NON-INVASIVE MV

Good news

• It works !!!!!!!

Warnings

• Not always• Not for all• Know the technique• Be skilled

(from Vitacca M. et al. AJRCCM 2001; 164: 638-641)

i-PSV and n-PSV delivered before andafter extubation in patients not weaned

Arterial Blood Gases

i-PSV

7.3859.1206

n-PSV

7.3861

210

pHPaCO2

PaO2/FIO2

T-tube

7.3369183

NIV

INTERFACESTUBING

MT

NURSES

LOCATION

PATIENTS

MONITORING

NON-INVASIVE MV

• NIV in the “real-world”

• Setting the ventilator

• Choice of interfaces

• Humidification and drug delivery

Assessment of Physiologic Variablesand Subjective Comfort Under DifferentLevels of Pressure Support Ventilation*Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD;Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; andEnrico Clini, MD, FCCP†

Chest 2004; 126: 851-59

Assessment of Physiologic Variablesand Subjective Comfort Under DifferentLevels of Pressure Support Ventilation*Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD;Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; andEnrico Clini, MD, FCCP†

Chest 2004; 126: 851-59

Appropiate setting for long-term NPSVAppropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (n=23 hypercapnic COPD patients)

Appropiate setting for long-term NPSVAppropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (n=23 hypercapnic COPD patients)

(from Vitacca M. et al. Chest 2000)

-100

-75

-50

-25

0

25

50

75

100

VT f Pdi PTPdi PEEPi

Usual (IPS 16±3, EPAP 3.6±1.4)Physiological (IPS 15±3, EPAP 3.1±1.6)

Ch

ang

e (%

of

SB

)

Pressurisation rate during NIV in COPDPressurisation rate during NIV in COPD

(from Prinianakis G. et al. ERJ 2004; 23: 314-320)

“… different pressurisation rates resulted in different reductions in the pressure time product of the diaphragm; this reduction was greater with the fastest rate, but was accompanied by significant air leaks and poor tolerance”

Leaks Tolerance

Study protocolStudy protocol

Time (min)

SB (baseline)

10

V’E, PTP

0setting

V’E, PTPPao, IE RANDOM of ventilatorsRANDOM of ventilators

comfort

NON-INVASIVE MV

• NIV in the “real-world”

• Setting the ventilator

• Choice of interfaces

• Humidification and drug delivery

(from BTS Guideline Thorax 2002;57:192-211)

SVANTAGGI:

•non permette l’espettorazione, né l’alimentazione

•aumenta il rischio di aspirazione

•è altamente traumatica

maschera facciale

Punti critici

• 1- ponte nasale

• 2- lati della bocca

• 3- base inferiore del labbro

22

3

1

VANTAGGI:

•miglior controllo delle perdite

•pressioni più elevate

N.B. La protesi dentaria va rimossa

maschera nasale

Punti critici • 1- ponte nasale

• 2- narici

• 3- base del naso

verificare• 4- pervietà delle cavità nasali

22

3

1

VANTAGGI:

•stabile, comfort maggiore

•bocca libera

•spazio morto ridotto

•svariati modelli

SVANTAGGI:

•perdite d’aria dalla bocca

•maggior resistenza

N.B. La protesi dentaria va conservata

Major problems with mask Major problems with mask during NIV supportduring NIV support

Major problems with mask Major problems with mask during NIV supportduring NIV support

Air leaksSide-effectsSize

Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)

Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)

(from Criner GJ. et al. Chest 1999;116:667-675)

Mask leaksSkin irritationRhinitis / aerophagiaDiscomfort

4323138

%

30

40

50

60

70

Untaped Taped

MOUTH LEAKS IN NASAL NPPVMOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years)(n=9, hypercapnic=7, COPD=6, age 64 years)

MOUTH LEAKS IN NASAL NPPVMOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years)(n=9, hypercapnic=7, COPD=6, age 64 years)

(from Teschler H. et al. ERJ 1999; 14: 1251-1257)

PtcCO2 (mmHg)

0

20

40

60

Untaped Taped

Arousal Index (events h-1)

p<0.001 p<0.0002

Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)

Side effects due to NPPVSide effects due to NPPVN=26 (compliant patients)N=26 (compliant patients)

(from Criner GJ. et al. Chest 1999;116:667-675)

Mask leaksSkin irritationRhinitis / aerophagiaDiscomfort

4323138

%

Tissue Necrosis Caused by Tissue Necrosis Caused by an Improperly Fitting Maskan Improperly Fitting Mask

(CCM 2002; 30: 602-608)

(Crit Care Med 2002; 30: 602-608)

CRITERI PER LA SCELTA DELLA

MASCHERA

Esperienza dell’équipe

Considerazioni anatomiche

Modalità di ventilazione

Compliance e sensorio del

paziente

(from BTS Guideline Thorax 2002;57:192-211)

NON-INVASIVE MV

• NIV in the “real-world”

• Setting the ventilator

• Choice of interfaces

• Humidification and drug delivery

In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification.

Crit Care Med 2002; 30:2515–2519

To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L*min-1

Respir Care 2004;49(3):270–275.

CONCLUSIONS Delivered oxygen concentration during BiPAP is a complex interaction between the leak port type, the site of oxygen injection, the ventilator settings, and the oxygen flow.Because of this, it is important to continuously measure arterial oxygen saturation via pulse oximetrywith patients in acute respiratory failure who are receiving noninvasive ventilation from a bi-level ventilator.