Non invasive ventilation beyond the ICU Positives

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Non invasive ventilation beyond the ICU
Positives

• Alexander C. White MD
• New England Sinai Hospital
• Tufts Medical Center

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Outline

• What is NIV
• How does it work Bipap and ASV
• Who needs it - evidence
• NIV at the LTACH

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Acute care hospital versus post acute care
setting
DRGs Length of stay Third party payor
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What is NIV?

• Increase minute ventilation
• No endotracheal tube or tracheostomy
• Interface that is applied to the face

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Interfaces
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BIPAP /NIV delivery devices
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Some physiology.
PaCO2 (CO2 production) VCO2
(Minute Ventilation) V
RR x VT
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Delivery of Non Invasive Ventilation

• BIPAP
• Volume cycled ventilation
• Pressure cycled ventilation
• Adaptive servo ventilation

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What is BIPAP?

• Form of non invasive ventilation
• Pressure differential augments tidal volume and
  thus improves ventilation

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Set two pressuresIPAP and EPAP
Reduce PaCO2
Augments VT
(CPAPsingle constant pressure)
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As opposed to CPAP.
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Adaptive servo ventilation
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ASV

• Baseline support ( 4 cm H2O 5 cm H2O)
• Ventilation is servo controlled
• High gain integral controller
• 0.3 cm H2O/L/min/sec clipped to 4-10 cm H2O
• Ventilation maintained at 90 of long term
  average within 12 s
• Maximum support 10 cm H2O ( on top of the 4 cm
  H2O cpap)

Teschler et al AJRCCM 2001
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Adaptive Servo Ventilation

• The usual type of interface
• Mean pressure
• 9 cm H2O - apnea/hypopnea
• 7 cm H2O) steady breathing

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Effect of ASV on sleep
Teschler et al AJRCCM 2001
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ASV

• Compared with nasal cpap or oxygen
• Improves sleep
• 83 reduction in CSA
• Preferred by patients
• Bilevel might be as effective
• Takes more time

Teschler et al AJRCCM 2001
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Adaptive servo ventilation

• Effect on Cheyne Stokes Respiration and quality
  of life
• Usage time 5.8 2 h per night
• Reduced
• AHI 48 11 to 6 8 (P lt 0.001)
• Nap duration (1.4 to 0.7 h)
• Nocturia (2.9 to 1.1)
• No effect on hypercapnic cerebral vascular
  reactivity

Topfer et al Pneumologie 2004 Morrell et al Sleep
2007
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Delivery of Non Invasive Ventilation

• BIPAP
• Volume cycled ventilation
• Pressure cycled ventilation
• Adaptive servo ventilation

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Who benefits from NIV?
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Who benefits from NIV?

• Exacerbation of COPD
• Acute cardiogenic CHF
• Post extubation or decannulation resp failure
• Palliative care (DNI)
• Neuromuscular disease
• Kyphoscoliosis

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Elevation in Pa CO2 and COPD

• Elevated CO2
• Inadequate ventilatory response to CO2
• Sleep
• Nocturnal hypoventilation REM sleep
• Increase upper airway resistance
• Reduction in VT
• V/Q mismatch

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NIV and COPD Is it effective?

• Lower CO2
• Improved quality of life
• Reduced intubation rate
• Reduction in hospital days
• Reduced mortality
• No effect
• Lung function
• Gas exchange
• Sleep quality(?)

Diaz et al E. Resp J 2002, 20 1490 Clini et al
E. Resp J 2002 20 529 Tuggery et al Thorax
2003 58 867 Keenan et al Ann Int Med 2003
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NIV and COPD

• Persistent hypercapnia sleep disordered
  breathing
• Demonstrate both

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PneumoniaNIV not routine

• Conflicting data on NIV efficacy
• Effective in subgroup of subjects with COPD
• Careful patient selection

Confalonieri et al Am J Resp Crit Care Med
1999 Jolliet P Int Care Med 2001 Hill et al CCM
2007
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NIV bridge to extubation in COPD

• Failed T-piece trial
• Extubate to NIV compared with continued
  intubation
• Increased weaning rate at 28 days
• Reduced
• rate of MV
• ICU LOS
• Incidence of nosocomial pneumonia
• 60 day mortality
• But .careful patient selection
• Avoid if difficult airway
• Need Ipap of 15 cm water

Nava et al Ann Int Med 1998 Ferrer Am et al J
Resp Crit care Med 2003
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Asthma and NIV?

• Weak evidence
• Improved gas exchange
• Reduced intubation rate
• ? Improved peak flow
• ? Reduced hospitalization
• Monitor low threshold to intubate

Meduri et al Chest 1996 Sorosky et al Chest 2003

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Cardiogenic pulmonary edemaRole for NIV?

• Increased functional residual capacity
• Re-expand alveoli improve oxygenation
• Improved lung compliance
• Improved cardiac output
• NIV or CPAP

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NIV and ALI/ARDS

• Failure rate gt 50
• Hypoxemia, shock, metabolic acidosis
• SAPS score gt 34
• PaO2/FiO2 lt 175

Antonelli et al CCM 2007
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NIV and extubation failure

• Not indicated for most subjects
• ? Helpful in
• COPD
• Cardiogenic pulmonary edema
• Hypercapnic respiratory failure
• Monitor closely
• Low threshold to intubate

Keenan SP et al JAMA 2002 Esteban A NEJM 2004
Nava CCM 2005
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Patient selection for NIV

• Need for ventilatory assistance
• No contraindications for NIV

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NIV use in long term acute care Is it different?

• Indications - as outlined
• Prolonged length of stay is an advantage
• NESH data
• 15-20 starts per week in peak season (season
  tickets available)
• Fall, winter, spring
• Scenarios

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NIV use in long term acute care When?

• Transferred to LTACH from acute hospital
• Initiate at LTACH
• Teaching/qualifying patient for discharge
• Aid to decannulation
• Part of comfort care in patients with DNI order

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COPD neuromyopathy of critical illness
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NIV and decannulation

• Transitioning from 16h to 24 h off PMV
• Size 6 tracheostomy tube
• Tolerate red cap
• Vocal cords, subglottic space
• Risk of failure with 24 h red cap
• COPD PaCO2 gt 52 mm hg
• Respiratory muscle weakness
• Neuromuscular disease
• Just not sure.

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How to set the machine

• IPAP
• EPAP
• Set rate ? Apnea (S/T)
• FiO2
• Rise time

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Monitoring the patient

• LTACH is not an ICU!
• ? Increased acuity unit
• RT/RN/patient ratios
• Central monitoring
• Oximetry
• Telemetry
• Sitters
• Restraints??

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Too sick for NIV at LTACH?

• Need 24 h NIV
• Unable to give nutrition
• Full code and desires ICU level care if needed
• Needs 11 staffing
• Difficult airway

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NIV at the LTACH other problems

• Transportation to the LTACH from the acute
  facility
• Risks
• Setting up NIV in the LTACH
• Patient selection
• DNR, DNI, do not transfer orders
• Families at the bedside

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Problems Discharging the patient on a vent

• Getting the patient home with NIV
• Criteria
• Qualifying
• DME providers
• Follow up
• Compared with trach - vent discharge

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Approval of BIPAP by Medicare

• Restrictive thoracic disorders
• Severe COPD
• Central or obstructive sleep apnea

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Saying

• People who think laughter is the best medicine..

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• Apparently have never had morphine.
• Compassionate weaning/end of life

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LTACH
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Extra slides
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COPD with hypercapnic encephalopathy NIV

• Matched study
• NIV versus invasive MV
• Kelly score gt 2
• NIV associated with
• Less nosocomial pneumonia and sepsis
• Less time on mechanical ventilator

Scala et al Int. Care Med 2007
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Need for ventilatory assistance

• Moderate to severe dyspnea
• Tachypnea ( 24-30)
• Accessory muscle use
• Abdominal paradox
• Abnormal gas exchange
• PaCO2 gt 45
• pH lt 7.35
• Pa/FiO2 lt 200

Hill et al CCM 2007
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Contraindications to NIV

• Respiratory arrest - intubate!
• Cannot protect airway
• Excessive secretions
• Agitated, uncooperative, delerium
• Recent airway or gastrontestinal surgery
• Unable to fit mask

Hill et al CCM 2007
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Restrictive thoracic disorders

• Progressive neuromuscular disorder
• (COPD not a cause of limitation)
• One of the following
• PaCO2 gt 45 mm hg awake usual FiO2
• Sleeping SpO2 lt 88 for 5 minutes (on usual FiO2)
  
• Maximal inspiratory pressure lt60 cm water or FVC
  lt 50 predicted
• Bilevel device back up rate

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Severe COPD

• Awake PaCO2 gt 52 mm Hg on usual FiO2 and
• Sleeping SpO2 lt 88 for 5 minutes (on usual FiO2
  or 2 L NC) and
• OSA has been excluded
• Bilevel device with no backup rate ( for 2
  months)

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Severe COPD Bilevel device with backup rate

• Awake PaCO2 gt 52 mm Hg on usual FiO2 ( done at
  gt61 days on initial device) and
• Sleeping SpO2 lt 88 for 5 minutes (on Bilevel
  device and on usual FiO2 or 2 L NC, after 61
  days) and
• Compliance and no documented effect of bilevel
  device without a backup feature

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Approval

• 3 months
• Then clinical re-evaluation
• Compliance ( 4h/24 h)
• Therapeutic efficacy