Non Invasive Artificial Ventilation: How, When and Why

210 Pages·2014·2.96 MB·English

by  Stefano Nava

Stefano Nava
Francesco Fanfulla
Non Invasive
Artificial Ventilation
How, When and Why
123
Non Invasive Artificial Ventilation
Stefano Nava Francesco Fanfulla
•
Non Invasive Artificial
Ventilation
How, When and Why
123
Stefano Nava Francesco Fanfulla
Respiratory and CriticalCare Unit SleepMedicine Unit
AOSant’OrsolaMalpighi Hospital FondazioneSalvatore Maugeri
AlmaMater University Pavia
Bologna Italy
Italy
ISBN 978-88-470-5525-4 ISBN 978-88-470-5526-1 (eBook)
DOI 10.1007/978-88-470-5526-1
SpringerMilanHeidelbergNewYorkDordrechtLondon
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ThisistheEnglishversionoftheItalianeditionpublishedunderthetitleVentilazionemeccanicanon
invasiva—come,quandoeperché,byStefanoNavaandFrancescoFanfulla.
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TranslationbyRachelStenner.
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ViaVald’Aposa7,40123Bologna,[email protected],www.seps.it.
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Contents
1 Why I Ventilate a Patient Non Invasively . . . . . . . . . . . . . . . . . . 1
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 The Physiology of Mechanical Ventilation. . . . . . . . . . . . . . . . . . 5
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3 (Almost) Everything You Wanted to Know
About a Ventilator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.1 How a Ventilator Works. . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.1.1 Pressurized Gas System. . . . . . . . . . . . . . . . . . . . . . 10
3.1.2 Source of Gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.3 Inspiratory and Expiratory Valves . . . . . . . . . . . . . . 11
3.1.4 Inspiratory and Expiratory Triggers . . . . . . . . . . . . . 12
3.1.5 Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1.6 The Monitoring System. . . . . . . . . . . . . . . . . . . . . . 12
3.1.7 Comparative Studies. . . . . . . . . . . . . . . . . . . . . . . . 13
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4 The Interfaces for NIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4.1 Mouthpieces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.2 Nasal Masks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.3 Nasal Pillows. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.4 Face Masks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.5 Helmets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
5 When to Start (or Not) Ventilation Treatment. . . . . . . . . . . . . . . 21
5.1 The Timing of Application . . . . . . . . . . . . . . . . . . . . . . . . . 21
5.2 Arterial Blood-Gas Analysis . . . . . . . . . . . . . . . . . . . . . . . . 22
5.3 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
5.4 Cyanosis, Tachypnea, and Recruitment
of Accessory Muscles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5.5 Neurological Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5.6 Cough Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
v
vi Contents
5.7 Other Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . 26
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6 How I Ventilate a Patient Non Invasively . . . . . . . . . . . . . . . . . . 29
6.1 Continuous Positive Airway Pressure . . . . . . . . . . . . . . . . . . 29
6.1.1 Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6.2 Volume Modes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
6.2.1 Assisted/Controlled Ventilation . . . . . . . . . . . . . . . . 33
6.2.2 Synchronized Intermittent Mandatory Ventilation. . . . 34
6.3 Pressure Modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.3.1 Pressure Support Ventilation . . . . . . . . . . . . . . . . . . 35
6.3.2 Pressure Controlled Ventilation . . . . . . . . . . . . . . . . 37
6.3.3 Proportional Assist Ventilation. . . . . . . . . . . . . . . . . 38
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7 How I Set a Ventilator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7.1 What do Volume and Pressure Mode Settings
Have in Common? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7.1.1 The Trigger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7.1.2 The Respiratory Rate . . . . . . . . . . . . . . . . . . . . . . . 45
7.1.3 Fraction of Inspired Oxygen . . . . . . . . . . . . . . . . . . 46
7.2 Specific Setting of Volume Modes. . . . . . . . . . . . . . . . . . . . 47
7.2.1 Tidal Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
7.2.2 Expiratory Pressure. . . . . . . . . . . . . . . . . . . . . . . . . 48
7.2.3 Inspiratory Flow. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.2.4 Inspiratory/Expiratory Ratio. . . . . . . . . . . . . . . . . . . 49
7.2.5 Setting Pressure Modes. . . . . . . . . . . . . . . . . . . . . . 49
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
8 Other Modes of Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
8.1 Neurally Adjusted Ventilatory Assist . . . . . . . . . . . . . . . . . . 57
8.2 Airway Pressure-Release Ventilation or Biphasic
Positive Airway Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8.3 High Frequency Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . 58
8.4 Volume-Assured Pressure Support Ventilation
and Volume-Guaranteed Ventilation. . . . . . . . . . . . . . . . . . . 60
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
9 Why is NIV Good?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
10 Myths, Prejudices and Real Problems. . . . . . . . . . . . . . . . . . . . . 67
10.1 The Side Effects are Negligible . . . . . . . . . . . . . . . . . . . . . . 67
10.2 NIV Does Not Work in Severely Ill Patients. . . . . . . . . . . . . 70
Contents vii
10.3 The Work Load Necessary for NIV is Too Onerous. . . . . . . . 70
10.4 The Helmet is the Interface of Choice . . . . . . . . . . . . . . . . . 72
10.5 It is Better Not to Use an Interface with a
Large Dead Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10.6 A Patient Being Non Invasively Ventilated Must
Not Be Sedated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10.7 It is (Almost) Impossible to Use NIV
in a Comatose Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
10.8 Reimbursement for NIV Through the DRG System . . . . . . . . 75
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
11 NIV in the Treatment of Acute Respiratory Failure:
The Magnificent Five . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
11.1 Exacerbation of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
11.2 Acute Pulmonary Edema. . . . . . . . . . . . . . . . . . . . . . . . . . . 82
11.3 Pneumonia in Immunocompromised Patients. . . . . . . . . . . . . 83
11.4 Weaning from Invasive Ventilation in COPD . . . . . . . . . . . . 84
11.5 Prevention of Post-Extubation Respiratory Failure
in High-Risk Subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Suggested reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
12 NIV in the Treatment of Acute Respiratory Failure:
Emerging Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
12.1 Prevention and Treatment of Surgical Complications . . . . . . . 91
12.2 Obesity Hypoventilation Syndrome. . . . . . . . . . . . . . . . . . . . 92
12.3 Palliation of Symptoms in the Terminally Ill Patient. . . . . . . . 92
12.4 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
12.5 Restrictive Neuromuscular and Chest Cage Disorders. . . . . . . 94
12.6 Ventilatory Support During Bronchoscopy. . . . . . . . . . . . . . . 95
12.7 Future Indications Supported by Single Studies . . . . . . . . . . . 95
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
13 NIV in the Treatment of Acute Respiratory Failure:
Controversial Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
13.1 Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
13.2 Acute Respiratory Distress Syndrome. . . . . . . . . . . . . . . . . . 100
13.3 Treatment of Post-extubation Respiratory Failure. . . . . . . . . . 101
13.4 Severe Acute Respiratory Syndrome
and Other Pandemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
viii Contents
14 Eight Rules to Remember When Ventilating
a Patient Non Invasively. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
14.1 Everything Must be Ready and Everything Must
be Familiar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
14.2 There is No Such Thing as the Best Method of Ventilation. . . 107
14.3 Choose the Ventilator According to the Patient’s Need. . . . . . 108
14.4 There is no Single Interface Valid for All Patients. . . . . . . . . 108
14.5 Explain What You Want to Do to the Patient . . . . . . . . . . . . 109
14.6 Never Work Alone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
14.7 Be Aware of Your Limits . . . . . . . . . . . . . . . . . . . . . . . . . . 110
14.8 Monitor and Record What You Do. . . . . . . . . . . . . . . . . . . . 110
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
15 Tricks and Traps of NIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
15.1 Tubing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
15.2 The Connections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
15.3 Non-rebreathing Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . 115
15.4 Humidification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
15.5 Administration of Bronchodilators . . . . . . . . . . . . . . . . . . . . 118
15.6 Administration of Oxygen. . . . . . . . . . . . . . . . . . . . . . . . . . 119
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
16 Predictors of Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
16.1 Hypercapnic Respiratory Failure. . . . . . . . . . . . . . . . . . . . . . 121
16.2 Hypoxic Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . 123
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
17 Where to Ventilate a Patient with NIV . . . . . . . . . . . . . . . . . . . . 125
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
18 Monitoring During NIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
18.1 Level I Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
18.1.1 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . 132
18.1.2 Respiratory Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . 133
18.1.3 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
18.1.4 Blood-Gas Analyses and Related Parameters. . . . . . . 134
18.1.5 Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
18.1.6 Basic Monitoring of Cardiovascular Function
(ECG and Non Invasively Measured Systemic
Arterial Blood Pressure) . . . . . . . . . . . . . . . . . . . . . 134
18.1.7 Exhaled Tidal Volume . . . . . . . . . . . . . . . . . . . . . . 135
18.1.8 Prognostic Scores. . . . . . . . . . . . . . . . . . . . . . . . . . 135
18.1.9 Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Contents ix
18.2 Level II Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
18.2.1 Measure of the Efficacy of the Respiratory
Muscles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
18.2.2 Transcutaneous Monitoring of Gases
(PtcCO and PtcO ) . . . . . . . . . . . . . . . . . . . . . . . . 137
2 2
18.2.3 Capnometry and Capnography. . . . . . . . . . . . . . . . . 137
18.2.4 The Alveolar-Capillary O Gradient . . . . . . . . . . . . . 138
2
18.2.5 Peripheral Venous Pressure . . . . . . . . . . . . . . . . . . . 138
18.2.6 Invasive Arterial Blood Pressure . . . . . . . . . . . . . . . 138
18.2.7 Static Lung Volumes . . . . . . . . . . . . . . . . . . . . . . . 138
18.2.8 Color-Doppler Echocardiography . . . . . . . . . . . . . . . 138
18.2.9 Ultrasonography. . . . . . . . . . . . . . . . . . . . . . . . . . . 139
18.3 Level III Invasive or Highly Specialized Monitoring . . . . . . . 139
18.3.1 Measurements of Respiratory Mechanics. . . . . . . . . . 139
18.3.2 Electromyography of the Respiratory Muscles. . . . . . 140
18.3.3 Inductive Plethysmography . . . . . . . . . . . . . . . . . . . 140
18.3.4 Hemodynamics. . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
18.3.5 Mixed Venous Blood O Saturation
2
and Venous Admixture . . . . . . . . . . . . . . . . . . . . . . 141
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
19 How to Interpret the Curves on the Ventilator Screen. . . . . . . . . 143
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
20 Chronic Mechanical Ventilation: Is There a Rationale?. . . . . . . . 149
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
21 Chronic Ventilation in COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . 155
21.1 Indications for Prescribing NIV and Possible Outcomes . . . . . 163
21.2 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
22 Ventilation in Patients with Restrictive Disorders . . . . . . . . . . . . 169
22.1 Duchenne’s Muscular Dystrophy . . . . . . . . . . . . . . . . . . . . . 171
22.2 Indications for NIV in Patients with Restrictive Chest
Diseases or with Restrictive Chest Disease . . . . . . . . . . . . . . 172
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
23 Rationale for Ventilation Therapy During Sleep . . . . . . . . . . . . . 177
23.1 Physiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
23.2 Pathological Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
23.3 Chronic Respiratory Failure. . . . . . . . . . . . . . . . . . . . . . . . . 187
x Contents
23.4 Obstructive Sleep Apnea Syndrome:
Obesity-Hypoventilation Syndrome. . . . . . . . . . . . . . . . . . . . 187
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
24 Nocturnal Ventilation: When to Use CPAP, When NIV. . . . . . . . 195
24.1 Obstructive Sleep Apnea Syndrome . . . . . . . . . . . . . . . . . . . 195
24.1.1 Titration of CPAP . . . . . . . . . . . . . . . . . . . . . . . . . 198
24.1.2 Adherence to Treatment . . . . . . . . . . . . . . . . . . . . . 199
24.1.3 Side Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
24.2 Persistence of OSA Despite CPAP Treatment . . . . . . . . . . . . 200
24.2.1 Therapeutic Alternatives to CPAP During OSAS . . . . 201
24.3 Obesity-Hypoventilation Syndrome. . . . . . . . . . . . . . . . . . . . 202
24.4 Alveolar Hypoventilation During Sleep. . . . . . . . . . . . . . . . . 204
24.4.1 Procedures for Prescribing Long-Term NIV. . . . . . . . 204
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209