NON-INVASIVE MV
Good news
Warnings
• It works !!!!!!!
• 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
i-PSV n-PSV T-tube
pH
PaCO2
PaO2/FIO2
7.38
59.1
206
7.38
61
210
(from Vitacca M. et al. AJRCCM 2001; 164: 638-641)
7.33
69
183
INTERFACES
TUBING
NURSES
PATIENTS
MT
LOCATION
NIV
MONITORING
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
60% Hypercapnic
55% Hypoxic
Conclusions: Use of NIV as the initial ventilation strategy for AECOPD varies
across hospitals. Institutions with greater use of NIV have lower rate of IMV
usage and better outcomes.
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
Appropiate setting for long-term NPSV
(n=23 hypercapnic COPD patients)
Usual (IPS 16±3, EPAP 3.6±1.4)
Physiological (IPS 15±3, EPAP 3.1±1.6)
Change (% of SB)
100
75
50
25
0
-25
-50
-75
-100
VT
f
Pdi
PTPdi
(from Vitacca M. et al. Chest 2000)
PEEPi
(from Vitacca M. et al.
MACD 2004; 61: 81-85)
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
Study protocol
SB (baseline)
V’E, PTP
RANDOM of ventilators
setting
0
Time (min)
V’E, PTP
Pao, IE
comfort
10
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
(from BTS Guideline Thorax 2002;57:192-211)
maschera facciale
1
Punti critici
• 1- ponte nasale
• 2- lati della bocca
• 3- base inferiore del labbro
2
VANTAGGI:
SVANTAGGI:
•miglior controllo
•non permette
delle perdite
•pressioni più
elevate
N.B. La protesi dentaria
va rimossa
l’espettorazione, né
l’alimentazione
•aumenta il rischio di
aspirazione
•è altamente traumatica
2
3
maschera nasale
1
Punti critici
• 1- ponte nasale
• 2- narici
• 3- base del naso
verificare
2
2
• 4- pervietà delle cavità nasali
VANTAGGI:
SVANTAGGI:
•stabile, comfort
•perdite d’aria dalla
•bocca libera
•maggior resistenza
maggiore
3
bocca
•spazio morto
ridotto
•svariati modelli
N.B. La protesi dentaria va conservata
Major problems with mask
during NIV support
Air leaks
Side-effects
Size
Side effects due to NPPV
N=26 (compliant patients)
%
Mask leaks
Skin irritation
Rhinitis / aerophagia
Discomfort
43
23
13
8
(from Criner GJ. et al. Chest 1999;116:667-675)
MOUTH LEAKS IN NASAL NPPV
(n=9, hypercapnic=7, COPD=6, age 64 years)
70
PtcCO2 (mmHg)
60
Arousal Index (events h-1)
60
40
p<0.001
50
p<0.0002
20
40
30
0
Untaped
Taped
Untaped
(from Teschler H. et al. ERJ 1999; 14: 1251-1257)
Taped
Side effects due to NPPV
N=26 (compliant patients)
%
Mask leaks
Skin irritation
Rhinitis / aerophagia
Discomfort
43
23
13
8
(from Criner GJ. et al. Chest 1999;116:667-675)
Tissue Necrosis Caused by an
Improperly Fitting Mask
… However, a chinstrap was required to
reduce oral leak in the majority of subjects
using the nasal mask.
(CCM 2002; 30: 602-608)
(Crit Care Med
2002; 30: 602-608)
Conclusions:
Helmet
NPPV is feasible and
can be used to treat
COPD patients with
acute exacerbation, but
it does not improve
CO2
elimination
as
efficiently as does FM
NPPV.
Esperienza
dell’équipe
Considerazioni
anatomiche
CRITERI PER LA
SCELTA DELLA
MASCHERA
Modalità di
ventilazione
Compliance e
sensorio del
paziente
(from BTS Guideline Thorax 2002;57:192-211)
NON-INVASIVE MV
• NIV in the “real-world”
• Setting the ventilator
• Choice of interfaces
• Humidification and drug delivery
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.
Crit Care Med 2002; 30:2515–2519
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
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.