2. Definition
Why do we use NIV?
Indications for BiPAP use
Contraindications to use
Patient selection
Set up
Monitoring
Escalation
Duration of treatment
Weaning
Palliation
Clinical scenarios
3. To gain a more in depth knowledge of BiPAP
and it’s clinical indications
4. To state the definition of NIV
To list 3 clinical indications to commence
BiPAP
To list 3 contraindications for its use
To discuss patient selection considerations
To be able to correctly describe set up
To be able to give clear instructions on
monitoring
To be able to relay that an escalation plan
should be documented at commencement
5. Non invasive ventilation – ‘the provision of
ventilatory support through the patient’s
upper airway using a mask or similar device’.
CPAP – continuous positive airway pressure
BiPAP – bilevel positive airway pressure.
6. NIV in T2RF in COPD - reduction in mortality
~50%
Reduces intubation rates in COPD pts with
decompensated respiratory acidosis
Reduction in need for ICU admission and
reduced hospital costs compared to standard
medical therapy
7. Acute exacerbation of COPD
Persistent respiratory acidosis :
PaCO2 > 6kPa, 7.26 < pH <7.35
- despite immediate maximal
standard medical treatment on
controlled oxygen therapy for no
more than one hour
8. Standard medical therapy:
Controlled oxygen to maintain SaO2 88-92%
Nebulised salbutamol 2.5 – 5mg
Nebulised ipratropium 0.5 mg
Prednisolone 30 mg
Antibiotics (when indicated)
9. Acute / acute on chronic hypercapnic
respiratory failure - chest wall deformity /
neuromuscular disease.
Decompensated OSA (esp if respiratory
acidosis)
?Acute exacerbation of bronchiectasis
ARDS / postoperative, post-transplantation
respiratory failure
Weaning from invasive ventilation
?Heart failure / pneumonia
10. Facial burns / trauma / recent facial or upper airway
surgery
Vomiting
Fixed upper airway obstruction
Undrained pneumothorax
Upper gastrointestinal surgery
Inability to protect the airway
Copious respiratory secretions
Life threatening hypoxaemia
Haemodynamically unstable requiring inotropes / pressors
(unless in a critical care unit)
Severe co-morbidity
Confusion / agitation
Bowel obstruction
Patient declines treatment
11. Place in one of 5 groups:
Immediate intubation and ventilation
Suitable for NIV and escalation to ICU /
intubation if required
Suitable for NIV but not suitable for escalation
Not suitable for NIV but for full active
management
Palliative care most appropriate
12. Premorbid state
Severity of physiological disturbance
Reversibility of acute illness
Presence of relative contraindications
Patients wishes (if possible)
13. Inclusion criteria
Sick but not moribund
Able to protect airway
Conscious and cooperative
No excessive respiratory secretions
Potential for recovery to quality of life
acceptable to the patient
Patient’s wishes considered
15. Continuous sats, cardiac monitoring (first 12
hours) RR, HR, BP and GCS
ABGs – minimum 1, 4 and 12 hours (1 hour
after further changes)
Management plan – within first 4 hours of NIV
– ?intubation
Compliance with NIV, patient-ventilator
synchrony and mask comfort – KEY FACTORS
IN DETERMINING OUTCOME!
Appropriately trained staff
16. Management plan in event of NIV failure
should be made at outset!
Uncertainty / not for escalation - discuss
with a consultant
Escalation appropriate – discuss with ICU
team early (ideally intubate first 4 hours)
In late NIV failure (>48 hours) intubation is
mx of choice
17. Benefit during first hours - NIV for as long as
possible during first 24 hours
Tx should last until the acute cause has
resolved, commonly 2 – 3 days
If NIV successful (pH> 7.35, resolution of
underlying cause and sx, RR normalized) –
appropriate to start weaning
18. Tx reduction – daytime periods first
After withdrawal in the day, a further night
of NIV is recommended
Documentation of weaning strategy in
nursing and medical records
19. When NIV failed, not for escalation – need
proactive approach to palliation
20. NIV works! – evidence based
Indicated in AECOPD – respiratory acidosis
(PaCO2>6kPa, pH<7.35 , >7.26) despite 1
hour medical therapy
Select your patients with thought!
Ensure no contraindications
Think of long term plan when starting
21.
22. 67 yo man with known moderate to
severe COPD
Multiple admissions with IECOPD, no ITU
admissions
3/7 hx of productive cough, increasing
SOB & wheeze
ABG (on non rebreathe mask put on by
ambulance):
pH 7.28, pCO2 9.1, pO2 58
HCO3 29.2, BE -2, lactate 1.9
MANAGEMENT?
23. Salbutamol neb 2.5–5 mg
Ipratroprium neb 500μg
Prednisolone 30mg PO or hydrocortisone
200mg IV (for minimum of 5 days)
Antibiotic (if evidence of infection)
CXR
Consider IV aminophylline
Most importantly controlled oxygen
25. 67 yo man with known moderate to
severe COPD
Multiple admissions with IECOPD, no ITU
admissions
3/7 hx of productive cough, increasing
SOB & wheeze
ABG (on non rebreathe mask put on by
ambulance):
pH 7.28, pCO2 9.1, pO2 58
HCO3 29.2, BE -2, lactate 1.9
Initial management as before
26. Initial ABG (100% non
rebreathe)
ABG at 1 hour (28%
venturi)
pH 7.28 7.21
pO2 58 26.2
pCO2 9.1 11.3
HCO3 29.2 28
BE -2
Sats 98 86
• What now?
27. NIV should be considered in all patients with
an acute exacerbation of COPD in whom a:
respiratory acidosis (pH <7.35, PaCO2 > 6kPa)
persists despite immediate maximum standard
medical treatment on controlled oxygen therapy
for no more than 1 hour
28. NIV started at
EPAP 4cm H20 (improves O2)
IPAP 10cm H20 (reduces PCO2)
O2 level to maintain 88-92% sats
Titrate up to therapeutic setting over 1
hour
IPAP by 2–5cm increments at ~ 5cm H20/10
mins, with usual target of 20 cm H20 or until
therapeutic response achieved or patient
tolerability reached
Within 1 hour, IPAP target of 18-22cm H20
29. Initial ABG (100%
non rebreathe)
ABG at 1 hour
(28% venturi)
ABG 2 hrs post
starting NIV
pH 7.28 7.21 7.36
pO2 58 26.2 18.1
pCO2 9.1 11.3 7.2
HCO3 29.2 28 24
BE -2
Sats 98 86 90
• What now?
30. ABG at 2 hours showing improved pH &
decreasing pCO2
What next?
If no longer acidotic and pCO2 normalising then
don’t stop immediately!
Remain on present settings, repeat ABG in 4-6hrs
Need to wean down the BiPAP over several days –
e.g. D1 24hr, D2 16hr, D3 8hr then stop
31. Initial ABG (100%
non rebreathe)
ABG at 1 hour
(28% venturi)
ABG 2 hrs post
starting NIV
pH 7.28 7.21 7.15
pO2 58 26.2 23.1
pCO2 9.1 11.3 13.5
HCO3 29.2 28 27
BE -2
Sats 98 86 82
• What now?
32. Still acidotic & pCO2 not improving despite
therapeutic settings
Is this person an ITU candidate?
Consider if development of complication
E.g. pneumothorax, mucus plugging, aspiration
pneumonia
Poor fitting mask, tubing disconnection
33. 57 yo lady with IHD and severe LV
dysfunction
Acute onset SOB 2 hours previously
Brought to resus – wheezy ++, accessory
muscle use ++, RR 40
ABG:
pH 7.23, pCO2 7.9, pO2 7.1, lactate 3.8, HCO3 18
on 15L non-rebreathe mask
Likely diagnosis?
Management?
34. Management:
O2, morphine, furosemide, GTN
CPAP
Reduces preload and afterload through positive
intrathoracic pressure, increases SV, decreases HR
Standard is not BiPAP
Studies show does improve pH/pCO2/HR/RR/SOB and
intubation rate
BUT possible increased MI rate (Mehta S et al,Crit Care
Med 1997; 25:620-628)
35. Acute exacerbation of COPD
Firstly 1 hour of maximum standard medical
treatment
ABG at 1 hour
If NIV started then ABG at 1-2 hours
Slow wean down of NIV if improvement
Consider complications/ITU if deterioration
BiPAP not standard for pulmonary oedema
36. Mehta S, Jay GD, Woolard RH, Hipona RA, Connolly EM, Cimini DM, Drinkwine JH,
Hill NS. “Randomized, prospective trial of bilevel versus continuous positive airway
pressure in acute pulmonary edema” Critical Care Medicine 1997; 25:620–628
http://www.brit-thoracic.org.uk
“Non-invasive ventilation in chronic obstructive pulmonary disorder: management of
acute type 2 respiratory failure” RCP/BTS Concise guideline, October 2008
“NIPPV Non-Invasive Ventilation in Acute Respiratory Failure” British Thoracic
Society Standards of Care Committee; Thorax 2002; 57:192-211
“The Use of Non-Invasive Ventilation in the management of patients with chronic
obstructive pulmonary disease admitted to hospital with acute type II respiratory
failure (with particular reference to Bilevel positive pressure ventilation)” British
Thoracic Society/Royal College of Physicians London/Intensive Care Society
guideline, October 2008
Lightowler JV, Wedzicha JA, Elliott MW et al; “Non-invasive positive pressure
ventilation to treat respiratory failure resulting from exacerbations of chronic
obstructive pulmonary disease: Cochrane systematic review and meta-
analysis.” BMJ 2003; 326:185–7.
Ram FSF, Picot J, Lighthowler J et al. “Non-invasive positive pressure ventilation for
treatment of respiratory failure due to exacerbations of chronic obstructive
pulmonary disease.” Cochrane Database Syst Rev 2004; 3.
Editor's Notes
NIV in T2RF in COPD patients represents one of major technical advances in respiratory care over the last decade with a reduction in mortality of approximately 50% demonstrated in studies’
Some evidence for NIV efficacy in more acidotic patients – higher rates of intubation and NIV failure
Trial with respiratory acidosis in acute exacerbation of bronchiectasis (not routine secondary to excessive secretions)
BiPAP is not treatment of choice for heart failure or pneumonia but is sometimes used if escalation to intubation and ventilation is deemed inappropiate
Note asthma not listed – should not be used routinely
Full face mask first 24 hours – come in range of sizes
Low starting IPAP (inspiratory positive airways pressure) enhances compliance but should be titrated upwards to achieve therapeutic effect
Bronchodilators preferably administered off NIV but can be given on.
If NG tube in place – fine bore to minimize mask leakage.
13 pts nasal CPAP vs 14 pts BiPAP - Conventional treatment for pulmonary oedema. BiPAP improved PaCO2/pH, HR and RR as well as dyspnea scores. Both reduced intubation. Howeve MI 71% BiPAP vs 38% CPAP. (Mehta S et al, Crit Care Med 1997; 25:620-628)