Part IV: Application of Part IV: Application of NPPV and CPAP in Specific NPPV and CPAP in Specific DisordersDisorders

By: By: Susan P. Pilbeam, MS, RRT, FAARCSusan P. Pilbeam, MS, RRT, FAARC

John D. Hiser, MEd, RRT, FAARCJohn D. Hiser, MEd, RRT, FAARC

Ray Ritz, BS, RRT, FAARCRay Ritz, BS, RRT, FAARC

American Association for Respiratory Care American Association for Respiratory Care

December, 2006December, 2006

OutlineOutline

Use of NPPV in patients with acute-on-chronic Use of NPPV in patients with acute-on-chronic respiratory failure, acute asthmarespiratory failure, acute asthma

Use of NPPV in immunocompromised Use of NPPV in immunocompromised patients.patients.

Use of CPAP in patients with acute congestive Use of CPAP in patients with acute congestive heart failure without myocardial infarctionheart failure without myocardial infarction

Use of NPPV in patients with do-not-intubate Use of NPPV in patients with do-not-intubate directivesdirectives

Use of NPPV to facilitate weaning from Use of NPPV to facilitate weaning from invasive ventilationinvasive ventilation

Use of NPPV in patients with acute-on-Use of NPPV in patients with acute-on-chronic respiratory failure.chronic respiratory failure.

NPPV is strongly recommended for NPPV is strongly recommended for patients with chronic COPD who are patients with chronic COPD who are experiencing worsening of their conditionexperiencing worsening of their condition

This is true as long as the individual This is true as long as the individual patient does NOT have any exclusionary patient does NOT have any exclusionary criteria (See Part II)criteria (See Part II)

Numerous studies support the use of NPPV Numerous studies support the use of NPPV in this patient groupin this patient group

Use of NPPV in patients with acute-on-Use of NPPV in patients with acute-on-chronic respiratory failure.chronic respiratory failure.

In this patient group, NPPV can result in:In this patient group, NPPV can result in:

Reduced need for intubationReduced need for intubation

Reduced in-hospital mortality Reduced in-hospital mortality

Reduced length of stayReduced length of stay

Results in fewer complications associated Results in fewer complications associated with an artificial airway and invasive with an artificial airway and invasive ventilation (example, ventilator associated ventilation (example, ventilator associated pneumonia)pneumonia)

NPPV in Acute AsthmaNPPV in Acute Asthma

More studies are needed to to determine if More studies are needed to to determine if NPPV is an effective treatment for patients NPPV is an effective treatment for patients with acute asthmawith acute asthma

Available studies suggest that NPPV in this Available studies suggest that NPPV in this patient group may improve oxygenation patient group may improve oxygenation and ventilationand ventilation

Intubation rate may also be reduced in this Intubation rate may also be reduced in this groupgroup

Immunocompromised PatientsImmunocompromised Patients

Immunocompromised patients are at Immunocompromised patients are at increased risk of infectionincreased risk of infection

This patient group can benefit from NPPV This patient group can benefit from NPPV because it helps avoid intubationbecause it helps avoid intubation

Airway damage during intubation and the Airway damage during intubation and the risk of ventilator associated pneumonia risk of ventilator associated pneumonia are two problems that are avoided if NPPV are two problems that are avoided if NPPV can be usedcan be used

Immunocompromised PatientsImmunocompromised Patients

In immunocompromised patients with In immunocompromised patients with moderate to severe respiratory distress, moderate to severe respiratory distress, NPPV may be used if no other NPPV may be used if no other contraindications (exclusionary criteria) contraindications (exclusionary criteria) existexist

Use of NPPV or CPAP in patients with Use of NPPV or CPAP in patients with acute congestive heart failureacute congestive heart failure

In patients with acute cardiogenic In patients with acute cardiogenic pulmonary edema, NPPV reduces the pulmonary edema, NPPV reduces the intubation rateintubation rate

It also reduces the mortality rate.It also reduces the mortality rate. Evidence is good that either CPAP by mask Evidence is good that either CPAP by mask

or NPPV improves clinical outcomes in this or NPPV improves clinical outcomes in this patient grouppatient group11

Use of NPPV in Patients with Do-Not-Use of NPPV in Patients with Do-Not-Intubate DirectivesIntubate Directives

Use of NPPV in patients with “do-not-Use of NPPV in patients with “do-not-intubate” directives is controversialintubate” directives is controversial

These patients typically have irreversible These patients typically have irreversible and terminal diseaseand terminal disease

Patients must understand NPPV cannot Patients must understand NPPV cannot cure themcure them

NPPV is a form of life support and may NPPV is a form of life support and may provide relief of symptoms of respiratory provide relief of symptoms of respiratory distressdistress

NPPV to Facilitate Weaning NPPV to Facilitate Weaning

In patients with chronic respiratory failure In patients with chronic respiratory failure who are invasively ventilated, NPPV may who are invasively ventilated, NPPV may facilitate weaningfacilitate weaning

In this patient group, NPPV, compared to In this patient group, NPPV, compared to invasive PSV, reduced the following:invasive PSV, reduced the following: Weaning timeWeaning time Length of stay in ICULength of stay in ICU Nosocomial pneumoniaNosocomial pneumonia 60-day mortality rate60-day mortality rate

NPPV to Facilitate WeaningNPPV to Facilitate Weaning

In patients with COPD who are difficult to In patients with COPD who are difficult to wean from invasive ventilation, caution wean from invasive ventilation, caution must be usedmust be used

The patient must be willing to cooperate.The patient must be willing to cooperate.

The patient must be able to maintain their The patient must be able to maintain their airway without risk of aspirationairway without risk of aspiration

The patient must be able to clear The patient must be able to clear secretionssecretions

Section SummarySection Summary NPPV has been shown to be beneficial to NPPV has been shown to be beneficial to

the following patient groupsthe following patient groups Acute-on-chronic respiratory failure Acute-on-chronic respiratory failure

(e.g. exascerbation of COPD) (e.g. exascerbation of COPD) Patients with acute asthmaPatients with acute asthma Acute congestive heart failure (not Acute congestive heart failure (not

caused by an acute myocardial caused by an acute myocardial infarction)infarction)

Patients who are immunocompromisedPatients who are immunocompromised To facilitate weaning from invasive To facilitate weaning from invasive

ventilation in difficult to wean patients ventilation in difficult to wean patients with COPDwith COPD