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Noninvasive ventilation

Noninvasive ventilation. นพ.ธรรมศักดิ์ ทวิชศรี หน่วยเวชบำบัดวิกฤต ฝ่ายวิสัญญีวิทยา รพ.จุฬาลงกรณ์. The earliest known ventilators, developed during the late 19th century,were the ‘body or tank’ type. Noninvasive ventilation !!. CPAP, initially used for the treatment of

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Noninvasive ventilation

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  1. Noninvasive ventilation นพ.ธรรมศักดิ์ ทวิชศรี หน่วยเวชบำบัดวิกฤต ฝ่ายวิสัญญีวิทยา รพ.จุฬาลงกรณ์

  2. The earliest known ventilators, developed during the late 19th century,were the ‘body or tank’ type

  3. Noninvasive ventilation !!

  4. CPAP, initially used for the treatment of acute pulmonary oedema, became popular in the 1980s for management of obstructive sleep apnoea

  5. Introduction to CPAP

  6. Noninvasive ventilation (NIV): a form of ventilatory support that avoids airway invasion improved outcomes in certain types of acute respiratory failure (ARF)

  7. The successful application of NIV requires the training & collaboration of an experienced ICU team, including intensivists, nurses, and respiratory therapists

  8. NIV FOR SPECIFIC TYPES OFACUTE RESPIRATORY FAILURE Hypercapnic Respiratory Failure

  9. Chronic Obstructive Pulmonary Disease “NIV should be considered first-line therapy in the management of ARF caused by COPD exacerbations”

  10. BMJ 2003;326:185–7

  11. BMJ 2003;326:185–7

  12. Asthma A trial of NIV can be considered in asthmatics who fail to respond adequately to initial bronchodilator therapy to improve air flow obstruction & decrease the work of breathing

  13. CHEST 2003; 123:1018–1025

  14. Asthma large randomized controlled trials (RCTs) are needed before recommending NIV use in status asthmaticus Cochrane Database Syst Rev 2005; 1:CD004360

  15. Facilitating Extubation in COPD a prospective, randomized, controlled trial in 43 mechanically ventilated patients who had failed a weaning trial for 3 consecutive days Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

  16. Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

  17. Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

  18. NIV NIV The probability of weaning success The cumulative survival probability Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

  19. Facilitating Extubation in COPD Earlier extubation with NIV results in shorter mechanical ventilation & length of stay, less need for tracheotomy, lower incidence of complications, and improved survival Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

  20. NIV FOR SPECIFIC TYPES OFACUTE RESPIRATORY FAILURE Hypoxemic Respiratory Failure

  21. Cardiogenic Pulmonary Edema The main physiologic benefit from NIV or CPAP in these patients is likely due to an increase in FRC that reopens collapsed alveoli & improves oxygenation Crit Care Med 2007; 35:2402–2407

  22. increases lung compliance & reduces work of breathing

  23. decreasing ventricular preload & afterload decrease preload & decrease afterload Anesthesiology 2005; 103:419–28

  24. NIV reduces the need for intubation & mortality in patients with acute cardiogenic pulmonary edema. There are no significant differences in clinical outcomes when comparing CPAP vs NIPSV JAMA. 2005;294:3124-3130

  25. JAMA. 2005;294:3124-3130

  26. JAMA. 2005;294:3124-3130

  27. JAMA. 2005;294:3124-3130

  28. Pneumonia a cautious trial of NIV may be considered in patients with pneumonia deemed to be excellent candidates, but they need careful monitoring, because the risk of failure is high

  29. AM J RESPIR CRIT CARE MED 1999;160:1585–1591

  30. Relapse of pneumonia was the leading cause of death after hospital discharge, and relapse occurred in previously intubated patients with COPD AM J RESPIR CRIT CARE MED 1999;160:1585–1591

  31. Acute Lung Injury/ARDS Studies on NIV to treat acute lung injury & ARDS have reported failure rates ranging from 50% to 80% Independent risk factors for NIV failure: severe hypoxemia, shock, & metabolic acidosis

  32. PaO2/FIO2 >175 In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients SAPS II >34 & the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure Crit Care Med 2007; 35:18–25

  33. Respiratory Failure in Immunocompromised Patients The data support NIV as the preferred initial ventilatory modality for these patients, to avoid intubation and its associated risks (reduced infectious complications)

  34. JAMA. 2000;283:235-241

  35. JAMA. 2000;283:235-241

  36. JAMA. 2000;283:235-241

  37. NIV FOR SPECIFIC TYPES OFACUTE RESPIRATORY FAILURE Postoperative Respiratory Failure

  38. Oxygen at an FiO2 of 0.5 plus a CPAP of 7.5 cmH2O 6 hours with oxygen through a Venturi mask at an FiO2 of 0.5 JAMA. 2005;293:589-595 Elective abdominal surgery & GA extubated & underwent 1-hour screening test(PaO2/FiO2  300)

  39. Patients who received oxygen plus CPAP had a lower intubation rate (1% vs 10%; P=.005; relative risk [RR], 0.099; 95% CI, 0.01-0.76) JAMA. 2005;293:589-595

  40. CPAP may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery JAMA. 2005;293:589-595

  41. CPAP

  42. A, multiple RCTs & meta-analyses B, more than one RCT, case control series, or cohort studies C, case series or conflicting data Crit Care Med 2007; 35:2402–2407

  43. General guidelines for selection of patients for noninvasive ventilation

  44. Predictors of failure: Noninvasive ventilation(NIV) for acute respiratory failure Crit Care Med 2007; 35:2402–2407

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