Practical Points in NIV

งานนำเสนอเรื่อง: "Practical Points in NIV"— ใบสำเนางานนำเสนอ:

1 Practical Points in NIV
นพ.รัฐภูมิ ชามพูนท รพ.พุทธชินราช

2 ใครในภาพต่อไปนี้ไม่ได้เป็น พรีเซนเตอร์ต่อต้านการสูบบุหรี่

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5 What is NIV When to use NIV Before Intubation Follow Extubation
Mechanical ventilation without using invasive airway When to use NIV Before Intubation Follow Extubation

6 TYPE of NIV 2 Types Negative Pressure Posive Pressure (NIPPV)

7 Normal breathing (Negative pressure breath)
+2 -2

8 Mechanical ventilation(positive pressure ventilation)

9 TYPE of NIV Negative Pressure
Can be provided without artificial airway Emerson Iron Lung (Past) Chest Cuirass Pneumobelt Rocking Bed Positive Pressure

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11 Postpolio era

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14 Use in Home mechanical ventilation
Communicate more effective Neuromuscular disease X Intrinsic lung disease X Body temp regulation X Not very comfortable

15 TYPE of NIV 2. Positive Pressure(NIPPV)
Higher than atmospheric pressure Push air into the lung Can be provided with artificial airway (variety Interface)

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18 Mode of NIPPV Volume limited Ventilation Pressure limited Ventilation
Pressure varied Discomfort , Gastric distention  Intolerance Air leakage Pressure limited Ventilation CPAP BiPAP PAV Mixed Volume and Pressure Limited Ventilation

19 Pressure-Limited Ventilation
CPAP Simplest Constant pressure provided through inspiration and expiration Decrease WOB , Increase FRC & Gas exchange BiPAP/NPPV IPAP V.S. EPAP Less expiratory resistance Spontaneous , Timed , S/T Mode Proportional Assisted Ventilation (PAV)

20 Interface

21 Nasal Mask Advantages Disadvantages Less risk of aspiration
Easier secretion clearance Less claustrophobia Easier speech May allow patient to eat Easy to fit and secure Less dead space Disadvantages Mouth leak Higher resistance through nasal passage Less effective with nasal obstruction Nasal irritation and rhinorrhea Mouth dryness

22 Oronasal Mask(full face)
Advantages Better control of mouth leak More effective with mouth breathers , particularly during acute application of NIPPV Disadvantages More dead space Claustrophobia More risk of aspiration More difficulty in eating and speaking Asphyxiation if ventilator malfunction

23 Circuit Type Single Limb Double Limb

24 Single Limb circuit system

25 Single Limb circuit system
ventilator

26 2 Limb circuit system

27 2 Limb circuit system ventilator

28 Leak valve system หายใจไม่ออก! ventilator ไม่มี Leak valve ใน circuit

29 Leak valve system ค่อยยังชั่วหน่อย แต่ทำไมลมดันไม่หยุด
ventilator มี Leak valve ใน circuit

30 Initial Settings EPAP = CPAP IPAP = Pressure Support
(Include PEEP or above PEEP) Back up Rate Pramp(Rising Time) Optional FiO2

31 Pressure support ventilation(PS)
The faster the initial rise to peak flow level,the sooner the set pressure limit is reached Slow rise to set pressure level is more comfortable for the patient Exessively fast rise to peak flow may cause the ventilator to overshoot the initial pressure limit and create a pressure spike,which can cause discomfort and increase WOB

32 เหมือนจะใช่ แต่ไม่ใช่
FAQ 1.อย่างนั้น mode CPAP with PS ในเครื่อง Invasive Mechanical ventilator ก็คือ NIPPV(Bilevel CPAP) ใช่หรือไม่ ?? เหมือนจะใช่ แต่ไม่ใช่

33 Phase variables 4 phases The change from expiration to inspiration
(triggered) Inspiration (limited) The change from inspiration to expiration (cycled) Expiration (baseline ,PEEP)

34 inspiration inspiration expiration expiration 5 limit baseline cycle
pressure inspiration inspiration expiration expiration 5 limit time baseline cycle trigger

35 Pressure support ventilation(PS)
Typically used in the SIMV mode to facilitate weaning in a difficult to wean patient Increase spontaneous Vt (set PS until a desired spontaneous Vt) Decrease spontaneous respiratory rate (set PS until a desired spontaneous RR) Decrease the work of breathing

36 Pressure support ventilation(PS)
End flow(resp. cycle off) Rise time

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38 NIV ต้องมี Leak บ้าง ถ้าใช้ CPAP with PS mode แทนจะเกิด
Auto-Triggering Prolong Inspiratory Time Alarm Low MV or Low Vt

39 วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV
Auto-Triggering Trigger Adaptation(Re-adjustment baseflow) Volume trigger eg.6 ml Shape signal

40 วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV
Prolong Inspiratory Time Good quality Leak compensation Spontaneous expiratory Threshold (% Peak flow cycle adaptation) Shape signal cycle Safety Feature eg.Flow reversal,max 3 sec inspiratory time

41 True NIV Adjustable Baseflow Variable Cycle Threshold Variable Trigger
PRESSURE Cm H2O EPAP IPAP Variable Cycle Threshold This slide to give our word definition to pass from IPAP to EPAP -> Cycling and EPAP to IPAP -> Triggering Variable Trigger Threshold

42 2. ใช้แทนกันได้ไหม??? ไม่ควร... ไม่ได้ครับ
FAQ 2. ใช้แทนกันได้ไหม??? ไม่ควร... ไม่ได้ครับ

43 3.ทำไม NIV ในแต่ละเครื่อง จึงสบายไม่เท่ากัน?
Leakage compensation Trigger Adaptation Inspiration Termination (cycle)

44 NIV made simple ไม่ง่ายนะจ้ะ

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46 Close monitoring

47 COPD Exacerbation (7.30≤pH<7.35)
Interface and type of circuit nasal mask Single limb with leakage valve Initial Settings EPAP 4-8 cmH2O IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt Back up rate 8-10/min FiO2 keep SpO2 >92%

48 Severe COPD Exacerbation(pH< 7.30)
Interface and type of circuit Oro-nasal mask Single limb with leakage valve Initial Settings EPAP 4-8 cmH2O IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt Back up rate 8-10/min FiO2 keep SpO2 >92% Close monitoring

49 Cardiogenic Pulmonary edema
Interface and type of circuit Oro-nasal mask (High Flow system ) Single limb with leakage valve Initial Settings EPAP 4-8 cmH2O titrate until ≈ 8-10 IPAP 8-10 (above EPAP 4-6) cmH2O titrate until Vt (OPTIONAL) Back up rate 8-10/min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

50 Hypoxic Respiratory Failure
Interface and type of circuit Oro-nasal mask (High Flow system ) Single limb with leakage valve Initial Settings EPAP 4-8 cmH2O IPAP (above EPAP 8-20) cmH2O titrate until Vt Back up rate /min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

51 How to succeed in NIV Not too bad ventilator!! Good candidate
Good initial settings Good monitoring Good criteria for termination (change to invasive) Not too bad ventilator!!

52 Long-term Mechanical Ventilation
Home Mechanical Ventilation Non-invasive Ventilation(NIV)

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