1/7/2014. Non Invasive Ventilation. Non Invasive Ventilation. Types on Non Invasive Ventilation

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1 Non Invasive Ventilation Wade Scoles RRT-NPS, NREMT Chief Respiratory Therapist NW MedStar Non Invasive Ventilation Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive artificial airway (Endotracheal tube) Nasal Mask Full Face Mask Types on Non Invasive Ventilation Continuous Positive Airway Pressure (CPAP) Bilevel Positive Airway Pressure (BiPAP) Provides positive pressure ventilation support during inspiration as well as baseline positive pressure 1

2 Continuous Positive Airway Pressure Early intervention with CPAP provides alternative to ET intubation. Mostly helps with oxygenation-not ventilation Becoming widely used by EMS 5 2

3 Indications CPAP: Respiratory distress / hypoxemia secondary to prematurity, newborn RDS, CHF, acute pulmonary edema, pneumonia, asthma and/or COPD without ventilatory failure BiPAP Respiratory distress/ hypoxemia secondary to CHF, acute pulmonary edema, pneumonia, asthma and/or COPD with impending or existing ventilatory failure 1. Unconscious/decreased LOC 2. respiratory arrest 3. agonal respirations 4. pneumothorax 5. hypovolemic shock 6. acute MI with hypotension 7. chest trauma 8. persistent nausea/vomiting 9. facial anomalies/stroke/facial trauma 10. active upper GI bleeding or recent history of gastric surgery Contraindications Decreases work of breathing. Benefits Improves oxygenation with PEEP. Induces positive pressure in thorax with resultant decrease in preload of RV. 3

4 Risks Gastric distention, vomiting, aspiration Drying of secretions, mucus plugging Hypotension Pneumothorax Corneal drying Patient Selection Obstructive Sleep Apnea (home CPAP) Hypoxemic Respiratory Failure Congestive Heart Failure Pneumonia Chronic Obstructive Pulmonary Disease (Usually require BiPAP) Asthma? 12 NIV in Congestive Heart Failure (CHF) 4

5 Congestive Heart Failure (CHF) is defined as, excessive blood or fluid in the lungs or body tissues caused by the failure of ventricles to pump blood effectively. Bottom line: The left side of the heart cannot keep up with the right side, which is pumping blood into the lungs 13 CHF Normal 14 Goal Increase oxygenation and ventilation Decrease WOB Decrease atelectasis recruitment of collapsed alveoli due to the flooding of alveoli with fluid. 15 5

6 Physiology of CPAP in CHF (why it works) Afterload and preload reduction This improves cardiac performance Increased pressure of CPAP stabilizes and recruits alveoli Afterload- The "load" that the heart must eject blood against Preload- The volume of blood present in the ventricles of the heart Components Of A CPAP System CPAP Control Unit Breathing Circuit and Positive Pressure Face Mask Components Of A CPAP System 6

7 Components Of A CPAP System Infant CPAP system for RDS Components Of A BiPAP System Ventilator with non-invasive capability and proper mask Some require vented masks, some non-vented Lots of Oxygen! Components Of A BiPAP System 7

8 Cases Patient #1: 68 year old male in moderate respiratory distress with history of CHF. Now has ankle edema, diffuse inspiratory crackles with SpO2 of 85% on NRB mask. His BP is 148/80, HR 96, RR24. CPAP (5-7.5) Patient #2: 72 year old female with long history of COPD. She is in severe resp. distress, alert & oriented, able to talk only in short bursts. HR 116, BP 132/78, RR20 with obvious accessory muscle use, Sp02 88% on NRB mask. Patient wants to avoid intubation if at all possible. BiPAP (Initial settings 12/5 and 50%) 8

9 Patient #3: 78 year male with history of COPD/CHF with respiratory failure and decreased level of consciousness. HR 124, BP 90/68, RR 16 with obvious accessory muscle use, Sp02 82% on NRB mask. Pt. is obtunded with GCS 7. Only response is moaning to noxious stimuli. CPAP Contraindicated due to Decreased LOC Patient #4: 62 year old acute anterior MI, required several defibrillations, is now in CHF with inspiratory crackles and Sp02 of 88% on NRB mask. He is in moderate respiratory distress, is dizzy & has vomited several times. HR 116, BP 78/50 CPAP contraindicated due to Unstable Acute MI with hypotension, persistent vomiting Patient #6: 67 year old obese female patient recently released from the hospital after gall bladder surgery. She is short of breath with inspiratory crackles in her lungs HR 112, RR24, BP 108/56, SpO2 78% room air Febrile CPAP may be helpful 9

10 Patient #6: Same patient on CPAP, Her SpO2 improves to 80 but she becomes more short of breath and PaCO2 is starting to rise. Can try Bi-PAP Patient placed on Vision and settings increased to 22/6 and 100% SpO2 now 88%, patient maintaining and call made to transport to Spokane Limitations of Transport Sophisticated hospital ventilators with non-invasive capability have internal exhalation valves and use much more gas Most transport ventilators have exhalation valves in the circuit which increases work of breathing some Aircraft and ambulances have limited gas supplies Flight crew may have to intubate patients on high non-invasive settings prior to transport Questions? 10

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