Approach to type 2

Respiratory Failure
Changing Nature of NIV
• Not longer just the traditional COPD
patients
• Increasingly
– Obesity
– Neuromuscular
– Pneumonias
• 3 fold increase in patients with Ph 7.25
and below
Impact
• Changing guidelines
• Increased complexity
• Increased number of patients
• Decreased threshold for initiation
• Lower capacity for ITU to help
• Higher demands on nursing staff
Resp Failure
• Type 1 Failure of Oxygenation
• Type 2 Failure of Ventilation
• Hypoventilation
• Po2 <8
• Pco2 >6
• PH low or bicarbonate high
Ventilation
• Adequate Ventilation
– Breathe in deeply enough to hit a certain
volume
– Breathe out leaving a reasonable residual
volume
– Breath quick enough
– Tidal volume and minute ventilation
Response to demand
• Increase depth of respiration
• Use Reserve volume
• Increase rate of breathing
• General increase in minute ventilation
• More gas exchange
Failure to match demand
• Hypoventilation
• Multifactorial
• Can't breathe to a high enough volume
• Can't breath quick enough
• Pco2 rises
• Po2 falls
Those at risk
• COPD
• Thoracic restriction
• Central
• Neuromuscular
• Acute aspects
– Over oxygenation
– Pulmonary oedema
Exhaustion
• Complicates all forms of resp failure
• Type one will become type two
• Needs urgent action
• Excessive demand
• Unable to keep up
• Resp muscle hypoxia
Exhaustion
• Muscles weaken
• Depth of inspiration drops
• Residual volume drops
• Work to breath becomes harder
• Spiral of exhaustion
• Pco2 rises, Po2 drops
Type 2 Respiratory Failure

Management
Identifying Those at Risk
• Pre-existing conditions
• Acute factors
– Bronchoconstriction/Pulmonary oedema
– Hypoxia
• Superimposed problems
– Metabolic acidosis
– Low cardiac output
Recognising the problem
• Pick them up early- plan escalation
• Confusion
• Flap
• Signs of exhaustion
• Agitation,
• High HR,
• High BP
• Sweaty
Why are they in type two?
• Don’t assume
• Multifactorial
• Examination- wheeze, opiods, oedema
• EARLY x-ray- Pneumothorax
• ECG- Myocardial infarction
• Bloods- Metabolic, BM, TSH
Simple Measures
• Reduce work of breathing
• Sit them up- 45 degree angle
• Good sputum clearance
• Enough oxygen- 88-92%? hypoxia will kill
you first
• Avoid resp depressants
• Max cardiac output
Treat underlying cause
• Bronchospasm
– Reduces air trapping and V/Q mismatch
– Lots of nebs, magnesium, aminophyline
• Pleural disease
– drain pneumothorax/effusions
• Cardiac output
– fluids/inotropes
Non Invasive Ventilation
• Augmenting patients breathing without an
ET tube
• Maximises Inspiratory volume (maintains
tidal volume)
• Stops airway collapse
• Can control rate of breathing
• Reduces the work of breathing
NIV
• Bilevel positive pressure ventilation
• Maintaining the volume in the lungs
between two ideal levels
• Applies pressure at maximum ventilation
(ipap)
• Applies pressure at maximum expiration to
splint airways (epap)
NIV- Does it work
• Up to 70% reduction in work of breathing
• Improved mortality over invasive
ventilation
• Reduced
– Invasive ventilation
– Hospital mortality
– Length of stay
• Mortality static over 10 years
• Effective in the elderly
Role of NIV
• Support tiring patient at early stage
• Treat type two resp failure to avoid
invasive ventilation
• Ceiling of treatment when invasive
ventilation is inappropriate
• Palliation
Timing of NIV
• Is the PH <7.35
• Is the Pco2 >6.5
(i.e. do they have a respiratory acidosis)
• Is their oxygen appropriate for the patient?
• Have you treated the correctable factors
for 30-60mins?
• If so consider starting NIV
Timing of NIV
• Maximise for an hour?
– Mild to Moderate Acidosis
– COPD
– 20% will improve
• Delay of more than hour is harmful
• Delay in other patient groups
– Poorer outcomes
Timing of NIV
• Maximise one hour if
– Simple copd exacerbation
– Ph 7.25 or above
– Capacity for review in one hour
– Capacity for immediate initiation of NIV
– No signs of exhaustion
Contra indications to NIV
• Very few
– No longer
• Low ph
• Low GCS
• Mainly indications for Invasive ventilation
• Facial injuries
• Poor upper airway
• Uncontrolled bowel obstruction- NG tube
Who should be invasively
ventilated
• 1) Reversible pathology
• 2) Remains active
• 3) Reasonable muscle bulk
And don’t forget
• 4) Patients wishes
• Contact early!!
Decision Time
• Is this patient more appropriate for
consideration for immediate invasive
ventilation?
• Poor upper airway
• very hypoxic
• severe sepsis
• bowel obstruction
• Not PH or decreased GCS
Decision Time
• Is the patient suitable for NIV but should
be considered for ITU if fails NIV?
– Protect respiratory muscles
– Prevent VAP
– Protect against muscle wasting
– Protect against ITU Psychosis
– Patients do better on NIV
NIV as a Trial
• Best done in ITU
– Ph < 7.15
– Decreased GCS
– Confusion
– Pneumonia
• Delayed intubation = increased mortality
• Make decisions early and be proactive
Special Circumstances
• Pulmonary Oedema
– Works
– May not keep them alive long term
• Asthma
– Just don't
• Pneumonia
– If not for ITU
Where to NIV?
• Initiation shouldn’t be delayed
• Specialist Unit
• Appropriate staffing
– Trained Nurses
– Capacity to do regular obs
– 2-1 nursing
– Level 2-3
Setting up
• Mode
– Bilevel/bipap/pressure support
• Ipap
– High pressure used to fill the lung
• Epap
– Low pressure use to keep lungs open
• Difference Ipap and Epap = Tidal volume
IPAP Vs EPAP
• IPAP controls depth of ventilation
• Bigger gap between ipap and epap =
deeper ventilation
• Therefore IPAP controls PCO2
• EPAP overcomes stiff and noncompliant
lungs and airways
• EPAP and help oxygenation
Rule of thumb
• Initial settings
• Start IPAP -15
EPAP – 3
• Review patient clinically.
Is their chest rising? Is their heart rate and BP
improving? Are they working less hard to
breath?
• If not titrate up IPAP in 2cm increments
Rule of thumb
• Are their sats low?
• Is their chest barely moving?
• Is the apnoea alarm buzzing at you?
• If any of yes to any of these increase both
the EPAP and IPAP by 2 increments.
• Once your happy repeat ABG in 1 hour
Oxygen
• Continue to aim 88-92%
• Supply oxygen through mask or tubing
• Difficult to predict how much they need
• Machine looses a lot of oxygen
• Patient is ventilating better
• Start high and titrate down
Failing on NIV
• High respiratory rate,
• High BP
• High pulse
• Agitation
• Working hard to breath with accessory
muscles
• Sweating
Pco2 not coming down
• Inadequate ventilation
• Assess airway
• Sit patient up
• Treat underlying cause
• Increase IPAP
• Repeat ABG
Po2 Poor
• Maximise ventilation
• Increased inspired Oxygen
• Increase EPAP and IPAP until chest rising
• Treat underlying cause
• Reassess for pneumothorax/mucus
plugging
Conclusion
• Changing nature of patients
• Reduce work of breathing
• Early planning- ?ITU
• Early initiation- ?wait until acidotic
• Very few contraindications