Expertise

NIV usage increases as clinicians become more familiar with the application. Follow the guidelines for patient selection and initiation of NIV.

 

Expertise is an important factor when it comes to successful NIV. Studies suggest that the usage of NIV increases over time as clinicians become more familiar with the application.¹

 

It takes time to become an expert. Below you can find useful information about the use of NIV leading to successful NIV.

 

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Contraindications to noninvasive ventilation

Absolute contraindications²

 

  • Cardiac or respiratory arrest
  • Non-respiratory organ failure (i.e, GI bleeding, hemodynamic instability..)
  • Upper airways obstruction
  • Need to protect the airways
  • Instability to clear secretion
  • Facial surgery or trauma

Relative contraindications

 

  • Coma and severe sensorium impairment³
  • Agitation or diaphoresis
  • Severe hypoxia (i.e. PaO2/FiO2 < 100)
  • Very limited spontaneous breathing

Guidelines for Patient Selection and Initiation of Noninvasive Ventilation


  1. Select appropriate patient. Patients with chronic obstructive pulmonary disease (COPD) or acute cardiogenic pulmonary edema are most likely to benefit. Noninvasive ventilation (NIV) should not be used in patients who require urgent intubation (respiratory arrest, severely depressed consciousness) and an endotracheal tube for airway protection, or in patients who don’t want to receive NIV.
  2. Choose a ventilator that meets the patient’s needs. Bi-level ventilators are commonly used, but any ventilator can be used. The most common mode is pressure-support ventilation.
  3. Choose the correct interface. For acute respiratory failure, an oronasal mask is commonly used. Avoid using a mask that is too large. If the patient is intolerant of oronasal mask, try nasal mask, nasal pillows, or total face mask.
  4. Explain NIV to the patient. It can be extremely frightening for a patient in acute respiratory failure to have a mask strapped over the face. Explain the goals of NIV and the alternatives. For patients who remain anxious, a small dose of anxiolytic may be appropriate.
  5. Silence alarms and begin with low settings, even if the settings are sub-therapeutic. This helps the patient acclimate to the mask and the pressure.
  6. Initiate NIV while holding the mask in place; do not apply the straps yet. This helps the patient acclimate to the mask without the fear that can be caused by having the mask strapped on.
  7. Secure the mask but avoid a too-tight fit. A common mistake is to strap the mask too tightly. Small leak is acceptable, and a bi-level ventilator compensates for leak. Strapping the mask too tightly decreases patient tolerance and increases the risk of facial skin breakdown. It should be possible to pass 1 or 2 fingers underneath the straps.
  8. Titrate the pressure support to patient comfort. With a bi-level ventilator the difference between the inspiratory pressure and expiratory positive determines the level of pressure support. Gradually increase the inspiratory pressure while observing accessory muscle use and respiratory rate, and ask the patient if breathing is becoming more comfortable. Initially, the inspiratory pressure setting may be a compromise between the therapeutic target and patient tolerance.
  9. Titrate the fraction of inspired oxygen to achieve an oxyhemoglobin saturation (SpO2) 90%.
  10. Avoid inspiratory pressure 20 cmH2O, which decreases patient comfort and increases the risk of gastric insufflation.
  11. Titrate expiratory pressure per trigger effort and SpO2. For patients with COPD, expiratory pressure (to 10 cmH2O) may counterbalance intrinsic positive end-expiratory pressure and improve the patient’s ability to trigger the ventilator. For patients with acute cardiogenic pulmonary edema, expiratory pressure (to 10 cmH2O) increases intrathoracic pressure, decreases pre-load and after-load, and improves SpO2. Remember that an increase in expiratory pressure requires an equivalent increase in inspiratory pressure to maintain the same level of pressure support.
  12. Continue to coach and reassure the patient. Make adjustments per patient comfort and adherence to therapy. It is acceptable to give the patient a break from NIV if the patient does not acutely decompensate when the mask is removed.
  13. Evaluate NIV success. If signs of improvement are absent 1–2 h after initiation of NIV, consider alternative therapies (eg, intubation).

 

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Sources

 

1: Hess D. How to Initiate a Noninvasive Ventilation Program: Bringing the Evidence to the Bedside. Respiratory Care (2009), Vol 54 No 2, p. 232-245

 

2: Hess D. How to Initiate a Noninvasive Ventilation Program: Bringing the Evidence to the Bedside. Respiratory Care (2009), Vol 54, No 2, p. 237

 

3: Evans TW. International Consensus Conferences in Intensive Care Medicine: Non-invasive positive pressure ventilation in acute respiratory failure. Intensive Care med (2001):27: p. 166-178

 

4: Scala, R., Naldi, M., Nava, S. Non-invasive positive pressure ventilation in COPD patients with acute hypercapnic respiratory failure and altered level of consciousness. Chest (2005): p. 128: 1657-1666

 

5: Constantin, JM., Schneider, E., Cayot-Constantin, S., et al. Remifentanil-based sedation to treat non-invasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med (2007): 35: p. 18-25

 

6: Antonelli, M., Conti, G., Esquinas, A., et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med (2007): 35: p. 18-25

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Despite its proven benefits to improve patient comfort and reduce mortality and also costs, noninvasive ventilation (NIV) is still underutilized at many hospitals. This website is designed to promote the usage of NIV by sharing the many situations in which NIV improves patients’ outcomes as well as to inform about the factors which are important in order to perform successful NIV.

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