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Use of Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure

Use of Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Mehrdad Ghaffari M.D Pulmonary/critical care/Sleep medicine The University of Tennessee Health Science Center Memphis. European Respiratory Monograph 2001; pages106-124. Aims of Positive Pressure Ventilation.

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Use of Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure

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  1. Use of Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Mehrdad Ghaffari M.D Pulmonary/critical care/Sleep medicine The University of Tennessee Health Science Center Memphis

  2. European Respiratory Monograph 2001; pages106-124.

  3. Aims of Positive Pressure Ventilation • To improve the pathophysiology of ARF • To reduce the work of breathing • To correct gas exchange abnormality • To ameliorate dyspnea

  4. Endotracheal Intubation • Invasive procedure • Potential complications • Discomfort • Confines the use of PPV to severe ARF

  5. Endotracheal TubeComplications

  6. Chest 1996;109: 179-93 Endotracheal Tube vs Mask • Since 1989 there has been a rapid increase in both published and clinical use of an alternative interface • 1997-2007: > 1,500 papers and 14 meta-analyses

  7. Early ARF Resolving ARF Mask ET Mask ET Evolving ARF Respiratory failure Resolving ARF Endotracheal Tube vs MaskComplimentary role

  8. Evidence for NPPV in ARF

  9. Advantages of NPPV in ARF • Flexibility in initiating and removing MV • Avoids ETI-associated complications • Decreases the need for invasive monitoring • Preserves airway defense mechanisms • Preserves speech and swallowing • Improves patient comfort • Decreases sedation requirements

  10. Reduction in VAP Respiratory Care 2004; 49: 810-829.

  11. Outline Patient SelectionVentilator Settings Interface Adjustments for air leak  Modes of ventilationCommunication  Initial setupMonitoring  ComfortCriteria to discontinue NPPV

  12. Patient Selection • Alert and cooperative  COPD and CO2 narcosis  Anxious patients may improve with NPPV • Absence of contraindications (next slide) • Managed only by experienced personnel • Morbidly obese • Acute myocardial infarction

  13. Contraindications • Cardiac or respiratory arrest • Hypoxemia refractory to 100% FiO2 by NRM • Nonrespiratory organ failure • Severe encephalopathy (e.g, GS < 10) • Severe upper gastrointestinal bleeding • Hemodynamic instability or unstable cardiac arrhythmia • Facial surgery, trauma, or deformity • Upper airway obstruction, excluding vocal cords edema • Inability to cooperate/protect the airway • Inability to clear copious amount of secretions • High risk for aspiration Am J Respir Crit Care Med 2001; 163:283-291.

  14. Interface: Nasal vs. Facial Mask Hess D. Respiratory Care 2004; 49: 810

  15. Interface: Facial Masks • Type of seals • contoured cushion • bladder cushion • foam cushion • double spring • Positions of prongs • central • peripheral

  16. Newer masks

  17. C B E D A Italian perspectives: Helmet • Latex-free transparent PVC • Secured by 2 arm = pit braces (A) at two hooks (B) of the metallic ring (C) joining helmet with a soft collar (D) • A seal connection (E) allowsthe passage of NGT Courtesy of Dr Massimo Antonelli (Rome)

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