Podcast
Questions and Answers
Which medical condition is associated with respiratory failure in immunocompromised patients?
Which medical condition is associated with respiratory failure in immunocompromised patients?
What is a primary goal when managing patients at high risk for reintubation?
What is a primary goal when managing patients at high risk for reintubation?
Which of the following conditions is NOT listed as a cause of pulmonary oedema?
Which of the following conditions is NOT listed as a cause of pulmonary oedema?
Idiopathic Pulmonary Fibrosis primarily affects which part of the body?
Idiopathic Pulmonary Fibrosis primarily affects which part of the body?
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In the context of respiratory diseases, which factor poses a significant risk for developing respiratory failure?
In the context of respiratory diseases, which factor poses a significant risk for developing respiratory failure?
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What is the recommended position for a patient after a procedure regarding mask usage?
What is the recommended position for a patient after a procedure regarding mask usage?
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What type of mask is preferred for the first 24 hours following a procedure?
What type of mask is preferred for the first 24 hours following a procedure?
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What should the patient be encouraged to do with the mask during the initial recovery period?
What should the patient be encouraged to do with the mask during the initial recovery period?
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After 24 hours, what is a possible option for mask usage if preferred by the patient?
After 24 hours, what is a possible option for mask usage if preferred by the patient?
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Which of the following is NOT a recommended guideline for post-procedure patient care?
Which of the following is NOT a recommended guideline for post-procedure patient care?
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What is a significant risk associated with the use of a full face mask during noninvasive ventilation?
What is a significant risk associated with the use of a full face mask during noninvasive ventilation?
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Which of the following noninvasive interfaces is primarily used for daytime breathing support?
Which of the following noninvasive interfaces is primarily used for daytime breathing support?
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Which of the following complications is associated with noninvasive ventilation (NIV)?
Which of the following complications is associated with noninvasive ventilation (NIV)?
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In what situation might a chin strap be required during noninvasive ventilation?
In what situation might a chin strap be required during noninvasive ventilation?
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What does CPAP stand for in the context of respiratory support?
What does CPAP stand for in the context of respiratory support?
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What is a significant indicator of success in a trial of non-invasive ventilation (NIV)?
What is a significant indicator of success in a trial of non-invasive ventilation (NIV)?
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What change in pH is considered a positive predictor of success during a trial of NIV?
What change in pH is considered a positive predictor of success during a trial of NIV?
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During the trial of ventilation, which outcome would suggest effective intervention?
During the trial of ventilation, which outcome would suggest effective intervention?
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What is the expected effect of a successful NIV trial on PaCO2 levels?
What is the expected effect of a successful NIV trial on PaCO2 levels?
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In evaluating the outcome of NIV, what is the minimum decrease in PaCO2 considered significant?
In evaluating the outcome of NIV, what is the minimum decrease in PaCO2 considered significant?
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What primary factor should guide the decision for tracheal intubation and mechanical ventilation?
What primary factor should guide the decision for tracheal intubation and mechanical ventilation?
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What does a deteriorating ABG indicate about the patient's condition?
What does a deteriorating ABG indicate about the patient's condition?
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Under what circumstances should mechanical ventilation be considered for a patient?
Under what circumstances should mechanical ventilation be considered for a patient?
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What might an increasing level of fatigue in a patient indicate regarding their respiratory status?
What might an increasing level of fatigue in a patient indicate regarding their respiratory status?
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What should be done if optimal settings do not improve the patient's ABG results?
What should be done if optimal settings do not improve the patient's ABG results?
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What is one of the primary goals of home mechanical ventilation?
What is one of the primary goals of home mechanical ventilation?
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Which condition is NOT listed as an indication for home mechanical ventilation?
Which condition is NOT listed as an indication for home mechanical ventilation?
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What physiological measurement indicates a need for home mechanical ventilation?
What physiological measurement indicates a need for home mechanical ventilation?
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Which symptom is commonly associated with the need for mechanical ventilation?
Which symptom is commonly associated with the need for mechanical ventilation?
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What does a maximal inspiratory pressure less than 60 indicate?
What does a maximal inspiratory pressure less than 60 indicate?
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A patient is experiencing morning headaches and insomnia. Which aspect might indicate a need for ventilation?
A patient is experiencing morning headaches and insomnia. Which aspect might indicate a need for ventilation?
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What is an essential criteria for a patient to be considered for home mechanical ventilation?
What is an essential criteria for a patient to be considered for home mechanical ventilation?
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Which of the following is considered a disorder of the respiratory pump?
Which of the following is considered a disorder of the respiratory pump?
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Study Notes
Home Mechanical Ventilation
- Goals: Extend lifespan, enhance quality of life, reduce morbidity, improve physiological function, obtain normal routines, reduce health care costs.
Indications
- Respiratory pump disorders: Neuromuscular diseases, chest wall conditions, spinal cord injuries.
- Airway obstructions: Obstructive diseases, craniofacial abnormalities, hypotonia, obesity, chronic obstructive pulmonary disease (COPD), asthma.
- Lung parenchymal diseases: Interstitial lung disease (ILD), cystic fibrosis.
- Control of respiration disorders: Central hypoventilation syndrome.
- Inability to wean from mechanical ventilation: After and acute illness, after prolonged ventilation for chronic disease, progressive chronic respiratory failure, sleep disturbance (central or obstructive, apnea or hypopnea).
Indications/Symptoms
- Shortness of breath: Especially on exertion or lying down.
- Morning headache and insomnia.
- Fatigue and lethargy.
- Increased respiratory rate.
- Restlessness and anxiety.
- Forced vital capacity < 50% predicted.
- Maximal inspiratory pressure < 60.
- ABG pCO2 > 45.
- Moderate to severe sleep apnea.
Patients
- Cardiopulmonary stability: Positive trend in nutrition/maintenance.
- Stamina for daily activities: Freedom from active/recurrent infection, fever, and deterioration.
Interfaces
- Noninvasive vs. Invasive: Age, cognitive ability, body habitus, ventilatory needs, anticipated length of ventilation, patient/family preference.
Definition of Noninvasive Ventilation (NIV)
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NIV: A ventilatory mode delivering mechanical support without an endotracheal tube/surgical airway. Uses a tight-fitting face or nasal mask.
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Decision to intubate: Made solely on clinical grounds without delay for laboratory evaluation.
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Types: Continuous positive airway pressure (CPAP), Bilevel positive airway pressure (BiPAP).
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CPAP: Does not directly increase tidal volume or minute ventilation.
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BiPAP: Provides supplemental inspiratory tidal volume.
Indications for NIV Use
- Respiratory failure: COPD exacerbation, pulmonary edema, respiratory failure in immunocompromised patients (e.g. AIDS, malignancy), weaning from conventional ventilation, and prevention of reintubation in high-risk patients.
- Specific conditions: Asthma, idiopathic pulmonary fibrosis, obesity hypoventilation, neuromuscular respiratory diseases.
- Do-not-intubate status: In terminal illness or malignancies.
Relative Contraindications
- Cardiac instability: Shock, need for pressor support, ventricular dysrhythmias, complicated acute myocardial infarction.
- Gastrointestinal (GI) bleeding: Intractable emesis and/or uncontrollable bleeding.
- Inability to protect airway: Impaired cough or swallowing, poor clearance of secretions, depressed sensorium and lethargy.
- Status epilepticus.
- Potential for upper airway obstruction: Extensive head/neck tumors, other tumors with extrinsic airway compression, angioedema or anaphylaxis causing airway compromise.
Absolute Contraindications
- Coma.
- Cardiac arrest.
- Respiratory arrest.
- Any condition requiring intubation.
- Non-compliant patient.
Guidelines for Providing NIV
- Duration of treatment starts: With the first 4 hours of treatment.
- Time of minimum treatment: Should receive NIV for as long as possible (a minimum of 6 hours) during the first 24 hours.
- Duration of treatment: Should last until the acute cause is resolved, typically after about 3 days
- Success Criteria: Successful NIV (pH > 7.35, resolution of cause, normal RR) after 24 hours indicates planning for weaning..
Protocol for Initiation of NIV
- Location: Appropriately monitored.
- Patient Position: Bed or chair sitting at > 30-degree angle.
- Mask Type: Full-face mask used for first 24 hours; nasal mask, if preferred.
- Patient Encouragement: Encourage patient to hold the mask.
- Harness and Tension: Apply a harness; avoid excessive strap tension.
- Ventilator Connection: Connect interface to ventilator tubing, turn on ventilator.
- Leak Check and Adjustments: Check for air leaks; readjust straps.
Guidelines for Providing BiPAP
- Initial pressures: IPAP of 10 cm H2O & EPAP of 4-5 cm H2O.
- IPAP increases: Increased by 2-5 cm increments at a rate of approximately 5 cm H2O every 10 minutes, with a usual target of 20 cm H2O.
- Oxygen adjustment: O2 entrained into circuit & flow adjusted to SpO2 >88-92%.
Oxygenation and Humidification
- Oxygen: Titrated to desired oxygen saturation 90-92%.
- Oxygen delivery: Use of oxygen blenders, and adjusting liter flow via oxygen tubing connected directly to the mask or ventilator circuit.
- Heated vaporizer: Use of heated blow over vaporizer if longer application intended.
Bronchodilators
- Administration: Preferably administered outside of the NIV.
- Placement: If necessary, entrain between expiration port and face mask.
- Effect on NIV: Delivery of both oxygen and nebulized solutions is affected by NIV settings.
- Nasogastric tube (NGT): If an NGT is present, a fine bore tube is recommended to avoid mask leakage.
Criteria for Terminating NIV and Switching to Mechanical Ventilation
- Deteriorating pH/PaCO2 levels.
- Tachypnea (>30 bpm).
- Hemodynamic instability.
- Low SpO2 (<90%).
- Decreased level of consciousness.
- Inability to clear secretions.
- Failure to tolerate the interface.
Weaning Strategy
- Day 2: Continue NIV for 16 hours.
- Day 3: Continue NIV for 12 hours, including 6-8 hours overnight use.
- Day 4: Discontinue NIV unless clinically indicated.
Complications of NIV
- Facial and orthodontic changes.
- Aerophagia (PIP > 25 cmH2O).
- Nasal drying/congestion: Humidification.
- Volutrauma (air leak).
- Inadequate ventilation.
- Other issues: • Facial and orthodontic changes, • Aerophagia (PIP > 25 cmH2O), • Nasal drying/congestion (humidify), • Volutrauma (air leak), • Inadequate ventilation, • Gastric distention, • Drying of mucous membranes of nose, nasal congestion, & thick secretions. • Aspiration of gastric contents, • General discomfort, • Claustrophobia,
Ventilator Settings
- Initiation: IPAP/EPAP start with 10/5 cm H2O, with goal to VT 6-7ml/kg.
- IPAP Adjustments: Increased in 2 cm increments up to a maximum of 20-25 cm H2O
- EPAP adjustments: Increase by 2 cm H2O if hypoxia; keep max at 10-15 cm H2O.
- Respiratory rate: Back up respiratory rate increased to 12-16/minute.
- Oxygen adjustment: Adjust FiO2 to achieve SaO2 90-92%.
- Other parameters: Most machines generate a maximum pressure of 20-23 cmH2O; if higher pressures are required, mask leakage will likely be a problem and conventional invasive ventilation will likely need to be prioritized.
FiO2 and Settings
- Initial FiO2: Start with FiO2 a little higher for that prior to NIV
- SaO2 targeting: Aim for SaO2 above 92%.
- Hypoxic patients: In hypoxic patients, increasing the FiO2 on a BiPAP circuit likely wont improve hypoxia because the decreased FiO2 is likely caused by increased gas flow through the circuit.
Monitor patient response
- Patient's feelings: The most helpful indicator is how the patient is feeling.
- Compliance: Patient compliance is a key indicator.
- ABGs: Use arterial blood gases (ABGs) to monitor oxygenation and CO2 clearance.
- Trial of ventilation: A trial (1-2 hours) will typically show a decrease in PaCO2 (>8 mmHg) increase in pH (>0.06) indicating successful NIV.
Predict failure
- Patient's feelings: Increasing tiredness or deteriorating ABGs despite optimal settings indicates a need for intubation and mechanical ventilation.
- Early intervention: Promptly recognize failure to respond, so that management strategies can be implemented prior to patient collapse.
- Indicators of failure: •Acidosis (pH <7.25) •Hypercapnia (>80 and PH <7.25) •APACHE II score higher than 20. •Neurologic score > 4 •Encephalopathy score >3 •Glasgow Coma Scale score less than 8
BiPAP Limitations
- Augmentation, not primary ventilation: BiPAP only augments respiratory function; not a primary ventilation method.
- Dependent factors: Tidal volume depends upon airway resistance, lung/chest wall compliance, patient synchrony with machine and absence of mask leakage.
Monitoring
- Vitals monitoring: Blood pressure, respiratory rate, heart rate, rhythm, oxygen saturation, level of consciousness.
- Treatment tolerance: Initial monitoring occurs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for 2 hours, and then every 4 hours thereafter..
- Oxygen saturation should be 94-98% (or 88-92% in CO2 retainers)
- Blood gas analysis (ABGs) before commencing treatment, after 1 hour, and within 1 hour of any change in ventilator settings. Further ABGs are performed as clinically indicated.
Advantages of NIV
- Lower intubation rate and mortality: reduced incidence of intubation and mortality in various patients..
- Reduced intensive care unit and hospital stays: reduced time in ICU and hospital.
- Prevention of ventilator-associated complications: Avoid complications of ventilator.
Complications of NIV
- Facial and nasal pressure injury.
- Gastric distension.
- Drying of mucous membranes, nasal congestion, and thick secretions.
- Aspiration of gastric contents.
- General discomfort.
- Claustrophobia.
Literature Review
- 1995 study: BiPAP reduced endotracheal intubation, hospital stay, and mortality in acute COPD patients. Key factors included PaO2 < 45 mmHg, pH< 7.35 and Respiratory Rate>30 bpm.
- 2003 Cochrane review: BiPAP decreased mortality, incidence of ventilator-associated pneumonia, ICU stay, and hospital stay in COPD patients.
Strong/Less Strong Evidence Levels
- Level A: Acute hypercapnic COPD, acute cardiogenic pulmonary edema, patients Immunocompromised.
- Level B: Asthma, Community Acquired Pneumonia, COPD; Weaning in COPD; Avoidance of extubation failure; Post Operative Respiratory Failure; Do not intubate patients.
- Weak/No Benefit: ARDS, Community acquired pneumonia (not COPD), Cystic fibrosis, Weaning (not COPD), OSA/Obstructive Sleep Apnea/Obesity Hypoventilation, Trauma.
- Not indicated: Acute deterioration in ILD, severe ARDS with multi organ failure, post op upper airway or esophageal surgery.
Present Status of NIV
- Increasing use: Application of mechanical ventilator support through a mask is increasingly accepted in emergency departments and ICUs.
Summary of COPD
- Suitable condition: COPD is the optimal condition for NIV
- Effectiveness: Most effective in patients with moderate-to-severe COPD.
- Best responders: Patients with hypercapnic respiratory acidosis (pH 7.20-7.30) are often the best candidates.
- Effectiveness variation dependent on pH: Noninvasive ventilation is also effective in patients with pH of 7.35-7.30, however there is no additional benefit if pH value is greater than 7.35. The lowest threshold for effective treatment is not well-defined but has been demonstrated with success in some patients with as low as 7.10 pH.
- Obtunded patients: Obtunded COPD patients respond better to treatment, but with a lower overall success rate.
- Improved after trial: Improvement after a 1-2 trial period may suggest successful NIV treatment in some patients.
Ventilator Choice Decisions
- Factors for choice: Portability, battery life, setting capabilities, reliability, and community support are key considerations.
Full Ventilation Description
- Types: Noninvasive or invasive ventilator systems. Pressure-cycled or volume-cycled ventilators.
- Adjustments possible: Allows for pressure support, PEEP, inspiratory time, flow to be altered and manipulated.
Control Mode vs. SIMV
- Control Mode: Fully supports every breath; weaning is not possible by reducing the rate. Risk of hyperventilation in agitated patients.
- SIMV Mode: Vent synchronizes with patient efforts, patients take breaths in between ventilator breaths, and increased work of breathing compared to control mode.
Specific Ventilator Techniques - Pressure vs. Volume
- Pressure Control: Set pressure, volume is variable; better control of oxygenation, generally better for younger, non-compliant lungs.
- Volume Control: Set volume, pressure is variable; better control of ventilation, generally better for older, more compliant lungs.
Pressure Support
- Trigger mechanism: Triggered by the patient, provides inspiratory flow during inspiration.
- Mimics BiPAP mode: Given to add breaths to other modes like IMV, or alone without a set rate, creating a BiPAP-like mode.
Bilevel Mode
- Mechanism: Pressure supported ventilation that imitates the actions of BiPAP. It does not have a backup rate.
- Application: Mimicked BiPAP without a backup rate.
Supporting Equipment
- External support (PEEP): Equipment required to provide external support and pressure.
- Monitoring: Alarms, pulse oximetry, apnea monitor, capnography
- Humidification: Humidification equipment.
- External heater: External heaters for humidification use.
- HME: Heat and Moisture Exchanger.
- Airway clearance: Airway clearance equipment/techniques (suctioning, vest, cough assist, and talking devices).
Discharge Criteria
- Stable airway: The presence and maintenance of a stable airway.
- Oxygen requirements: Oxygen requirements (FiO2 less than 40%).
- Carbon dioxide levels: Maintaining carbon dioxide levels (PCO2) within a safe range.
- Nutritional intake: Meeting optimal nutritional intake.
- Other medical conditions: Other medical conditions well-controlled.
- Palliative care adjustments: above may need adjustments for palliative care patients.
- Discharged preparation: Goal clarity with family; family/respite care givers are trained for ventilator use, nursing is arranged for nighttime; equipment lists, supply, and funding issues are addressed.
Continuing Assessment
- Titration sleep studies: Titration and sleep studies need to be continued as per patient needs,.
- Blood gas analyses: Continuation of blood gas analyses are performed.
- Bronchoscopy: Bronchoscopies may be required in certain situations.
- Home monitoring: Ongoing home monitoring will be necessary through assessment and re-evaluation..
- Weaning and Decannulation: Ongoing assessment and evaluation will be necessary during weaning and decannulation.
Complications
- Ventilator failure.
- Tracheostomy related issues.
- Decannulation/blockage/infections.
- Mask-related issues.
- Pressure sores.
- Facial growth concerns.
- Under- or over-ventilation.
Outcomes
- Underlying disease dependence: Outcomes dependent on underlying disease severity and patient factors.
- High survival rates: Over 70% of patients survive 10 years after home mechanical ventilation.
Quality of Life
- Generally good: Patients often report good quality of life.
- Fewer hospitalizations: Fewer hospitalizations compared to other treatment methods..
- Better sleep quality: Improved sleep quality may be reported..
- Improved daytime functionality: Daily functionality may be improved.
- Potential caregiver stress: Some stress related for patients/caregivers are related to care and support needs.
Home Ventilation Reality
- Individualized approach: Every patient's ventilation needs are unique.
- Guidelines vs. Rules: The guidelines are helpful but not absolute rules.
- Patient goals: Goal-setting and teamwork to achieve optimal health and quality of life.
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Description
This quiz covers key topics related to respiratory failure, management strategies in high-risk patients, and best practices for mask usage in post-procedure care. Test your knowledge on pulmonary conditions and the critical factors affecting respiratory health, particularly in immunocompromised individuals.
