NIV - Non invasive ventilation in unusual situations Ajay...

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Non invasive ventilation in unusual situations Ajay Handa Dept of Pulmonary Medicine PGIMER
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Introduction • Equipment • Effects of NIV • Complications • Patient selection • Practical aspects
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Noninvasive ventilation • Delivery of positive pressure ventilation through an interface to upper airways of the patient without the use of invasive airway • NIV is able to improve gas exchange and unload respiratory muscles as efficiently as invasive ventilation Wysocki M et al, Eur respir J 2001
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Advantages:NIV • Achieves alveolar ventilation and gas exchange parameters similar to IMV • Avoids invasive airway • Avoids sedation /paralysis • Can be applied intermittently as required • Permits removal of secretions, eating and speech • Patient participates in decision making Reduced Infections (VAP, sinusitis) Antonelli M et al, Crit Care 2000
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Nasal Vs oronasal mask Liesching T et al , Chest 2003
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Portable vs critical care ventilators Liesching T et al , Chest 2003 +
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Modes of NIV • Continuous positive airway pressure • Pressure support ventilation( IPAP alone) • Bilevel positive airway pressure : BiPAP (IPAP+ EPAP) • Proportional assist ventilation • Assist-controlled ventilation (mask IPPV) Craig TH, Emerg Med 2002 Mehta Set al, AJRCCM 2001
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Effects : IPAP • Reduces the work of breathing – Alleviates respiratory distress – Unloads respiratory muscles – Improves respiratory muscle function • Auguments alveolar ventilation: reduces dead space ventilation • Reduces rate related auto PEEP dynamic hyperinflation • Improves gas exchange : hypoxemia and hypercapnia Antonelli M et al, Crit Care 2000
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Effects : EPAP • Improves gas exchange: by alveolar recruitment and corrects hypoxemia • Increases FRC by preventing end exp collapse : improves lung compliance into advantageous position, higher tidal volumes generated for same pressure change • Improves respiratory muscle fn : reduces dynamic hyperinflation advantage to the diaphragm and intercostals • Auto PEEP (Inspiratory threshold load) : reduces effort trigger ventilator by equalization of pressures • Enhances the delivery of bronchodilators to distal bronchial tree Antonelli M et al, Crit Care 2000
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Triggering • Most portable ventilators have flow triggering • Pressure triggering : associated with increased work of triggering with auto PEEP (in AE of COPD) • Auto PEEP significantly lower with flow triggering in PSV mode
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Fractional inspired Oxygen •F i O 2 variable: pulse oximetry and serial ABG are a must 2 ) – Oxygen flow rate – Site of oxygen source (mask hole/ventilator/ circuit) – Site of leak port – Air leak Hess DR, Respir Care 2004
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• Controversy related to use of humidifier as upper airways are not bypassed • NIV is required for longer periods >48-72h recommended to use( prevent inspissated secretions due to high flow rates) • Mouth leak : nasal resistance can be
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NIV - Non invasive ventilation in unusual situations Ajay...

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