Are You Optimizing Every Bilevel Breath?

1. Are You Optimizing Every Bilevel Breath? Jim Eddins, RRT

2. Objectives Discuss the basics of non-invasive ventilation and the benefits of using NIV Discuss features that improve bilevel tolerance Determine the most effective bilevel settings based on disease state

3. Consider Using NIV When … Patient is not tolerating high pressure settings or is complaining of inability to exhale, despite expiratory pressure relief feature Use NIV Obstructive events persist at 15 cm H2O Respirations are characterized by CSA, CSR or CompSA Patient has a history of ventilatory insufficiency

4. Utilizing Pressures Effectively

5. Breath Cycle on Bilevel Inhalation Trigger Cycle Patient Flow Exhalation Delivered Pressure IPAP EPAP Pressure support ( P)

6. The Problem with Asynchrony

7. How Can Inspiratory Time Controls Help Increase Compliance? Ti Max IPAP Ti Min Rise Time EPAP Breath cycle 0

8. Rise Time Problem: Patient describes “Pressure is too STRONG!” Solution: Increase rise time

9. Maximum Inspiratory Time Problem: Patient requires longer expiratory time (i.e. COPD) Solution: Best option – Shorten inspiratory time Additional options – Select higher cycle sensitivity, Select faster rise time

10. Minimum Inspiratory Time Problem: Patient’s inspiratory effort is weak (i.e. restrictive disease)/can’t sustain adequate inspiration Solution: Best option – Increase/prolong Ti Min Second option – Select lower cycle sensitivity

11. Trigger & Cycle Sensitivities Adjustable Trigger Sensitivity Adjustable Cycle Sensitivity Patient Flow Patient Flow EPAP EPAP

12. Cycling for COPD Patients Increased inflammation and mucus Slower inspiratory flow rates Delayed cycling to expiration Less time for exhalation Increased air trapping (PEEPi) Increased trigger delay and trigger workload Increased missed triggers Increased work of breathing

13. COPD

14. Synchrony Insight - Ti Min “However, premature cycling may also have detrimental effects on patient-ventilator synchrony. Premature cycling is simply when the ventilator terminates the breath while the patient requires a long inspiratory period.” Gentile, Respiratory Care, 2011

15. Restrictive Disease

16. Clinical Parameters

17. Conclusion • There are multiple benefits to using NIV, particularly in patients with chronic hypoventilation • There are additional features on some devices that modify pressure waveforms and work to improve bilevel tolerance