1. Dr. Masroor Afreedi Non Invasive Ventilation

2. What is it?

3. What is it? Respiratory support given without an endotracheal tube Spontaneously breathing patients

4. Normal Breathing • negative pressure • air is drawn in when the diaphragm descends

5. 3 types: IPPB Intermittent Positive Pressure Breathing CPAP Continuous Positive Airways Pressure BiPAP Bi-level Positive Airways Pressure

6. CPAP High flow oxygen + PEEP • Wispaflow • Dräger Raises FRC away from residual volume Splints alveoli open:  work of breathing  PaO2 re-expand atelectasis Helps resolution of pulmonary oedema

7. Lung Capacities Maximal inspiration TV Resting expiratory level FRC Maximal expiration RV

8. Closing Volume and Functional Residual Capacity FRC Increased CV CV Decreased FRC FRC – Functional Residual Capacity CV – Closing Volume

9. BiPAP IPAP + EPAP EPAP = PEEP Inspiratory pressure increases tidal volume •  PaCO2 •  PaO2 •  work of breathing and fatigue

10. Terminology 16 12 IPAP Pressure Support 8 4 EPAP 0

11. CPAP or BiPAP?

12. Respiratory Failure Type I low PaO2 < 8 kPa all else normal Type II low PaO2 high PaCO2

13. ABGs Normal Values pH 7.35 - 7.45 PaO2 10.7 - 13.3 kPa PaCO2 5.6 - 6.7 kPa HCO3- 22 - 26 mmol BE -2 - +2

14. Type I Failure Type II Failure Hypoxia Hypercapnia Hypoxia CPAP BiPAP

15. Clinical benefits Acute • Type I respiratory failure • Type II respiratory failure • Pulmonary oedema Sub-acute • Weaning • Post-extubation Chronic • Sleep apnoea • Type II respiratory failure • COPD • CF • Neuromuscular diease

16. Precautions • Impaired consciousness • Confusion/agitation • CXR showing consolidation • Drained pneumothorax • Copious secretions • Inability to protect airway • Haemodynamic instability • Recent upper GI surgery or bowel obstruction

17. Contraindications • Need for immediate intubation • Facial trauma/burns • Frequent vomiting • Recent facial/upper airway surgery • Undrained pneumothorax

18. Advantages of avoiding intubation No paralysis or sedation • Ability to move – pressure relief • Able to communicate • Able to eat and drink • Self care • Less need for invasive monitoring • Less risk of infection

19. No endotracheal tube •  infection risk • No tracheal damage • Able to communicate Decreased need for ITU • Cost • Patient and carer experience • Less debilitating

20. Implications • Mask fitting • Deoxygenation • Expectoration • Familiarity with machines/alarms

21. Skills needed • Patient handling/communication • Knowledge of respiratory physiology • Familiarity with interfaces • Knowledge of pressure area care • Time to spend with patient • Patience

22. Thank you