Practical Points in NIV

1. Practical Points in NIV นพ.รัฐภูมิ ชามพูนท รพ.พุทธชินราช

2. ใครในภาพต่อไปนี้ไม่ได้เป็นพรีเซนเตอร์ต่อต้านการสูบบุหรี่ใครในภาพต่อไปนี้ไม่ได้เป็นพรีเซนเตอร์ต่อต้านการสูบบุหรี่

5. What is NIV Mechanical ventilation without using invasive airway When to use NIV • Before Intubation • Follow Extubation

6. TYPE of NIV 2 Types • Negative Pressure • Posive Pressure (NIPPV)

7. Normal breathing (Negative pressure breath) pressure +2 0 -2

8. Mechanical ventilation(positive pressure ventilation) 0

9. TYPE of NIV • Negative Pressure Can be provided without artificial airway • Emerson Iron Lung (Past) • Chest Cuirass • Pneumobelt • Rocking Bed • Positive Pressure

11. Postpolio era

14. Use in Home mechanical ventilation • Communicate more effective • Neuromuscular disease • X Intrinsic lung disease • X Body temp regulation • X Not very comfortable

15. TYPE of NIV 2. Positive Pressure(NIPPV) • Higher than atmospheric pressure • Push air into the lung • Can be provided with artificial airway (variety Interface)

18. Mode of NIPPV • Volume limited Ventilation • Pressure varied • Discomfort , Gastric distention  Intolerance • Air leakage • Pressure limited Ventilation • CPAP • BiPAP • PAV • Mixed Volume and Pressure Limited Ventilation

19. Pressure-Limited Ventilation • CPAP • Simplest • Constant pressure provided through inspiration and expiration • Decrease WOB , Increase FRC & Gas exchange • BiPAP/NPPV • IPAP V.S. EPAP • Less expiratory resistance • Spontaneous , Timed , S/T Mode • Proportional Assisted Ventilation (PAV)

20. Interface

21. Advantages Less risk of aspiration Easier secretion clearance Less claustrophobia Easier speech May allow patient to eat Easy to fit and secure Less dead space Disadvantages Mouth leak Higher resistance through nasal passage Less effective with nasal obstruction Nasal irritation and rhinorrhea Mouth dryness Nasal Mask

22. Advantages Better control of mouth leak More effective with mouth breathers , particularly during acute application of NIPPV Disadvantages More dead space Claustrophobia More risk of aspiration More difficulty in eating and speaking Asphyxiation if ventilator malfunction Oronasal Mask(full face)

23. Circuit Type • Single Limb • Double Limb

24. Single Limb circuit system

25. Single Limb circuit system ventilator

26. 2 Limb circuit system

27. 2 Limb circuit system ventilator

28. Leak valve system หายใจไม่ออก! ventilator ไม่มี Leak valve ใน circuit

29. Leak valve system ค่อยยังชั่วหน่อย แต่ทำไมลมดันไม่หยุด ventilator มี Leak valve ใน circuit

30. Initial Settings • EPAP = CPAP • IPAP = Pressure Support (Include PEEP or above PEEP) • Back up Rate • Pramp(Rising Time) Optional • FiO2

31. Pressure support ventilation(PS) • The faster the initial rise to peak flow level,the sooner the set pressure limit is reached • Slow rise to set pressure level is more comfortable for the patient • Exessively fast rise to peak flow may cause the ventilator to overshoot the initial pressure limit and create a pressure spike,which can cause discomfort and increase WOB

32. FAQ 1.อย่างนั้น mode CPAP with PS ในเครื่อง Invasive Mechanical ventilator ก็คือ NIPPV(Bilevel CPAP) ใช่หรือไม่ ?? เหมือนจะใช่ แต่ไม่ใช่

33. Phase variables 4 phases • The change from expiration to inspiration (triggered) • Inspiration (limited) • The change from inspiration to expiration (cycled) • Expiration (baseline ,PEEP)

34. pressure inspiration inspiration expiration expiration 5 limit 0 time baseline cycle trigger

35. Pressure support ventilation(PS) • Typically used in the SIMV mode to facilitate weaning in a difficult to wean patient • Increase spontaneous Vt (set PS until a desired spontaneous Vt) • Decrease spontaneous respiratory rate (set PS until a desired spontaneous RR) • Decrease the work of breathing

36. Pressure support ventilation(PS) End flow(resp. cycle off) Rise time

38. NIV ต้องมี Leakบ้าง ถ้าใช้ CPAP with PS mode แทนจะเกิด • Auto-Triggering • Prolong Inspiratory Time • Alarm Low MV or Low Vt

39. วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV • Auto-Triggering • Trigger Adaptation(Re-adjustment baseflow) • Volume trigger eg.6 ml • Shape signal

40. วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV • Prolong Inspiratory Time • Good quality Leak compensation • Spontaneous expiratory Threshold (% Peak flow cycle adaptation) • Shape signal cycle • Safety Feature eg.Flowreversal,max 3 sec inspiratory time

41. IPAP PRESSURE Cm H2O EPAP Variable Cycle Threshold Adjustable Baseflow Variable Trigger Threshold True NIV

42. FAQ 2. ใช้แทนกันได้ไหม??? ไม่ควร... ไม่ได้ครับ

43. 3.ทำไมNIV ในแต่ละเครื่องจึงสบายไม่เท่ากัน? • Leakage compensation • Trigger Adaptation • Inspiration Termination (cycle)

44. NIV made simple ไม่ง่ายนะจ้ะ

46. Close monitoring

47. COPD Exacerbation(7.30≤pH<7.35) Interface and type of circuit • nasal mask • Single limb with leakage valve Initial Settings • EPAP 4-8 cmH2O • IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt 400-500 • Back up rate 8-10/min • FiO2 keep SpO2 >92%

48. Severe COPD Exacerbation(pH< 7.30) Interface and type of circuit • Oro-nasal mask • Single limb with leakage valve Initial Settings • EPAP 4-8 cmH2O • IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt 400-500 • Back up rate 8-10/min • FiO2 keep SpO2 >92% Close monitoring

49. Cardiogenic Pulmonary edema Interface and type of circuit • Oro-nasal mask (High Flow system ) • Single limb with leakage valve Initial Settings • EPAP 4-8 cmH2O titrate until ≈ 8-10 • IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt 400-500 (OPTIONAL) • Back up rate 8-10/min • FiO2 keep SpO2 >92%(High FiO2) Close monitoring

50. Hypoxic Respiratory Failure Interface and type of circuit • Oro-nasal mask (High Flow system ) • Single limb with leakage valve Initial Settings • EPAP 4-8 cmH2O • IPAP 12-25 (above EPAP 8-20) cmH2O titrate until Vt 400-500 • Back up rate 12-16 /min • FiO2 keep SpO2 >92%(High FiO2) Close monitoring