Transcript Long Term Ventilation

Practical Points in NIV
นพ.รัฐภูมิ ชามพูนท
รพ.พุทธชินราช
ใครในภาพต่ อไปนีไ้ ม่ ได้ เป็ น
พรีเซนเตอร์ ต่อต้ านการสูบบุหรี่
What is NIV
Mechanical ventilation without
using invasive airway
When to use NIV
•Before Intubation
•Follow Extubation
TYPE of NIV
2 Types
1. Negative Pressure
2. Posive Pressure (NIPPV)
Normal breathing (Negative pressure breath)
pressure
+2
0
-2
Mechanical ventilation(positive pressure ventilation)
0
TYPE of NIV
1.Negative Pressure
Can be provided without artificial airway
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Emerson Iron Lung (Past)
Chest Cuirass
Pneumobelt
Rocking Bed
Postpolio era
Use in Home mechanical ventilation
 Communicate more effective
 Neuromuscular disease
X Intrinsic lung disease
X Body temp regulation
X Not very comfortable
TYPE of NIV
2. Positive Pressure(NIPPV)
• Higher than atmospheric pressure
• Push air into the lung
• Can be provided with artificial airway
(variety Interface)
Mode of NIPPV
• Volume limited Ventilation
– Pressure varied
– Discomfort , Gastric distention  Intolerance
– Air leakage
• Pressure limited Ventilation
– CPAP
– BiPAP
– PAV
• Mixed Volume and Pressure Limited Ventilation
Pressure-Limited Ventilation
1. CPAP
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Simplest
Constant pressure provided through inspiration
and expiration
Decrease WOB , Increase FRC & Gas exchange
2. BiPAP/NPPV
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IPAP V.S. EPAP
Less expiratory resistance
Spontaneous , Timed , S/T Mode
3. Proportional Assisted Ventilation (PAV)
Interface
Nasal Mask
• Advantages
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Less risk of aspiration
Easier secretion clearance
Less claustrophobia
Easier speech
May allow patient to eat
Easy to fit and secure
Less dead space
• Disadvantages
– Mouth leak
– Higher resistance through
nasal passage
– Less effective with nasal
obstruction
– Nasal irritation and
rhinorrhea
– Mouth dryness
Oronasal Mask(full face)
• Advantages
– Better control of mouth
leak
– More effective with mouth
breathers , particularly
during acute application of
NIPPV
• Disadvantages
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More dead space
Claustrophobia
More risk of aspiration
More difficulty in eating
and speaking
– Asphyxiation if ventilator
malfunction
Circuit Type
• Single Limb
• Double Limb
Single Limb circuit system
Single Limb circuit system
2 Limb circuit system
2 Limb circuit system
Leak valve system
หายใจไม่ ออก!
ไม่มี Leak valve ใน circuit
Leak valve system
ค่ อยยังชั่วหน่ อย
แต่ ทาไมลมดันไม่ หยุด
มี Leak valve ใน circuit
Initial Settings
• EPAP = CPAP
• IPAP = Pressure Support
(Include PEEP or above PEEP)
• Back up Rate
• Pramp(Rising Time)
Optional
• FiO2
Pressure support ventilation(PS)
• The faster the initial rise to peak flow level,the
sooner the set pressure limit is reached
• Slow rise to set pressure level is more
comfortable for the patient
• Exessively fast rise to peak flow may cause the
ventilator to overshoot the initial pressure limit
and create a pressure spike,which can cause
discomfort and increase WOB
FAQ
1.อย่ างนั้น mode CPAP with PS ในเครื่อง
Invasive Mechanical ventilator ก็
คือ NIPPV(Bilevel CPAP) ใช่ หรือไม่ ??
เหมือนจะใช่ แต่ ไม่ ใช่
Phase variables
4 phases
• The change from expiration to inspiration
(triggered)
• Inspiration (limited)
• The change from inspiration to expiration
(cycled)
• Expiration (baseline ,PEEP)
pressure
inspiration
expiration
inspiration
expiration
5
limit
0
time
baseline
trigger
cycle
Pressure support ventilation(PS)
•
Typically used in the SIMV mode to
facilitate weaning in a difficult to wean
patient
1. Increase spontaneous Vt
(set PS until a desired spontaneous Vt)
2. Decrease spontaneous respiratory rate
(set PS until a desired spontaneous RR)
3. Decrease the work of breathing
Pressure support ventilation(PS)
End flow(resp. cycle off)
Rise time
NIV ต้ องมี Leak
บ้ าง
ถ้ าใช้ CPAP with PS mode แทนจะเกิด
• Auto-Triggering
• Prolong Inspiratory Time
• Alarm Low MV or Low Vt
วิธีแก้ปัญหาเหล่านีใ้ นเครื่อง (TRUE) NIV
• Auto-Triggering
Trigger Adaptation(Re-adjustment baseflow)
Volume trigger eg.6 ml
Shape signal
วิธีแก้ปัญหาเหล่านีใ้ นเครื่อง (TRUE) NIV
• Prolong Inspiratory Time
 Good quality Leak compensation
 Spontaneous expiratory Threshold
(% Peak flow cycle adaptation)
 Shape signal cycle
 Safety Feature eg.Flow reversal,max 3
sec inspiratory time
True NIV
IPAP
PRESSURE Cm H2O
EPAP
Variable Cycle
Threshold
Adjustable Baseflow
Variable Trigger
Threshold
FAQ
2. ใช้ แทนกันได้ ไหม???
ไม่ ควร... ไม่ ได้ ครับ
3.ทาไม NIV ในแต่ ละเครื่อง
จึงสบายไม่ เท่ ากัน?
• Leakage compensation
• Trigger Adaptation
• Inspiration Termination (cycle)
NIV made simple
ไม่ ง่ายนะจ้ ะ
Close monitoring
COPD Exacerbation
(7.30≤pH<7.35)
Interface and type of circuit
• nasal mask
• Single limb with leakage valve
Initial Settings
• EPAP 4-8 cmH2O
• IPAP 8-10 (above EPAP 4-6) cmH2O
titrate until Vt 400-500
• Back up rate 8-10/min
• FiO2 keep SpO2 >92%
Severe COPD
Exacerbation(pH< 7.30)
Interface and type of circuit
• Oro-nasal mask
• Single limb with leakage valve
Initial Settings
Close monitoring
• EPAP 4-8 cmH2O
• IPAP 8-10 (above EPAP 4-6) cmH2O
titrate until Vt 400-500
• Back up rate 8-10/min
• FiO2 keep SpO2 >92%
Cardiogenic Pulmonary edema
Interface and type of circuit
• Oro-nasal mask (High Flow system )
• Single limb with leakage valve
Initial Settings
Close monitoring
• EPAP 4-8 cmH2O titrate until ≈ 8-10
• IPAP 8-10 (above EPAP 4-6) cmH2O
titrate until Vt 400-500 (OPTIONAL)
• Back up rate 8-10/min
• FiO2 keep SpO2 >92%(High FiO2)
Hypoxic Respiratory Failure
Interface and type of circuit
• Oro-nasal mask (High Flow system )
• Single limb with leakage valve
Initial Settings
Close monitoring
• EPAP 4-8 cmH2O
• IPAP 12-25 (above EPAP 8-20) cmH2O
titrate until Vt 400-500
• Back up rate 12-16 /min
• FiO2 keep SpO2 >92%(High FiO2)
How to succeed in NIV
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Good candidate
Good initial settings
Good monitoring
Good criteria for termination
(change to invasive)
• Not too bad ventilator!!
Long-term Mechanical Ventilation
• Home Mechanical Ventilation
• Non-invasive Ventilation(NIV)