Non-Invasive Ventilation Strategies for Managing Acute Respiratory Failure in COPD Patients

1. NIMV Dr. Güngör Ateş 16/04/2011

2. No conflict of interest

3. CASE 1 • 66 yo M with known COPD presents with 5 days of worsening dyspnea. RR=30, BP:80/40, pulse oximetry 83%. Alert. • chest discomfort and difficulty in breathing since the last hour ↑ ↑ • ECG: evidence of AMI • Chest X-ray. Lucency ↑ ↑ • lack of significant response to treatment • ABG : pH=7.26, pO2=55, CO2=56, Bicarb=34

4. Treatment does not really help—what should you do? • A. Addition of a diuretic • B. Intubation and ventilation • C. NIMV • D.All of the above

5. BTS GUIDELINE Non-invasive ventilation in acute respiratory failure British Thoracic Society Standards of Care Committee. Thorax 2002;57:192–211 • Chawla R, Khilnani GC, Suri JC, et al. Guidelines for noninvasive ventilation in acute respiratory failure. Indian J Crit Care Med 2006;10:117-47 • Royal College of Physicians, British Thoracic Society, Intensive Care Society Chronic obstructive pulmonary disease: non-invasive ventilation with bi-phasic positive airways pressure in the management of patients with acute type 2 respiratory failure. Concise Guidance to Good Practice series, No 11. London RCP, 2008. • Bernd Schönhofer. Clinical Practice Guideline: Non-Invasive Mechanical Ventilation as Treatment of Acute Respiratory Failure. Dtsch Arztebl Int 2008; 105(24): 424–33. • Sean P. Keenan MD MSc. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ, February 22, 2011, 183(3)

6. Acute Respiratory Failure/ NIMV • Clinical Criteria • Moderate to severe respiratory distress • Tachypnea (>24/min) • Accessory muscle use or abdominal paradox • Gas Exchange Criteria • PaCO2>45 mmHg, pH <7.35; >7.10 • pO2 <60 mm on high flow O2 • Exclusion Criteria (Contraindications)

7. NIMV • Clinical Criteria • Gas Exchange Criteria • Exclusion Criteria (Contraindications) • Respiratory arrest or immediate need for intubation • Medically unstable • Acute MI, uncontrolled arrhythmias, cardiac ischemia, upper GI bleeding, hypotensive shock • Unable to protect airway • Impaired swallowing or cough • Excessive secretion • Agitated or uncooperative • Recent upper airway or esophageal surgery • Unable to fit mask

8. CASE2: • 66 year old male • Smoker /COPD • presents with 3 days of worsening dyspnea and sputum • Pulse 112, RR 33, BP 100/50, alert, afebrile. • Chest: distant wheezes, no infiltration • Increase work of breathing • Treatment initiated with oxygen, nebs, steroids,ab • ABG: pH 7.28, pCO2 58 and pO2 70 on 2l nasal • lack of significant response to treatment

9. What should be the furthercourse of action? • A. Continue treatment with continuous nebulization • B. Consider intubation and ventilation • C. NIMV • D. Addition of a diuretic

10. NIV should be considered for all COPD patients with a persisting respiratory acidosis after a maximum of one hour of standard medical therapy [A] • Patients with a pH <7.26 may benefit from NIV but such patients have a higher risk of treatment failure and should be managed in a high dependency or ICU setting [A]

11. 80 60 40 20 0 0 1 2 3 6 12 24 48 72 NIV in Acute Respiratory Failure: Control 12 (8) 67% NPPV 11 (1) 9% % COPD Patients Needing Intubation * * * p < 0.05 Time in Hours Kramer et al, Am J RespirCrit Care Med 1995; 151: 1799-806

12. Respiratory Failure due to Acute Exacerbation of COPD • First line intervention as an adjunct to usual medical care. NPPV should be considered early in the course of respiratory failure. • Decrease in mortality of 48% • RR=0.52, (95%CI .35-.76) • Decrease of intubation by 59% • RR=.41, (95%CI .33-.53) • Decrease hospital length of stay 3.24 days • 95%CI -4.42 to -2.06 Ram FSF, Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2004. Brochard L et al. N Eng J Med 323:1523, 1990 Krammer N et al. Am J Respir Crit Care Med 15:1799, 1995

13. ABG taken 1 and 2 hours after NIMV, / no improvementWhat is your next step strategy? • A. Cont. NIMV • B. Medical treatment • C. IMV • D.Add nebul. steroids

15. Nasal Masks • Advantages • Less risk of aspiration • Easier secretion clearance • Less claustrophobia • Easier speech • Less dead space • Disadvantages • Mouth leak • Higher resistance through nasal passages • Less effective with nasal obstruction • Nasal irritation and rhinorrhea • Mouth dryness

16. Some are More Complicated than Others

17. Full Face Masks • Advantages • Better ventilation for dyspneic patients • Disadvantages • Increased dead space • Increased risk of facial pressure sores • Claustrophobia • Increased aspiration risk • Cannot speak or eat • Asphyxiation with ventilator malfunction • Difficult to fit

20. Initiating NIMV • Appropriate patient selection and TIME! • Semi-recumbent position • Select mask / comfort (full face mask) • Set IPAP at 8-10 cm/EPAP at 4-5 cm • Titrate IPAP slowly to maintain tidal volume 6 cc/kg snd reduce RR, and EPAP for hypoxemia • Monitor oxygen sats, heart rate and resp. rate

21. Monitoring • ABG: at 1,4 and 12 hours • RR and HR:at 1 hour • Level of consciousness,Chest wall movement, Use of accessory muscles • SpO2 and cardiac monitoring, first 12 hours • Patient comfort/compliance are key factors • Synchrony of ventilation • Assessment of mask fit/skin condition / degree of leak

22. Mask-related Frequency (%) Discomfort 30-50 Facial skin erythema 20-34 Claustrophobia 5-10 Nasal bridge ulceration 5-10 Acneiform rash 5-10 Complications of NIMV

23. Management of Mask-Related Problems • Check fit • Adjust strap • Apply water based jelly to mask contact points • Try new mask type • Apply artificial skin • Adj. pressure

24. Management of Mask-Related Problems • Claustrophobia • Small mask/nasale mask • Sedation • Nasal bridge ulceration • Loosen strap tension • Apply artificial skin • New mask • Acneiform rash • Topical steroids or antibiotics

25. Management of Air Pressure- 0r Flow-Related Problems • Nasal congestion • Nasal steroids • Decongesestants/antihistamine • Sinus/oral dryness • Nasal saline • Add humidifier • Reduce air leak • Sinus/ear pain • Reduce pressure if intolerable

26. Management of Air Pressure- 0r Flow-Related Problems • Eye irritation • Check mask fit • Readjust straps • Gastric insufflation • NG • Simethacone • Reduce pressure if intolerable

27. Frequency (%) Air leaks 80-100 Major complications Aspiration pneumonia < 5 Hypotention < 5 Pneumothorax < 5 Complications of NIMV

28. Management of Air Leaks • Encourage mouth closure • Oro-nasal mask if using nasal mask • Apply water-based jelly to mask contact points • Reduce pressure slightly • Readjust straps

29. Management of Major Complications • Aspiration pneumonia • Select patients carefully • Hypotension • Reduce inflation pressure • Pneumothorax • Stop ventilation if possible • Reduce airway pressure • Insert a thoracostomy tube if indicated

30. Humidification during NIMV • No humidification: drying of nasal mucosa; increased airway resistance; decreased compliance. • HME lessens the efficacy of NIMV • Only pass-over humidifiers should be used Intensive Care Med. 2002;28

31. MESSAGE Compliance with NIV, patient-ventilator synchrony and mask comfort are key factors in determining outcome and should be checked regularly [C] Staff/ appropriately trained and experienced [B]

32. THANK YOU