Transcript Part II: Introduction to Noninvasive Positive Pressure Ventilation in the Acute Care Setting By: Susan P.

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
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
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
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
Additional Benefits of NPPV in
the Acute Care Setting

Preserves the ability to communicate

Enhances patient comfort
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.
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
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
Establishing the Need for
Ventilation

Signs and Symptoms of Distress in the Adult
– Tachypnea (respiratory rate >24
breaths/min)
– Accessory muscle use, and paradoxical
breathing
– ABG results:
• pH < 7.35 and PaCO2 > 45 mm Hg, or
• PaO2/FiO2 < 200
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
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
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. 19:82-91
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
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.
Interfaces


A variety of interfaces can be used to
provide NPPV
This section will focus on those devices used
in the acute care setting
Nasal Masks
Dual density
foam bridge
forehead
support
Thin flexible
& bridge
material
Respironics Contour Deluxe™ Mask
Dual flap
cushion
360
swivel
standard
elbow
Fitting Nasal Masks


Nasal fitting template
Choose the smallest mask without
obstructing the nostrils
Courtesy of Respironics
Anatomic Landmarks for
Nasal Mask Fit

Anatomic Landmarks
a) Sides of nose
b) Bridge of nose
(caution)
c) Above the lip
Courtesy of Respironics
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
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
Advantages of Nasal Masks

Less risk of aspiration

Enhanced secretion clearance

Less claustrophobia

Easier speech

Less dead space
Disadvantages of Nasal Masks

Mouth leak

Less effectiveness with nasal obstruction

Nasal irritation and rhinorrhea

Mouth dryness
Full Face Masks

Most often successful in the
critically ill patient
Double-foam
cushion
Adjustable
Forehead Support
Entrainment
valve
Respironics PerformaTrak® Full Face Mask
Pressure
pick-off
port
Ball and
Socket Clip
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.
Fitting Full Face Mask

Landmarks
a) Below the lower lip
with mouth open
c
b) Corners of the mouth
c) Just below the
junction of nasal
bone and cartilage
1
b
b
a
Courtesy of Respironics, Inc
Full Face Masks


It should fit even if the patient’s mouth is
slightly open
Be sure the mask fits well and does not
leak excessively, particularly not into the
eyes
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
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
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
Nasal Pillows or Nasal Cushions
Pillow Cushion
Nasal Cushion
Nasal Pillows
to seal nares
Respironics Comfort Lite Nasal Mask
Nasal Pillows or Nasal Cushions
(continued)

Suitable for patients
with
– Claustrophobia
– Skin sensitivities
– Need for visibility
Respironics Comfort Lite Nasal Mask
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.
Total Face Mask

Interface selection
– Total face mask
– Mouthpiece
Respironics Total Face Mask
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
Mask Selection Guide
NPPV- Masks With Leaks

Respironics BiPAP Vision ® Noninvasive Ventilator
with a Nasal Mask
Vented masks
require a vent for
exhalation and use
only one corrugated
tube to connect to
the ventilator
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
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 patient’s facial contours
change, for example if facial edema
develops
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.
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
Example NPPV Settings
20
IPAP = 12
10
0


PS = 8
EPAP = 4
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 2004;49(1):72-87
Initial Ventilator Settings


Progressively increase the pressure until the
ordered pressures are achieved
Then assess patient
– Patient’s adaptability and comfort
– Acceptable tidal volumes
– SpO2 and vital signs
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 > 90%
Monitor HR and respiratory rate
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
Steps For Initiating NPPV




Avoid peak pressures > 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
Monitoring the Leak Size
Air Leak Guidelines for
Vision BiPAP Noninvasive Ventilator
0-6 L/min
=
Mask may be too tight
7-25 L/min
=
Just right
26-60 L/min
=
Adjust mask and monitor
> 60 L/min
=
Caution
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.
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
Complications or Problems
Associated with NPPV
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
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 patient’s 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)
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 < 20 cm
H20)
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
Claustrophobia
Try using a nasal interface or,
Try using a total face mask, or
Try mild sedation (use caution).
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
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
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
NG tube applied
to groove
Mask interface
across beveled
side
Flat surface
applied on
patient’s face
Respironics NG Sealing Pad Image
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
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
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
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)
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
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
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
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
Criteria for Termination of NPPV
for Invasive Ventilation

Worsening pH and PaCO2

Tachynpnea (> 30 breaths/min)

Hemodynamic instability

SpO2 < 90%

Decreased level of consciousness

Inability to clear secretions

And inability to tolerate interfaces
Predictors of Success with NPPV

Higher level of consciousness

Younger age

Lower severity of illness; no co-morbidities

Less severe gas exchange (pH < 7.35, >
7.10; PaCO2 < 92 mm Hg)

Minimal air leakage around the interface

Dentition intact
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
Weaning Algorithm
Does
patient meet
weaning guidelines?
YES
Slowly titrate IPAP
downward in decrements
of 2-3 cm H2O
Trial off NPPV with
supplemental
oxygen
Does
patient demonstrate
clinical evidence
of respiratory
distress?
NO
 Clinically stable
 RR < 24
 HR < 110
 pH > 7.35
 SpO2 >90%
on< 50%
NO
Continue with
NPPV therapy
If patient status does
not improved consider
intubation
Discontinue NPPV and place on
supplemental oxygen
YES
Restart NPPV at
previous settings
Respir Care 2004. Vol. 49 (1):72-89
Section Summary

This section has reviewed initiating NPPV,
the interfaces used in NPPV, complications
and problems along with possible solutions,
and weaning from NPPV