Practical Points in NIV นพ.รัฐภูมิ ชามพูนท รพ.พุทธชินราช

ใครในภาพต่อไปนี้ไม่ได้เป็น พรีเซนเตอร์ต่อต้านการสูบบุหรี่

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

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

Normal breathing (Negative pressure breath) +2 -2

Mechanical ventilation(positive pressure ventilation)

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

Postpolio era

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

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

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

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)

Interface

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

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

Circuit Type Single Limb Double Limb

Single Limb circuit system

Single Limb circuit system ventilator

2 Limb circuit system

2 Limb circuit system ventilator

Leak valve system หายใจไม่ออก! ventilator ไม่มี Leak valve ใน circuit

Leak valve system ค่อยยังชั่วหน่อย แต่ทำไมลมดันไม่หยุด ventilator มี Leak valve ใน circuit

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

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

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

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

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

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

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

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

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

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

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

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

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

NIV made simple ไม่ง่ายนะจ้ะ

Close monitoring

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 400-500 Back up rate 8-10/min FiO2 keep SpO2 >92%

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 400-500 Back up rate 8-10/min FiO2 keep SpO2 >92% Close monitoring

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 400-500 (OPTIONAL) Back up rate 8-10/min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

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 12-25 (above EPAP 8-20) cmH2O titrate until Vt 400-500 Back up rate 12-16 /min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

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!!

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