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Non Invasive Ventilation in copd Sarah Davey Specialist Registrar Emergency Medicine. Pinderfields General Hospital. Introduction NIV is the provision of ventilatory support through the patient’s upper airway using a mask or similar device.

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non invasive ventilation in copd

Non Invasive Ventilation in copd

Sarah Davey

Specialist Registrar Emergency Medicine.

Pinderfields General Hospital.

introduction
Introduction
  • NIV is the provision of ventilatory support through the patient’s upper airway using a mask or similar device.
  • NIV is patient triggered and air/oxygen is delivered under preset pressure.
  • NIV used in treatment for hypercapnic respiratory failure, particularly in those patients with COPD.
  • NIV may avoid intubation and avoid ICU/HDU admission.
terminology
Terminology
  • IPAP – Inspiratory Positive Airways Pressure.

- Pressure set during inspiration.

- Cm of H2O above atmospheric.

- Increases Tidal volume, reduces

work of breathing and increases

alveolar ventilation, reducing pCO2.

* usually set at 10-14 cmH2O and gradually increased as tolerated to a max. 20 cmH2O.

terminology cont
Terminology Cont.
  • EPAP – Expiratory Positive Airways Pressure.

- Pressure set during expiration.

- Recruits under ventilated lung.

- Offsets intrinsic PEEP, aids triggering.

- Reduces perceived effort.

- Serves to vent exhaled gas thru the exhaust

port and reduce rebreathing.

* Set at 4-5 cmH2O.

terminology cont5
Terminology Cont.
  • BPM – Breaths Per Minute.

- Back-up breath rate.

- Machine will automatically deliver

a breath to the patient if the resp.

rate falls below the set value.

- Usually set to 12-14 if available.

terminology cont6
Terminology Cont.
  • Rise Time.

- Controls the rate of pressure change

during transition from EPAP to IPAP

phase of ventilation.

- i.e. Time taken to reach IPAP pressure.

- Intended for patient comfort.

- If respiratory rate is high then a faster

rise time is required.

indications in copd
Indications In COPD.
  • Considered in all patients with acute exacerbation of COPD in whom a respiratory acidosis persist despite maximal medical treatment with controlled oxygen therapy.
  • Respiratory acidosis – pH 7.25-7.35.
  • Able to protect airway.
  • Conscious and cooperative.
  • Haemodynamically stable.
  • No excessive respiratory secretions
  • No contraindications.
contraindications
Contraindications.
  • Facial trauma/Burns.
  • Recent facial, upper airway or upper GI surgery *
  • Fixed obstruction of upper airway.
  • Inability to protect airway.*
  • Life threatening hypoxia.*
  • Haemodynamic instability.*
  • Severe co-morbidity.*
  • Impaired consciousness.*
  • Confusion/agitation.*
  • Vomiting.
  • Bowel Obstruction.*
  • Copious respiratory secretions.*
  • Focal consolidation on CXR.*
  • Undrained pneumothorax.
predictions of success
Predictions of Success.
  • pH 7.25-7.35.
  • Improvement of pH at 1hr.
  • Good level of consciousness.
  • Poor outcome associated with:

- Co-existing pneumonia.

- Copious resp. secretions.

- Edentulous.

- Poor nutritional state.

- Confusion.

how to perform
How To Perform.
  • Practical Time!
equipment needed
Equipment Needed.
  • BiPAP machine.
  • Disposable circuit (tubing, filter & expiration port).
  • Appropriate mask.
  • Green Oxygen tubing.
  • SaO2 Monitor.
how to set up niv
How To Set Up NIV.
  • Obtain baseline obs.
  • Check for contraindications.
  • Explain procedure to patient and the reasons for use.
  • Select mask of appropriate size to fit patient.
  • Set up circuit.
  • Set ventilator settings.
  • Commence NIV and apply mask.
  • Reassess after a few mins.
  • Add oxygen if sats <85%. (aim sats 90%).
  • Adjust settings as required.
  • Request repeat ABG at 1hr adjusting BiPAP accordingly.
typical initial settings
Typical Initial Settings.
  • IPAP – 10-14 cmH2O.
  • EPAP – 4-5 cmH2O.
  • Oxygen – 2-4 l/min.
  • BPM - 12-14/min.
  • I:E – 1:3
treatment failure
Treatment Failure.
  • Is Medical management optimal?
  • Developed complications?
  • PaCO2 remains high?
  • PaO2 remains low with PaCO2 improving?
paco 2 remains high
PaCO2 Remains High.
  • Too much oxygen?

- adjust O2 to maintain sats of 85-90%.

  • Excessive Leak?

- check mask fit.

  • Re-breathing occurring?

- check exhaust valve.

- consider increasing EPAP.

  • Poor synchronising with ventilator?

- observe patient.

- consider inc. EPAP or adjust rate.

  • Inadequate ventilation?

- increase IPAP.

- Consider increasing inspiratory time.

paco 2 improves but pao 2 remains low
PaCO2 improves but PaO2 remains low.
  • Increased inspired O2.
  • Consider increasing EPAP.
slide17

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Questions?

summary
Summary
  • NIV effect therapy when used in appropriate patients.
  • Use local protocols.
  • Know your own equipment.
  • Seek senior help early.