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Are You Optimizing Every Bilevel Breath?. Jim Eddins, RRT. Objectives. Discuss the basics of non-invasive ventilation and the benefits of using NIV Discuss features that improve bilevel tolerance Determine the most effective bilevel settings based on disease state. - PowerPoint PPT Presentation
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Are You Optimizing Every Bilevel Breath?
Jim Eddins, RRT
Objectives• Discuss the basics of non-invasive
ventilation and the benefits of using NIV• Discuss features that improve bilevel
tolerance • Determine the most effective bilevel
settings based on disease state
Consider Using NIV When …
Use NIVUse NIVObstructive events
persist at 15 cm H2O
Respirations are characterized by CSA,
CSR or CompSA
Patient has a history of ventilatory insufficiency
Patient is not tolerating high pressure settings or
is complaining of inability to exhale, despite expiratory
pressure relief feature
Utilizing Pressures Effectively
Breath Cycle on Bilevel
Patient Flow
Delivered Pressure IPAP
EPAP
Exhalation
TriggerCycle
Inhalation
Pressure support ( P)
The Problem with Asynchrony
How Can Inspiratory Time Controls Help Increase Compliance?
IPAP
EPAP
Ti Max
Ti Min
Breath cycle
0
RiseTime
Rise Time
Problem: Patient describes “Pressure is too STRONG!”Solution: Increase rise time
Maximum Inspiratory Time
Problem: Patient requires longer expiratory time (i.e. COPD)
Solution: Best option – Shorten inspiratory time
Additional options – Select higher cycle sensitivity,Select faster rise time
Minimum Inspiratory Time
Problem: Patient’s inspiratory effort is weak (i.e. restrictive disease)/can’t sustain adequate inspiration
Solution: Best option – Increase/prolong Ti Min
Second option – Select lower cycle sensitivity
Trigger & Cycle Sensitivities
Very High Quick to trigger 2.4 L/min
High More sensitive 4 L/min
Med Default 6 L/min
Low Less sensitive 10 L/min
Very Low Slow to trigger 15 L/min
Very High Quick to cycle 50% of peak flow
High More sensitive 35%
Med Default 25%
Low Less sensitive 15%
Very Low Slow to cycle 8%
Adjustable Trigger Sensitivity
Patient Flow
EPAP
Adjustable Cycle Sensitivity
Patient Flow
EPAP
Cycling for COPD PatientsIncreased inflammation and mucus
Slower inspiratory flow rates
Delayed cycling to expiration
Less time for exhalation
Increased air trapping (PEEPi)
Increased trigger delay and trigger workload
Increased missed triggers
Increased work of breathing
COPD
Synchrony Insight - Ti Min
Gentile, Respiratory Care, 2011
“However, premature cycling may also have detrimental effects on patient-ventilator
synchrony. Premature cycling is simply when the ventilator terminates the breath while the patient requires a long
inspiratory period.”
Restrictive Disease
Clinical Parameters
Conclusion•There are multiple benefits to using NIV, particularly in patients with chronic hypoventilation
•There are additional features on some devices that modify pressure waveforms and work to improve bilevel tolerance