Non-invasive ventilation – setting up a service

1. Non-invasive ventilation – setting up a service Andrew Bentley Critical Care & Chest Medicine North Manchester General Hospital

2. Setting up an acute non-invasive ventilation service

3. Acute Non-invasive ventilation Why? Cost effectiveness of ward based NIV for acute exacerbations Of COPD: economic analysis of randomised controlled trial. PK Plant, JL Owen, S Parrott, MW Elliott. BMJ 2003;326:956-959

4. Respiratory failure in acute COPD- role of non-invasive ventilation • Improvement in gas exchange • Reduced work of breathing • Unloading of inspiratory muscles • In-hospital mortality is 20-40% despite selective use of mechanical ventilation

5. Bott et al, Lancet 1993;341:1555-1557

6. Brochard et al, Lancet 1995;333:817-822 N=85

7. Brochard et al, NEJM 1995;333:817-822 P<0.05 P<0.05 P<0.05 P<0.05 n=32

8. Brochard et al, NEJM 1995;333:817-822 No. of patients Hospital stay

9. Brochard et al, NEJM 1995;333:817-822 No. of patients Endotracheal intubation

10. Kramer et al, Am J Resp Crit Care Med 1995;151:1799-1806 N=31

11. Acute Non-invasive ventilation Who?

12. COPD Reduced mortality Reduced morbidity related to endotracheal intubation Reduced ICU admissions Reduced hospital length of stay Acute Respiratory failure Acute pneumonia & ARDS Post surgery Solid organ transplant Immunosuppressed with pulmonary infiltrates Haematological malignancy Antonelli et al. NEJM 1998;339:429-435 Antonelli et al. JAMA 2000;283:235-241 Hilbert et al. NEJM 2001;344:481-487 Confalonieri et al. AmJRespCritCareMed1999;160:1585-1591 Non-invasive ventilation – patient groups

13. Acute non-invasive Ventilation in COPD - predictors of poor outcome • Low pH • Pneumonia (consolidation) on CXR • Low body weight • Bronchiectasis (excessive secretions) • Poor neurological status Ambrosino et al, Thorax 1995;50:755-757 Simonds et al, Thorax 1995;50:595-596

14. Acute Non-invasive ventilation How?

15. Non-invasive ventilationat NMGH • 1996 – Medical HDU • Sullivan ST VPAPs • Non-invasive monitoring • Entrained supplemental oxygen via mask • Respiratory physio led service • 1999 – 12 bedded medical & surgical HDU • Vision BiPAPs • Invasive monitoring • Nurse led service • Protocol driven (for acute hypercapnic COPD) • Automatic referral to chest consultant

16. Non-invasive pressure support ventilation (NPSV) vs NIPPV (assist-control) Success rate (NPSV 87.5%; NIPPV 77%) Compliance score (NPSV 4 vs NIPPV 3, p<0.02) Reduced work of breathing assist control>NPSV Patient comfort NPSV>assist control IPAP v IPAP +EPAP v CPAP v volume cycled NIPPV No difference between Pressure support, CPAP & volume cycled NIPPV No advantage conferred by EPAP Non-invasive modalities of positive pressure ventilation in acute exacerbations of COPD Vitacca et al, Int Care Med 1993;19:450-455 Meecham-Jones et al , Thorax 1994;49:1222-1224 Girault et al, Chest 1997;111:1639-1648

17. Documented resuscitation and ICU admission status. Medical treatment: Controlled oxygen therapy Nebulised bronchodilators Antibiotics IV aminophylline Systemic corticosteroids Inclusion criteria pH <7.36 pCO2 > 45 mmHg pO2 < 60 mmHg Exclusion criteria Hypotension Primary metabolic acidosis Untreated pneumothorax Compromised airway NIPPV to be considered if: No improvement in oxygenation and the same or deteriorating pH after 2 hours of medical therapy. Improvement in oxygenation but same or worsening pH after 2 hours of medical therapy. Obvious clinical deterioration. Non-invasive ventilation at NMGH

18. Standard medical treatment Controlled oxygen (SaO2 85-90%) Nebulised salbutamol 5mg every 4-6 hours Nebulised ipratroprium 500µg 6 hourly Prednisolone 30mg daily for minimum of 5 days Antibiotic agent NIV BiPAP through face mask or nasal mask IPAP 10cm H2O, increased to 20 cm H2O EPAP 5 cm H2O Target duration first day 24 hours, second day 16 hours, third day 8 hours, fourth day discontinued Oxygen in circuit to maintain SaO2 85-90% Acute Non-invasive ventilation Plant PK, Owen JL , Elliott MW. Early use of NIV for acute exacerbations Of COPD on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000;355:1931-1935

19. Acute Non-invasive ventilation • Training • On the job, self directed, protocol driven • Locally organised sessions & study days • Company organised • Courses – national & international Eg. ERS School courses 2004: NIPPV June 10-12th Pisa, Italy

20. Acute Non-invasive ventilation • Training requirements • Understanding rationale for assisted ventilation • Mask & headgear assembly • Ventilator circuit assembly • Theory of operation & adjusting ventilation to desired outcome • Cleaning & general maintenance • Problem solving, recognise serious situations and act accordingly • General overall acceptance that technique works

21. Acute non-invasive ventilation • Monitoring • Pulse oximetry • NIBP • Peripheral venous access • Arterial blood gas sampling • ECG • Capillary gases • Arterial lines

22. Acute Non-invasive ventilation When?

23. Acute Non-invasive ventilation Where?

24. Acute hypercapnic exacerbations of COPD in A&E • Little advantage of NIV over conventional therapy Barbe et al. EurRespJ 1996;9:1240-1245 Wood et al. Chest 1998;113:1339-1346 • 1 year prevalence study of acute COPD exacerbations in Leeds A&E departments (n=954) • 25% acidotic on arrival to A&E and 25% of these had corrected pH on arrival to ward • Relationship between PaO2 on arrival and presence of respiratory acidosis Plant et al. Thorax 2000;55:550-554

25. Non-invasive ventilation - Location of provision of service • YONIV study (Plant et al, Lancet 2000;355:1931-1935) • NIV can be applied successfully outside of ICU/HDU setting • Outcome not as good as in HDU setting if pH<7.30 • Outside of ICU cost efficacy related to prevention of ICU admission • Training, patient throughput, skill retention – single location (Doherty et al, Thorax 1998;53:863-866) • 1998 – acute NIV service (48% hospitals) • Ward (40%), HDU (12%), ICU (13%) • Acute Respiratory Care Units • NHS Modernisation Agency (Critical Care Programme) weaning & long term ventilation (April 2002)

26. Acute non-invasive ventilation • Where - factors to consider • Location of staff with training & expertise • Adequate staff available over 24 hour period • Rapid access to endotracheal intubation and invasive mechanical ventilation • Severity of respiratory failure and liklihood of success • Facilities for monitoring

27. Non-invasive ventilation on HDU at NMGH • Audit of practice 1999 • “Uncontrolled “ oxygen therapy prior to arrival in A+E. • Poor documentation • High mortality despite treatment (45%) • Low pH on admission (mean pH <7.20) • Multiple comorbid factors as predictors of poor outcome

28. Non-invasive ventilation on HDU at NMGH • Audit March 2000 –March 2001 • Appropriate for NIPPV n = 69 • NIPPV instituted n = 43 (62%) • NIPPV not instituted n = 26 (38%) • Recovered with medical therapy n = 14 (20%) • Admitted to ICU n = 1 (1.5%) • Contraindication to NIPPV n = 2 (3%) • No documentation / unclear n = 9 (13%)

29. Non-invasive ventilation on HDU at NMGH Findings: NIPPV instituted 43 Resuscitation state documented 15 (35%) Maximal medical treatment 26 (60%) 2nd blood gas not documented 11 (25%) Documentation of termination of NIPPV: weaned 1 not tolerated 9 hypotension 2 ICU 1 Unclear 30 Outcome of NIPPV: - Survived with no re-admission to date: 14 (33%) - Re-admission within study time period: 9 (21%) - Death same admission: 20 (46%) - HDU / Ward 19 - ICU 1

30. Interrogating KSM, James Wheeler,March 5th 2003 “The Washington Times” recently published a method for the efficient interrogation of Al Quaeda suspect Khalid Shaikh Mohammed, suggested by the president of the Freedom Research Foundation. This involved ventilation by nasal mask of a paralysed subject, with the ventilator turned off to provide transient suffocation whenever the interrogator was dissatisfied.” Summerfield D. BMJ 2003;326:773-774