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NIV type 2 respiratory failure

NIV type 2 respiratory failure. up to 20% mortality during an acute exacerbation of COPD with acidosis 30% who survive an exacerbation of COPD with acidotic type 2 failure die in 18 months acidosis predicts mortality and ICU usage

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NIV type 2 respiratory failure

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  1. NIV type 2 respiratory failure • up to 20% mortality during an acute exacerbation of COPD with acidosis • 30% who survive an exacerbation of COPD with acidotic type 2 failure die in 18 months • acidosis predicts mortality and ICU usage • hypercapneic patients with a higher PaO2 are more likely to be acidotic

  2. Hypercarbia PaCO2 > 6.7kPa (50 mmHg) Hypoventilation V/Q inequality Headache, restless or narcosis Flapping tremor, Oedema Acidosis

  3. Effects of Acidosis • Hyperventilation • Cardiac dysfunction • Vasoconstriction • Cerebral dysfunction • Renal dysfunction & electrolyte changes • Muscle fatigue

  4. Some Equations • PaCO2 is inversely proportional to alveolar ventilation • CO2 + H2O = H2CO3 = H+ + HCO3- • pH = pKA + log(HCO3-/CO2) Buffering system keeps pH 7.35 – 7.45 Kidneys & Lungs act together

  5. NIV The delivery of mechanically assisted or generated breaths without the placement of an artificial airway such as an endotracheal tube or tracheostomy, usually via a tightly fitting nasal or full face mask.

  6. NIV Benefits • increased alveolar ventilation • decreased work of breathing with ‘resting of respiratory muscles’ • cheaper than ITU and easy wean • reduced infection risk • able to eat and speak

  7. NIV & Dead Space Minute Ventilation = Tidal Volume x Resp Rate Tidal Volume = Dead Space + Alveolar Space Minute Alveolar Ventilation = Alveolar Space x Resp Rate MV = (250 + 250) x 10 = 5L normal MAV = 250 x 10 = 2.5L

  8. NIV & Dead Space COPD unwell TV = 300mls MV = (250 + 50) x 30 = 9L MAV = 50 x 30 =1.5L COPD unwell on BIPAP TV = 350mls MV = (250 + 100) x 20 = 7L MAV = 100 x 20 = 2L

  9. NIV YONIV • Plant et al Lancet 2000 Previous randomised controlled trials of NIV, conducted in ITU have shown reduced need for intubation, shorter stay and reduced hospital mortality. Can NIV be used on a DGH general medical ward to the same effect

  10. NIV YONIV • NIV less likely to be associated with treatment failure in the first 2 weeks p=0.02 • NIV group less likely to die (at any time during admission) p=0.05 • NIV group had a more rapid correction of acidosis and greater fall in RR p<0.05

  11. NIV & COPDCochrane Review 2004 • Treatment Failure • RR 0.48 (0.37-0.63) • NNT 5 • Mortality • RR 0.52 (0.35-0.76) • NNT 10 • Intubation • RR 0.41 (0.33-0.53) • NNT 4

  12. NIV & COPDCochrane Review 2004 • Length of Stay • -3.2 days (-4.4 - -2.1) • Length of ICU Stay • -4.7 days (-9.6 - 0.2) • Complications of Treatment • Risk reduction of 62% • No significant differences found with pH and setting of treatment

  13. NIV why have a service • Mortality • Cost saving • ITU bed usage • Training issues

  14. NIV indications • acute exacerbation of COPD causing acidotic type 2 respiratory failure, not responding to conventional treatment • no need for urgent intubation or if intubation deemed inappropriate

  15. NIV selection • Inclusion • COPD • pH<7.35 & PaCO2 >6 kPa post treatment • resp rate > 20 bpm • Exclusion • immediate intubation required • CXR pneumothorax, LVF and lobar pneumonia • +++ vomiting or sputum

  16. NIV Equipment • BIPAP machine • Face mask • Tubing • Oxygen if necessary • Bacterial filter

  17. NIV Set Up • Decision re intubation • HDU v MAU • IPAP 10 • EPAP 4 • Resp Rate 8 bpm Titrate IPAP according to patient comfort up to 20

  18. NIV Monitoring • Continuos oxygen saturations • Add oxygen if necessary aiming for saturations between 85 - 90% • ABG or capillary blood gases at 1,4 ,12 and 24 hours • Respiratory rate • Tidal volume • Pressures

  19. NIV Treatment failure • Failure to correct acidosis • Worsening hypoxia • Increasing confusion/agitation • Will not wear it • Pressure areas break down

  20. NIV Treatment success • Improved ABG within 4 hours • reduced respiratory rate & increased tidal volume • less confusion Aim to withdraw over 3 days Day 1 24hours Day 2 18 hours Day 3 12 hours

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