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Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU

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Shahnaali

Non-invasive ventilation (NIV) delivers mechanical ventilation without an endotracheal tube. It is used for acute or chronic respiratory failure. NIV uses interfaces like masks to deliver bilevel positive airway pressure (BiPAP). It has advantages over invasive ventilation like avoiding complications of intubation and allowing oral communication. Selection criteria, monitoring, interfaces, modes and settings are described. NIV is assessed for improvement in blood gases and symptoms. Weaning involves gradually decreasing pressure support. NIV may need to be changed to invasive ventilation if a patient deteriorates on NIV.

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NON-INVASIVE VENTILATION DR SHAHNA ALI DEPARTMENT OF ANAESTHESIOLOGY& CRITICAL CARE
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
WHAT IS NON INVASIVE VENTILATIONWHAT IS NON INVASIVE VENTILATION???? “NIV is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway.”
WHERE TO USE NIV?? A) Acute respiratory failure 1. Hypercapnic acute respiratory failure • Acute exacerbation of COPD • Post extubation • Weaning difficulties • Chest wall deformities/ neuromuscular disease • Cystic fibrosis • Status asthmaticus • Acute respiratory failure in obesity hypoventilation INDICATIONS
2)Hypoxemic acute respiratory failure • Cardiogenic pulmonary edema • Community acquired pnemonia • ARDS • Weaning difficulties
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
B)Chronic respiratory failure C)Immuno-compromised patients D)Do not intubate patients E) Post surgical respiratory support
WHY TO USE NIV ?? (Advantages)WHY TO USE NIV ?? (Advantages) 1) Noninvasiveness Avoids the complications of endotracheal intubation - Early (local trauma, aspiration) - Late (injury to the the hypopharynx, larynx, and trachea, nosocomial infections) 2 ) Ease of application - Easy to implement - Easy to remove
3) Allows intermittent application 4) Can be used in non ICU settings 5) Improves patient comfort 6) Reduces the need for sedation 7) Oral patency (preserves speech, swallowing, and cough)
Disadvantages of NIVDisadvantages of NIV 1.System – Increased initial time commitment, – Gastric distension – manpower consuming 2.Mask - Air leakage - Eye irritation - Facial skin necrosis/ulcers 3.Lack of airway access and protection - Suctioning of secretions
WHAT IS THE SELECTION CRITERIA ??WHAT IS THE SELECTION CRITERIA ?? A) ACUTE RESPIRATORY FAILURE Atleast 2 of the following criteria must be present 1. Respiratory distress with dyspnoea 2. Use of accessory muscles of respiration 3. Abdominal paradox 4. Respiratory rate > 24/min 5. ABG shows pH< 7.35 or PaCO2 >45 mmHg or PaO2/FiO2 <200
B) CHRONIC RESPIRATORY FAILURE( OBSTRUCTIVE LUNG DISEASE) 1. Fatigue, Hypersomnalence, dyspnea 2. ABG shows Ph<7.35. Paco2>55 mmHg 3. Oxygen saturation <88% for >10 min despite O2 supplementation
C) THORACIC RESTRICTIVE/CEREBRAL HYPOVENTILATION DISEASES 1. Fatigue, morning headache, hypersomnalence, nightmares, enuresis, dyspnea 2. ABG shows PaCo2 >45 mmHg 3. Nocturnal SaO2 <90% for more than 5 minutes sustained Eg: Muscular dystrophy Multiple sclerosis Amyotrophic lateral scloresis Kyphpscoliosis
WHAT TO SEE BEFORE STARTING NIV ??WHAT TO SEE BEFORE STARTING NIV ?? • Cardiac or respiratory arrest • Nonrespiratory organ failure Severe encephalopathy (eg, GCS <10) Severe upper gastrointestinal bleeding Hemodynamic instability or unstable cardiac arrhythmia • Facial or neurological surgery, trauma, or deformity • Upper airway obstruction • Inability to cooperate/protect airway • Inability to clear secretions • High risk for aspiration
WHAT EQUIPMENTS ARE REQUIRED FOR NIV???WHAT EQUIPMENTS ARE REQUIRED FOR NIV???
• PORTABLE NIV MACHINES – Advantages • Portability • Ease of use – Disadvantages • Cannot develop pressures >30cm H2O • Lack of sophisticated alarm systems, battery backup • CRITICAL CARE VENTILATORS
PRESSURE MODES Better tolerated than volume‐cycled vents – Constant positive airway pressure(CPAP) – Bilevel or biphasic positive airway pressure (BiPAP) – Pressure support ventilation(PSV) VOLUME MODES Initial tidal volumes range from 10 to 15 mL/kg – Control – Assist control – Proportional assist control WHAT ARE THE MODES OF NIV ??WHAT ARE THE MODES OF NIV ??
© 2014 ResMed I MODES OF NIV 19 CPAP - Pure Obstructive Sleep Apnea, Cardiogenic Pulmonary Oedema S Mode – Best for spontaneously breathing patients (chronic RF), if breathing efforts are good – there is good synchrony with the ventilator – but be cautious of apneas ST Mode - Patients with central hypoventilation, significant central apneas, inappropriately low respiratory rate, and those who unreliably trigger (mode of choice in Acute RF) T Mode – Rarely Used. Can be tried in patients failing ST – on max pressures, or as a rescue mode if invasive vent not available PAC Mode – Mainly used in weaning off from invasive vent, or recovery from acute injury (similar to PACV mode in invasive vent) iVAPS - Best for chronic use with changing lung compliance over a longer period – excellent results in OHS, Restrictive Diseases, Chronic COPD. For acute scenario, clinical investigations underway – to be used with caution
© 2014 ResMed I COMMON SETTINGS IN NIV To be prescribed •Mode •EPAP •IPAP •Backup Rate / Target Patient Rate •Inspiratory time (minimum and maximum) •(Inspiratory) Trigger Sensitivity •Cycle (Expiratory Trigger) Sensitivity •Rise Time Important but often missed •Mask Type •Tube Type •AB Filter 20
CPAP • Continuous Positive Airways Pressure – Same pressure (5‐10 cmH2O) throughout respiratory cycle • Increases intra‐alveolar and intra‐bronchiolar pressure – Recruits alveoli – Dec Pulmonary oedema – Increase FRC – Dec WOB 5‐10cmH2O
BIPAP • Bi‐level Positive Airways Pressure – Lower positive pressure during expiration (EPAP) (equivalent to CPAP) – Higher positive airways pressure during inspiration (IPAP) 5‐10cmH2O12‐20cmH2O IPAPEPAP
BIPAP • EPAP (PEEP) – Recruits alveoli – Increases VQ matching – Improves oxygenation • IPAP – EPAP (pressure support) – Increases tidal volume – Reduces CO2 – Improves Ventilation and decrease work of breathing 5‐10cmH2O 12‐20cmH2O IPAP EPAP
© 2014 ResMed I BACKUP RATE / TARGET PATIENT RATE • Target Patient Rate is the rate where you want your patient to be ideally breathing • This is usually higher in case of patients with restrictive disorders • The backup rate should be set to 3-4 breaths less than the target patient rate – this prevents aschrony, while also ensuring adequate ventilation • The S Mode does not require a backup rate 24
WHAT IS INTERFACE?? “The device that makes physical contact between the patient and the ventilator is termed the Interface.” • Interfaces should be comfortable, offer a good seal, minimize leak, limit dead space
CHOOSING THE INTERFACECHOOSING THE INTERFACE
Nasal Masks 360° swivel standar d elbow
Anatomic Landmarks for Nasal Mask Fit • Anatomic LandmarksAnatomic Landmarks a)a) Sides of noseSides of nose b)b) Bridge of noseBridge of nose (caution)(caution) c)c) Above the lipAbove the lip Foam “bridges” that attach to the end of the mask and rest on the forehead help reduce pressure on the bridge of the nose. Nasal template to size.
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Full Face Masks • Most often successful in the critically ill patient Full Face Mask Entrainment valve Adjustable Forehead Support Ball and Socket Clip Double-foam cushion Pressure pick-off port
Fitting 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 a b c b
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Pillow Cushion Nasal Cushion Nasal Pillows to seal nares Nasal pillows/cushions
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
1. Appropriately monitored location, oximetry, respiratory impedance, vital signs as clinically indicated 2. Patient in bed at >30 angle 3. Select ventilator 4. Select interface, check fit 5. Connect interface to ventilator tubing and turn on ventilator, hold the mask initialy 6. Apply headgear; avoid excessive strap tension (one or two fingers under strap) 7. Start with low pressure in spontaneously triggered mode with backup rate; pressure limited: 8 to 10 cm H2O inspiratory pressure; 4 to 5 cm H2O expiratory pressure; PS 5-6 cm of H2O. CPAP is 5 cm of H2O 8. Gradually increase inspiratory pressure IPAP should be increased by 2–3 cm increments at a rate of approximately every 10 mins, with a usual IPAP target of 20 cm H2O (10 to 20 cm H2O) as tolerated to achieve alleviation of dyspnea, decreased respiratory rate, increased tidal volume (if being monitored), and good patient-ventilator synchrony 9. Provide O2 supplementation as need to keep O2 sat >90 percent 10. Check for air leaks, readjust straps as needed 11. Add humidifier as indicated 12. Monitor blood gases (1 Hour)
O2CO2
WHAT TO MONITOR??WHAT TO MONITOR??
HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??
HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ?? Goals
HOW TO WEAN FROM NIV??HOW TO WEAN FROM NIV?? No NO Continue with NPPV therapy Continue 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
•Worsening pH and arterial partial pressure of carbon dioxide (PaCO2 ) •Tachypnea (over 30 breaths/min) •Hemodynamic instability •Oxygen saturation by pulse oximeter (SpO2 ) less than 90% •Decreased level of consciousnees •Inability to clear secretions •Inability to tolerate interface WHEN TO TERMINATE NIV AND SWITCH TOWHEN TO TERMINATE NIV AND SWITCH TO INVASIVE MECHANICAL VENTILATION??INVASIVE MECHANICAL VENTILATION?? Call for help !!
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Claustrophobia 1. Try using a nasal interface or, 2. Try using a total face mask, or 3. Try mild sedation (use caution). Gastric Insufflation (Aerophagia) and Gastric Distention 1. Excessive pressure or air swallowing can cause air gastric inflation (insufflation) and gastric distention 2. Use pressures less than 20 to 25 cm H2O
Use of Nasogastric Tubes 1.The tube increases leaking around the mask 2.The tube itself blocks a nasal passage 3.Compression of tube against the skin by the mask may increase risk of skin breakdown NG tube applied to groove Flat surface applied on patient’s face Mask interface across beveled side NG Sealing PadNG Sealing Pad
Eye Irritation 1. Eye irritation may result from air blowing in the eye 2. Be sure mask fit is appropriate 3. Spacers used on the forehead or the bridge of the nose 4. Readjust headgear straps
Skin Problems Due to Interface 1. Pressure lesions (skin breakdown, necrosis) if mask is to tight or left on for extended periods of time 2. Use of skin dressings Possible Solutions to Skin Irritation 1.Use the least amount of pressure to fit the mask that still prevents excessive leaks 2.Use spacers 3.Alternate devices to reduce skin breakdown 4.Use a skin barrier lotion and/or topical corticosteroids
Nasal or Oral Dryness, Nasal Congestion, Mucus Plugging When these problems occur, possible solutions include the following: 1. Add or increase humidification 2. Irrigate nasal passages with a saline spray 3. Use topical decongestants or steroids
Hypotension 1. If hypotension was present prior to therapy, treat the cause 2. Be sure ventilating pressures are not excessively high (peak pressures < 20 cm H20) 1.Maintain a policy of selecting patients appropriately for NPPV patients who can protect their own airway Risk of Aspiration
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU
Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU

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Non invasive ventilation for nurses-dr Shahna Ali,JNMC,AMU

  • 1. NON-INVASIVE VENTILATION DR SHAHNA ALI DEPARTMENT OF ANAESTHESIOLOGY& CRITICAL CARE
  • 4. WHAT IS NON INVASIVE VENTILATIONWHAT IS NON INVASIVE VENTILATION???? “NIV is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway.”
  • 5. WHERE TO USE NIV?? A) Acute respiratory failure 1. Hypercapnic acute respiratory failure • Acute exacerbation of COPD • Post extubation • Weaning difficulties • Chest wall deformities/ neuromuscular disease • Cystic fibrosis • Status asthmaticus • Acute respiratory failure in obesity hypoventilation INDICATIONS
  • 6. 2)Hypoxemic acute respiratory failure • Cardiogenic pulmonary edema • Community acquired pnemonia • ARDS • Weaning difficulties
  • 8. B)Chronic respiratory failure C)Immuno-compromised patients D)Do not intubate patients E) Post surgical respiratory support
  • 9. WHY TO USE NIV ?? (Advantages)WHY TO USE NIV ?? (Advantages) 1) Noninvasiveness Avoids the complications of endotracheal intubation - Early (local trauma, aspiration) - Late (injury to the the hypopharynx, larynx, and trachea, nosocomial infections) 2 ) Ease of application - Easy to implement - Easy to remove
  • 10. 3) Allows intermittent application 4) Can be used in non ICU settings 5) Improves patient comfort 6) Reduces the need for sedation 7) Oral patency (preserves speech, swallowing, and cough)
  • 11. Disadvantages of NIVDisadvantages of NIV 1.System – Increased initial time commitment, – Gastric distension – manpower consuming 2.Mask - Air leakage - Eye irritation - Facial skin necrosis/ulcers 3.Lack of airway access and protection - Suctioning of secretions
  • 12. WHAT IS THE SELECTION CRITERIA ??WHAT IS THE SELECTION CRITERIA ?? A) ACUTE RESPIRATORY FAILURE Atleast 2 of the following criteria must be present 1. Respiratory distress with dyspnoea 2. Use of accessory muscles of respiration 3. Abdominal paradox 4. Respiratory rate > 24/min 5. ABG shows pH< 7.35 or PaCO2 >45 mmHg or PaO2/FiO2 <200
  • 13. B) CHRONIC RESPIRATORY FAILURE( OBSTRUCTIVE LUNG DISEASE) 1. Fatigue, Hypersomnalence, dyspnea 2. ABG shows Ph<7.35. Paco2>55 mmHg 3. Oxygen saturation <88% for >10 min despite O2 supplementation
  • 14. C) THORACIC RESTRICTIVE/CEREBRAL HYPOVENTILATION DISEASES 1. Fatigue, morning headache, hypersomnalence, nightmares, enuresis, dyspnea 2. ABG shows PaCo2 >45 mmHg 3. Nocturnal SaO2 <90% for more than 5 minutes sustained Eg: Muscular dystrophy Multiple sclerosis Amyotrophic lateral scloresis Kyphpscoliosis
  • 15. WHAT TO SEE BEFORE STARTING NIV ??WHAT TO SEE BEFORE STARTING NIV ?? • Cardiac or respiratory arrest • Nonrespiratory organ failure Severe encephalopathy (eg, GCS <10) Severe upper gastrointestinal bleeding Hemodynamic instability or unstable cardiac arrhythmia • Facial or neurological surgery, trauma, or deformity • Upper airway obstruction • Inability to cooperate/protect airway • Inability to clear secretions • High risk for aspiration
  • 16. WHAT EQUIPMENTS ARE REQUIRED FOR NIV???WHAT EQUIPMENTS ARE REQUIRED FOR NIV???
  • 17. • PORTABLE NIV MACHINES – Advantages • Portability • Ease of use – Disadvantages • Cannot develop pressures >30cm H2O • Lack of sophisticated alarm systems, battery backup • CRITICAL CARE VENTILATORS
  • 18. PRESSURE MODES Better tolerated than volume‐cycled vents – Constant positive airway pressure(CPAP) – Bilevel or biphasic positive airway pressure (BiPAP) – Pressure support ventilation(PSV) VOLUME MODES Initial tidal volumes range from 10 to 15 mL/kg – Control – Assist control – Proportional assist control WHAT ARE THE MODES OF NIV ??WHAT ARE THE MODES OF NIV ??
  • 19. Š 2014 ResMed I MODES OF NIV 19 CPAP - Pure Obstructive Sleep Apnea, Cardiogenic Pulmonary Oedema S Mode – Best for spontaneously breathing patients (chronic RF), if breathing efforts are good – there is good synchrony with the ventilator – but be cautious of apneas ST Mode - Patients with central hypoventilation, significant central apneas, inappropriately low respiratory rate, and those who unreliably trigger (mode of choice in Acute RF) T Mode – Rarely Used. Can be tried in patients failing ST – on max pressures, or as a rescue mode if invasive vent not available PAC Mode – Mainly used in weaning off from invasive vent, or recovery from acute injury (similar to PACV mode in invasive vent) iVAPS - Best for chronic use with changing lung compliance over a longer period – excellent results in OHS, Restrictive Diseases, Chronic COPD. For acute scenario, clinical investigations underway – to be used with caution
  • 20. Š 2014 ResMed I COMMON SETTINGS IN NIV To be prescribed •Mode •EPAP •IPAP •Backup Rate / Target Patient Rate •Inspiratory time (minimum and maximum) •(Inspiratory) Trigger Sensitivity •Cycle (Expiratory Trigger) Sensitivity •Rise Time Important but often missed •Mask Type •Tube Type •AB Filter 20
  • 21. CPAP • Continuous Positive Airways Pressure – Same pressure (5‐10 cmH2O) throughout respiratory cycle • Increases intra‐alveolar and intra‐bronchiolar pressure – Recruits alveoli – Dec Pulmonary oedema – Increase FRC – Dec WOB 5‐10cmH2O
  • 22. BIPAP • Bi‐level Positive Airways Pressure – Lower positive pressure during expiration (EPAP) (equivalent to CPAP) – Higher positive airways pressure during inspiration (IPAP) 5‐10cmH2O12‐20cmH2O IPAPEPAP
  • 23. BIPAP • EPAP (PEEP) – Recruits alveoli – Increases VQ matching – Improves oxygenation • IPAP – EPAP (pressure support) – Increases tidal volume – Reduces CO2 – Improves Ventilation and decrease work of breathing 5‐10cmH2O 12‐20cmH2O IPAP EPAP
  • 24. Š 2014 ResMed I BACKUP RATE / TARGET PATIENT RATE • Target Patient Rate is the rate where you want your patient to be ideally breathing • This is usually higher in case of patients with restrictive disorders • The backup rate should be set to 3-4 breaths less than the target patient rate – this prevents aschrony, while also ensuring adequate ventilation • The S Mode does not require a backup rate 24
  • 25. WHAT IS INTERFACE?? “The device that makes physical contact between the patient and the ventilator is termed the Interface.” • Interfaces should be comfortable, offer a good seal, minimize leak, limit dead space
  • 28. Anatomic Landmarks for Nasal Mask Fit • Anatomic LandmarksAnatomic Landmarks a)a) Sides of noseSides of nose b)b) Bridge of noseBridge of nose (caution)(caution) c)c) Above the lipAbove the lip Foam “bridges” that attach to the end of the mask and rest on the forehead help reduce pressure on the bridge of the nose. Nasal template to size.
  • 30. Full Face Masks • Most often successful in the critically ill patient Full Face Mask Entrainment valve Adjustable Forehead Support Ball and Socket Clip Double-foam cushion Pressure pick-off port
  • 31. Fitting 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 a b c b
  • 33. Pillow Cushion Nasal Cushion Nasal Pillows to seal nares Nasal pillows/cushions
  • 35. 1. Appropriately monitored location, oximetry, respiratory impedance, vital signs as clinically indicated 2. Patient in bed at >30 angle 3. Select ventilator 4. Select interface, check fit 5. Connect interface to ventilator tubing and turn on ventilator, hold the mask initialy 6. Apply headgear; avoid excessive strap tension (one or two fingers under strap) 7. Start with low pressure in spontaneously triggered mode with backup rate; pressure limited: 8 to 10 cm H2O inspiratory pressure; 4 to 5 cm H2O expiratory pressure; PS 5-6 cm of H2O. CPAP is 5 cm of H2O 8. Gradually increase inspiratory pressure IPAP should be increased by 2–3 cm increments at a rate of approximately every 10 mins, with a usual IPAP target of 20 cm H2O (10 to 20 cm H2O) as tolerated to achieve alleviation of dyspnea, decreased respiratory rate, increased tidal volume (if being monitored), and good patient-ventilator synchrony 9. Provide O2 supplementation as need to keep O2 sat >90 percent 10. Check for air leaks, readjust straps as needed 11. Add humidifier as indicated 12. Monitor blood gases (1 Hour)
  • 36. O2CO2
  • 37. WHAT TO MONITOR??WHAT TO MONITOR??
  • 38. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ??
  • 39. HOW DO WE ASSESS NIV ??HOW DO WE ASSESS NIV ?? Goals
  • 40. HOW TO WEAN FROM NIV??HOW TO WEAN FROM NIV?? No NO Continue with NPPV therapy Continue 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
  • 41. •Worsening pH and arterial partial pressure of carbon dioxide (PaCO2 ) •Tachypnea (over 30 breaths/min) •Hemodynamic instability •Oxygen saturation by pulse oximeter (SpO2 ) less than 90% •Decreased level of consciousnees •Inability to clear secretions •Inability to tolerate interface WHEN TO TERMINATE NIV AND SWITCH TOWHEN TO TERMINATE NIV AND SWITCH TO INVASIVE MECHANICAL VENTILATION??INVASIVE MECHANICAL VENTILATION?? Call for help !!
  • 43. Claustrophobia 1. Try using a nasal interface or, 2. Try using a total face mask, or 3. Try mild sedation (use caution). Gastric Insufflation (Aerophagia) and Gastric Distention 1. Excessive pressure or air swallowing can cause air gastric inflation (insufflation) and gastric distention 2. Use pressures less than 20 to 25 cm H2O
  • 44. Use of Nasogastric Tubes 1.The tube increases leaking around the mask 2.The tube itself blocks a nasal passage 3.Compression of tube against the skin by the mask may increase risk of skin breakdown NG tube applied to groove Flat surface applied on patient’s face Mask interface across beveled side NG Sealing PadNG Sealing Pad
  • 45. Eye Irritation 1. Eye irritation may result from air blowing in the eye 2. Be sure mask fit is appropriate 3. Spacers used on the forehead or the bridge of the nose 4. Readjust headgear straps
  • 46. Skin Problems Due to Interface 1. Pressure lesions (skin breakdown, necrosis) if mask is to tight or left on for extended periods of time 2. Use of skin dressings Possible Solutions to Skin Irritation 1.Use the least amount of pressure to fit the mask that still prevents excessive leaks 2.Use spacers 3.Alternate devices to reduce skin breakdown 4.Use a skin barrier lotion and/or topical corticosteroids
  • 47. Nasal or Oral Dryness, Nasal Congestion, Mucus Plugging When these problems occur, possible solutions include the following: 1. Add or increase humidification 2. Irrigate nasal passages with a saline spray 3. Use topical decongestants or steroids
  • 48. Hypotension 1. If hypotension was present prior to therapy, treat the cause 2. Be sure ventilating pressures are not excessively high (peak pressures < 20 cm H20) 1.Maintain a policy of selecting patients appropriately for NPPV patients who can protect their own airway Risk of Aspiration

Editor's Notes

  • #28: This slide shows some of the nasal masks and their components. (Respironics, Inc.)
  • #32: Use the sizing gauge to select the appropriate size mask. Place the bottom portion of the mask below the lower lip while the mouth is slightly open. The mask should cover the mouth entirely.
  • #37: The major function of the lung is to get oxygen into the body and carbon dioxide out
  • #41: There are two currently used forms of weaning from NPPV. The first method is a combination of weaning the ventilatory support and taking the patient off for incremental periods of spontaneous breathing through the day or over the course of a few days. During the trial periods, the patient should be placed on supplemental oxygen equal to their previous FIO2 setting. Some patients with chronic respiratory failure may continue to require long term nocturnal ventilatory support. The second method of weaning involves a gradual reduction in the levels of ventilatory support and FIO2. The oxygen is weaned to less than 50% keeping the SpO2 greater than 90%. Then the IPAP is gradually titrated downward in decrements of 2-3 cmH2O until reaching 5 cm H2O or the EPAP level. Whatever weaning method is used, noninvasive ventilation should be restarted if a patient manifests signs of fatigue and clinical evidence of respiratory distress appear. Restart patient on their previous NPPV settings. Monitoring respiratory rate, tidal volumes, and Ti/Tot are good indicators of the patient’s response to the weaning process. When the noninvasive pressure is removed, the patient should be placed on supplemental oxygen. (From Respiratory Care 49: 72, 2004.
  • #43: A number of complications arise when using NPPV. Some are related to the gas flow and pressures. Some are associated with the interface. Problems with the interface device accounts for a majority of the problems associated with noninvasive ventilation. Some of the various problems and complications of NPPV will be reviewed in the next few slides. In addition, possible solutions will be recommended.
  • #44: Some people become very claustrophobic when anything is place over their face or head.
  • #45: The prophylactic use of a nasogartric tube in patients receiving NPPV is controversial. The NG tube can, itself, increase the risk of leaks, block the airway and increase the risk of pressure sores.
  • #46: Eye irritation and conjunctivitis can be caused by gas blowing into the eyes or from aerosolized medications being directed at the eyes. Readjustment of the mask and headgear can often correct eye irritation and dryness.
  • #47: This photograph illustrates necrosis of the skin at the bridge of the nose. Keep in mind that damage to the cartilage and skin of the nose can result in permanent damage.
  • #48: Nasal and/or oral drying, nasal congestion and mucus plugging can occur if the inhaled air is too dry and when flows and pressures are high. Using a nasal saline spray, and adding or increasing humidification can help.
  • #49: If the patient is hypotensive prior to beginning ventilation, the cause of the hypotension needs to be corrected. For example, if the patient is dehydrated and thus hypotensive they may need fluids.