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Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting

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Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting By: Susan P. Pilbeam, MS, RRT, FAARC John D. Hiser, MEd, RRT, FAARC – PowerPoint PPT presentation

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Title: Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting


1
Part II Introduction to Noninvasive Positive
Pressure Ventilation in the Acute Care Setting
  • By Susan P. Pilbeam, MS, RRT, FAARC
  • John D. Hiser, MEd, RRT, FAARC
  • Ray Ritz, BS, RRT, FAARC
  • American Association for Respiratory Care
  • December, 2006

2
Benefits of Using NPPV
  • NPPV provides greater flexibility in initiating
    and removing mechanical ventilation
  • Permits normal eating, drinking and communication
    with your patient
  • Preserves airway defense, speech, and swallowing
    mechanisms

3
Benefits of Using NPPV Compared to Invasive
Ventilation
  • Avoids the trauma associated with intubation and
    the complications associated with artificial
    airways
  • Reduces the risk of ventilator associated
    pneumonia (VAP)
  • Reduces the risk of ventilator induced lung
    injury associated with high ventilating pressures

4
Other Benefits of Using NPPV
  • Reduces inspiratory muscle work and helps to
    avoid respiratory muscle fatigue that may lead to
    acute respiratory failure
  • Provides ventilatory assistance with greater
    comfort, convenience and less cost than invasive
    ventilation
  • Reduces requirements for heavy sedation
  • Reduces need for invasive monitoring

5
Additional Benefits of NPPV in the Acute Care
Setting
  • Preserves the ability to communicate
  • Enhances patient comfort

6
Examples of Patient Problems that may Benefit
from NPPV in the Acute Care Setting
  • Acute Exacerbation of COPD
  • Hypoxemic Respiratory Failure/ARDS
  • Community Acquired Pneumonia (CAP)
  • Asthma
  • Immunocompromised States
  • Acute Cardiogenic Pulmonary Edema (CPE) - when
    hypercapnia is present.

7
Additional Examples of Disorders in which NIPPV
by Nasal or Face Mask has been Used
  • Neuromuscular disorders
  • Central alveolar hypoventilation
  • Cystic fibrosis
  • Bronchiectasis
  • Postoperative complications
  • Postextubation failure in difficult-to-wean
    patients
  • Do-not-intubate patients

8
First Step Selection Criteria for Patients in
the Acute Care Setting
  • Consider the patient's diagnosis, clinical
    characteristics and the risk of failure of the
    procedure
  • Applying NPPV too early may be unnecessary for
    patients with mild respiratory distress
  • On the other hand, applying NPPV when a patient
    has already deteriorated to severe respiratory
    failure may potentially delay life-saving
    intubation and ventilation

9
Establishing the Need for Ventilation
  • Signs and Symptoms of Distress in the Adult
  • Tachypnea (respiratory rate gt24 breaths/min)
  • Accessory muscle use, and paradoxical breathing
  • ABG results
  • pH lt 7.35 and PaCO2 gt 45 mm Hg, or
  • PaO2/FiO2 lt 200

10
Patient Medical History
  • The underlying patient disorder must be taken
    into account
  • For example, does the patient have acute
    respiratory failure with a history of COPD. Or,
    does the patient have acute congestive heart
    failure with an elevated CO2?
  • Next exclusionary criteria must be evaluated

11
Second Step Exclusionary Criteria
  • Respiratory arrest (apnea) or the need for
    immediate intubation
  • Unable to protect the airway (impaired cough or
    swallowing)
  • Excessive secretions
  • Hemodynamic instability
  • Agitated and confused patients
  • Paradoxical breathing
  • Upper airway obstruction

12
Additional Exclusionary Criteria
  • Facial deformities or conditions that prevent
    mask fit, e.g. facial burns, severe facial
    trauma, craniofacial surgery, fixed anatomic
    abnormalities of the nasopharynx

J Crit Care 2004 Vol. 1982-91
13
Additional Exclusionary Criteria
  • Untreated pneumothorax
  • Uncooperative or unmotivated patients
  • Brain injury with unstable respiratory drive
  • Other major organ involvement for example,
    severe hemorrhaging
  • Recent esophageal or gastric surgery (relative
    contraindication)
  • Finally, irreversibility of disorder

14
NPPV Initiated
  • Once the patients signs and symptoms are
    evaluated,
  • And the underlying disorder is considered,
  • And finally exclusionary criteria are eliminated,
  • Then NPPV may be justified IF the acute
    respiratory failure is likely to resolve in a few
    days.

15
Interfaces
  • A variety of interfaces can be used to provide
    NPPV
  • This section will focus on those devices used in
    the acute care setting

16
Nasal Masks
Respironics Contour Deluxe Mask
17
Fitting Nasal Masks
  • Nasal fitting template
  • Choose the smallest mask without obstructing the
    nostrils

Courtesy of Respironics
18
Anatomic Landmarks for Nasal Mask Fit
  • Anatomic Landmarks
  • Sides of nose
  • Bridge of nose (caution)
  • Above the lip

Courtesy of Respironics
19
Nasal Mask Fit
  • Top of the mask placed just above the junction
    of the nasal bone and the cartilage (dorsum of
    the nasal bridge)
  • The fit should be not pinch the nose at the side
  • The lower part of the mask fits just above the
    upper lip
  • A common error is to pick a mask that is too large

20
Nasal Mask Fit (continued)
  • Foam bridges that attach to the end of the mask
    and rest on the forehead help reduce pressure on
    the bridge of the nose

21
Advantages of Nasal Masks
  • Less risk of aspiration
  • Enhanced secretion clearance
  • Less claustrophobia
  • Easier speech
  • Less dead space

22
Disadvantages of Nasal Masks
  • Mouth leak
  • Less effectiveness with nasal obstruction
  • Nasal irritation and rhinorrhea
  • Mouth dryness

23
Full Face Masks
  • Most often successful in the critically ill
    patient

Respironics PerformaTrak Full Face Mask
24
Mask Fitting is Essential
  • A full face mask surrounds the nose and mouth and
    rests below the lower lip
  • Using a template can give an estimate of the
    appropriate mask size

Courtesy of Respironics, Inc.
25
Fitting Full Face Mask
  • Landmarks
  • Below the lower lip with mouth open
  • Corners of the mouth
  • Just below the junction of nasal bone and
    cartilage

1
Courtesy of Respironics, Inc
26
Full Face Masks
  • It should fit even if the patients mouth is
    slightly open
  • Be sure the mask fits well and does not leak
    excessively, particularly not into the eyes

27
Minimizing Leaks
  • Sometimes leaks are caused by the mask not being
    correctly seated on the face
  • Some leaks can even be caused by excessive
    tension of the head straps. Minimize headgear
    tension (1-2 fingers should fit between head
    straps and face)
  • In patients without a full set of teeth, using a
    full face or total face mask can help minimize
    leaks

28
Advantages and Disadvantages of Oronasal or Full
Face Masks
  • More effective for dyspneic patients
  • Disadvantages
  • Increased dead space
  • Difficulty in maintenance of adequate seal
  • Increased risk of facial pressure sores
  • Claustrophobia

29
More Disadvantages of Full Face Masks
  • Increased risk of aspiration
  • More difficulty with speech
  • Inability to eat with mask in place
  • More difficulty with secretion clearance
  • Possible asphyxiation with ventilator malfunction

30
Nasal Pillows or Nasal Cushions
Pillow Cushion
Nasal Cushion
Nasal Pillows to seal nares
Respironics Comfort Lite? Nasal Mask
31
Nasal Pillows or Nasal Cushions (continued)
  • Suitable for patients with
  • Claustrophobia
  • Skin sensitivities
  • Need for visibility

Respironics Comfort Lite? Nasal Mask
32
Fitting Nasal Pillows or Nasal Cushions
  • Using the plastic sizing gauge, insert each size
    into the nostril
  • Choose the size that best seals the nostril

Courtesy of Respironics, Inc.
33
Total Face Mask
  • Interface selection
  • Total face mask
  • Mouthpiece

Respironics Total? Face Mask
34
Mouthpiece/Lip Seal
  • Mouth pieces with or without lip seals can also
    be used for an interface
  • Their use is generally restricted to patients who
    are ventilator-dependent (chronic conditions)
  • Some mouthpieces are used with nose clips
  • Some patients use custom-made oral appliances for
    ventilation

35
Mask Selection Guide
36
NPPV- Masks With Leaks
  • Vented masks require a vent for exhalation and
    use only one corrugated tube to connect to the
    ventilator

Respironics BiPAP? Vision Noninvasive
Ventilator with a Nasal Mask
37
NPPV Masks Without Leaks
  • Non-vented masks have both inspiratory and
    expiratory lines
  • Exhaled volumes, flows and pressures can be
    monitored

Respironics Esprit? Critical Care Ventilator with
PerformaTrak? SE Full Face Mask
38
Tips on Initiating NPPV Ventilation
  • Essential elements are staff competence and
    patient compliance
  • Have a variety of masks available to ensure a
    proper fit.
  • Change mask if the patients facial contours
    change, for example if facial edema develops

39
Tips on Initiating NPPV Ventilation, (continued)
  • Let the patient breath through the mask before
    connecting the system in order to reduce anxiety
    (Perhaps allow the patient to hold the mask.)
  • If the patient is claustrophobic, try a nasal
    mask (Make sure patient has their mouth closed or
    a chin strap may be needed)

Courtesy of Respironics, Inc.
40
Tips on Initiating NPPV Ventilation, (continued)
  • Place patient in an upright or sitting position
  • Carefully explain the NPPV procedure to the
    patient including goals and potential
    complications

41
Example NPPV Settings
  • Common IPAP orders
  • 8 to 12 cm H2O
  • Adjust to change tidal volume
  • Typical EPAP setting
  • 4 cm H2O
  • Increase to improve oxygenation

Respir Care 200449(1)72-87
42
Initial Ventilator Settings
  • Progressively increase the pressure until the
    ordered pressures are achieved
  • Then assess patient
  • Patients adaptability and comfort
  • Acceptable tidal volumes
  • SpO2 and vital signs

43
Completing NPPV Setup
  • Determine desired FIO2
  • Set back-up rate
  • Begin ventilation, coaching the patient until the
    patient becomes comfortable
  • Monitor SpO2 and adjust FIO2 to maintain O2
    saturation gt 90
  • Monitor HR and respiratory rate

44
Steps For Initiating NPPV
  • Secure the mask to the patient
  • Avoid excessive tightening of the straps. Attach
    the interface to the ventilator (1-2 fingers
    space)
  • Titrate IPAP, EPAP, inspiratory rise time,
    sensitivity (patient trigger), flow cycle,
    exhaled tidal volume, and synchrony with the
    ventilator

45
Steps For Initiating NPPV
  • Avoid peak pressures gt 20 to 25 cm H20
  • Check for leaks and readjust the mask and head
    straps if necessary (It is essential to minimize
    leaks)
  • Small leaks are compensated by most ventilators
  • Allowing a small leak may avoid an excessively
    tight fit and possibly reduce the risk of skin
    breakdown

46
Monitoring the Leak Size
Air Leak Guidelines for Vision? BiPAP?
Noninvasive Ventilator
Note Leak compensation for noninvasive
ventilation in critical care ventilators varies
and could be as low as 20 L/min. Therefore,
management of smaller leaks is required.
47
Predictors of Success with NPPV
  • Positive initial response to NPPV within
    1-2 hours
  • Correction of pH
  • Decreased respiratory rate
  • Reduced PaCO2
  • Synchronous breathing efforts with ventilator
  • Lower quantity of secretions
  • Absence of pneumonia

48
Complications or Problems Associated with NPPV
49
Failure to Ventilate Inadequate Volume
  • Tidal volume is inadequate for patient
  • Check ventilating pressures to be sure the Delta
    P is sufficient for the patient DP
    IPAP EPAP or PS PEEP
  • Be sure the rise time to pressure is sufficient
  • Be sure the flow-cycle criteria is not too
    short, thus compromising volume delivery

50
Failure to Ventilate Lack of Synchrony
  • Patient and ventilator are not synchronous.
  • Check the sensitivity. Is it easy for the patient
    to trigger a breath?
  • Check the rise time to full pressure. Does it
    meet the patients flow demand?
  • Check the flow-cycle criteria during PSV. Make
    sure it is set appropriate for the patient. (see
    section III of this teaching module)

51
Hypotension
  • If hypotension was present prior to therapy,
    treat the cause
  •  If hypotension resulted after initiating NPPV,
    be sure ventilating pressures are not excessively
    high (peak pressures lt 20 cm H20)

52
Risk of Aspiration
  • The risk of aspiration exists in some patients
  • Maintain a policy of selecting patients
    appropriately for NPPV patients who can protect
    their own airway
  • Examples of patients who may not be able to
    protect their airways
  • Stroke victims, and individuals with a drug
    overdose. In these examples, an endotracheal
    tube should be inserted to protect the airway

53
Claustrophobia
  • Try using a nasal interface or,
  • Try using a total face mask, or
  • Try mild sedation (use caution).

54
Gastric Insufflation (Aerophagia) and Gastric
Distention
  • Excessive pressure or air swallowing can cause
    air gastric inflation (insufflation) and gastric
    distention
  • Use pressures less than 20 to 25 cm H2O
  • Use simethicone (anti-flatulent) agent

55
Use of Nasogastric Tubes
  • Use of nasogastric tubes to take air from the
    stomach is controversial
  • The tube increases leaking around the mask
  • The tube itself blocks a nasal passage
  • Compression of tube against the skin by the mask
    may increase risk of skin breakdown

56
Possible Solution with Nasogastric Tubes
  • If an NG tube must be used, one possible solution
    is to use an interface between the tube and the
    skin and mask

Respironics NG Sealing Pad Image
57
Eye Irritation
  • Eye irritation may result from air blowing in the
    eye
  • Be sure mask fit is appropriate
  • Spacers used on the forehead or the bridge of the
    nose, depending on the type of mask, may need to
    be adjusted
  • Readjust headgear straps

58
Skin Problems Due to Interface Devices
  • Skin irritation or rashes may occur due to
    pressure from a mask, frictional irritation
    between the skin and mask or due to allergies to
    the mask material
  • Facial discomfort or pain can also occur

59
Possible Solutions to Skin Irritation
  • Use the least amount of pressure to fit the mask
    that still prevents excessive leaks
  • Use spacers
  • Alternate devices to reduce skin breakdown
  • Use a skin barrier lotion and/or topical
    corticosteroids

60
Skin Problems Due to Interface Devices
  • Pressure lesions (skin breakdown, necrosis) if
    mask is to tight or left on for extended periods
    of time
  • Use of Duodenum or Restore (skin dressings)

61
Poor Sleep Quality
  • Inability to sleep well can be due to many causes
    such as anxiety, frequent disruptions of the
    patient at night during normal sleeping hours,
    discomfort caused by the mask or ventilating
    pressures
  • Using an appropriate medication to reduce
    anxiety, and promote sleep may be appropriate
  • Be sure the patient is able to protect their
    airway and is not likely to aspirate

62
Nasal or Oral Dryness, Nasal Congestion, Mucus
Plugging
  • When these problems occur, possible solutions
    include the following
  • Add or increase humidification
  • Reduce leaks
  • Irrigate nasal passages with a saline spray

63
Nasal or Oral Dryness, Nasal Congestion, Mucus
Plugging
  • Use topical decongestants or steroids
  • Perform oral and/or nasal hygiene
  • If nasal mask is in use, use a chin strap to keep
    mouth closed or change to full face mask

64
Sinus or Ear Pain
  • High inspiratory pressures may affect the ear and
    sinuses
  • Use lower inspiratory pressure to help reduce ear
    and sinus pain
  • Tight fitting masks may also put pressure on the
    nose and upper face and may affect sinus pressure
    and sinus drainage

65
Criteria for Termination of NPPV for Invasive
Ventilation
  • Worsening pH and PaCO2
  • Tachynpnea (gt 30 breaths/min)
  • Hemodynamic instability
  • SpO2 lt 90
  • Decreased level of consciousness
  • Inability to clear secretions
  • And inability to tolerate interfaces

66
Predictors of Success with NPPV
  • Higher level of consciousness
  • Younger age
  • Lower severity of illness no co-morbidities
  • Less severe gas exchange (pH lt 7.35, gt 7.10
    PaCO2 lt 92 mm Hg)
  • Minimal air leakage around the interface
  • Dentition intact

67
Weaning
  • If NPPV is successful, the patient may only
    require support for 2 to 3 days or less
  • Currently there is no specific procedure for
    weaning from mechanical ventilation
  • Trials of NPPV as tolerated

68
Weaning Algorithm
NO
YES
Continue with NPPV therapy
Trial off NPPV with supplemental oxygen
Slowly titrate IPAP downward in decrements of 2-3
cm H2O
If patient status does not improved consider
intubation
Does patient demonstrate clinical evidence of
respiratory distress?
NO
Discontinue NPPV and place on supplemental oxygen
YES
Restart NPPV at previous settings
Respir Care 2004. Vol. 49 (1)72-89
69
Section Summary
  • This section has reviewed initiating NPPV, the
    interfaces used in NPPV, complications and
    problems along with possible solutions, and
    weaning from NPPV
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