogastric Tubes
If an NG tube must be used, one possible solution is to use an interface between the tube and the skin and mask
Respironics NG Sealing Pad ImageRespironics NG Sealing Pad Image
NG tube applied to groove
Flat surface applied on patient’s face
Mask interface across beveled side
Eye IrritationEye Irritation
Eye irritation may result from air blowing in the eye
Be sure mask fit is appropriate
Spacers used on the forehead or the bridge of the nose, depending on the type of mask, may need to be adjusted
Readjust headgear straps
Skin Problems Due to Skin Problems Due to Interface Devices Interface Devices
Skin irritation or rashes may occur due to pressure from a mask, frictional irritation between the skin and mask or due to allergies to the mask material
Facial discomfort or pain can also occur
Possible Solutions to Possible Solutions to Skin IrritationSkin Irritation
Use the least amount of pressure to fit the mask that still prevents excessive leaks
Use spacers
Alternate devices to reduce skin breakdown
Use a skin barrier lotion and/or topical corticosteroids
Skin Problems Due to Skin Problems Due to Interface DevicesInterface Devices
Pressure lesions (skin breakdown, necrosis) if mask is to tight or left on for extended periods of time
Use of Duodenum or Restore (skin dressings)
Poor Sleep QualityPoor Sleep Quality
Inability to sleep well can be due to many causes such as anxiety, frequent disruptions of the patient at night during normal sleeping hours, discomfort caused by the mask or ventilating pressures
Using an appropriate medication to reduce anxiety, and promote sleep may be appropriate
Be sure the patient is able to protect their airway and is not likely to aspirate
Nasal or Oral Dryness, Nasal Nasal or Oral Dryness, Nasal Congestion, Mucus PluggingCongestion, Mucus Plugging
When these problems occur, possible solutions include the following:– Add or increase humidification– Reduce leaks– Irrigate nasal passages with a saline
spray
Nasal or Oral Dryness, Nasal Nasal or Oral Dryness, Nasal Congestion, Mucus PluggingCongestion, Mucus Plugging
Use topical decongestants or steroids
Perform oral and/or nasal hygiene
If nasal mask is in use, use a chin strap to keep mouth closed or change to full face mask
Sinus or Ear PainSinus or Ear Pain
High inspiratory pressures may affect the ear and sinuses
Use lower inspiratory pressure to help reduce ear and sinus pain
Tight fitting masks may also put pressure on the nose and upper face and may affect sinus pressure and sinus drainage
Criteria for Termination of Criteria for Termination of NPPV for Invasive Ventilation NPPV for Invasive Ventilation
Worsening pH and PaCO2
Tachynpnea (> 30 breaths/min)
Hemodynamic instability
SpO2 < 90%
Decreased level of consciousness
Inability to clear secretions
And inability to tolerate interfaces
Predictors of Success with Predictors of Success with NPPV NPPV
Higher level of consciousness
Younger age
Lower severity of illness; no co-morbidities
Less severe gas exchange (pH < 7.35, > 7.10; PaCO2 < 92 mm Hg)
Minimal air leakage around the interface
Dentition intact
WeaningWeaning
If NPPV is successful, the patient may only require support for 2 to 3 days or less
Currently there is no specific procedure for weaning from mechanical ventilation
Trials of NPPV as tolerated
Weaning AlgorithmWeaning Algorithm
Respir Care 2004. Vol. 49 (1):72-89
NOContinue with NPPV therapyContinue with NPPV therapy
Does patient meet
weaning guidelines? Clinically stable
RR < 24 HR < 110 pH > 7.35 SpO2 >90% on< 50% If patient status does
not improved consider intubation
NO
YES
Restart NPPV at previous settings
Restart NPPV at previous settings
YES
Trial off NPPV with supplemental oxygen
Trial off NPPV with supplemental oxygen
Slowly titrate IPAP downward in decrements of 2-3 cm H2O
Slowly titrate IPAP downward in decrements of 2-3 cm H2O
Does patient demonstrate
clinical evidence of respiratory
distress?
Discontinue NPPV and place on supplemental oxygen
Section SummarySection Summary
This section has reviewed initiating NPPV, the interfaces used in NPPV, complications and problems along with possible solutions, and weaning from NPPV