Non-Invasive Ventilation (NIV)

• Respiratory Management & Considerations for PT/OT/Speech involves respiratory care services

Non-Invasive Ventilation (NIV)

• Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BIPAP) are two types
• CPAP typically treats OSA (Obstructive Sleep Apnea) and helps with oxygenation
• CPAP forces interstitial fluid out of the lungs, improving oxygenation in cardiogenic pulmonary edema
• CPAP is beneficial for immunosuppressed and hypoxic patients
• CPAP setting example: 10 cmH2O
• BIPAP primarily treats patients with increased breathing work and poor ventilation
• BIPAP helps patients with elevated PaCO2 levels (hypercarbic) to "blow off" CO2, prevents intubation, and helps post-extubation
• BIPAP is used for acute exacerbation of COPD and DNI patients
• Average Volume Assured Pressure Support (AVAPS) was originally designed for ALS patients
• AVAPS allows a guaranteed tidal volume or target tidal volume
• Set a Minimum IPAP and a Maximum IPAP

AVAPS Settings

• Respiratory Rate (RR)
• Tidal Volume Goal
• Minimum IPAP (Inspiratory Positive Airway Pressure)
• Maximum IPAP (Inspiratory Positive Airway Pressure)
• EPAP (Expiratory Positive Airway Pressure)
• FiO2
• Oxygen bleed-in is possible on home vents like Trilogy
• The amount of support from NIV determines how much a patient can do
• High FiO2 and pressure settings (15/5 or greater) may indicate low reserve or high WOB/SOB, and low therapy tolerance
• Some NIV machines are portable

Ventilator Controls

• Optiflow is a high flow oxygen delivery system where FiO2 can be titrated independently of flow
• Optiflow operates from 20-60 lpm with a FiO2 range of 21%-100%
• Changes to either of the settings requires the other to change as well
• Optiflow: Provides ventilator support without requiring high FiO2 levels
• High flow nasal cannula ranges from 6-15 lpm of 100% oxygen
• High flows through the nasal passage create a CPAP-like effect
• Optiflow indications include COPD exacerbation requiring support but not high FiO2
• Optiflow can help patients weaning from BiPAP/CPAP and reduces WOB before/after intubation
• Optiflow is usually tolerated better than BiPAP/CPAP
• Optiflow can provide comfort to DNR/DNI patients

Optiflow Considerations

• Settings indicate therapy levels
• Higher flow (lpm) indicates greater ventilator support needed
• Lower level of oxygen indicates diminished oxygen reserve, lack of endurance, or inability to perform therapy
• Because optiflow devices don't have battery backups they can't be transported
• Nasal cannula provides 1-6 lpm
• High flow nasal cannula provides 6-15 lpm
• Venturi mask provides 24-50% oxygen (3L or 6L)
• Non-rebreather mask should always be set to 10-15 lpm with fully inflated or deflating bag with each breath
• Humidified face tent/mask provides 28-100% oxygen

Ventilator Settings

• Respiratory Rate (RR or f): Breaths per minute, with a normal range of 12-20
• Tidal Volume (Vt) or Drive Pressure (Pinsp): Size of breaths, set in mL (Vt) or cmH2O (Pinsp)
• FiO2: Percentage of oxygen the patient receives
• PEEP: Pressure at the end of each breath to prevent lung collapse and help with oxygenation, the low limit is 5cmH2O

Ventilator Monitoring - Patient Values

• Peak Airway Pressure: Maximum pressure in the lungs during each breath and normal amount is under 30cmH2O
• Respiratory Rate: Breaths, normal is at 12-20
• Tidal Volume (Vt): Breath size, measured in mL
• Minute Ventilation: Calculated as RR x Vt

Ventilator Controls (for Non-RT's)

• Alarm silence: Silences all alarms for 2 minutes
• Alarm reset
• 100% O2

Modes of Ventilation

• Assist Control (AC): Mandatory breaths; patient can assist and over-breathe; volume-controlled (VC) or pressure-controlled (PC)
• SIMV: Like AC; VC or PC breaths with set RR; patient can breathe spontaneously between mechanical breaths with pressure support
• Bilevel: Lung recruitment mode; breaths held for extended periods, patients usually have high oxygen needs and are very sick
• Pressure Support Ventilation (PSV): Spontaneous breathing mode, constant pressure to assist spontaneous effort, primary weaning mode

Red and Yellow Alarms

• Red Alarms are critical alerts, which require immediate action with pausing therapy
• Yellow Alarms not critical, but a notification, which indicate a parameter that lies beyond established bounds
• Types of alarms include increase RR, Minute Ventilation Ve, and Tidal Volume V₁
• Critical RED Alarms includes and are Circuit Disconnect/Severe Occlusion and Peak Airway Pressure (Ppeak)
• Circuit Disconnect/Severe Occlusion occurs when the patient becomes detached, worst case being occluded
• Peak Airway Pressure (Ppeak) could stem from coughing, lung compliance, bronchospasm, and obstructed airways
• Neither Requires terminating therapy, but requires immediate intervention

Weaning

• PSV (Pressure support ventilation) is when patients breath through the ventilator - not ready to breath independently
• PSV is done in time increments that increase daily with a normal range of 5-10
• T-Piece: Breaths come from the supplemental oxygen with end tidal CO2 monitoring
• Trach Collar: Breaths come fully from supplemental oxygen

COVID-19 Considerations

• There are two COVID-19 patient types which are ARDS (Acute Respiratory Distress Syndrome) and those who were managed with Optiflow and NIV
• COVID pt treatment includes Prone positioning, High mechanical ventilator and stiff lungs

When to Terminate Therapy

• RR rises by 10-12 breaths per minute above resting RR
• Pt becomes diaphoretic and SOB, gasping
• SpO2 drops below 92%, with exception to COPD patients below 88%
• Critical Alarm cannot be resolved by RT/RN
• Vital signs become unstable

Decreased SpO2/Increased O2 demand

• Check waveform and move probe
• Increase oxygen as needed to keep SpO2 per physician order to non-rebreather at a 15lpm if needed
• Contact physician/respiratory

Respiratory Distress (signs)

• Accessory muscle use (neck muscles moving when breathing, retractions)
• Tripoding while breathing
• Diaphoretic
• Wheezing/stridor
• Less alert than baseline
• Restlessness or inability to sit still
• Dusky skin, lips and nails

What To Do During Respiratory Distress

• Sit patient upright
• Put them on oxygen, use caution with COPD (keep SpO2 in the low 90%
• Calm them down
• Call respiratory and physician
• Call Rapid Response Team/Code if needed