1 / 41

All About Home NIV

All About Home NIV. Respiratory Mechanics. Spontaneous Breathing. Upper airways Nose functions. Warm inspired gas. Filtre. humidification. What is spontaneous ventilation?. Purpose of ventilation

irina
Download Presentation

All About Home NIV

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. All About Home NIV

  2. Respiratory Mechanics

  3. Spontaneous Breathing

  4. Upper airwaysNose functions Warm inspired gas Filtre humidification

  5. What is spontaneous ventilation? • Purpose of ventilation • Supply fresh gas to the lungs, to be exchanged at the alveolar-capillary level • through blood circulation • Provide cells with adequate 02 (Oxygenation) • get rid of CO2 (Alveolar ventilation) • Maintain normal acid base balance

  6. Arterial Blood GasesNormal values • ABGs: Arterial Blood Gases • Pa02 and PaC02 • Oxygenation assessment • Pa02 80-100 mmHg • Sa02: 92% to 100% • Ventilation assessment • PaC02: 35-45 mmHg • Acid base status • pH:7,35-7,45

  7. Some Definitions • Tidal Volume (Vt) • Quantity of air in the lungs in 1 inspiration • Minute Ventilation • Quantity of air in the lungs in 1 min (= Vt x respiratory rate) • Hypoxemia • state in which Pa02<60mmHg (in the blood) • Sa02<92% (Oxygen saturation) • Hypoxia • state in which there is inadequate 02 at the tissue level

  8. Some Definitions • Hypercapnia • when PaC02 >45mmHg • Hypocapnia • when PaC02<35mmHg • Acidosis: • pH<7,35 • Alkalosis: • pH>7,45

  9. Spontaneous breathing At Rest Pressures Equal No Air Flow 0 0 0

  10. Spontaneous breathing On Inspiration: Active phenomena Muscles Contract Pressure Changes Air Flows Into Lungs 0 -2 -2

  11. Spontaneous breathing On Expiration: passive phenomena Muscles Contract Pressure Changes Air Flows out Lungs 0 +15 +15

  12. Spontaneous breathing EndExpiration: Intrinsic PEEP Resistance creates a residual pressure at the end of expiration 0 +5 +5 Extra work is needed to generate the following inspiration

  13. Spontaneous breathing Opposing Forces to Ventilation Elastic recoil Resistance of the lungs to airflow Work of Breathing

  14. Opposing Forces to Ventilation • Tendency of the Lungs to Resist Inflation Pressure/Volume = Elastance • Resistance to Air Movement in the Airways Pressure / Flowrate = Airways Resistance

  15. Breathing with Lung Disease Decreased Elastance Increased Resistance Stronger Muscle Contractions Required Larger Patient Effort Excessive Work of Breathing Respiratory Failure

  16. Breathing with Lung Disease Flowand/orVolume Normal Disease Patient Effort

  17. Consequences of Respiratory Failure • Excessive Work of Breathing • Respiratory Muscle Dysfunction • Inadequate Alveolar Ventilation • Severe Hypoxia

  18. Goals of Ventilatory Support • Improve Alveolar Minute Ventilation • Decrease the Work of Breathing • Correct Gas Exchange Abnormalities

  19. Types of Ventilatory Support • Invasive • endotracheal tube • tracheostomy • Noninvasive • mask

  20. Home NIV Objectives • Correct hypoventilation and associated syndromes (like OSA): • Despite the leaks • Ensuring a good comfort • Preserving a good quality of sleep • Provide a comfortable ventilation to ensure a good patient compliance • May prefer comfortable parameters (IPAP, EPAP, RR) with a higher CO2 level • Adapt the patient to his therapy takes time: if it has already failed once then it is even more difficult the second time!

  21. Expected Results

  22. Which pathologies would benefits from Home NIV?

  23. What is CRF? • Chronic respiratory failure (CRF) may result from different pathologies, which make the body inept to bring oxygen and/or wash out its CO2. • As a result there is a decrease of the PaO2 (hypoxemia) and/or an increase of the Pa CO2 (hypercapnia) noticed during blood gases analysis

  24. Chronic Respiratory Failure Patients Management « The management strategy is based on an individualized assessment of disease severity and response to various therapies. » Source: Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease GOLD scientific committee - NHLBI/WHO workshop summary - AJRCCM 2001 Therapy depends upon the patient’s pathology type and severity

  25. COPD and Ventilation

  26. COPD Patient Some definitions COPD Chronic Obstructive Pulmonary Disease is the name given to the progressive narrowing of the airways This narrowing may result from an obstruction of the airways in patients with Chronic Bronchitis (scarring of the airways and sputum secretion) or emphysema Emphysema Emphysema is brought about by cigarette smoking which results in chemical changes that destroy lung tissue: • Loss of lung tissue: reduction of elasticity • Airways tend to close

  27. COPD Swollen airways Alveoli collapse Phlegm damages the tissue Chronic Bronchitis Narrowed airways Emphysema

  28. Pink pufferEmphysema dominant COPD Blue bloaterBronchitis dominant

  29. Moderate stage Severe stage Worsening airflow limitation Severe airflow limitation Mild stage Mild airflow limitation COPD Patient Therapies <70% FEV1/FVC <30% Drugs & Physiotherapy Long Term Oxygen Therapy Noninvasive Ventilation « As the disease progresses, hypoxemia occurs and hypercapnia is seen in advanced disease » Source: Global Strategy for the Diagnosis, Management, and Preventation of Chronic Obstructive Pulmonary Disease GOLD scientific committee - NHLBI/WHO workshop summary - AJRCCM 2001

  30. COPD Patient Oxygen Therapy • LTOT (12-17hrs/day) has been shown to • Increase survival • Decrease hospitalization rate • Adverse effects: • Hypoventilation and CO2 retention • Increased PaCO2 at night may contribute to arousals • Sudden High PaCO2 deteriorate the gas balance and may lead to acidosis (exacerbation risks)

  31. COPD PatientsHome NIV Therapy • Conflicting results of studies • COPD population likely to benefit from NIPPV : • Substantial daytime CO2 retention • Severe airway obstruction • Nocturnal oxygen desaturation • Benefits: • Reduce nocturnal hypoventilation: allows respiratory centre to reset, improves daytime hypercapnia. • Improve sleep quality by reduced episodes of hypoventilation and desaturations • Resting chronically fatigued respiratory muscles, allowing recovery of inspiratory muscle function • Decrease Decompensation episodes risks/severity Benefits: improve patient quality of life Source:Consensus conference : « Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD and Nocturnal hypoventilation » Chest 1999

  32. COPD Patient & NonInvasive Ventilation • Gas exchange criteria • Daytime PaCO2 > 55 mmHg or • Nocturnal oxygen desaturation : SaO2 < 88% for > 5 min sustained while receiving oxygen therapy (<2l) • PaCO2 of 50-54 mmHg and hospitalization related to recurrent episodes of hypercapnic respiratory failure (> 2 episodes in 1 year) Source:Consensus conference - Chest 1999 • Criteria usually followed in the daily practice: • Repeated decompensation episodes in the last 3 months • High CO2level • Acceptation of the therapy (compliance: 8hrs ventilation at night)

  33. Evidence Statements from NICE • Addition of NIV to LTOT improved daytime PaCO2 during oxygen breathing • Resting dyspnoea improved in NIV+LTOT group, and was significantly better at month 24 • After 2 years QOL was significantly improved • Overall hospital admissions decreased by 45% in the NIV+LTOT group compared with increase of 27% in LTOT (follow back period of 12 months) http://thorax.bmjjournals.com/content/vol59/suppl_1/

  34. NICE Recommendation Adequately treated patients with chronic hypercapnic respiratory failure who have required assisted ventilation (whether invasive or non-invasive) during an exacerbation or who are hypercapnic or acidotic on LTOT should be referred to a specialist centre for consideration of long-term NIV. Chronic Obstructive Pulmonary Disease: National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care Thorax 2004;59(suppl 1) 1-232

  35. Restrictive Patients and Ventilation

  36. Restrictive PatientsDifferent Diseases • Obese Hypoventilation • Chest wall deformities • Kyphoscoliosis • Sequel of tuberculosis • Non progressive or slowly progressive neuromuscular disorders • Central hypoventilation • Spinal cord injury, spinal muscular dystrophy • Myopathies • Sequel of Poliomyelitis • Progressive neuromuscular disorders • Amyotrophic Lateral Sclerosis (ALS) • Duchenne muscular dystrophy

  37. Restrictive PatientsPathology Progression <50% FVC <20% Mild stage Moderate stage Severe stage Physiotherapy Noninvasive Ventilation Invasive ventilation Source: book “Assistance Ventilatoire à Domicile” D Robert, B.J. Make, P Léger, A. L. Goldberg, J. Paulus, T. Willig – 1994 Source: Consensus Conference - Chest 1999

  38. Restrictive Patients • 10 years ago: Invasive ventilation/volume at the late stage of the disease • Today: • Start at the early stage in pressure support • Use security functions while patient becomes dependant • Ends up with invasive ventilation (< 5% of patients) “More recent reviews have cited the advantages of pressure targeted devices for comfort and their ability to compensate for leaks. Volume targeted equipment may be favorable for many patients simply because triggering mechanism are more adjustable and pressure targeted systems are not able toguarantee a minimum minute ventilation.” Source: Consensus Conference - Chest 1999

  39. Restrictive PatientsWhen shall we start NIV? • Gas exchange criteria • PaCO2 > 45mmHg • Or SaO2<88% during 5min • Or VC<50% of predicted Source:Consensus conference - Chest 1999

More Related