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NON-INVASIVE MV

NON-INVASIVE MV. Good news It works !!!!!!!. Warnings Not always Not for all Know the technique Be skilled. i-PSV and n-PSV delivered before and after extubation in patients not weaned. Arterial Blood Gases. pH PaCO 2 PaO 2 /FIO 2. i-PSV 7.38 59.1 206. n-PSV 7.38 61 210.

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NON-INVASIVE MV

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  1. NON-INVASIVE MV • Good news • It works !!!!!!! • Warnings • Not always • Not for all • Know the technique • Be skilled

  2. i-PSV and n-PSV delivered before and after extubation in patients not weaned Arterial Blood Gases pH PaCO2 PaO2/FIO2 i-PSV 7.38 59.1 206 n-PSV 7.38 61 210 T-tube 7.33 69 183 (from Vitacca M. et al. AJRCCM 2001; 164: 638-641)

  3. INTERFACES TUBING PATIENTS NURSES MT LOCATION MONITORING NIV

  4. NON-INVASIVE MV • NIV in the “real-world” • Setting the ventilator • Choice of interfaces • Humidification and drug delivery

  5. Assessment of Physiologic Variables and Subjective Comfort Under Different Levels of Pressure Support Ventilation* Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD; Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; and Enrico Clini, MD, FCCP† Chest 2004; 126: 851-59

  6. Appropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) Change (% of SB) (from Vitacca M. et al. Chest 2000)

  7. Leaks Tolerance Pressurisation rate during NIV in COPD “… different pressurisation rates resulted in different reductions in the pressure time product of the diaphragm; this reduction was greater with the fastest rate, but was accompanied by significant air leaks and poor tolerance” (from Prinianakis G. et al. ERJ 2004; 23: 314-320)

  8. V’E, PTP Study protocol SB (baseline) V’E, PTP Pao, IE RANDOM of ventilators comfort 0 setting 10 Time (min)

  9. NON-INVASIVE MV • NIV in the “real-world” • Setting the ventilator • Choice of interfaces • Humidification and drug delivery

  10. (from BTS Guideline Thorax 2002;57:192-211)

  11. maschera facciale 1 Punti critici • 1- ponte nasale • 2- lati della bocca • 3- base inferiore del labbro 2 2 • VANTAGGI: • miglior controllo delle perdite • pressioni più elevate • SVANTAGGI: • non permette l’espettorazione, né l’alimentazione • aumenta il rischio di aspirazione • è altamente traumatica 3 N.B. La protesi dentaria va rimossa

  12. 1 2 2 3 maschera nasale Punti critici • 1- ponte nasale • 2- narici • 3- base del naso • verificare • 4- pervietà delle cavità nasali • VANTAGGI: • stabile, comfort maggiore • bocca libera • spazio morto ridotto • svariati modelli • SVANTAGGI: • perdite d’aria dalla bocca • maggior resistenza N.B. La protesi dentaria va conservata

  13. Major problems with mask during NIV support Air leaks Side-effects Size

  14. Side effects due to NPPVN=26 (compliant patients) % Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 (from Criner GJ. et al. Chest 1999;116:667-675)

  15. MOUTH LEAKS IN NASAL NPPV(n=9, hypercapnic=7, COPD=6, age 64 years) PtcCO2 (mmHg) Arousal Index (events h-1) p<0.001 p<0.0002 (from Teschler H. et al. ERJ 1999; 14: 1251-1257)

  16. Side effects due to NPPVN=26 (compliant patients) % Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 (from Criner GJ. et al. Chest 1999;116:667-675)

  17. Tissue Necrosis Caused by an Improperly Fitting Mask

  18. (CCM 2002; 30: 602-608)

  19. (Crit Care Med 2002; 30: 602-608)

  20. Esperienza dell’équipe Considerazioni anatomiche CRITERI PER LA SCELTA DELLA MASCHERA Compliance e sensorio del paziente Modalità di ventilazione

  21. (from BTS Guideline Thorax 2002;57:192-211)

  22. NON-INVASIVE MV • NIV in the “real-world” • Setting the ventilator • Choice of interfaces • Humidification and drug delivery

  23. In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification.

  24. Crit Care Med 2002; 30:2515–2519

  25. To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L*min-1

  26. Respir Care 2004;49(3):270–275. CONCLUSIONS Delivered oxygen concentration during BiPAP is a complex interaction between the leak port type, the site of oxygen injection, the ventilator settings, and the oxygen flow. Because of this, it is important to continuously measure arterial oxygen saturation via pulse oximetry with patients in acute respiratory failure who are receiving noninvasive ventilation from a bi-level ventilator.

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