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NPPV Egans 42

Noninvasive Positive Pressure Ventilation

Noninvasive Positive Pressure Ventilation The application of positive pressure via the upper respiratory tract for the purpose of augmenting alveolar ventilation Typically administered through a nasal or oral mask Increasingly popular due to newer vents & patient interfaces
Goals of Noninvasive Ventilation (Acute Care) Avoid intubation Relieve symptoms Improve gas exchange Improve patient/vent. Synchrony Maximize patient comfort Decrease length of stay
Indications of NPPV Acute Care COPD Asthma Acute cardiogenic pulmonary edema Community acquired pneumonia Hypoxemic respiratory failure Immunocompromised state Do not intubate oreders Postoperative status Difficult weaning
Goals of Noninvasive Ventilation (Chronic care) Improve symptoms Enhance QOL Increase survival Improve mobility
Indications of NPPV Chronic Care Restrictive thoracic disease COPD Nocturnal hypoventilation
COPD Studies have shown a reduction in the need for intubation of patients with acute exacerbations Reduction in in-hospital mortality Reduced length of stay NIPPV is an acceptable alternative to intubation in patients with acute exacerbation of COPD
Asthma The Meduri study reported positve results in the care of 17 patients with status asthmaticus Previous authors studied suggested NIPPV was not indicated for status asthmaticus
Acute Cardiogenic Pulmonary Edema (a restrictive disorder) A CPAP of 10 to 12.5 cm H20 should be considered before NPPV is used in the care of patients with acute pulmonary edema Caused by increased pulmonary capillary hydrostatic pressure pushing fluid into the interstitual space and alv.
Community Acquired Pneumonias Found to be useful in only those patients with underlying COPD Current recommendations are to use NPPV on patients with community acquired pneumonias only on patients with COPD
Hypoxemic Respiratory Failure Defined by PaO2/FiO2 ratio of less than 200 Studies have shown some success while others show no benefit to reduce intubations, LOS, and mortality Conflicting reports limit clinical recommendations at this time
Other Indications Providing support for do-not –intubate patients Postoperative patients Difficult weans Lower nosocomial infections Use recommended for pts with mod to severe distress and immunocompromised diseases
Do Not Intubate NPPV in care of do not intubate patients with irreversible disease is controversial Does offer some relief of symptoms Current recommendations is that the use of NPPV with do not intubate patients is justified if pt. Disease is reversible
Post Operative Patient’s After lung resection increased PaO2 without air leaks or increasing deadspace Propholactic use after gastric bypass improved SpO2 and FVC Outcome potential looks promising
Difficult Weaning Patients NPPV reduces weaning time, length of stay, incidence of VAP, and 60 day mortality Studies supported NPPV in weaning of COPD patients but cautioned in pt selection Pt. Must be cooperative, maintain airway, and clear secretions
Reintubations Patients who are difficult to reintubate should not be extubated early to receive NPPV COPD patients who’s extubation failed. had improved gas exhange and reduced need for reintubation
Extubations Patients who may benefit from NPPV after extubation include: COPD Acute Pulmonary Edema Post Extubation Stridor
Restrictive Thoracic Diseases Includes Neuromuscular diseases, spinal cord injuries, dyphoscoliosis Provides rest to respiratory muscles Lowers PaCO2 Improves lung compliance, volume, and deadspace Pts should have symptoms of nocturnal hypoventilation before NPPV is considered
Long-Term care of COPD The current recommendation is to use NPPV with pt.s having severe COPD when they exhibit Nocturnal hyupoventilation PaCO2 of 55 mm Hg or greater or PaCO2 between 50 and 54 with nocturnal desaturations
NPPV Criteria for Acute Respiratory Failure Use of accessory muscles Paradoxical breathing RR > 25 b/m Dyspnea PaCO2 > 45 mmHg with pH < 7.35 PaO2/FiO2 ratio< 200
Exclusion Criteria for NPPV Apnea Cardiac instability Uncooperative Facial burns Facial trauma Aspiration concerns Secretions
Predictors of Success in Acute Care Setting Minimal air leak Low severity of illness PaCO2 > 45 mm Hg but < 92 mm Hg pH < 7.35 but > 7.22 Improvement within 30 minutes-2 hrs Improve RR and HR
Noninvasive Ventilators Electrically powered, blower driven, and microprocessor controlled Single circuit design for constant flow Small leak is required Trigger must tolerate leak in system
Noninvasive Ventilators Capabilities Provide rates to 30 b/m Pressures to 30 cm H20 EPAP to 15 cm H20 Flows of 60 l/m at 20 cm H20 pressure FiO2 to 50% Minimal re-breathing potential
Initial settings NPPV Ventilator Appropriate sized interface Patient seated at 30 degree angle IPAP of 8 to 12 cm H20 EPAP of 3 to 5 cm H20 Back up rate
Noninvasive Ventilators Alarms Circuit disconnect Loss of power Battery failure
Initial Setting Critical Care Ventilator PSV with 5 to 8 cm H20 PEEP 0 to 5 cm H20 Flow triggering at 2 to 5 l/m
Initial Setting Critical Care Ventilator A/C Mode VT of 10 ml/kg Flow of 60 l/m F of 10 b/m PEEP of 0 to 5 cm H20 Flow triggering between 2 and 5 l/m
Initiations of NPPV Encourage patient to hold the mask in place while head gear is applied After pt is comfortable with initial settings, increase the inspiratory pressures or Vt until 5 to 7 ml/kg is obtained Check for leaks/adj. strap tension
Complications of NPPV Mask Related Discomfort Skin erythema Claustrophobia Nasal bridge ulceration Rash
Complications of NPPV Flow/Pressure Related Nasal congestion Sinus or ear pain Nasal or oral dryness Eye irritation Gastric insufflation
Major Complications of NPPV Aspiration Pneumonia Hypotension Pneumothorax
Air Leaks Mask fit essential Use of ExpSen% and RiseTime % to improve ventilator/pt synchrony
Created by: stephnpc