NIV: dove ventilare il paziente
Dott Michele Vitacca
Divisione Pneumologia Riabilitativa e Centro svezzamento Fondazione S.
Maugeri IRCCS Lumezzane (BS)

IDENTIFY PATIENTS (according to location ?)
1. Clinical abnormalities
- moderate to severe dyspnea
- RR > 24 b/min in COPD
- RR > 30 – 35 b/min in AHRF
- accessory muscle use, paradoxal breathing
2. Gas exchange abnormalities
- PaCO
2
> 45 mmHg, pH < 7.35
- PaO
2
/FiO
2
< 250 mmHg
Am J Respir Crit Care M d 2001 ; 163: 283-291; Intensive Care Medicine 2001 ; 27: 166-178

Difficult intubation !
(according to location ?)
Am J Respir Crit Care M d 2001 ; 163: 283-291; Intensive Care Medicine 2001 ; 27: 166-178

• Model of health care delivery varies markedly
– From country to country
– Within a country
– Within an institution
• Randomised controlled trials performed in one country may not be generalisable to another

• Start early but not too early (Barbe study)
• You are too late if…
• Pt on verge of respiratory arrest
• Pt severely hypoxaemic (PaO2/FiO2 < 75)
• Pt comatose or hugely agitated
• Medically unstable: acute MI, GI bleed, shock
Simonds ERS school

The concept of the traffic light
ICU RICU/
HDU
WARD ER
Staff number
Safety
Monitoring
Equipment
Familiarity with NIV

• Concentrate staff expertise
• Training focus for NIV for medical, nursing and paramedical staff
• Concentrate equipment
• Facilitate link with ICU
• Audit, data collection
• Cost savings (?)

• Patient selection
• Safe staffing levels
• Rolling programme of staff training and protocols
• Adequate monitoring
• Ability to intubate
& transfer pts to
ICU
• Suitable alarms
Simonds ERS school

Staffing of resp int care unit
( or location with high number of NIV pts)
• Nurse to pt ratio 1:4 (1:6 ?)
• Senior Physician on call for 24 hours
• Training for nurses and trainee medical staff
• Dedicated physiotherapist
• Technical service
• Strong links with ICU
Simonds ERS school

HUMAN WORKLOAD in RICU
Nava et al.Chest 97;111:1631

BTS Equipment Recommendations
Staff familiarity is key to success

• Clinical status, respiratory rate, heart rate, dyspnoea score, secretion clearance
• Pulse oximetry
• Continuous display of ECG and non-invasive BP
• Arterial blood gases (ABG machine easily accessed)
• Continuous non-invasive monitoring of CO2 helpful eg.
Transcutaneous, end-tidal
• Duration of NIV use
• Ventilatory settings, FiO2, leak
• Severity score
• Side effects : skin integrity, GI, nasal symptoms
• CXR, screening bloods etc.
Simonds ERS school

25% of the respondents use hand restraints
Is this the way to solve the problem ?
in >30% of the patients.
Some mild sedation may be prescribed

Complimentary role
Mask ET
Evolving ARF Respiratory failure
Mask ET
Resolving ARF

Noninvasive ventilation in pre-clinical care
Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für
Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim
Respiratory rate +
SatO2
Blood pressure and heart rate before CPAP during CPAP before CPAP during CPAP

Noninvasive ventilation in pre-clinical care
Jerrentrup A, Kill C. et al. Vortrag auf dem Kongress der Deutschen Gesellschaft für
Pneumologie und Beatmungsmedizin e.V. 2007, Mannheim clincal situation with
CPAP: much improved 51 % improved unchanged worse
40 %
3 %
3 % with the use of pre-clinical
CPAP, intubation was avoided not avoided
59 %
9 % was not necessary 32 %

Considera la patologia !
Carlucci A. AJRCCM 2001;163:874

Eur Respir J 2005; 25:348-355
100 – 75 % 74 -50 % 49 -25 %
Percentage of patients who fail NIV
24 -0 %

Perchè si sbaglia paziente
Perchè non si rispettono le controindicazioni
Perchè si sbaglia maschera
Perchè si sbaglia modalità di ventilazione
Perchè si sbaglia il settaggio
Perchè il paziente non supporta più la NIV
Perchè non miglioranono i gas
Perchè vi è cattiva interazione con il ventilatore
PERCHE ‘ SI SBAGLIA LOCATION !!!!!!

Interface: Facial Masks

Thorax 2011;66:43e48. doi:10.1136/thx.2010.153114
232 H units for 9716 patients,
1678 (20%) on admission were acidotic and 6% became acidotic later .
1077 patients received NIV (11%),
55% had a pH <7.26
30% patients with persisting respiratory acidosis did not receive NIV.
Hospital mortality was 25% for patients receiving NIV but 39% for those with late onset acidosis.
Only 4% of patients receiving NIV who died had invasive mechanical ventilation.

VENTILAZIONE INVASIVA
(IV) N= 2656 (73%)
POPOLAZIONE DELLO STUDIO
N = 3617 (81%)
VENTILAZIONE NON INVASIVA
(NIV) N= 961 (27%)
Early NIV success
N=652 (68%)
Late NIV failure
INTUBAZIONE NO
N=153 (25%)
DESISTENZA
TERAPEUTICA (EOLC)
N = 207 (6%)
NIV failure
N=309 (32%)
INTUBAZIONE SI
N=309 (32%)
Cortesia dott. Gristina

No. of responses
20
10
0
Physicians lack of experience
Equipment not appropriate
Other
Poor previous experience
Hospital staff inadequately trained
Maheshwari v et al Chest 2006:129: 1226-33

USE in the “REAL” WORLD of ICUs
Hypercapnic Respiratory Failure
• NPPV is the first attempt of MV in ICU in 63% of Pts
• Success rate is 66%
Carlucci A. AJRCCM 2001;163:874

From 4% to 14%

Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012
H admissions pts from NIV to EI
N° pts
NIV deaths

Am J Respir Crit Care Med Vol 185, Iss. 2, pp 152–159, Jan 15, 2012
NIV and EI
EI
NIV no EI
No support

SITE
Respiratory
WARD
No resp ward
Hospice
ER
RICU
ICU
Pre H
Location summary (1)
Preferred diseases
COPD, restrictive, Elective, semielective NIV, pH >7.30
COPD, CHF, PE, Aged
All
PE, COPD, Aged
All, NM
ALS, 1 system failure, first
12 hours NIV. Confusion, poor tolerance, labile bronchospasm, disability with high nursing dependency
Pure Ipoxemic,
Sedation, Post op ARF, comorbidities,
Weaning and NIV, Multi system organ failure. Haemodynamic instability. Severe confusion. Pre coma
PE
Condition
Ph > 7.25
Monitoring
Ph > 7.30
No comatose
Palliative, ceiling intrevention
Ph > 7.20
paO2/FI02 >150 < 200
Ph > 7.20
paO2/FI02 >150 < 200
Ph <7.20
paO2/FI02<150
High expertize

ER
Hospice
RICU
ICU
Pre H
SITE
Respiratory
WARD
No resp ward
Location summary (2) advantages
More enthusiasm, skills,
No aggressive location,
RT presence
Cough assistance combination, cost effectiveness cost effectiveness geriatric skills
Beds availability
Early good outcome , triage
Advanced plan respect
Palliative competence
High enthusiasm, skills,
RT presence
Cough assistance combination, cost effectiveness
Monitoring
EI availability
Complexity case mix
Early good outcome
Contra
No sufficient staff
Night duty ?
Delay in EI
Low monitoring on ventilators
No adequate devices
No sufficient staff
Night duty ?
Delay in EI
Low monitoring on ventilators
No adequate devices
Low case mix
Low respiratory skills
Low expertize on NIV and chronic diseases
No adequate devices
Low case mix
Low respiratory skills
Rapid worsening in Hypox
Low expertize on NIV and chronic diseases
Costs
High expertize, Delay in EI

NIV success: staff training and experiance are more important than location