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Non Invasive Ventilation in copd

Non Invasive Ventilation in copd Sarah Davey Specialist Registrar Emergency Medicine. Pinderfields General Hospital. Introduction NIV is the provision of ventilatory support through the patient’s upper airway using a mask or similar device.

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Non Invasive Ventilation in copd

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  1. Non Invasive Ventilation in copd Sarah Davey Specialist Registrar Emergency Medicine. Pinderfields General Hospital.

  2. Introduction • NIV is the provision of ventilatory support through the patient’s upper airway using a mask or similar device. • NIV is patient triggered and air/oxygen is delivered under preset pressure. • NIV used in treatment for hypercapnic respiratory failure, particularly in those patients with COPD. • NIV may avoid intubation and avoid ICU/HDU admission.

  3. Terminology • IPAP – Inspiratory Positive Airways Pressure. - Pressure set during inspiration. - Cm of H2O above atmospheric. - Increases Tidal volume, reduces work of breathing and increases alveolar ventilation, reducing pCO2. * usually set at 10-14 cmH2O and gradually increased as tolerated to a max. 20 cmH2O.

  4. Terminology Cont. • EPAP – Expiratory Positive Airways Pressure. - Pressure set during expiration. - Recruits under ventilated lung. - Offsets intrinsic PEEP, aids triggering. - Reduces perceived effort. - Serves to vent exhaled gas thru the exhaust port and reduce rebreathing. * Set at 4-5 cmH2O.

  5. Terminology Cont. • BPM – Breaths Per Minute. - Back-up breath rate. - Machine will automatically deliver a breath to the patient if the resp. rate falls below the set value. - Usually set to 12-14 if available.

  6. Terminology Cont. • Rise Time. - Controls the rate of pressure change during transition from EPAP to IPAP phase of ventilation. - i.e. Time taken to reach IPAP pressure. - Intended for patient comfort. - If respiratory rate is high then a faster rise time is required.

  7. Indications In COPD. • Considered in all patients with acute exacerbation of COPD in whom a respiratory acidosis persist despite maximal medical treatment with controlled oxygen therapy. • Respiratory acidosis – pH 7.25-7.35. • Able to protect airway. • Conscious and cooperative. • Haemodynamically stable. • No excessive respiratory secretions • No contraindications.

  8. Contraindications. • Facial trauma/Burns. • Recent facial, upper airway or upper GI surgery * • Fixed obstruction of upper airway. • Inability to protect airway.* • Life threatening hypoxia.* • Haemodynamic instability.* • Severe co-morbidity.* • Impaired consciousness.* • Confusion/agitation.* • Vomiting. • Bowel Obstruction.* • Copious respiratory secretions.* • Focal consolidation on CXR.* • Undrained pneumothorax.

  9. Predictions of Success. • pH 7.25-7.35. • Improvement of pH at 1hr. • Good level of consciousness. • Poor outcome associated with: - Co-existing pneumonia. - Copious resp. secretions. - Edentulous. - Poor nutritional state. - Confusion.

  10. How To Perform. • Practical Time!

  11. Equipment Needed. • BiPAP machine. • Disposable circuit (tubing, filter & expiration port). • Appropriate mask. • Green Oxygen tubing. • SaO2 Monitor.

  12. How To Set Up NIV. • Obtain baseline obs. • Check for contraindications. • Explain procedure to patient and the reasons for use. • Select mask of appropriate size to fit patient. • Set up circuit. • Set ventilator settings. • Commence NIV and apply mask. • Reassess after a few mins. • Add oxygen if sats <85%. (aim sats 90%). • Adjust settings as required. • Request repeat ABG at 1hr adjusting BiPAP accordingly.

  13. Typical Initial Settings. • IPAP – 10-14 cmH2O. • EPAP – 4-5 cmH2O. • Oxygen – 2-4 l/min. • BPM - 12-14/min. • I:E – 1:3

  14. Treatment Failure. • Is Medical management optimal? • Developed complications? • PaCO2 remains high? • PaO2 remains low with PaCO2 improving?

  15. PaCO2 Remains High. • Too much oxygen? - adjust O2 to maintain sats of 85-90%. • Excessive Leak? - check mask fit. • Re-breathing occurring? - check exhaust valve. - consider increasing EPAP. • Poor synchronising with ventilator? - observe patient. - consider inc. EPAP or adjust rate. • Inadequate ventilation? - increase IPAP. - Consider increasing inspiratory time.

  16. PaCO2 improves but PaO2 remains low. • Increased inspired O2. • Consider increasing EPAP.

  17. ?? Questions?

  18. Summary • NIV effect therapy when used in appropriate patients. • Use local protocols. • Know your own equipment. • Seek senior help early.

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