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Position Mask Initial ventilatory setting Comfort Nasogastric tube placement

Initial Setup. Position Mask Initial ventilatory setting Comfort Nasogastric tube placement. Mask. Position head of the bed at a 45° angle Select the correct size mask. Mask. Connect the mask to the ventilator. Comfort. Explain the modality and provide reassurance

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Position Mask Initial ventilatory setting Comfort Nasogastric tube placement

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  1. Initial Setup • Position • Mask • Initial ventilatory setting • Comfort • Nasogastric tube placement

  2. Mask • Positionhead of the bed at a 45° angle • Select the correct size mask

  3. Mask • Connect the mask to the ventilator

  4. Comfort • Explain the modality and provide reassurance • Hold the mask in place until patient is • comfortable • in synchrony with the ventilator • Secure the mask avoiding a tight fit • Skin patch to minimize abrasion and necrosis • nasal bridge and chin

  5. Mask • Hold the mask until the patient is • Comfortable and • In synchrony with the ventilator

  6. Mask • Secure the mask and avoid a tight fit

  7. Mask • Allow passage of two fingers beneath head straps • Allow small air leaks if exhaled Vt is adequate

  8. Nasogastric Tube • Avoid nasogastric tube placement • resting upper esophageal sphincter pressure = 33 ± 12 mmHg • aerophagia is rare with peak mask pressure < 25 cmH2O • Monitor forabdominal distention

  9. Ventilatory Parameters • Adjust to patient needs • increase CPAP to ≥ 5 cmH2O* • increase PSV to • – VT > 7ml/kg and RR < 25 bpm • – relaxation of sternocleidomastoid muscle (palpation) • – highest exhaled Vt without significant air leak • Adjust to patient comfort • avoid contraction of transversus abdominal m. • ask what setting is the most comfortable • * CPAP offsets PEEPi and recruits alveoli but may worsen air leakage

  10. Ventilatory Parameters • CPAP ≥ 5 cmH2O • PSV to Vt > 7 ml/kg and RR < 25 bpm • Reset alarms and apnea backup

  11. Delivery of Mechanical Ventilation • Continuous until resolution of ARF • intermittent 5-15 m breaks, Q 3-4 has tolerated • – stable patients with CPAP < 5cm H2O • – once stable, after 4-6 h of continuous NPPV • – remove face mask, providing adequate FiO2 for: • oral intake (liquid diet, medications) or expectoration • – 6-12 hours/day for several days

  12. Thorax 2002; 57: 192-211.

  13. Changes in PaCO2 and pHHypercapnic respiratory failure Chest 1996; 109: 179

  14. Changes in PaO2:FiO2 over time Forty patients with hypoxemic ARF - ABG correction in 31 (78%) Chest 1996; 109:179

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  16. Criteria to Discontinue NPPV • Need for endotracheal intubation to •  protect airways •  clear copious amounts of secretions • Cardiovascular instability •  hypotension or significant arrhythmia • Inability to improve •  gas exchange •  mental status •  dyspnea • Intolerance to NPPV

  17. Mask Mask ET ET Resolving ARF Evolving ARF Respiratory failure Duration of Mechanical Ventilation UT experience with 203 patients: mean duration of MV 25 hours • earlier intervention • avoiding sedation and paralysis • reduced incidence of MV-induced respiratory muscle atrophy 1 • eliminating the imposed work by the endotracheal tube • lower rate of complications, especially infections 2-6 • earlier removal 1. Le Bourdelles et al. AJRCCM 1994;149:1539-1544. 2. Brochard et al. NEJOM 1995; 333: 817-822. 3. Antonelli et al. NEJOM 1998; 339: 429-435. 4. Guerin et al. Intensive Care Med. 1998; 24: 27. 5. Nourdine et al. Intensive Care Med. 1999; 25:567-573. 6. Girou et al. JAMA 2000; 284: 2361-2367.

  18. Conventional MV with ETI Early Established Resolving Post-extubation 1 2 4 3 Timing of NPPV Application • 1. Early: to prevent intubation • 2. Established: as alternative to intubation • 3. Resolving: to wean from ventilation • 4. Post-extubation: to prevent re-intubation

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