Ventilation

NIV: What’s the big deal?

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Terminology:

In general,
Type 1 RF requires CPAP type of NIV.

Type 2 RF requires BPAP type of NIV.

PEEP=EPAP=CPAP i.e. they all mean the same!

So you can say in Type 1 RF (Hypoxic failure), the pressure we provide is PEEP or just EPAP or CPAP. 

For Type 2 RF (Hypercapnic), we provide IPAP as well as EPAP. IPAP is greater than EPAP, PS (Pressure Support is the difference between IPAP and EPAP). For instance if IPAP = 15 and EPAP is 10 then PS = 15-10 i.e. 5cm H2O.

Non-Invasive Ventilation

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Noninvasive ventilation decreased endotracheal intubation rates and hospital mortality in acute hypoxemia non-hypercapnic respiratory failure excluding chronic obstructive pulmonary disease exacerbation and cardiogenic pulmonary edema patients. There is no sufficient scientific evidence to recommend bi-level positive airway pressure or helmet due to the limited number of trials available. Large rigorous randomized trials are needed to answer these questions definitely.

 

How to set up Non-Invasive Ventilation (NIV)

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Who Needs It?

  1. Patients with moderate to severe COPD exacerbations
  2. Those patients with cardiogenic pulmonary edema with increased work of breathing or hypercapnia
  3. Patients with isolated blunt thoracic trauma
  4. The immunocompromised patient with hypoxic respiratory failure
  5. Patients who require pre-oxygenation prior to intubation
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Optimal Bag-Valve-Mask Ventilation

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Sexy Bagging

 

  1. Remember to connect the device to an Oxygen Supply
  2. Use two providers wherever possible – one to maintain a good seal by lifting the face into the mask and applying a steady downward counter pressure to the mask using both hands (see image) and the other colleague squeezes the bag to ventilate.
  3. Don’t ‘bag’ too fast or hard – we recommend aiming for 1 breath every 6 seconds and just enough volume to make the chest rise (it’s a patient, not a balloon)
  4. Patients receiving BVM for cardiac arrest can do as well if not better than those who are intubated (there is NO EVIDENCE that use of an advanced airway in resuscitation saves lives)

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Emergency Ventilation

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BMV is always a 2 person procedure (regardless of technique used) – Skilled person holds the mask and anyone else can provide the breaths + Consider the 2 thumbs down technique for BMV instead of the CE clamp. And Believe it or Not – Learning BMV is more important than mastering Laryngoscopy !!

Mechanical Ventilation- Terminology

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Volume controlled ventilation

We can put a certain volume of air into the patient with each breath in mechanical ventilation.

Pressure controlled ventilation

We can put air into the patient until the pressure reaches a certain value.

Rate

We can decide how often we give the patient a breath each minute.

Flow rate

For example, we can give a certain volume of gas , but the flow rate will determine whether we give that volume slowly or quickly over that breath.

FiO2

In other words, the oxygen concentration we give to the patient, from 21% (room air) to 100%.

What triggers the breath?

Do we have the patient decide when they want to breathe, or do we have the ventilator decide when to initiate a breath? Or indeed a combination of the two? Is it ventilator controlled or patient controlled?

 

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