2. What we are going to coverWhat we are going to cover What is NIV?What is NIV? Ventilation Physiology & TerminologyVentilation Physiology & Terminology Types of NIVTypes of NIV Indications for NIVIndications for NIV Contra-indicationsContra-indications Case examplesCase examples 3. What is Non-InvasiveWhat is Non-InvasiveVentilation (NIV)Ventilation (NIV)Delivery of ventilatory support without theDelivery of ventilatory support without theneed for an invasive artificial airwayneed for an invasive artificial airway 4. SomeSomePhysiology.zzzzzzz!Physiology.zzzzzzz! VentilationVentilation- process by which O2 and CO2 are- process by which O2 and CO2 aretransported to and from the lungstransported to and from the lungs Venous bloodVenous blood- lower pO2 higher pCO2 than inspired- lower pO2 higher pCO2 than inspiredgasgas- partial pressure gradient driving O2 in- partial pressure gradient driving O2 inand CO2 outand CO2 out 5. Ventilation of lungs with inspired gasesVentilation of lungs with inspired gasesleads to mixing with alveolar gasleads to mixing with alveolar gas If no ventilation at all, no replenishmentIf no ventilation at all, no replenishmentof O2 and no removal of CO2of O2 and no removal of CO2 Arterial pO2 falls and pCO2 risesArterial pO2 falls and pCO2 risestowards that of venoustowards that of venous If ventilation greater than needed,If ventilation greater than needed,alveolar gas closer to inspired gasalveolar gas closer to inspired gas 6. TerminologyTerminology Tidal Volume (VT) amount of gas expiredTidal Volume (VT) amount of gas expiredper breath (~ 500ml at rest)per breath (~ 500ml at rest) Minute Volume amount of expired gas perMinute Volume amount of expired gas perminuteminute Alveolar Ventilation amount of gas reachingAlveolar Ventilation amount of gas reachingfunctional alveolifunctional alveoli Work of Breathing usually ~5% of total bodyWork of Breathing usually ~5% of total bodywork most used to overcome lung and chestwork most used to overcome lung and chestwall stiffness during inspirationwall stiffness during inspiration 7. PEEPPEEP Pressure Support (cmH2O) positivePressure Support (cmH2O) positivepressure applied to airway to supportpressure applied to airway to supportpatients own breathpatients own breath Opening Pressure pressure requiredOpening Pressure pressure requiredto open collapsed alveolito open collapsed alveoli 8. Types of NIVTypes of NIV Negative-Pressure Ventilation (IronNegative-Pressure Ventilation (IronLung)Lung) Continuous Positive Airway PressureContinuous Positive Airway Pressure(CPAP) (Not really NIV!)(CPAP) (Not really NIV!) Bi-level Positive Airway PressureBi-level Positive Airway Pressure(BiPAP)(BiPAP) 9. Negative-Pressure VentilationNegative-Pressure Ventilation Late 1880s iron lungsLate 1880s iron lungsfirst usedfirst used Early 1900s iron lungsEarly 1900s iron lungsused for polio epidemicsused for polio epidemics This continuedThis continuedthroughout the 20throughout the 20ththcentury until 1960s whencentury until 1960s wheninvasive ventilationinvasive ventilationbecame availablebecame available 10. CPAPCPAP Nasal or face maskNasal or face mask Continuous positive pressureContinuous positive pressureapplied to the airwaysapplied to the airways Usually well-toleratedUsually well-tolerated Similar to use of PEEPSimilar to use of PEEP Reduces work of breathingReduces work of breathing Improve ventilation toImprove ventilation tocollapsed areas of lungcollapsed areas of lung 11. BiPAPBiPAP Bi-Level pressure supportBi-Level pressure support Inspiratory Positive Airway Pressure (IPAP) &Inspiratory Positive Airway Pressure (IPAP) &Expiratory PAP (EPAP)Expiratory PAP (EPAP) IPAP is the pressure support machine givesIPAP is the pressure support machine givesto help patients own inspirationto help patients own inspiration Helps to reduce WOB and increase alveolarHelps to reduce WOB and increase alveolarventilationventilation EPAP is essentially PEEP and help toEPAP is essentially PEEP and help toprevent alveolar collapseprevent alveolar collapse 12. Indications for CPAPIndications for CPAP Cardiogenic Pulmonary OedemaCardiogenic Pulmonary Oedema Obstructive Sleep ApnoeaObstructive Sleep Apnoea Chest Wall Trauma if hypoxic onChest Wall Trauma if hypoxic onadequate analgesiaadequate analgesia PneumoniaPneumonia 13. Indications for BiPAPIndications for BiPAP Exacerbation of COPD with RespiratoryExacerbation of COPD with Respiratoryacidosisacidosis Type II respiratory failure with chest wallType II respiratory failure with chest walldeformity or neuromuscular diseasedeformity or neuromuscular disease Failure of CPAPFailure of CPAP Pneumonia with respiratory acidosisPneumonia with respiratory acidosis Therapeutic trial with a view to intubation if itTherapeutic trial with a view to intubation if itfailsfails Others (ARDS, post-op respiratory failure, toOthers (ARDS, post-op respiratory failure, tobuy time prior to intubation)buy time prior to intubation) 14. Patient SelectionPatient Selection Sick but not moribundSick but not moribund Able to protect airwayAble to protect airway Conscious and co-operativeConscious and co-operative Haemodynamically stableHaemodynamically stable No excessive secretionsNo excessive secretions Few co-morbiditiesFew co-morbidities Improvement on ABG with NIVImprovement on ABG with NIV 15. Patient RejectionPatient Rejection Respiratory arrestRespiratory arrest Haemodynamically unstableHaemodynamically unstable UncooperativeUncooperative Unable to protect airway (swallowing andUnable to protect airway (swallowing andcough impaired or vomiting)cough impaired or vomiting) Facial, oesophageal, or gastric surgeryFacial, oesophageal, or gastric surgery Craniofacial trauma or burnsCraniofacial trauma or burns Airway obstructionAirway obstruction Undrained PneumothoraxUndrained Pneumothorax 16. Case 1Case 1 76yr old female76yr old female Lifelong smokerLifelong smoker 1/52 productive cough1/52 productive cough BP140/90 P120 RR40 SaO2 89% on 10LBP140/90 P120 RR40 SaO2 89% on 10LpHpH 7.37.3pCO2pCO2 8.28.2pO2pO2 6.96.9HCO3HCO3 2020BEBE 4.2 4.2 17. Case 2Case 2 83yr old man83yr old man Known IHD, previous MIKnown IHD, previous MI Wife says he has not been wellWife says he has not been well BP170/95 P120 RR38 SaO2 87% on 15LBP170/95 P120 RR38 SaO2 87% on 15LpHpH 7.287.28pCO2pCO2 5.25.2pO2pO2 7.17.1HCO3HCO3 2121BEBE -3.2-3.2 18. Case 3Case 3 49yr old man49yr old man 2/52 Hx of feeling unwell with D&V2/52 Hx of feeling unwell with D&V Not eating or drinkingNot eating or drinking Not passing urineNot passing urine BP89/50 P130 RR40 SaO2 96% on NRBMBP89/50 P130 RR40 SaO2 96% on NRBMpHpH 6.986.98pCO2pCO2 2.92.9pO2pO2 14.214.2HCO3HCO3 13.913.9BEBE -21.4-21.4 19. Case 3 Contd.Case 3 Contd. UreaUrea 3232 CreatCreat 444444 KK 6.26.2 HbHb 9.29.2 WCCWCC 2424 PLTPLT 4747 PTPT 2020 APTTAPTT 100100 20. Case 4Case 4 50yr old man50yr old man On the wardOn the ward Nurses report that he snores a lotNurses report that he snores a lot Wife tells you he has seen a specialistWife tells you he has seen a specialistand has a machine at home that makesand has a machine at home that makesa lot of noisea lot of noise What is it ???!!!What is it ???!!! 21. SummarySummary What NIV is and the different typesWhat NIV is and the different types Basic respiratory physiologyBasic respiratory physiology Indications for NIVIndications for NIV When not to use itWhen not to use it Thought about some casesThought about some cases 22. Any Questions?Any Questions???