NIV

outside the ICU

For certain acute respiratory failure (ARF) indications NIV can be used in non-acute settings to relieve pressure on the intensive care unit (ICU).

 

Although it is more commonly used in ICU and high acuity care areas, NIV also has the potential to be used outside the ICU setting. One reason to consider the use of NIV in sub-acute settings is that it could relieve some of the pressure on the scarce resource of ICU beds as seen in some countries as well as the high costs related to an ICU treatment.

 

Even though most evidence refers to use in acute care settings, the International Consensus supports the approach of performing NIV in lower acuity settings in hospitals. The International Consensus states: “[...] NPPV (unlike invasive mechanical ventilation) provides an opportunity for delivering ventilatory support elsewhere. NPPV need not be delivered continuously to be effective, can be reasonably initiated in the earliest stages of ARF, and administered by means of small, portable equipment. Potentially, NPPV can be administered in the emergency department, intermediate care unit, or general respiratory ward by physicians, nurses, or respiratory care practitioners. Potential benefits of use outside the ICU include early intervention to prevent further respiratory deterioration (7), access to respiratory support for patients who would not otherwise be admitted to the ICU (25-29), and the provision of support in a less intimidating setting.”¹

 

In sub-acute settings, NIV will mostly be used for patients with exacerbations of chronic obstructive pulmonary disease (COPD).

 

Deciding where to perform NIV should be less related to the actual care area, but rather to the care setting and staff knowledge.

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NPPV has been shown to be cost-effective both in the

ICU and when performed on general wards.²

 

The following criteria are relevant when deciding where to preform NIV:

 

  • Trained staff with expertise in NIV
  • 24 hour staff availability
  • Rapid access to invasive ventilation in case of NIV failure
  • Severity of patient’s respiratory failure and likelihood of success / adequate patient selection
  • Monitoring facilities²

 

A study conducted by Plant et al. demonstrated that NIV could be instrumental in reversing mild to moderate acute respiratory failure on the wards. In the study, 15 percent of the 118 patients randomized to an NIV therapy group required intubation, whereas 27 percent in the standard therapy group required this intervention. The NIV group reflected a quicker relieve of dyspnea and improvement of pH than the standard therapy group. It is important to note that nurses on the wards of the multicenter trial had not previously conducted NIV, but were exposed to an average of eight(8) hours of training on noninvasive ventilation and the involved equipment. Importantly, the study highlighted that nursing time increased by 26 minutes in the first eight hours and remained the same as the standard therapy group in the following hours.

 

Lastly, the subset of patients in the NIV group who were intubated were found to have lower PH’s, and it was postulated that these patients may have been better managed in the ICU.³

 

Predictors of failure for NIV

COPD exacerbation

 

  • Arterial blood gases at 2 hrs
  • Breathing frequency at 2 hrs
  • If pH does NOT improve ≥ 7.25 and/or respiratory rate is still ≥ 35 breath/min then rate of NIV failure is very high
  • SAPS II > 29 at admission

Cardiogenic pulmonary edema

 

  • At admission
  • pH < 7.25
  • Acute myocardial infarction
  • Hypercapnia
  • Ejection fraction < 30%
  • Blood pressure < 140 mmHg

Acute hypoxic respiratory failure

 

  • SAPS II > 34 at enrolment
  • PaO2/FiO2 < 175 after 1 hr of NIV

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NIV is used post-extubation period to reduce the length of invasive ventilation and prevent extubation failure. NIV can also play a role after invasive mechanical ventilation in the post-extubation periods. The main reasons to use NIV after extubations are to reduce the length of invasive ventilation and to prevent extubation failure. However, NIV can also...

 

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Sources

 

1: International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. American Journal of Respiratory and Critical Care Medicine, Vol. 163, No. 1 (2001), pp. 283-291

 

2: Elliott, MW., Confalonieri, M., Nava, S. Where to perform noninvasive ventilation?, Eur Respir J 2002;19(6): p.1159-1166

 

3: Plant PK., Owen JL, Elliott MW. “Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomized controlled trial”, Lancet, 2000 Vol 355; p. 1931-1935

 

4: Nava, S., Ceriana, P. Causes of failure of non-invasive ventilation. Respir Care (2004): 49: p. 295-303

 

5: Confalorieri, M., Garuti, G., Cattaruzza, MS., et al. A chart of failure risk for non-invasive ventilation in patients with COPD exacerbation. EUR Respir J (2005): 25: p. 348-355

 

6: Masip J, Montzerrat JP, Parejo MS, et al: “Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema”, Intensive Care Med (2003): 29: p. 1921-1928

 

7: 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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thinkNIV

 

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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