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CHHS12/304

Canberra Hospital and Health ServicesOperational ProcedureNon-invasive ventilation management for ward patients Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Ward Inclusion Criteria...........................................................................................2

Section 2 – Ward Exclusion Criteria..........................................................................................2

Section 3 – Initiation of NIV therapy – medical management...................................................3

Section 4 – Initiation of NIV therapy – nursing management...................................................4

Section 5 – NIV Monitoring requirements................................................................................5

Section 6 – Medication assessment requirements...................................................................6

Section 7 – Weaning of NIV.......................................................................................................6

Section 8 – Discontinuation of NIV............................................................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................7

Definition of Terms (if applicable).............................................................................................8

Search Terms............................................................................................................................ 8

Doc Number Version Issued Review Date Area Responsible PageCHHS12/304 1 01/07/2012 01/07/2018 Medicine 1 of 9

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS12/304

Purpose

To ensure the safety of adult patients in hospital requiring non-invasive ventilation (NIV) by the safe administration and monitoring of appropriate NIV therapy outside of the ICU/HDU environment.

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Scope

This document refers to adult patients requiring NIV therapy at the Canberra Hospital (TCH) outside of the ICU/HDU environment.

This document applies to: Medical Officers Registered Nurses and Midwives who are working within their scope of practice (Refer to

Nursing and Midwifery Continuing Competence Policy) Physiotherapists who are working within their scope of practice Undergraduate Nursing Students under direct supervision Respiratory/Sleep Scientists


Section 1 – Ward Inclusion Criteria

Acute Exacerbation of COPD with hypercapnea and respiratory acidosis pH <7.35 or PaCO2 >45mmHg, PaO2 <60mmHg

Hypercapneic respiratory failure secondary to chest wall deformities (scoliosis, thoracoplasty) or neuromuscular diseases (e.g. muscular dystrophy, motor neurone disease)

Obesity hypoventilation syndrome Cystic fibrosis as a bridge to transplantation Stable patients who use non-invasive ventilation at home


Section 2 – Ward Exclusion Criteria

Impending cardiorespiratory arrest – MET call Multi -organ failure requiring extensive monitoring Haemodynamic instability with hypotension or unstable cardiac arrhythmia Untreated pneumothorax Pneumonia in immunocompromised patients Reduced level of consciousness and inability to protect airways Confusion requiring sedative medications or physical restraints to apply NIV Vomiting or haematemesis



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Recent facial/ENT/Upper GI or neurological surgery, trauma, or deformity Acute burn with possible airway involvement Barotrauma Allergic reaction to materials of the face/nose mask


Section 3 – Initiation of NIV therapy – medical management

The decision to commence NIV is a medical one. It should be initiated by the respiratory advanced trainee or respiratory physician during office hours, Monday to Friday 0800hrs – 1700hrs. If a patient requires NIV after-hours, NIV should be initiated by the medical registrar on duty after discussion with the respiratory physician on call. The name of the responsible respiratory physician needs to be clearly documented in the patient’s medical notes.

A written prescription for NIV must be provided by the medical registrar or respiratory physician prior to commencement of therapy on the NIV prescription form. This must include: inspiratory and expiratory positive airway pressures (IPAP/EPAP), mode of ventilation (spontaneous, spontaneous-timed or timed), back-up respiratory rate (BPM) as well as prescription for supplemental oxygen both on and off NIV and the target oxygen saturation.

All patients should have a management plan documented in the notes with regard to failure of NIV and this needs to include resuscitation status. This is the responsibility of the medical team. If the patient will require ICU care/intubation in the event of NIV failure, ICU team should be consulted shortly after commencement of NIV. In some cases, it may be appropriate to have NIV as the ceiling treatment.

All patients MUST have had a chest X-ray and ABGs within 2 hours prior to commencement of NIV and the results must be reviewed by the medical registrar prior to application of NIV. The medical staff should explain the reason for NIV therapy to the patient and family and obtain verbal consent when possible.

Timed mode should not be used in spontaneously breathing patients.

The respiratory physician or respiratory advanced trainee MUST review the patient within 24 hours of NIV commencing.




CHHS12/304

Section 4 – Initiation of NIV therapy – nursing management

Hand hygiene is to be performed using either alcohol based hand rub (ABHR) or hand washing prior to the procedure as per the 5 moments of hand hygiene. Hand hygiene is to be performed before and after patient contact and before and after any procedure.

Patients receiving NIV may require a nurse ratio of 1:1 or 1:2 dependent on the patient’s needs for at least the first 48 hours. Patients on NIV therapy must be clinically monitored by a Registered Nurse experienced in the management and care of NIV.

All masks used for NIV must have an exhalation port built into the mask. Full face masks must also have an anti-asphyxiation valve built into the mask for safety in the event of power or machine failure.

NIV machines should be plugged into essential power outlets which are marked red. Reassure the patient receiving NIV to minimise anxiety and improve compliance. Sit the patient in an upright or semi-recumbent position to assist with ventilation. Ensure the mask is comfortable. A full face mask should be applied for most patients

with acute respiratory failure. The mask should be applied to achieve the best seal to minimise air leaks and the least tension in the straps to avoid skin erosions. It is important to ensure that air is not blowing directly into the patient’s eyes.

It is often helpful to start NIV at relatively low pressures e.g. IPAP 8cmH2O EPAP 4cmH2O initially and increase the pressure gradually as tolerated over 20 minutes to the prescribed pressure.

Patients receiving semi-continuous NIV should have NIV delivered with humidification to improve patient comfort and tolerance. Antibacterial filters should not be applied downstream from the humidifier.

Regular oral hygiene, eye care and pressure area care to the bridge of nose and ears are essential. Application of dressings such as comfeel or duoderm may be helpful in preventing patients developing a pressure area over the nasal bridge.

Common NIV settings for Acute Exacerbation of COPD

IPAP 15cmH2OEPAP 5cmH2OMode Spontaneous timed (S/T)BPM 14%I:E 40%




CHHS12/304

Section 5 – NIV Monitoring requirements

All patients receiving NIV require regular observations of the following: Full MEWS and NIV observations are completed, on both the NIV and MEWS charts, half

hourly for the first four hours, then hourly for the first 24 hours recording the following:o Oxygen saturationo Cardiovascular observationso Flow rate of supplemental oxygen if requiredo NIV settingso Time on and time off machine

In addition, observe:o Hand hygiene using either ABHR or hand washingo Patient comfort and accessory muscle useo Coordination of respiratory effort with the ventilatoro Fluid balance chart o Observe for abdominal distension due to aerophagiao Skin integrity – check at all pressure points i.e. bridge of nose, tips of ears as well as

sacrum and heelso Daily weighto Ensure all equipment used on the patient is cleaned in the correct manner as per the

manufactures instructions.

Alert: If the patient meets MET criteria at any time, call a MET

Observations should continue to be recorded on the patient’s general observation chart to allow trending of observations. The 24hour NIV prescription form should continue to record parameter checks, work of breathing, pressure area care, mouth care and ABGs. For stable patients who are established on NIV (>48hours), observations may be done less frequently following discussion with the treating respiratory physician. This must be documented in the patient’s medical notes.

Patients who show a benefit from NIV in the first few hours should be ventilated semi-continuously (i.e. as much as possible during the first 24 hours, but NIV can be interrupted for short periods if the patient is awake for medications, meals and physiotherapy). When off NIV, supplemental oxygen should be applied according to the medical prescription.

Oxygen saturation should be maintained at 88-92% unless otherwise stated. Improvements in tachypnoea and level of consciousness are usually seen within 1-2 hours and ABG’s should start to improve within 1-2 hours after commencement of NIV.

All NIV circuits must be changed every 7 days or as required if visibly soiled. Masks are to be wiped out daily with detergent and dried thoroughly.




CHHS12/304

Section 6 – Medication assessment requirements

Ongoing Medical Assessment Reassess the patient 1-2 hours after commencement of NIV and document any changes

to the NIV prescription on the NIV prescription chart. Review the patient and prescribe NIV daily. If required, the withdrawal of NIV therapy should be discussed with the respiratory

physician/advanced trainee and documented in the medical notes. Arterial blood gases are required prior to commencement of NIV and at 1-2 hours, 4-6

hours, 24 hours and as required. Early enteral feeding should be considered if the patient is likely to have minimal oral

intake for more than 48 hours.

Treatment FailureThe following findings indicate treatment failure and will require urgent medical assessment: Decreasing level of consciousness Increasing agitation Worsening respiratory distress Worsening gas exchange, e.g. fall in oxygen saturation, increasing oxygen requirement or

worsening ABGs Increasing MEWs Poor synchrony between patient and ventilator Intolerance of therapy

The appropriate action in this case would include a medical registrar review and repeat arterial blood gas. The Specialist Respiratory Physician responsible for the patient’s NIV should be consulted and Intensive Care Unit should be consulted at this stage if medically appropriate.


Section 7 – Weaning of NIV

Weaning of non-invasive ventilation may be appropriate once the patient’s condition has stabilised. In general, Non-invasive ventilation weaning should only commence once paCO2 is less than 60mmHg.

NIV should be changed from semi-continuous to intermittent NIV during the day initially, but continuous NIV should continue at night.

Weaning of NIV must be monitored closely with regular arterial blood gas measurements to ensure paCO2 is stable each time the duration of NIV is altered.

Once the patient is on nocturnal NIV only, the medical team will need to make a decision to either continue with long term nocturnal NIV, change to CPAP or cease therapy. If long term nocturnal NIV or CPAP is planned, a sleep physician should be consulted and an inpatient sleep study may be appropriate.



CHHS12/304


Section 8 – Discontinuation of NIV

NIV may be discontinued for the following reasons following discussion with the medical team: NIV is no longer required because of clinical improvement NIV is not tolerated by the patient and the patient does not wish to continue with

therapy Patient is vomiting and at risk of aspiration There has been a complication to NIV i.e. pneumothorax Endotracheal intubation is required because of NIV treatment failure

Discontinuation of NIV is a medical decision. The decision should be made by the medical team after appropriate discussions with the patient and this must be documented in the progress notes. The responsible Specialist Respiratory Physician must be notified.

Consult the CNC / Team Leader and medical staff in the event of significant changes in patient status.


Implementation

Staff will be advised of this procedure via the DDG Clinical Alert and ward staff meetings.


Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy

Procedures CHHS Healthcare Associated Infections Clinical Procedure

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


Definition of Terms (if applicable)

NIV is delivery of mechanically assisted or generated breaths without placement of an artificial airway using a mask or similar interface. This technique is distinguished from those



CHHS12/304

which bypass the upper airway with an endotracheal tube, laryngeal mask, or tracheostomy and are therefore considered invasive. This is the preferred term and supersedes BPAP, BiPAP and BIPAP. BiPAP and BIPAP are registered trade names for NIV modes on ventilators from specific manufacturers.

CPAP is positive airway pressure therapy throughout the respiratory cycle to spontaneously breathing patients. One nominated pressure splints the airway open throughout the respiratory cycle thereby maintaining oxygen saturation, functional residual capacity and preventing alveolar collapse.

Inspiratory Positive Airway Pressure (IPAP) is titrated to maintain tidal volume, support and augment ventilation, reduces the work of breathing and thereby reduces CO2 retention.

Expiratory Positive Airway Pressure (EPAP) is titrated to eliminate airway obstruction and prevent end expiratory collapse of airways and thereby able recruit alveoli. Combination of above two thereby maintains oxygenation.

Mode: Delivery system selected on the machine – may be CPAP, Spontaneous, Spontaneous/Timed or Timed.

Spontaneous Mode (S): The machine provides ventilatory support in response to the patient’s breathing effort but provides no back-up safety rate, should the patient not trigger the machine. This mode is referred to ‘Spontaneous’ mode on NIV machines

Spontaneous Timed Mode (ST): The machine provides ventilatory support in response to the patient’s breathing effort but provides back-up safety rate, should the patient not trigger the machine. This mode is referred to ‘spontaneous / timed’ mode on NIV machines (S/T)

Timed Mode (T): There is no patient effort required and the ventilator provides full ventilatory support. On NIV machines this is referred to as ‘timed’ mode (T)


Search Terms

Ventilation, NIV, Non-invasive, non invasive, ward ventilation, CPAP, IPAP


Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval



CHHS12/304

This document supersedes the following: Document Number Document Name



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