Noninvasive Oxygenation and Ventilation - PowerPoint PPT Presentation

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Noninvasive Oxygenation and Ventilation
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Noninvasive Oxygenation and Ventilation

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  1. Noninvasive Oxygenation and Ventilation

  2. Goals of noninvasive measures • Either short term or long term support of pulmonary function • Short Term • Hospital NC • BiPAP for acute respiratory distress • Long Term • Home O2 for chronic COPDers • CPAP for Obesity Hypoventilation Syndrome or OSA

  3. What goal for oxygen? • COPDers • Between 88 and 95% • PaO2 >= 60 • Non-COPDers • >= 92% • PaO2 > 60

  4. O2 Saturation vs. PaO2 • 40-50-60 to 70-80-90 rule

  5. Types of NIV • Nasal Cannula • Venti-Mask • Non-rebreathers • BiLevel • CPAP

  6. Non-Invasive Oxygenation: Achieved FiO2

  7. Venti-Mask colors

  8. Non-Rebreather versus Partial Non-rebreather

  9. Non-Invasive Ventilation • BiLevel • CPAP (not discussed)

  10. Advantages to Noninvasive Ventilation • No internal traumatic complications • Decreased infections • Less interference with communication and swallowing • Less need for sedation

  11. Indications • Well established • COPD exacerbation • Weaning in COPD patients • Acute cardiogenic pulmonary edema • Immunocompromised patients • DNI patients • Weaker indications • Asthma exacerbations • Cystic fibrosis • Hypoxemic respiratory failure • Extubation failure

  12. NIV and COPD • RCTs have shown • 20-50% reduced intubation rate • Improved RR, dyspnea and gas exchange • Decreased length of stay • Lowered mortality • Intubated COPD patients who have failed T “piece” trials • Should be able to breath without assistance for 5 minutes • Can tolerate levels of pressure generated by NIV • Should not be “difficult” intubations

  13. NIV and Asthma • Physiological Rationale • Decrease work of breathing • Improve exchange • Limited evidence • No consistent recommendations for trial of NIV in patients failing standard therapy

  14. Acute Cardiogenic Pulmonary Edema • Physiology • Recruits “flooded” alveoli • Reduces preload and afterload • RCTs have shown that BiPAP/CPAP can • Improve dyspnea and oxygenation • Lowers intubation rate • Reduced intubation • Reduced LOS • Reduced mortality

  15. Immunocompromised Patients • Mechanical ventilation in these patients have a high risk of • Nosocomial infection (VAP) and septicemia • Fatal airway hemorrhage caused by thrombocytopenia and platelet dysfunction • NIV begun in these patients before respiratory failure becomes severe may halve mortality • Greatest benefit with early initiation and single-organ failure

  16. Post-op Patients • CPAP reduces intubation in patients after abdominal surgery (reduces atelectasis) • NIV improves outcomes in hypoxemic respiratory failure after lung resection

  17. Predictors of NIV success in acute respiratory distress • Cooperative patient • Intact neurological function • Good synchrony with ventilator • APACHE score <29 • pH > 7.25 • Intact dentition • Air leaking well-controlled • Able to control secretions

  18. Selection guidelines for use of NIV in acute respiratory distress • Appropriate diagnosis with potential reversibility over hours to days • Ascertain need for ventilatory assistance • Moderate to severe respiratory distress • Tachypnea (>24/min for COPD, >30/min for hypoxemia • Accessory muscle use or abdominal paradox • Blood gas abnormality • pH < 7.35, PaCO2 > 45 or PaO2/FiO2 < 200

  19. Contraindications for NIV • Respiratory arrest/Cardiac arrest • Medically unstable (hemodynamically unstable, arrythmias, cardiogenic shock/MI, GIB, ABG pH < 7.1) • Unable to protect airway (bulbar dysfunction, AMS) • Excessive secretions • Uncooperative or agitated • Unable to fit mask (facial trauma/surgery) • Recent upper airway or GI surgery

  20. BiLevel – What is it? • IPAP (Inspiratory Positive Airway Pressure) • Excess pressure to move air into lungs • EPAP(Expiratory Positive Airway Pressure) • Increased minimum lung pressure maintained to increase alveolar recruitment • PS (Pressure Support) • PS = IPAP - EPAP

  21. BiLevel – Setting? • IPAP • Usually 8-12 cm H2O • EPAP • Usually 4-5 cm H2O

  22. BiLevel - Recheck • A baseline ABG should be done during initial episode of respiratory distress • Patient should be followed-up in 1-2 hours depending on condition after BiLevel NIV is placed

  23. BiLevel – Recheck Criteria • Objective • Compare repeat ABG to baseline • PaO2/FiO2 should be > 150 after 1st hour • Gas Exchange: Oximetry, PaCO2, pH • RR, HR, BP, cough strength and ability to raise secretions should be improved • Subjective • Comfort/Discomfort • Feeling of dyspnea • Ventilatory Function • Synchrony • Tidal Volume • Airleaks • Wave form

  24. BiLevel - Complications