2. Modes of Non-Invasive Ventilation

Pts need to be what on NIV?

spontaneously breathing and awake

• ventilation supports/augments pts effort

What are the NIV mode options?

1. CPAP

2. PSV, BiPAP or Bilevel, S/T

3. PC

4. AVAPS (average volume assured pressure support)

5. PAV/PPV

6. NAVA

When is CPAP used in the hospital?

Only if WOB is relatively normal

• to recruit collapsed lung units

• decrease venous return & improve compliance

• may decrease WOB if compliance improves

What should be our range for CPAP/EPAP and what do we start at?

Range: 5-15cmH2O

Start: 5-10 cmH2O

What is C-Flex? and what ventilator is it on?

Decreases circuit pressure @ start of exhalation = exhalation is easier

- As expiratory flow decreases circuit pressure raised back up to set EPAP

• on V60 vents

When do we use PSV, BiPAP, BiLevel?

• When WOB is elevated

• improve oxygenation & ventilation

• recruit collapsed alveoli

• improve compliance

• decrease venous return & negative intra-thoracic pressure

What is PSV/BiPAP/BiLevel?

2 levels of pressure to ventilate pt

• baseline pressure during expiration (EPAP/ PEEP)

• higher pressure on inspiration to assist volume delivery (IPAP) like PSV on invasive

Are the V60s PEEP componsated?

NO

• so if you have a EPAP @ 5 and IPAP @ 5 you are giving the same pressure

Why do we set a RR and Ti on S/T?

This a back up

• so if pts respiratory rate goes below what is set it will give a breath

What is the RAMP option?

• starts at lower pressure than set and slowly increases over time until set pressures are reached

How is inspiration ended on V60?

when flow delivered decreases and circuit pressure raises based on their algorithm

• we don’t have to set something to end it like on normal dual limb we set a Esens

How does inspiration end of the PB980?

• maximum Ti

When would we consider using NIV PC?

• palliative care pts

• “do not intubate”

• apneic or erratic drive to breath

What is the negative of using PC on these kinds of pts?

Without the pt actively trying to inhale/ having no inspiratory effort we can be ventilating against a closed glottis

What is AVAPS?

volume supported mode type

How does AVAPS work?

We set:

• The VT

• A pressure range to ventilate within

Ventilator adjusts pressure on a minute by minute basis to target the VT we set

***Pressure adjusted a max of 1 cmH2O per minute***

• pressure is not adjusted breath to breath

Which patients would we use AVAPS for?

Neuromuscular disorders or nocturnal hypoventilation

• gives better alveolar ventilation than PSV or BiPAP

If a patient has high efforts and workload what pressure should we start them at?

higher pressures

If the patient has moderate efforts what pressure should we start at?

Lower pressures and ramp up if needed

What would a low pressure be considered on CPAP?

2-5 cmH2O

What are considered high pressures for CPAP?

8-10 cmH2O

What is the max CPAP pressure we would use?

12-15 cmH2O

What would be considered low pressures for BiPAP?

Plow = 2-5 cmH2O

Delta P = 2-5 cmH2O

What would be considered high pressures for BiPAP?

Plow = 6-8 cmH2O

Delta P = 6-8 cmH2O

What is the max PIP we use for BiPAP?

20-24 cmH2O

If using NIVPPV for extended periods of time what needs to be considered?

humidification

How is the temperature set on NIVPPV for humidification?

Lower than invasive

Could we use HME for humidification?

No

Since we use specfic masks for the V60 vents how do we let the vent know this and why do we do this?

We change the mask option to: Other

We change the port to: DEP

• in doing this we let the vent know how much leak there is and it will be able to compensate for it

When should we reassess a pt on NIV and what are we looking at?

within 1-2 hours

• improvement in appearance (WOB)

• improvement in oxygenation

• improvement in acid-base balance

• improvement in cardiac status

When would we consider an alternate or more invasive therapy?

After 2 hours with no improvement

What are some risks or complications of NIV?

• aspiration

• gastric insufflation

• leaks

• may delay intubation

• limits options for other care

• rebreathing

• dyssynchrony (seen in almost ½ of all NIV Pts)