Non-Invasive Ventilation

Dr Duncan Mitchell Ealing Hospital

What we are going to cover

What is NIV? Ventilation Physiology & Terminology Types of NIV Indications for NIV Contra-indications Case examples

What is Non-Invasive Ventilation (NIV)

Delivery of ventilatory support without the need for an invasive artificial airway

Some Physiology.zzzzzzz!
Ventilation - process by which O2 and CO2 are transported to and from the lungs Venous blood - lower pO2 higher pCO2 than inspired gas - partial pressure gradient driving O2 in and CO2 out

Ventilation of lungs with inspired gases leads to mixing with alveolar gas If no ventilation at all, no replenishment of O2 and no removal of CO2 Arterial pO2 falls and pCO2 rises towards that of venous If ventilation greater than needed, alveolar gas closer to inspired gas

Terminology
Tidal Volume (VT) amount of gas expired per breath (~ 500ml at rest) Minute Volume amount of expired gas per minute Alveolar Ventilation amount of gas reaching functional alveoli Work of Breathing usually ~5% of total body work most used to overcome lung and chest wall stiffness during inspiration

PEEP Pressure Support (cmH2O) positive pressure applied to airway to support patients own breath Opening Pressure pressure required to open collapsed alveoli

Types of NIV
Negative-Pressure Ventilation (Iron Lung) Continuous Positive Airway Pressure (CPAP) (Not really NIV!) Bi-level Positive Airway Pressure (BiPAP)

Negative-Pressure Ventilation
Late 1880s iron lungs first used Early 1900s iron lungs used for polio epidemics This continued throughout the 20th century until 1960s when invasive ventilation became available

CPAP
Nasal or face mask Continuous positive pressure applied to the airways Usually well-tolerated Similar to use of PEEP Reduces work of breathing Improve ventilation to collapsed areas of lung

BiPAP

Bi-Level pressure support Inspiratory Positive Airway Pressure (IPAP) & Expiratory PAP (EPAP) IPAP is the pressure support machine gives to help patients own inspiration Helps to reduce WOB and increase alveolar ventilation EPAP is essentially PEEP and help to prevent alveolar collapse

Indications for CPAP

Cardiogenic Pulmonary Oedema Obstructive Sleep Apnoea Chest Wall Trauma if hypoxic on adequate analgesia Pneumonia

Indications for BiPAP

Exacerbation of COPD with Respiratory acidosis Type II respiratory failure with chest wall deformity or neuromuscular disease Failure of CPAP Pneumonia with respiratory acidosis Therapeutic trial with a view to intubation if it fails Others (ARDS, post-op respiratory failure, to buy time prior to intubation)

Patient Selection
Sick but not moribund Able to protect airway Conscious and co-operative Haemodynamically stable No excessive secretions Few co-morbidities Improvement on ABG with NIV

Patient Rejection

Respiratory arrest Haemodynamically unstable Uncooperative Unable to protect airway (swallowing and cough impaired or vomiting) Facial, oesophageal, or gastric surgery Craniofacial trauma or burns Airway obstruction Undrained Pneumothorax

Case 1
76yr old female Lifelong smoker 1/52 productive cough BP140/90 P120 RR40 SaO2 89% on 10L pH 7.3 pCO2 8.2 pO2 6.9 HCO3 20 BE 4.2

Case 2
83yr old man Known IHD, previous MI Wife says he has not been well BP170/95 P120 RR38 SaO2 87% on 15L pH 7.28 pCO2 5.2 pO2 7.1 HCO3 21 BE -3.2

Case 3

49yr old man 2/52 Hx of feeling unwell with D&V Not eating or drinking Not passing urine BP89/50 P130 RR40 SaO2 96% on NRBM pH 6.98 pCO2 2.9 pO2 14.2 HCO3 13.9 BE -21.4

Case 3 Contd.

Urea Creat K Hb WCC PLT PT APTT

32 444 6.2 9.2 24 47 20 100

Case 4
50yr old man On the ward Nurses report that he snores a lot Wife tells you he has seen a specialist and has a machine at home that makes a lot of noise What is it ???!!!

Summary
What NIV is and the different types Basic respiratory physiology Indications for NIV When not to use it Thought about some cases

Any Questions?