Noninvasive Positive Noninvasive Positive Pressure Ventilation (NIV)Pressure Ventilation (NIV)

Dr. Samir Sahu,Dr. Samir Sahu,

Intensivist,Intensivist,

Kalinga Hospital, Kalinga Hospital, BhubaneswarBhubaneswar..

Aim of VentilationAim of Ventilation

• To support the overloaded To support the overloaded ventilatory pumpventilatory pump

• To improve arterial blood gases & pHTo improve arterial blood gases & pH• To relieve dyspnea & unload the To relieve dyspnea & unload the

respiratory muscles respiratory muscles • To buy time for the patient until the To buy time for the patient until the

causes of exacerbation are resolved causes of exacerbation are resolved by medical therapyby medical therapy

NIVNIV

Noninvasive Ventilation means Noninvasive Ventilation means augmenting Alveolar Ventilation augmenting Alveolar Ventilation without endotracheal tube or without endotracheal tube or tracheostomy tube.tracheostomy tube.

It consists of a Nasal or a Facial MaskIt consists of a Nasal or a Facial Mask It can be used in the Casualty, ICU, It can be used in the Casualty, ICU,

Ward for Acute RF or at Home for Ward for Acute RF or at Home for Chronic RF.Chronic RF.

Avoids intubation & VAPAvoids intubation & VAP

Indication for Noninvasive Indication for Noninvasive Ventilatory SupportVentilatory Support

Depends onDepends on

• Severity of Exacerbation Severity of Exacerbation

• Severity of Respiratory AcidosisSeverity of Respiratory Acidosis

• Timing of InterventionTiming of Intervention

• Patient CharacteristicsPatient Characteristics

• Skill of the TeamSkill of the Team

• Available monitoring facilitiesAvailable monitoring facilities

Indications of NIVIndications of NIV

Hypercapnic Acute Respiratory FailureHypercapnic Acute Respiratory Failure• Acute exacerbation of COPDAcute exacerbation of COPD• Thoracic Wall DeformitiesThoracic Wall Deformities• Neuromuscular DiseasesNeuromuscular Diseases• WeaningWeaningHypoxaemic Acute Respiratory FailureHypoxaemic Acute Respiratory Failure• Cardiogenic Pulmonary OedemaCardiogenic Pulmonary OedemaChronic Respiratory FailureChronic Respiratory Failure• Polio,TB,NMD,KS,COPD,BronchiectasisPolio,TB,NMD,KS,COPD,Bronchiectasis..

Indications of NIVIndications of NIV

NIV in AE of COPDNIV in AE of COPD

A meta-analysis of 15 trials found that A meta-analysis of 15 trials found that adding NPPV to standard care reduced rates adding NPPV to standard care reduced rates of endotracheal intubation, length of hospital of endotracheal intubation, length of hospital stay & in-hospital mortality rates in patients stay & in-hospital mortality rates in patients with severe exacerbations. with severe exacerbations. (Worsening dyspnoea, increase in sputum (Worsening dyspnoea, increase in sputum purulence, increase in sputum volume) purulence, increase in sputum volume)

Keenan et al;Ann Intern Med. 2003Keenan et al;Ann Intern Med. 2003

COPDCOPD

• Acute exacerbation (pH<7.35, Acute exacerbation (pH<7.35, PaCO2>45PaCO2>45

• Mild exacerbations (pH>7.35) may not Mild exacerbations (pH>7.35) may not benefit benefit Keenan et al, 2003Keenan et al, 2003

• Can be used in ICU/HDU/Wards, Can be used in ICU/HDU/Wards, Patients with severe exacerbations Patients with severe exacerbations (pH<7.3) are better managed in the ICU(pH<7.3) are better managed in the ICU

COPDCOPD

• Recent studies demonstrate that Recent studies demonstrate that outcomes of severe COPD exacerbations outcomes of severe COPD exacerbations are no worse if treated with NIV than with are no worse if treated with NIV than with endotracheal intubation, indicating that an endotracheal intubation, indicating that an initial trial with NIV is not deleterious, even initial trial with NIV is not deleterious, even in severely ill COPD patients.in severely ill COPD patients.

Scala R et al, Scala R et al, ChestChest 2005 2005

Conti G et al, Conti G et al, Intensive Care MedIntensive Care Med 2002 2002

COPD – Practice pointsCOPD – Practice points

• All AE-COPD should have ABG on All AE-COPD should have ABG on presentation besides clinical examinationpresentation besides clinical examination

• NIV preferably started in ICUNIV preferably started in ICU• Patients closely monitored during first 1-2 Patients closely monitored during first 1-2

hourshours• ABG should be repeated at end of 1-4 hrsABG should be repeated at end of 1-4 hrs• NIV should be given almost continuously in NIV should be given almost continuously in

first 24 hours except during feeding. Later first 24 hours except during feeding. Later on duration can be reduced depending on on duration can be reduced depending on clinical condition & physiological clinical condition & physiological parameter(SpO2,ABG) parameter(SpO2,ABG)

Neuromuscular Disease/Neuromuscular Disease/Chest wall DeformityChest wall Deformity

• NIV is recommended when they NIV is recommended when they present in Acute-on chronic present in Acute-on chronic respiratory failurerespiratory failure

Acute AsthmaAcute Asthma

• Not recommended for routine use in Asthma Not recommended for routine use in Asthma exacerbationexacerbation

• NIV may be tried in ICU in patients of Acute NIV may be tried in ICU in patients of Acute Severe Asthma who fail to respond quickly to Severe Asthma who fail to respond quickly to medical treatment & have no medical treatment & have no contraindicationcontraindication

• Patients should be monitored closely and Patients should be monitored closely and intubated promptly if there is no intubated promptly if there is no improvement in the first hour or two, because improvement in the first hour or two, because these patients can deteriorate rapidly. these patients can deteriorate rapidly.

Obstructive Sleep ApneaObstructive Sleep Apnea

• CPAP/NIV is recommended for CPAP/NIV is recommended for Obstructive Sleep Apnea presenting Obstructive Sleep Apnea presenting as acute respiratory failureas acute respiratory failure

• NIV is recommended for patients of NIV is recommended for patients of Obesity Hypoventilation Syndrome Obesity Hypoventilation Syndrome with acute respiratory failurewith acute respiratory failure

Interstitial Lung DiseasesInterstitial Lung Diseases

• NIV is not recommended for NIV is not recommended for Interstitial Lung Disease with acute Interstitial Lung Disease with acute or chronic respiratory failureor chronic respiratory failure

Cardiogenic Pulmonary Cardiogenic Pulmonary EdemaEdema• CPAP/NIV are recommended in addition CPAP/NIV are recommended in addition

to standard medical treatment in to standard medical treatment in cardiogenic pulmonary edemacardiogenic pulmonary edema

• CPAP/NIV are equally effective in CPAP/NIV are equally effective in cardiogenic pulmonary edemacardiogenic pulmonary edema

• NIV is preferable in patients associated NIV is preferable in patients associated with hypercapnic respiratory failurewith hypercapnic respiratory failure

Cardiogenic Pulmonary Cardiogenic Pulmonary EdemaEdema

• The main physiologic benefit from NIV or The main physiologic benefit from NIV or CPAP in these patients is likely due to an CPAP in these patients is likely due to an increase in functional residual capacity that increase in functional residual capacity that reopens collapsed alveoli and improves reopens collapsed alveoli and improves oxygenation. This also increases lung oxygenation. This also increases lung compliance and reduces work of breathing. compliance and reduces work of breathing. The increased intrathoracic pressure also The increased intrathoracic pressure also can improve cardiac performance by can improve cardiac performance by decreasing ventricular preload and decreasing ventricular preload and afterload.afterload.

Immunosupressed PatientsImmunosupressed Patients

• NIV is recommended early in the course NIV is recommended early in the course of hypoxic respiratory failure in of hypoxic respiratory failure in immunocompromised patients, immunocompromised patients, particularly in those with hematological particularly in those with hematological malignanciesmalignancies

• NIV as the preferred initial ventilatory NIV as the preferred initial ventilatory modality for these patients (solid organ & modality for these patients (solid organ & bone marrow transplants, HIV) to avoid bone marrow transplants, HIV) to avoid intubation and its associated risks. intubation and its associated risks.

Lung Resection/Abdominal Lung Resection/Abdominal SurgerySurgery

• NIV may be used in patients who NIV may be used in patients who develop respiratory failure after lung develop respiratory failure after lung resection or abdominal surgeryresection or abdominal surgery

Severe Community Acquired Severe Community Acquired PneumoniaPneumonia

• NIV may be used in the ICU with caution in NIV may be used in the ICU with caution in selected patients with community selected patients with community acquired pneumonia particularly in those acquired pneumonia particularly in those associated with COPDassociated with COPD

• A cautious trial of NIV may be considered A cautious trial of NIV may be considered in patients with pneumonia deemed to be in patients with pneumonia deemed to be excellent candidates, but they need excellent candidates, but they need careful monitoring, because the risk of careful monitoring, because the risk of failure is high.failure is high.

ARDSARDS

• NIV may be used with great caution NIV may be used with great caution in cases of Acute Lung Injury & that in cases of Acute Lung Injury & that too only in ICU. too only in ICU.

• Reserved for hemodynamically Reserved for hemodynamically stable patient who can be closely stable patient who can be closely monitored in an ICU where facilities monitored in an ICU where facilities for invasive ventilation are presentfor invasive ventilation are present

ARDSARDS

• Independent risk factors for NIV failure include Independent risk factors for NIV failure include severe hypoxemia, shock, and metabolic acidosis.severe hypoxemia, shock, and metabolic acidosis.

• Those with > 2 organ failures, hemodynamic Those with > 2 organ failures, hemodynamic instability, or encephalopathy were excludedinstability, or encephalopathy were excluded

• Predictors of NIV failure were Simplified Acute Predictors of NIV failure were Simplified Acute Physiology Score II > 34 and Pao2/Fio2 ≤ 175 after Physiology Score II > 34 and Pao2/Fio2 ≤ 175 after the first hour of therapy. the first hour of therapy.

• NIV cannot be recommended as routine therapy for NIV cannot be recommended as routine therapy for ALI/ARDS, a cautious trial in highly selected patients ALI/ARDS, a cautious trial in highly selected patients with a Simplified Acute Physiology Score II ≤ 34 and with a Simplified Acute Physiology Score II ≤ 34 and readiness to promptly intubate if oxygenation fails readiness to promptly intubate if oxygenation fails to improve sufficiently within the first hour.to improve sufficiently within the first hour.

Rana S. Rana S. Crit CareCrit Care 2006, Antonelli M. 2006, Antonelli M. Crit Care MedCrit Care Med 2007 2007

TraumaTrauma

• CPAP/NIV can be recommended for CPAP/NIV can be recommended for hemodynamically stable patients of hemodynamically stable patients of chest trauma with flail chest chest trauma with flail chest

Palliative Care & Palliative Care & Do not Intubate PatientsDo not Intubate Patients• NIV offers an effective, comfortable & dignified NIV offers an effective, comfortable & dignified

method of supporting patients with end stage method of supporting patients with end stage disease & acute respiratory failuredisease & acute respiratory failure

• If the patient and/or family desire prolonged If the patient and/or family desire prolonged survival, then use should be reserved primarily survival, then use should be reserved primarily for COPD and congestive heart failure patients. for COPD and congestive heart failure patients.

• On the other hand, if the goal is to palliate, to On the other hand, if the goal is to palliate, to relieve dyspnea, or to delay death so that affairs relieve dyspnea, or to delay death so that affairs can be settled, then NIV can be used for these as can be settled, then NIV can be used for these as well as other diagnoses.well as other diagnoses.

• However, it should be reassessed frequently and However, it should be reassessed frequently and stopped if the goal of palliation is not being met. stopped if the goal of palliation is not being met.

Hypoxemic Respiratory Failure Hypoxemic Respiratory Failure Practice PointsPractice Points• Preferably Full-face mask during acute phasePreferably Full-face mask during acute phase• Preferably ICU Ventilator as a high FiO2 can Preferably ICU Ventilator as a high FiO2 can

be administeredbe administered• Pressure support with PEEP with fast rise Pressure support with PEEP with fast rise

time high inspiratory flow to compensate for time high inspiratory flow to compensate for air leaksair leaks

• NIV should be discontinued if no NIV should be discontinued if no improvement in gas exchange & dyspnea, improvement in gas exchange & dyspnea, significant mouth leak, severe mask significant mouth leak, severe mask intolerance, no improvement in mental intolerance, no improvement in mental status in 30 min in a agitated hypoxemic status in 30 min in a agitated hypoxemic patient patient

Postextubation Respiratory Postextubation Respiratory FailureFailure

• Support the use of NIV in patients at Support the use of NIV in patients at high risk of extubation failure, high risk of extubation failure, particularly if they have COPD, particularly if they have COPD, congestive heart failure, and/or congestive heart failure, and/or hypercapnia. However, early hypercapnia. However, early indiscriminate use in all patients with indiscriminate use in all patients with risk factors is discouraged. Patients with risk factors is discouraged. Patients with extubation failure treated with NIV extubation failure treated with NIV should be monitored closely and delays should be monitored closely and delays in needed intubation avoided in needed intubation avoided

Facilitating Extubation in Facilitating Extubation in COPDCOPD

• Patients intubated for hypercapnic Patients intubated for hypercapnic respiratory failure due to COPD who fail respiratory failure due to COPD who fail spontaneous breathing trials should be spontaneous breathing trials should be considered for a trial of extubation to NIV. considered for a trial of extubation to NIV. This approach should be reserved for This approach should be reserved for patients who are good candidates for NIV in patients who are good candidates for NIV in other respects and who are able to tolerate other respects and who are able to tolerate levels of pressure support easily levels of pressure support easily administered via mask (i.e., ≤ 15 cm H2O). administered via mask (i.e., ≤ 15 cm H2O). In addition, they should not have been a In addition, they should not have been a difficult intubation.difficult intubation.

Ventilation in COPDVentilation in COPD

• Non Invasive VentilationNon Invasive Ventilation

• Invasive Ventilation as rescue Invasive Ventilation as rescue interventionintervention

• Invasive Ventilation as first choiceInvasive Ventilation as first choice

• NIV to speed up liberation from NIV to speed up liberation from ventilationventilation

Weaning – Practice PointsWeaning – Practice Points

• SBT after at least 48hrs of stabilization with SBT after at least 48hrs of stabilization with invasive ventilationinvasive ventilation

• If SBT successful – extubateIf SBT successful – extubate• If SBT fails then stabilize patient with full If SBT fails then stabilize patient with full

support on MV for 1 hrsupport on MV for 1 hr• After stabilization extubate & start NIVAfter stabilization extubate & start NIV• Initially apply NIV continuously(22-24hrs) Initially apply NIV continuously(22-24hrs)

with discontinuation for feeding, with discontinuation for feeding, expectorationexpectoration

• Gradually reduce time on NIV as per Gradually reduce time on NIV as per patients improvement patients improvement

Preoxygenation Before Preoxygenation Before

IntubationIntubation • Critically ill patients with hypoxic respiratory Critically ill patients with hypoxic respiratory

failure are at high risk of oxygen desaturations failure are at high risk of oxygen desaturations during intubation. A recent RCT of such during intubation. A recent RCT of such patients showed that preoxygenation with NIV patients showed that preoxygenation with NIV before intubation resulted in improved oxygen before intubation resulted in improved oxygen saturation during and after intubation and saturation during and after intubation and decreased the incidence of oxygen decreased the incidence of oxygen desaturations below 80% during intubation. desaturations below 80% during intubation. This approach is promising but should be This approach is promising but should be further studied before routine use can be further studied before routine use can be recommended.recommended.

Baillard C. Baillard C. Am J Respir Crit Care MedAm J Respir Crit Care Med 2006 2006

Fiberoptic BronchoscopyFiberoptic Bronchoscopy

Selection Criteria for NPPVSelection Criteria for NPPV

Acute Respiratory FailureAcute Respiratory Failure• Respiratory DistressRespiratory Distress (moderate to severe dyspnoea, use of (moderate to severe dyspnoea, use of

accessory muscles, abdominal paradox)accessory muscles, abdominal paradox)• Respiratory Rate Respiratory Rate

(>25/min hypercapnic, >30 hypoxemic) (>25/min hypercapnic, >30 hypoxemic)• pH <7.35 & PaCOpH <7.35 & PaCO22 >45mm Hg >45mm HgAny 2 of the aboveAny 2 of the above• PaOPaO22 <60mm Hg (SpO <60mm Hg (SpO22 <90%), P/F <200 <90%), P/F <200

Exclusion Criteria for NIVExclusion Criteria for NIV

• Cardiac or Respiratory ArrestCardiac or Respiratory Arrest• Haemodynamic Instability - HypotensionHaemodynamic Instability - Hypotension• Cannot protect airways - Coma, secretionsCannot protect airways - Coma, secretions• Craniofacial Trauma (unable to fit mask)Craniofacial Trauma (unable to fit mask)• Life threatening hypoxiaLife threatening hypoxia• Copious secretionsCopious secretions• Severe GI symptoms (vomiting, obstruction, Severe GI symptoms (vomiting, obstruction,

recent upper GI & airway surgery))recent upper GI & airway surgery))• More than 2 organ failureMore than 2 organ failure• Extreme ObesityExtreme Obesity• Agitated or UncooperativeAgitated or Uncooperative

NIV - ApparatusNIV - Apparatus

• Bilevel Pressure Support VentilatorBilevel Pressure Support Ventilator

(portable)/ ICU Ventilator(portable)/ ICU Ventilator

• Silicon Bubble cushion Nasal maskSilicon Bubble cushion Nasal mask

• Silicon Full Face mask (better in acute Silicon Full Face mask (better in acute RF)RF)

• Interface is crucial to success of NIVInterface is crucial to success of NIV

• Head gearHead gear

• Oxygen supplementationOxygen supplementation

EquipmentEquipment

• Pressure preset is now the Pressure preset is now the predominant mode used in NIVpredominant mode used in NIV

• EPAP – flushes dead space CO2, EPAP – flushes dead space CO2, helps alveolar recruitment, stabilizes helps alveolar recruitment, stabilizes upper airway during sleepupper airway during sleep

• Trigger – flow trigger is betterTrigger – flow trigger is better

• Cycling – Inspiratory time 1-0.8secCycling – Inspiratory time 1-0.8sec

NIV Masks

Nasal Mask Full Face Nasal Mask Full Face MaskMask

Nasal PillowsNasal Pillows

Initiation of NIVInitiation of NIV• Appropriately monitored location(SpOAppropriately monitored location(SpO22, Vitals), Vitals)• Patient > 30Patient > 30o o angleangle• Select Interface (mask), Select VentilatorSelect Interface (mask), Select Ventilator• Apply Headgear ,Connect interface to Apply Headgear ,Connect interface to

ventilator tubing & turn on ventilatorventilator tubing & turn on ventilator• Start IPAP 8-12 & EPAP 3-5 cm HStart IPAP 8-12 & EPAP 3-5 cm H22OO• Gradually increase IPAP(10-20) to alleviate Gradually increase IPAP(10-20) to alleviate

dyspnea, decrease RR (IPAP-EPAP>4)dyspnea, decrease RR (IPAP-EPAP>4)• Obese or OSA patients require higher EPAPObese or OSA patients require higher EPAP• Provide OProvide O22 supplementation to keep O supplementation to keep O22 >90% >90% • Check for air leaks, readjust straps as neededCheck for air leaks, readjust straps as needed

Continuation of NIVContinuation of NIV

• ABG at initiation & after 2hrsABG at initiation & after 2hrs

• If PCOIf PCO22 decreases, pH increases & SpO decreases, pH increases & SpO22 is is maintained continue treatmentmaintained continue treatment

• Consider reduction in duration of NPPVConsider reduction in duration of NPPV

• Light diet to avoid nausea & vomitingLight diet to avoid nausea & vomiting

• Continue other medicationContinue other medication

The first few hours are Labour intensiveThe first few hours are Labour intensive

Motivation, training,& dedication leads to Motivation, training,& dedication leads to successsuccess

Predictors of success of Predictors of success of NPPVNPPV

• Younger ageYounger age• Lower acuity of illness (APACHE score)Lower acuity of illness (APACHE score)• Able to cooperate; better neurologic scoreAble to cooperate; better neurologic score• Able to coordinate breathing with Able to coordinate breathing with

ventilatorventilator• Less air leak; intact dentitionLess air leak; intact dentition• Less severe Hypercarbia (PCOLess severe Hypercarbia (PCO22>45,<92)>45,<92)• Less severe Acidemia (pH<7.35,>7.10)Less severe Acidemia (pH<7.35,>7.10)• Improvements in gas exchange,HR,RR Improvements in gas exchange,HR,RR

within 1-4 hourswithin 1-4 hours

Predictors of Failure - COPDPredictors of Failure - COPD

• Air leakingAir leaking

• Apache II >29Apache II >29

• AsynchronyAsynchrony

• Copious secretionsCopious secretions

• GCS <11GCS <11

• Lack of compliance & toleranceLack of compliance & tolerance

• pH < 7.25pH < 7.25

• Respiratory rate >35/minRespiratory rate >35/min

Predictors of Failure – Predictors of Failure – Hypoxemic Respiratory FailureHypoxemic Respiratory Failure

• ALI/ARDSALI/ARDS

• SAPS >35SAPS >35

• Metabolic AcidosisMetabolic Acidosis

• P/F <146 (<175 in ARDS) after 1 hr NIVP/F <146 (<175 in ARDS) after 1 hr NIV

• PneumoniaPneumonia

• Severe hypoxemiaSevere hypoxemia

• ShockShock

FailureFailure

• Early Failure – 1-3 hrsEarly Failure – 1-3 hrs• Late Failure – subsequent failure during Late Failure – subsequent failure during

hospital stay (>48hrs) hospital stay (>48hrs)• 20% of COPD AE experience a new 20% of COPD AE experience a new

episode of Res. Failure. Mortality is 91% episode of Res. Failure. Mortality is 91% with continued NIV compared to 52.6% in with continued NIV compared to 52.6% in those who are intubated & ventilatedthose who are intubated & ventilated

• Mechanical Ventilation allow the patient to Mechanical Ventilation allow the patient to improve sufficiently to take advantage of improve sufficiently to take advantage of NIV which was ineffective earlierNIV which was ineffective earlier

Predictors of NIV FAILUREPredictors of NIV FAILURE

• At admission – At admission –

GCS <11GCS <11

Apache II >29Apache II >29

RR >35/minRR >35/min

pH <7.25pH <7.25

>50% if any 3 & 82% if all 4>50% if any 3 & 82% if all 4

• 2hr after NIV – 75% any 3 & 99% if all 42hr after NIV – 75% any 3 & 99% if all 4

What the Literature saysWhat the Literature says

• Early Failure – (1-3hrs)Early Failure – (1-3hrs)

• Late Failure – (>48hrs) – 10-20%Late Failure – (>48hrs) – 10-20%

• Failure Rate – 5-40%Failure Rate – 5-40%

• Second episode of ARF(same admn) – Second episode of ARF(same admn) – 20% (more severe disease)20% (more severe disease)

• Readmission after 1 year – 80%Readmission after 1 year – 80%

Life threatening – 63%Life threatening – 63%

Death – 49% Death – 49%

Monitoring of NIVMonitoring of NIV• Subjective - Mask comfort Subjective - Mask comfort

- Tolerance of ventilator settings - Tolerance of ventilator settings - Respiratory distress - Respiratory distress

• Physical findings – Respiratory rate Physical findings – Respiratory rate – Other – Other

vital signs vital signs – Accessory muscle use – Accessory muscle use

– Abdominal paradox – Abdominal paradox• Ventilator parameters – Air leaking Ventilator parameters – Air leaking

– Adequacy of Pressure – Adequacy of Pressure support support – Adequacy of PEEP – Adequacy of PEEP – – Tidal volume 5-7 ml/kg Tidal volume 5-7 ml/kg – – Patient-ventilator synchronyPatient-ventilator synchrony

NIV MonitoringNIV Monitoring

• Gas Exchange Gas Exchange – Continuous oximetry until stable – Continuous oximetry until stable – ABGs baseline & 1-2 hrs, then as – ABGs baseline & 1-2 hrs, then as indicatedindicated

• Location Location – Usually ICU to start – Usually ICU to start – General Ward if stable – General Ward if stable – Depends on monitoring needs of – Depends on monitoring needs of patient & monitoring capabilities patient & monitoring capabilities

Complications of NIVComplications of NIV

• Air LeaksAir Leaks

• Nasal/Oral drynessNasal/Oral dryness

• Mask discomfortMask discomfort

• Gastric distentionGastric distention

• Failure to VentilateFailure to Ventilate

Survival using long-term Survival using long-term NPPVNPPV

Selection Criteria for NPPVSelection Criteria for NPPV

Chronic Respiratory Failure - COPDChronic Respiratory Failure - COPD• Failure of standard medical therapy Failure of standard medical therapy

(bronchodilators & LTOT)(bronchodilators & LTOT)• Fatigue, Dyspnea, morning headache,etcFatigue, Dyspnea, morning headache,etc (Symptomatic Diurnal Respiratory (Symptomatic Diurnal Respiratory

Failure)Failure)• PaCOPaCO22 > 55 mm Hg > 55 mm Hg• PaCOPaCO22 50-55 mm Hg with Nocturnal 50-55 mm Hg with Nocturnal

desaturationdesaturation

NPPV in Chronic RF in COPDNPPV in Chronic RF in COPD

2yr multicentric RCT in 122 patients2yr multicentric RCT in 122 patients• Slightly decreased trend to PaCOSlightly decreased trend to PaCO22 reten. reten.• Improved Dyspnoea & Health related Improved Dyspnoea & Health related

quality of lifequality of life• Further work required for frequency & Further work required for frequency &

severity of exacerbations severity of exacerbations Clini et al, Clini et al, Eur Res J 2002Eur Res J 2002

NPPV - DiagnosisNPPV - Diagnosis

• COPD - 125COPD - 125

• + pneumonia - 17+ pneumonia - 17

• + A Renal F - 5+ A Renal F - 5

• + CAD - 5+ CAD - 5

• + Sepsis - 3+ Sepsis - 3

• + CVA - 3+ CVA - 3

• + Pericard E - 1+ Pericard E - 1

• + Trauma - 1+ Trauma - 1

• + OHS - 1+ OHS - 1

• TB sequalae - 16TB sequalae - 16

• TB sequelae - 16TB sequelae - 16

• Bronchiectasis - 2Bronchiectasis - 2

• Kyphoscoliosis - 1Kyphoscoliosis - 1

• CRF/ARF -12CRF/ARF -12

• Obstructive S A – 9Obstructive S A – 9

• Pulmonary Oed. 66Pulmonary Oed. 66

• Bronchial Asthma-2Bronchial Asthma-2

• Collapse Lung - 1Collapse Lung - 1

• Pulm. Embolism - 2Pulm. Embolism - 2

• ARDS - 5ARDS - 5

• Pneumonia - 3Pneumonia - 3

NPPVNPPV

1999-2004

2005 2006 2007 Total

Hypercapnic 74 25 37 40 136

Hypoxic 3 5 22 47 30

Wean 6 2 6 11 14

Place of NPPVPlace of NPPV

1999-2004

2005 2006 2007 Total

ICU 79 30 44 88 241

HDU 3 4 17 24 48

Ward 1 0 1 2 4

THANK YOUTHANK YOU