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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 Mehrdad Ghaffari M.D Pulmonary/critical care/Sleep medicine The University of Tennessee Health Science Center Memphis
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
Endotracheal Intubation • Invasive procedure • Potential complications • Discomfort • Confines the use of PPV to severe ARF
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
Early ARF Resolving ARF Mask ET Mask ET Evolving ARF Respiratory failure Resolving ARF Endotracheal Tube vs MaskComplimentary role
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
Reduction in VAP Respiratory Care 2004; 49: 810-829.
Outline Patient SelectionVentilator Settings Interface Adjustments for air leak Modes of ventilationCommunication Initial setupMonitoring ComfortCriteria to discontinue NPPV
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
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.
Interface: Nasal vs. Facial Mask Hess D. Respiratory Care 2004; 49: 810
Interface: Facial Masks • Type of seals • contoured cushion • bladder cushion • foam cushion • double spring • Positions of prongs • central • peripheral
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)