Guideline for the use of Non-Invasive Ventilation (NIV) TCP 180

Transcription

1 Guideline for the use of Non-Invasive Ventilation (NIV) CROSS REFERENCE Progress/date of approval This Strategy/ Policy should be read in conjunction with: Mental Capacity Act Policy -TCP 199 June 2009 Infection control - IC Management of medical devices training May 2009 TCP163 Guideline for the use of CPAP in acute Under development (lead Sarah Young) cardiogenic pulmonary oedema Minimum standard for patient Under review observations TCP188 Manager Responsible Author Denise Hinge & NIV group Date: September 2009 Policy Number Version number 2 Approving Committee Trustwide Clinical Policies Signed by Chair of the Committee Review Date August of 21

2 Consultation and Ratification Schedule Name of Committee Date of Committee NIV Group 29 April 2009 Trustwide Clinical Policies May 2009 The group have reviewed the policy development over the period from April to September 2009 Name of Person / Team Dr Mark B Jackson Dr Jenny Messenger Denise Hinge Dr Mark Jackson Steve Hunter Marie Dormer Katy Osbaldeston Debbie Eaton Dr Paul Ransom Anne Christensen Sarah Goodhew Date Acknowledgements This policy has been adapted from the template policy from the British Thoracic Society (2008) Impact Assessment This policy was screened for impact assessment on 20 August 2009 and does not require full impact assessment (see appendix 8) 2 of 21

3 CONTENTS PAGE 1.0 Introduction and key principles Respiratory failure definition 2.0 Patient selection and management plan Stratification Inclusion criteria Exclusion criteria Patient management Management and care of patient on NIV Initial settings Ongoing care Weaning from NIV Hospital discharge Equipment 4.1 Decontamination Equipment purchase Knowledge and skills Documentation Monitoring for effectiveness References 9 APPENDICES 1 NIV Prescription chart 10 2 NIV audit tool 12 3 Set up guide 13 4 Troubleshooting guide 14 5 NIV Competency framework 16 6 Core care nursing plan 17 7 Ordering consumables 19 8 Impact assessment screening tool 20 3 of 21

4 1.0 Introduction and key principles This guideline is for use by the multi-professional team (trained nursing staff, physiotherapists and medical staff) in the acute hospital setting. 1.1 Responsibilities It is the responsibility of the individual nursing, physiotherapy and medical team to ensure that they are competent in the use of NIV devices if regularly caring for patients who require this therapy. Ward managers should keep records of staff training and achievement of competence in the use of NIV. 1.2 Key principles Non invasive ventilation (NIV) is the provision of ventilatory support through a patients upper airway using a mask or similar device (RCP/ BTS /ICS 2008). The choice of NIV therapy will depend on the patients underlying problem and may be: Continuous Positive Airways Pressure (CPAP) or Bi-Level positive airways pressure These treatments may be used as the sole treatment, a holding measure, a trial prior to intubation or the ceiling of treatment (BTS 2002) with the aim to produce: Decreased work of breathing Increased tidal volume Decreased respiratory rate CPAP is indicated for patients with acute hypoxaemia respiratory failure or cardiogenic pulmonary oedema. This guidance does not cover the intended use of CPAP within BSUH. BiPAP is indicated in the ward environment for patients with chronic obstructive pulmonary disease (COPD) with hypercapnic respiratory failure but can be used in specialist areas such as the intensive care unit (ICU) for other indications such as weaning from invasive ventilation. NIV is generally contra indicated in patients with asthma and those patients who do not respond to early treatment. NIV has been used to support patient care in critical care areas (A/E, ICU and HDU) and ward areas for a considerable time. Recently there has been an increase in the use of NIV in ward areas as the evidence for this therapy increases and the ward population becomes more acute. For example the National Institute for Clinical Excellence (NICE) guidance for the management of COPD (2004) recommend that all acute units that admit patients with exacerbations of COPD should have the capability to provide NIV 24 hours/day. This policy identifies the expected standard of care required for patients receiving NIV and identifies the minimum standard for: Patient management Knowledge and skills Equipment Documentation Monitoring for effectiveness 4 of 21

5 1.1 Respiratory failure can be defined as the: Failure to maintain adequate gas exchange. This may be acute, chronic or acute on chronic. i) Type 1 respiratory failure: Arterial blood gas (ABG) analysis: PaO 2 <8 kpa with normal or low PaCO 2. ii) Type 2 respiratory failure: Arterial blood gas (ABG) analysis: PaO 2 <8 kpa with PaCO 2 > 6 kpa ABG analysis is therefore essential before NIV is commenced to ensure that the appropriate choice of therapy is made. 2.0 Patient selection for NIV and management plan NIV should be considered for all patients with acute exacerbation of COPD in whom a respiratory acidosis (PaCO 2 >6 kpa, ph <7.35) persists despite immediate maximum standard medical treatments on controlled oxygen for no more than one hour. BIPAP is less effective with severe acidosis (ph <7.26) but may still be considered in these patients if it is established that BIPAP is the ceiling of care. Standard medical therapy (within first hour) should include: Controlled oxygen to maintain oxygen saturations 88-92% (prescribed on patients drug chart) Nebulised salbutamol mg (on air) Nebulised ipratroprium 500mcgs (on air) Prednisolone 30-40mg Antibiotic agent (as per BSUH guidelines) All should be administered within one hour and response assessed. 2.1 Patient stratification - 5 groups: To assist assessment process the patient should be stratified into one of 5 groups based on their pre morbid state, the severity of physiological disturbance, the reversibility of the acute illness, the presence of relative contraindications and where possible the patient s wishes. This stratification recorded in the patient s health records. If appropriate, consultation with ICU medical staff should be made at an early stage. 5 groups 1. Patient requires immediate intubation and ventilation. 2. Patient is suitable for NIV and suitable for escalation to intensive care treatment / intubation and ventilation if required. 3. Patient is suitable for NIV but not suitable for escalation to intensive care treatment / intubation and ventilation. 4. Patient is not suitable for NIV but for full active treatment. 5. Palliative care agreed as the most appropriate patient management see care of the dying patient pathway. 2.2 NIV inclusion criteria 5 of 21

6 Sick but not moribund Able to protect airway Conscious and co-operative No excessive respiratory secretions Potential for recovery to quality of life acceptable to the patient Patient s wishes considered 2.3 NIV exclusion criteria Patient declines treatment Facial burns / trauma / recent facial or upper airway surgery Fixed upper airway obstruction Undrained pneumothorax Haemodynamically unstable requiring inotropes/pressors (unless in a critical care unit) Severe co-morbidity Inability to protect airway (relative contraindication) Copious respiratory secretions (relative contraindication) Upper gastrointestinal surgery (relative contraindication) Vomiting (relative contraindication as NG tube can be considered in these patients if intubation is not an option) Confusion / agitation (relative contraindication) Bowel obstruction (relative contraindication) To ensure that the patient is managed safely in the initiation, optimisation, maintenance and weaning of non-invasive ventilation the patient must be monitored carefully. This will require increased nursing time to support the patient, particularly in the first 4 hours of therapy. A patient requiring NIV is considered to be a level 2 patient (ICS, 2002). 3.0 Patient management During daytime hours, patients identified as suitable for NIV using the NIV guidelines should be referred to the respiratory team SpR. Out of hours, cases that do not fulfil the guideline criteria must be discussed with the on call respiratory consultant (RSCH) or medical registrar (PRH). BiPAP should be prescribed using the tool in appendix 1 Care of the patient requiring NIV should be limited to A/E, medical assessment unit, respiratory wards and adult intensive care units. These clinical areas must ensure that staff are adequately trained and that staff competent in the use of NIV therapy are available at all times. The clinical site manager/critical Care outreach team, if not already aware, should be informed of the patient, their current condition and the patient must be included in the Hospital at Night handover meeting. Transfer from A/E to an appropriate ward may be delayed due to the patient requiring extended treatment in A/E resus or a delay in providing a bed as outlined above. 3.1 Management and care of patient on NIV 6 of 21

7 Continuous clinical assessment of the patient is needed including: Respiratory rate Continuous pulse oximetry Heart rate and blood pressure Chest wall movement Co-ordination of respiratory effort with ventilator Increased use of accessory muscles Chest pain / indicators of myocardial ischaemia Patient comfort Mental state. 3.2 Initial settings for NIV To allow acclimatisation of the patient to NIV the initial settings should be: Inspiratory pressure (IPAP): 10 cmh 2 O Expiratory pressure (EPAP): 4 cmh 2 O The IPAP should be gradually be increased over the next 20 minutes to a target IPAP of 20 cmh 2 O to achieve a therapeutic response (or patient tolerability is reached). Further increases of EPAP are not recommended without obtaining expert advice. Oxygen should be entrained into the circuit using the same settings/litres/minute as was used through the venturi mask prior to starting NIV and adjusted to maintain the target saturation (usually 88 92%). 3.3 Ongoing care Improvements in clinical parameters e.g. respiratory rate are usually seen within 1 2 hours, and are usually accompanied by improvement in neurological state. Therefore a full clinical and blood gas review should be made after 120 minutes of treatment. A decision should then be made as to whether NIV is being effective. Patient assessment and observations should be clearly documented using the prescription and observation chart (reviewing individualised core care plan as appropriate, see appendix 6). If NIV continues, arterial blood gases should be monitored until the ph is normal and PCO 2 has stabilised. The need for an indwelling arterial line should be considered if frequent ABG sampling is being undertaken (this can only be managed in a critical care unit). If the treatment with NIV is not effective, see troubleshooting guide (appendix 4). If NIV has been optimised without an improvement in clinical or blood gas parameters it should not be continued. The patient should either have escalation of care to intubation, where appropriate, or conventional medical therapy alone. The patient should have regular medical review (at least daily) to ensure NIV treatment remains optimal. Other care: o Provide care to eyes and mouth. o Breaks from NIV should be made for drinks, drugs, physiotherapy, meals etc. o Assess and monitor oral and dietary intake (see core care plan appendix 6) 7 of 21

8 o All patients receiving NIV therapy should have a fluid balance chart to assist hydration assessment o NIV should be interrupted for the administration of bronchodilators 3.4 Weaning from NIV The patient should be assessed on an individual basis for suitability for weaning from NIV. Generally once the patient is either showing signs of continued improvement* or if NIV is making no difference to the patients condition weaning from NIV should be considered. Principles of weaning ; Build period of time off NIV continued oxygen therapy via nasal specs or venturi mask, monitor for any signs of work of breathing (increased respiratory rate / decreased oxygen saturation, increased use of accessory muscles) *Re check ABG 2 hours after discontinuation of therapy. Consider use of NIV overnight if nocturnal hypoventilation is present 3.5 Hospital discharge Prior to hospital discharge an ABG on room air should be performed and spirometry to aid future assessment. As part of ongoing rehabilitation, following successful weaning from NIV, patients should be assessed for suitability for pulmonary rehabilitation and if applicable smoking cessation support. 4.0 Equipment Non specialist NIV equipment is stored in the equipment library and is maintained and managed by medical physics. Location of machines is outlined in Table 1. Table 1: Equipment location Machine Hospital Ward / Dept BiPAP Focus x1 RSCH A/E BiPAP Focus x2 RSCH MASU BiPAP Focus x1 RSCH Catherine James / Egremont BiPAP Focus x3 RSCH Equipment library BiPAP Synchrony x1 PRH A/E BiPAP Focus x2 PRH Pyecombe Synchrony x1 PRH Pyecombe Consumables are to be purchased by each ward separately via NHS supplies (appendix 7) 4.1 Decontamination & cleaning Following use the machine should be cleaned and decontaminated following infection control and manufacturers instructions. The device should labelled using the yellow medical device label to clearly show it is ready for use. For further details see set up guide in Appendix 3 and troubleshooting guide Appendix 4. 8 of 21

9 4.2 Equipment purchase NIV equipment purchases should be agreed by all clinical teams involved in NIV management to reduce any error produced by unfamiliarity with equipment. Replacement machines will be co-ordinated by the medical devices committee to ensure a corporate approach to purchasing. 5.0 Knowledge and skills All caring for a patient with NIV must be deemed competent in the use of NIV before caring for a patient (Appendix 5: competency framework). Staff should attend the NIV workshop to gain theoretical / practical understanding of the therapy ensuring they understand the medical device used. 6.0 Documentation The NIV prescription chart (Appendix 1) should be used for all patients receiving NIV outside the adult intensive care units and used in conjunction with BSUH observation chart incorporating the Modified Early Warning Score (MEWS). Limitations on treatment, weaning regime, further treatment proposals, response to treatment and indications for the treatment following NIV must be clearly documented in the patient s health records. The nursing core care plan should be completed and evaluated (Appendix 6). 7.0 Monitoring for effectiveness The NIV service will be audited, in line with British Thoracic Society guidelines by the lead nurse in NIV in each clinical area and NIV group. (See audit tool Appendix 2). The respiratory registrar will be responsible for the ongoing audit of the NIV service. The audit form (attached to the prescription sheet) will be detached and collected from the patient records following completion of therapy. 8.0 References 1. Baudouin, S et al Non invasive ventilation in acute respiratory failure British Thoracic Society Standards of Care Committee. Thorax. 57: Royal College of Physicians, British Thoracic Society, Intensive care Society Chronic obstructive pulmonary disease: non invasive ventilation with biphasic positive airways pressure in the management of patients with acute type 2 respiratory failure. Concise Guidance to Good Practice series. No 11. London RCP. 3. Intensive Care Society Levels of Critical Care for Adult Patients. Standards and Guidelines. 4. NICE Chronic Obstructive Pulmonary Disease. Management of chronic obstructive pulmonary disease in primary and secondary care. 9 of 21

10 Appendix 1: NIV prescription chart Name Trust ID DoB (Attach patient sticker) Non Invasive Ventilation (NIV) Prescription Chart Name of doctor completing chart (Print). Bleep. Does the patient have the mental capacity to provide consent for this procedure? Refer to Mental Capacity Act 2005 and Code of Practice) If Yes the patient should provide oral consent If No patient should be treated according to best interests YES NO If the patient has capacity to consent has consent been provided? If No treatment should not be provided Is there a respiratory acidosis (i.e. ph <7.35, PaCO 2 >6) despite best medical therapy? Has the patient been discussed with the on call SpR / Consultant Physician? If YES, with whom?... Has a decision been made and documented about escalation of treatment if NIV fails? If the patient is a candidate for intubation, have they been discussed with the on call ICU registrar / consultant Daytime Inform Critical care outreach (RSCH 8485, PRH 331) Out of hours clinical site team (RSCH 8152, PRH 014) YES NO YES NO YES NO YES NO Date & Time Complete NIV settings overleaf THIS PATIENT SHOULD NOT RECEIVE SEDATION Patient Handover (medical) All patients on NIV should be handed over to the respiratory team as soon as possible for ongoing care Respiratory SpR (during daytime hours) RSCH bleep 8398 / 8060 PRH bleep 048 Date / time respiratory team contacted : 10 of 21

11 NIV prescription and changes to settings Date Time IPAP EPAP Back up breaths O 2 on NIV O 2 off NIV Recommended NIV use Name & Sig Arterial blood gas trends Date Time ph PaCO 2 PaO 2 HCO 3 Base Excess FiO 2 SpO 2 IPAP/ EPAP Setting Resp rate Monitor SpO 2 continuously aiming for SpO 2 >85%. Blood gases should be repeated 1-2 hours after initiating NIV and 4-6 hours later and then dependent on progress. Suggested NIV usage and weaning guide Patients should be encouraged to use NIV as much as possible (i.e. 24 hours) initially. As blood gases improve this can be reduced. For example 2 hours off in the morning and evening one day, 4 hours off in the morning and evening the next, all day off the next day. Please contact respiratory teams for advice. Date Comments / Communication Signature Print name 11 of 21

12 Appendix 2: NIV audit proforma For completion by respiratory team 12 of 21

13 Appendix 3: NIV set up guide Action Ensure ward emergency equipment available Patient discussed with nursing staff, medical staff (at all times) and physiotherapists (in hours) Ensure the NIV chart has been fully completed with an appropriate prescription Check with medical staff that the patient has had a recent CXR which is clear of pneumothorax / pneumonia Explain procedure to the patient positively and calmly. Gain verbal consent from patient. The patient will require reassurance throughout the procedure. Optimise the patient in an upright position Set up the equipment as shown in the diagram. Ensure filter is connected to the port on the NIV machine prior to attaching the tubing Carry out as much preparation as possible away from the bed area Use full face mask. Assess mask size using gauge on mask pack. It should fit firmly and not encroach on the upper lip and into corners of the eye. Apply hydrocolloid semi permeable dressing to bridge of patient s nose. Check for any poor facial skin condition Connect patients current O 2 supply to second O 2 supply Set mode to spontaneous / timed mode Set IPAP, EPAP and back up BPM setting as per prescription Rationale To provide a safe environment To ensure NIV is the appropriate intervention and that support is available To ensure the appropriate settings are maintained Pneumothorax must be discounted prior to starting NIV as positive pressure can cause lung barotraumas. If a patient already has a pneumothorax the size can be increased by NIV. NIV is unlikely to succeed if pneumonia is present. To gain consent and co-operation. This is potentially a frightening and claustrophobic experience To prevent contamination of the machine To prevent distressing the patient To ensure seal and prevent air leaks which may reduce the effectiveness or cause complications e.g. conjunctivitis This is a very high risk pressure area. Existing poor facial skin condition may also be exacerbated Maintain O 2 supply whilst preparing equipment To ensure the machine is functioning correctly and that back up rate is provided in the spontaneous / timed mode Turn on machine and connect entrained O 2 supply To commence treatment and provide O 2 supply Ask patient to breathe through nose and maintain a To reassure patient and acclimatize tight mouth seal. Hold mask to patients nose for a few minutes Attach head strap to mask and obtain a seal. The mask should be firm but not tight and small leaks may be acceptable. Ensure that exhalation port is not blocked and is facing away from the patient Document a set of observations (including MEWS score) Watch chest wall movement and titrate settings to achieve therapeutic effect increase chest wall movement and improved clinical signs To ensure there are no leaks To prevent build up of CO 2 Provide baseline for assessing progress Improving the tidal volume is the aim. An inadequate tidal volume is the cause of the patients ventilatory failure 13 of 21

14 Appendix 4 NIV Troubleshooting guide Problem Persistently elevated PaCO 2 Mask leaks Asynchrony between patient and ventilator Hypocapnia / alkalosis Is there an excessive mask leak? Check mask fit. Is the circuit set up correctly? Check connections and identify leaks. Is there rebreathing? Is the expiratory port patent? Is the patient being over oxygenated? Especially consider aim of oxygen therapy during period off NIV. Consider the acceptable level of PaO 2 to be aimed for. Consider increase in IPAP Is the patient spending sufficient time on BiPAP? Encourage more sustained periods of use (particularly during sleep). Address compliance issues. Consider decrease in EPAP if high level set (>8cmH 2 O) Small leaks are normal and acceptable but larger leaks may cause inefficient ventilation, eye irritation, noise, dry mouth and nasal symptoms Be prepared to try different mask types Consider granuflex on nasal bridge for comfort This is rare if using respironics Focus or Synchrony machine due to their triggering sensitivity Check correct tubing is used in the circuit. The tubing should have a smooth interior to allow air flow to be detected accurately If the patient s respiratory effort is inadequate the machine may not sense inspiration. An increase in EPAP may help. If the patient is very tachypnoeic increasing the IPAP may help: ensure rise time is as quick as possible. Minute ventilation is too high. Reduce IPAP Is BIPAP still required? Difficulty inflating the chest Poor expansion of the chest and desaturation may be due to bronchospasm, mucous plugging, pneumothorax, atelectasis / collapse, consolidation, pulmonary oedema or rarely circuit tube obstruction/ kinking. Clinical examination is required. Chest X-ray may be required Nasal problems Nasal redness / nasal bridge sores? Appropriate padding or change of mask may be necessary. Rhinitis / nasal crusting / bleeding? Ask about nasal symptoms. Consider short term use of 0.5% ephedrine nose drops for stuffiness. Alternatively, nasal steroid preparation can be employed (nose bleeds are a 14 of 21

15 Dry mouth Gastric distension Persistent hypoxaemia Patient position Non co-operation / aggressive behaviour relative contraindication to nasal steroids). Anticholinergic drops (ipratropium bromide) or aqueous spray may be helpful for nasal streaming. Regular mouth care is essential Consider humidification Check for abdominal pain or distension occurring during NIV Try to reduce IPAP if possible Consider nasogastric tube with a nasogastric tube guard accepting a small leak will occur. Small leaks should not cause a problem Consider anti-emetics Check correct O 2 entrainment into circuit of machine. If there is a definite OSA or atelectasis then increasing EPAP may help (remembering to increase IPAP by same level to maintain the same pressure support) Deteriorating clinical condition in the presence of hypoxaemia should lead to an urgent review of the patient and consideration of intubation and mechanical ventilation (if appropriate) CONTACT ITU The patient should be positioned upright with their head up Consider additional support if necessary (soft collar, rolled up towel) Assess for patient agitation, confusion and not maintaining mask ventilation This may be due to hypoxaemia or hypercapnia. Ensure constant supervision as it maybe necessary to hold the mask in place initially until ABG s have corrected themselves before the agitation / confused state settles. This may be life saving. Relatives may also be helpful to calm the patient. SEDATION MUST BE AVOIDED WITHOUT SENIOR MEDICAL OR ANAESTHETIC INPUT. Haloperidol may be useful to decrease agitation and facilitate tolerance of NIV therapy. Avoid benzodiazepines. 15 of 21

16 Appendix 5: NIV competency Staff Name Staff ID. Ward. Non Invasive Ventilation NIV competency The practitioner must be able to: 1 Identify appropriate patients for NIV and explain the basic physiology behind their decision 2 Identify the contraindications for NIV 3 Correctly assemble and prepare the equipment 4 Provide an explanation to the patient 5 Demonstrate the ability to commence the treatment (on a patient ) and explain their rationale for doing so 6 Explain and implement the safety measure required 7 Accurately record the treatment of the patient, changes in the patients condition and maintain appropriate documentation throughout the patient treatment 8 Demonstrate the ability to assess for and understand the signs of success or not of the treatment and explain their subsequent actions e.g. settings, changes and rationale for doing so 9 List the potential complications and limitation of NIV therapy 10 Can discuss process for device decontamination following use Date Demonstrated Not yet demonstrated Assessors comments Assessor signature Aim of assessment that practitioner should be able to perform this activity satisfactorily without supervision and/or assistance. Record of competence should be held by the practitioner and ward manager 16 of 21

17 Appendix 6: Core care nursing plan Name Trust ID DoB Core Nursing Care Plan for a patient on non invasive ventilation Date Problem Cause Goal Nursing Intervention Ineffective Breathing pattern shown by breathlessness respiratory rate, pulse, BP. Abnormal Arterial blood gas analysis: ph:.. paco 2 ( >6.0 Kpa) : pao 2 ( <8.0 Kpa): HCO 3 : O 2 Saturation. Identified need for NIV Worsening COPD +/- acute respiratory infection To promote normal and effective breathing patterns (Attach patient sticker) Record BP, pulse, respiratory rate and Glasgow coma scale prior to commencing BiPAP. Ensure equipment is correctly set according to guidelines. Check NIV prescription Assess patient for type and size of mask. Ensure good fit and minimal leakage. Check hourly for pressure damage. Give O 2 via mask as prescribed Monitor O 2 saturation continuously and report if decreases Record BP, pulse, respiratory rate and Glasgow coma scale half hourly for first two hours then hourly thereafter. Report changes from baseline. Ensure blood gases are taken after first hour Signature. Receiving adequate ventilation Reduced ability to clear airways shown by shortness of breath, respiratory rate, decreased O 2 saturations Worsening COPD +/- acute respiratory infection or chest wall deformity and BiPAP Worsening COPD +/- acute respiratory infection To ensure patient receives optimal levels of IPAP and EPAP as defined in management plan To increase the ability to clear airways Start patient at IPAP 10 cmh2o and EPAP 4 cmh2o Titrate to agreed IPAP level within 20 minutes of starting therapy Check patient is not exceeding the set IPAP level After first hour reassess respiratory rate, work of breathing and oxygen saturations Medical staff to recheck ABG Give nebulisers as prescribed Ensure nursed in upright position Encourage regular movement Ensure adequate fluid intake Ensure physiotherapy referral Give antibiotics as prescribed Signature. Alteration in comfort shown by verbal expression, body language Worsening COPD +/- acute respiratory infection and BiPAP Promote comfort Ensure NIV is fitted comfortably. Allow patient rest periods if necessary starting with 5 minutes each hour. Ensure patient is given oxygen via nasal specs or venturi mask during rest period Modify patient position if necessary Protect nasal bridge and cheeks with duoderm as appropriate 17 of 21

18 Risk of dehydration shown by reduced tissue turgor, coated tongue, concentrated urine. Risk of skin damage shown by inability to change position Worsening COPD +/- acute respiratory infection and BiPAP Worsening COPD +/- acute respiratory infection and BiPAP To prevent or correct dehydration To prevent pressure damage Signature. Encourage hourly fluids orally during NIV rest periods Accurate input and output fluid balance chart Give I.V. fluids as prescribed Signature. Ensure pressure risk assessment complete (Waterlow score) Patient to be nursed on profiling bed with suitable mattress Position to be changed 2 hourly or more depending on assessment of need Ensure adequate nutrition hydration Signature. Anxiety shown by verbal expression, body language Worsening COPD +/- acute respiratory infection and BiPAP To alleviate anxiety Give clear, simple explanation of CPAP / BiPAP to patient Ensure NIV is fitted comfortably and correctly Allow rest periods from NIV Remain with patient if necessary Where possible involve relatives in care Signature. Weaning from BiPAP To plan weaning from BIPAP according to patients individual requirements Plan weaning from BIPAP with multi professional team Agree aim of oxygen saturations Stop BiPAP Continue oxygen therapy via nasal specs or venturi mask Monitor for signs of respiratory distress/increased work of breathing 18 of 21

19 Appendix 7 NIV consumables Item Mask (single) Performatrak S (small) Performatrak M (medium) Performatrak L (large) NHS code FDD611 FDD613 FDD614 Tubing : 9624c Dry circuit pack for Focus Filter Grey Foam pollen filter (Pack of 2) White disposable ultrafine filter (Pack 2) of 21

20 Equality IMPACT ASSESSMENT FORM (EIAF) Race (including Gypsy and Traveller Communities), Gender, Religion/Belief, Disability, Age and Sexual Orientation Section One: Screening / Prioritising for Full Impact Assessment Name of the Function/Policy/Project/Service: BSUH Guidelines for Non Invasive Ventilation Which of the 3 parts does it apply to (if any) 1. Eliminating discrimination? 2. Promoting equal opportunities? 3. Promoting good community relations? Is there evidence or reason to believe that some groups could be differently affected? Which groups are affected How much evidence do you have? 0-2 None or little 3-4 Some 5-6 Substantial Is there public concern that the function/policy is being carried out in a discriminatory way? 0-2 None or little 3-4 Some 5-6 Substantial Priority (add columns 3 & 4) RACE including None Gypsy and Traveller Communities RELIGION/BELIEF None None None DISABILITY None * Chronic Respiratory Conditions MEN / WOMEN / None None TRANSGENDER AGE None * People aged 50+ lifetime smokers are increased risk of developing respiratory disease and may require this therapy if presenting with acute respiratory failure SEXUAL None None ORIENTATION This policy is a sympathetic local translation of national guidelines from the British Thoracic Society (2008) 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 of 21

21 Equality Impact Assessment Action Plan Action Sheet Issue Action Required How would you measure impact/outcomes in practice See policy aims to simplify Ongoing audit as part of the monitoring and ensure that NIV is used for effectiveness process, co-ordinated by appropriately, by including a the respiratory registrar. NIV prescription chart. Those suffering from chronic respiratory conditions. 50+ lifetime smokers, more prone to respiratory diseases. Consent required for this procedure. See above and Community Health and PCT Health promotions work actively going on. Refer to Consent and MCA policies Ongoing Timescale Responsible Officer Respiratory Registrar See above See above See Above Refer to Consent and MCA policies Refer to Consent and MCA policies Refer to Consent and MCA policies You are required to report back on your Action Plan on a yearly basis to the Equality and Diversity Manager in order for the progress to be measured and shared with all stakeholders. 21 of 21