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Non-Invasive Ventilation. Dr Duncan Mitchell Ealing Hospital. What we are going to cover…. What is NIV? Ventilation Physiology & Terminology Types of NIV Indications for NIV Contra-indications Case examples. What is Non-Invasive Ventilation (NIV).

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non invasive ventilation

Non-Invasive Ventilation

Dr Duncan Mitchell

Ealing Hospital

what we are going to cover
What we are going to cover…
  • What is NIV?
  • Ventilation Physiology & Terminology
  • Types of NIV
  • Indications for NIV
  • Contra-indications
  • Case examples
what is non invasive ventilation niv
What is Non-Invasive Ventilation (NIV)

‘Delivery of ventilatory support without the need for an invasive artificial airway’

some physiology zzzzzzz
Some Physiology…….zzzzzzz!
  • Ventilation

- process by which O2 and CO2 are transported to and from the lungs

  • Venous blood

- lower pO2 higher pCO2 than inspired gas

- partial pressure gradient driving O2 in and CO2 out

slide5
Ventilation of lungs with inspired gases leads to mixing with alveolar gas
  • If no ventilation at all, no replenishment of O2 and no removal of CO2
  • Arterial pO2 falls and pCO2 rises towards that of venous
  • If ventilation greater than needed, alveolar gas closer to inspired gas
terminology
Terminology
  • Tidal Volume (VT) – amount of gas expired per breath (~ 500ml at rest)
  • Minute Volume – amount of expired gas per minute
  • Alveolar Ventilation – amount of gas reaching functional alveoli
  • Work of Breathing – usually ~5% of total body work – most used to overcome lung and chest wall stiffness during inspiration
slide7
PEEP
  • Pressure Support (cmH2O) – positive pressure applied to airway to support patients own breath
  • Opening Pressure – pressure required to open collapsed alveoli
types of niv
Types of NIV
  • Negative-Pressure Ventilation (Iron Lung)
  • Continuous Positive Airway Pressure (CPAP) (Not really NIV!)
  • Bi-level Positive Airway Pressure (BiPAP)
negative pressure ventilation
Negative-Pressure Ventilation
  • Late 1880s – iron lungs first used
  • Early 1900s – iron lungs used for polio epidemics
  • This continued throughout the 20th century until 1960s when invasive ventilation became available
slide10
CPAP
  • Nasal or face mask
  • Continuous positive pressure applied to the airways
  • Usually well-tolerated
  • Similar to use of PEEP
  • Reduces work of breathing
  • Improve ventilation to collapsed areas of lung
bipap
BiPAP
  • Bi-Level pressure support
  • Inspiratory Positive Airway Pressure (IPAP) & Expiratory PAP (EPAP)
  • IPAP is the pressure support machine gives to help patients own inspiration
  • Helps to reduce WOB and increase alveolar ventilation
  • EPAP is essentially PEEP and help to prevent alveolar collapse
indications for cpap
Indications for CPAP
  • Cardiogenic Pulmonary Oedema
  • Obstructive Sleep Apnoea
  • Chest Wall Trauma if hypoxic on adequate analgesia
  • Pneumonia
indications for bipap
Indications for BiPAP
  • Exacerbation of COPD with Respiratory acidosis
  • Type II respiratory failure with chest wall deformity or neuromuscular disease
  • Failure of CPAP
  • Pneumonia with respiratory acidosis
  • Therapeutic trial with a view to intubation if it fails
  • Others (ARDS, post-op respiratory failure, to buy time prior to intubation)
patient selection
Patient Selection
  • Sick but not moribund
  • Able to protect airway
  • Conscious and co-operative
  • Haemodynamically stable
  • No excessive secretions
  • Few co-morbidities
  • Improvement on ABG with NIV
patient rejection
Patient Rejection
  • Respiratory arrest
  • Haemodynamically unstable
  • Uncooperative
  • Unable to protect airway (swallowing and cough impaired or vomiting)
  • Facial, oesophageal, or gastric surgery
  • Craniofacial trauma or burns
  • Airway obstruction
  • Undrained Pneumothorax
case 1
Case 1
  • 76yr old female
  • Lifelong smoker
  • 1/52 productive cough
  • BP140/90 P120 RR40 SaO2 89% on 10L

pH 7.3

pCO2 8.2

pO2 6.9

HCO3 20

BE – 4.2

case 2
Case 2
  • 83yr old man
  • Known IHD, previous MI
  • Wife says he has “not been well”
  • BP170/95 P120 RR38 SaO2 87% on 15L

pH 7.28

pCO2 5.2

pO2 7.1

HCO3 21

BE -3.2

case 3
Case 3
  • 49yr old man
  • 2/52 Hx of feeling unwell with D&V
  • Not eating or drinking
  • Not passing urine
  • BP89/50 P130 RR40 SaO2 96% on NRBM

pH 6.98

pCO2 2.9

pO2 14.2

HCO3 13.9

BE -21.4

case 3 contd
Case 3 Contd….
  • Urea 32
  • Creat 444
  • K 6.2
  • Hb 9.2
  • WCC 24
  • PLT 47
  • PT 20
  • APTT 100
case 4
Case 4
  • 50yr old man
  • On the ward
  • Nurses report that he snores a lot
  • Wife tells you he has seen a specialist and has a machine at home that makes a lot of noise
  • What is it ???!!!
summary
Summary
  • What NIV is and the different types
  • Basic respiratory physiology
  • Indications for NIV
  • When not to use it
  • Thought about some cases