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Non-Invasive Ventilation

Non-Invasive Ventilation. Dr Duncan Mitchell Ealing Hospital. What we are going to cover…. What is NIV? Ventilation Physiology & Terminology Types of NIV Indications for NIV Contra-indications Case examples. What is Non-Invasive Ventilation (NIV).

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Non-Invasive Ventilation

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  1. Non-Invasive Ventilation Dr Duncan Mitchell Ealing Hospital

  2. What we are going to cover… • What is NIV? • Ventilation Physiology & Terminology • Types of NIV • Indications for NIV • Contra-indications • Case examples

  3. What is Non-Invasive Ventilation (NIV) ‘Delivery of ventilatory support without the need for an invasive artificial airway’

  4. Some Physiology…….zzzzzzz! • Ventilation - process by which O2 and CO2 are transported to and from the lungs • Venous blood - lower pO2 higher pCO2 than inspired gas - partial pressure gradient driving O2 in and CO2 out

  5. Ventilation of lungs with inspired gases leads to mixing with alveolar gas • If no ventilation at all, no replenishment of O2 and no removal of CO2 • Arterial pO2 falls and pCO2 rises towards that of venous • If ventilation greater than needed, alveolar gas closer to inspired gas

  6. Terminology • Tidal Volume (VT) – amount of gas expired per breath (~ 500ml at rest) • Minute Volume – amount of expired gas per minute • Alveolar Ventilation – amount of gas reaching functional alveoli • Work of Breathing – usually ~5% of total body work – most used to overcome lung and chest wall stiffness during inspiration

  7. PEEP • Pressure Support (cmH2O) – positive pressure applied to airway to support patients own breath • Opening Pressure – pressure required to open collapsed alveoli

  8. Types of NIV • Negative-Pressure Ventilation (Iron Lung) • Continuous Positive Airway Pressure (CPAP) (Not really NIV!) • Bi-level Positive Airway Pressure (BiPAP)

  9. Negative-Pressure Ventilation • Late 1880s – iron lungs first used • Early 1900s – iron lungs used for polio epidemics • This continued throughout the 20th century until 1960s when invasive ventilation became available

  10. CPAP • Nasal or face mask • Continuous positive pressure applied to the airways • Usually well-tolerated • Similar to use of PEEP • Reduces work of breathing • Improve ventilation to collapsed areas of lung

  11. BiPAP • Bi-Level pressure support • Inspiratory Positive Airway Pressure (IPAP) & Expiratory PAP (EPAP) • IPAP is the pressure support machine gives to help patients own inspiration • Helps to reduce WOB and increase alveolar ventilation • EPAP is essentially PEEP and help to prevent alveolar collapse

  12. Indications for CPAP • Cardiogenic Pulmonary Oedema • Obstructive Sleep Apnoea • Chest Wall Trauma if hypoxic on adequate analgesia • Pneumonia

  13. Indications for BiPAP • Exacerbation of COPD with Respiratory acidosis • Type II respiratory failure with chest wall deformity or neuromuscular disease • Failure of CPAP • Pneumonia with respiratory acidosis • Therapeutic trial with a view to intubation if it fails • Others (ARDS, post-op respiratory failure, to buy time prior to intubation)

  14. Patient Selection • Sick but not moribund • Able to protect airway • Conscious and co-operative • Haemodynamically stable • No excessive secretions • Few co-morbidities • Improvement on ABG with NIV

  15. Patient Rejection • Respiratory arrest • Haemodynamically unstable • Uncooperative • Unable to protect airway (swallowing and cough impaired or vomiting) • Facial, oesophageal, or gastric surgery • Craniofacial trauma or burns • Airway obstruction • Undrained Pneumothorax

  16. Case 1 • 76yr old female • Lifelong smoker • 1/52 productive cough • BP140/90 P120 RR40 SaO2 89% on 10L pH 7.3 pCO2 8.2 pO2 6.9 HCO3 20 BE – 4.2

  17. Case 2 • 83yr old man • Known IHD, previous MI • Wife says he has “not been well” • BP170/95 P120 RR38 SaO2 87% on 15L pH 7.28 pCO2 5.2 pO2 7.1 HCO3 21 BE -3.2

  18. Case 3 • 49yr old man • 2/52 Hx of feeling unwell with D&V • Not eating or drinking • Not passing urine • BP89/50 P130 RR40 SaO2 96% on NRBM pH 6.98 pCO2 2.9 pO2 14.2 HCO3 13.9 BE -21.4

  19. Case 3 Contd…. • Urea 32 • Creat 444 • K 6.2 • Hb 9.2 • WCC 24 • PLT 47 • PT 20 • APTT 100

  20. Case 4 • 50yr old man • On the ward • Nurses report that he snores a lot • Wife tells you he has seen a specialist and has a machine at home that makes a lot of noise • What is it ???!!!

  21. Summary • What NIV is and the different types • Basic respiratory physiology • Indications for NIV • When not to use it • Thought about some cases

  22. Any Questions? ?

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