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CI2 > NIV for Physios > Flashcards

NIV for Physios Flashcards

1
Q

What is non-invasive ventilation (NIV)?

A

Application of bi-level positive pressure to a patient by a non-invasive interface

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2
Q

What is a continuous positive airway pressure (CPAP) machine used for?

A
  • Obstructive sleep apnoea (OSA)
  • Pulmonary oedema
  • Hypoxemia
  • Post-surgical airway collapse
  • Splinting airway open
  • Increasing lung volume
  • Improving oxygenation (doesn’t do much for CO2)
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3
Q

What happens to the pressure in CPAP?

A

Pressure is constant throughout inspiration & expiration (e.g. 5cmH2O)

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4
Q

What is bilevel positive airway pressure (BiPAP)?

A
  • 2 levels of positive airway pressure
  • Expiratory (EPAP): Maintained during expiration & pause between breaths
  • Inspiratory (IPAP)
  • Delta pressure: Difference between IPAP & EPAP, driving pressure for increasing TV
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5
Q

What is the function of EPAP in BiPAP?

A
  • Has the same effects as CPAP

- Makes the patient breathe deeper, which lowers CO2 production & WOB

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6
Q

When does sleep apnoea occur?

A

When the upper airway closes during sleep, causing oxygen levels to drop

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7
Q

What common physical features are associated with snoring?

A
  • Retrognathia: Jaw seems small for the skull, or is not in line with the plane of the face
  • Neck circumference > 43cm (male) or 39cm (female)
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8
Q

What is the role of the dilator muscles during sleep?

A

Contract to keep the airway open during inspiration

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9
Q

What is upper airway resistance?

A
  • Hypopnoea: Partial obstruction of the airway
  • When a person unconsciously wakes up/comes to a more wakeful level of sleep to prevent hypopnea, constantly throughout the night
  • No drop in oxygen levels
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10
Q

What is sleep apnoea a risk factor for?

A
  • Hypertension (approx 40%)
  • Acute myocardial infarction
  • Stroke
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11
Q

What are the patient-reported symptoms of OSA?

A
  • Sleepiness
  • Concentration, memory, learning problems
  • Daytime fatigue/reduced energy
  • Unrefreshing sleep
  • Nocturnal choking or gasping for breath
  • Nocturia & enuresis (excessive urination during the night)
  • Mood problems & depression
  • Decreased libido & erectile dysfunction
  • Recent weight gain
  • Dry mouth or throat in the morning
  • Morning headache
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12
Q

What are some of the symptoms reported by the bed partner in OSA?

A
  • Snoring
  • Witnessed apneas
  • Restless sleep
  • Irritability
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13
Q

What are the treatment options for OSA?

A
  • Lifestyle changes (weightless, alcohol)
  • Oral appliances
  • Surgery
  • CPAP
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14
Q

What are the benefits of CPAP in patients with OSA?

A
  • Improves subjective & objective sleepiness
  • Improves neurocognitive function
  • Improves QOL measures
  • Reduces BP
  • Reduces arrhythmia
  • Improves cardiac function in heart failure
  • May improve insulin sensitivity
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15
Q

What are the main findings in CPAP users?

A
  • Risk of serious CV event is not less in users
  • Less sleepiness
  • Improved health-related QOL
  • Improved mood
  • Increased attendance at work
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16
Q

When can severe sleep apnoea cause respiratory failure?

A
  • Morbid obesity

- Frequently associated with excessive alcohol intake

17
Q

What is one of the most common causes of respiratory failure that is linked to sleep?

A

Kyphoscoliosis

  • Causes a weak diaphragm
  • During REM, results in patient hypoventilating/shallow breathing
18
Q

Why would a person with kyphoscoliosis have higher CO2 levels in the morning than when they went to sleep the night before?

A
  • CO2 increases during REM sleep due to hypoventilation caused by weak diaphragm
  • Medullary receptors adapt to higher CO2 levels
  • Causes CO2 levels to remain high during the day
  • Patient in compensated respiratory failure
19
Q

Apart from kyphoscoliosis, in what other conditions does REM-related hypoventilation/respiratory failure occur?

A
  • Neuromuscular disease (MND, muscular dystrophy)
  • Chest wall deformity
  • Lung disease (COPD, CF)
  • Control of breathing abnormality (obesity hypoventilation syndrome, stroke)
20
Q

What are the common characteristics of someone in acute respiratory failure (ARF)?

A
  • Increased RR
  • Mouth breathing
  • Full face mask more appropriate
21
Q

What are the aims of NIV use in ARF?

A
  • Improve pathophysiology of ARF
  • Improve clinical outcome
  • Economic savings (reduced ICU & LOS)
22
Q

How can NIV improve the pathophysiology of ARF?

A
  • Reduce WOB
  • Augment alveolar ventilation
  • Improve dyspnoea
  • Improve gas exchange
23
Q

How can NIV improve clinical outcome in ARF?

A
  • Improve survival

- Reduce need for tracheal intubation (maintain airway defence, speech & swallowing, less airway trauma)

24
Q

What are the limitations of NIV in ARF?

A
  • Need for patient cooperation

- Lack of direct access to the airway (risk of sputum retention & aspiration)

25
Q

What are the indications for NIV in ARF?

A
  • Exacerbation of COPD
  • Hypoxaemic respiratory failure
  • Acute carcinogenic pulmonary oedema
  • Weaning from mechanical ventilation
  • Acute pulmonary infection
  • Asthma
  • Post-op
  • Following intubation
  • Obesity hypoventilation syndrome
  • Neuromuscular disease
  • Chest wall dysfunction
  • Other (e.g. CF, patients not for intubation)
26
Q

What did the Cochrane review of NIV use in ARF COPD find?

A

NIV resulted in:

  • Decreased mortality
  • Decreased need for intubation
  • Reduced complications
  • Reduced hospital stays
  • Rapid improvement in pH in the 1st hour
  • Improvement in RR
27
Q

What should you consider if a patient has been on NIV for 2 hours and isn’t responding?

A

Consider invasive ventilation

28
Q

What are the considerations for NIV in an acute exacerbation of COPD?

A
  • Very SOB (rapid RR, short inspiratory time, high ventilatory demand)
  • Anxious/distressed
  • Mouth breathing
  • Comatose or confused/combative
  • Acidotic
29
Q

What does further deterioration of an acute exacerbation of COPD require?

A

Intubation & sedation

30
Q

What are the management considerations in an acute exacerbation of COPD?

A
  • Usually breathing fast & triggering
  • Mod-high levels inspiratory support to reduce WOB
  • Impact of PEEPi
  • Need fast inspiratory flow
  • Can’t afford long Ti due to leaks
  • May initially need a FFM
  • Supplemental oxygen
  • Close monitoring
  • Safety issues
  • ICU vs ward
31
Q

What are the absolute CIs to NIV?

A
  • Respiratory arrest
  • Life threatening hypoxaemia
  • Fixed obstruction of upper airway
  • Uncontrolled ischaemia/arrhythmia
  • SBP <90
  • Severely depressed LOC
  • Unable to protect airway
  • Inability to clear secretions
  • Recent facial/upper airway surgery
  • Extensive facial lacerations/burns
  • Unstable facial fractures
  • CSF leak
  • Vomiting
  • Undrained pneumothorax
32
Q

What are the relative CIs to NIV?

A
  • Copious secretions
  • Severe comorbidity
  • Confusion/agitation
  • Bowel obstruction
  • GI surgery
  • Focal consolidation on CXR
33
Q

What are the potential complications with NIV?

A
  • Aerophagia, gastric distension
  • Aspiration
  • Decreased CO
  • Hypoventilation, CO2 retention
  • Hyperventilation, alkalosis
  • Patient discomfort, facial erosion
  • Pulmonary barotrauma
  • Pneumoencephalus
34
Q

What are some of the factors that influence the delivered oxygen concentration?

A
  • Oxygen flow rate
  • Leak
  • Pressure settings
  • Site at which oxygen is added to the circuit

Measure the results of oxygen delivery (SpO2)

35
Q

What did Kennan et al 2002 find regarding NIV in post-extubation failure?

A
  • Patients who developed ARS within 48 hours of extubation

- No difference in rates of reintubation, hospital mortality or LOS

36
Q

What did Estaban et al 2004 find regarding NIV in post-extubation failure?

A
  • No difference in need for reintubation, rate of death in ICU higher in NIV group
  • Longer period to reintubation in NIV group

CI2 (17 decks)

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