Important: After steps 1, 2 and 3:
Set patient’s ventilation
2.0 Initial settings • EPAP = 4-10 cmH2O (titration is explained in step 2.3) • IPAP 8-10 cmH2O above EPAP, or IPAP to achieve a desired Vte as detailed in this guideline • RR = 10 to 12 BPM
for patient ventilation set-up
2.1 Increase IPAP • If patient wants more air • To target patient tidal volume at 8 ml/kg of ideal weight • Or if the PaCO2 does not change 2.2 Increase EPAP • If Auto-PEEP in COPD patients: patient is using his accessory muscles to trigger to inspiration • If obstructive sleep apnoea events
Check patient arterial blood gases (PaCO2 and PaO2) and oxygen saturation (SpO2). The effect on blood gases will begin to show after 2 hours on NIV.
2.3 Set the respiratory rate back up • Set to 2-3 BPM under patient’s spontaneous frequency
2.6 Adding oxygen • If unable to obtain SpO2 >90-93% with NIV alone, oxygen can be added to the ventilation circuit
2.4 Set the inspiratory time for the controlled breaths (see timetable) • Set Ti between 25% and 33% for obstructive patients • Set Ti between 33% and 50% for restrictive patients
2.7 Adapt the ventilation to patient needs • Change the parameters step by step under close supervision and communicate with the patient • Turn on AVAPS to automatically adjust the pressure support and ensure an average tidal volume for the patient - 'Do you get enough air?' (IPAP, rise time) - 'Is the machine too slow or too fast?' (RR) - 'Can you exhale easily?' (EPAP)
2.5 Adjust rise time to the patient’s comfort • Obstructive patients prefer short rise time: from 1 to 4 (100 ms to 400 ms) • Restrictive patients prefer long rise time: from 3 to 6 (300 ms to 600 ms)
Adapt the ventilation to patient’s disease progression The patient cannot cycle to expiration (long Ti) or the patient cannot hold a breath (short Ti)
The patient can hardly trigger to inspiration (increased weakness)
You need to ensure minimum ventilation
Set the AVAPS support function: If needed, set the appropriate alarms: patient disconnection, low minute ventilation and low tidal volume alarms
Switch to sensitive Auto-Trak if using Auto-Trak, or increase sensitivity of flow trigger if using flow triggering. Alternatively, increase the rate if the patient is still unable to trigger.
Switch to PC mode: the patient can still trigger to inspiration but the inspiratory time is fixed
Ventilation with AVAPS AVAPS (Average Volume Assured Pressure Support) adjusts the pressure support to ensure average tidal volume: • to facilitate titration • to automatically adapt ventilation to patient changes in status and pathology progression
Choose the appropriate mask Full face
Immediate ventilation required
Lack of teeth
2. Set IPAP limits IPAP max = 25 to 50 cmH2O depending on patient condition and maximum pressure available on the machine and IPAP min = EPAP + 8-10 cmH2O
1. Set the target tidal volume To 8ml/kg of the ideal weight and adjust depending on patient condition
Other restrictive diseases (NMD, etc.)
8 ml/kg of ideal body weight (refer to table overleaf)
IPAPmin = EPAP + 4 cmH2O
AVAPS rate setting depends on patient needs and clinical condition: 0.5 cmH2O/min to 3 cmH2O/min so target tidal volume is reached smoothly; 3 cmH2O/min to 5 cmH2O/min so target tidal volume is reached more rapidly
IPAPmin = efficient IPAP
IPAPmin = efficient IPAP
IPAP max IPAP IPAP min
Target volume Patient volume
In some individual cases, mouthpieces are used, e.g. long-term NPPV in neuromuscular diseases.
ventilation for your patients © 2016 Koninklijke Philips N.V. All rights reserved. Specifications are subject to change without notice. Trademarks are the property of Koninklijke Philips N.V. (Royal Philips) or their respective owners.
www.philips.com/respironics Broudy TB 3/16/16 MCI 4107411 PN 1127984
Management of acute respiratory distress/failure adult patients using
Noninvasive Positive Pressure Ventilation (NPPV) Workflow established in partnership with
Professor Michael Arzt | Universitätsklinikum, Regensburg, Germany and Professor Winfried Randerath | Krankenhaus Bethanien, Solingen, Germany This poster is provided for general information only and is not intended as a substitute for user manuals or other documentation supplied with the applicable product, nor is it intended as a substitute for advice from a registered physician or other healthcare professional. Humidification
Identify candidates for NPPV
• • • • •
B • • • • • •
Evidence of respiratory distress in spontaneously breathing patient
COPD exacerbation Acute pulmonary edema/CHF Immunosuppressed patients Weaning failure (COPD) OHS patient (Obesity Hypoventilation Syndrome)
Any of the below (moderate to severe): • Dyspnoea • Accessory muscle use • Paradoxical breathing
Hypercapnic respiratory failure in neuromuscular disease or: Chest wall deformity Asthma exacerbation Postextubation failure Patients with DNR/DNI status Decompensated obstructive sleep apnoea Postoperative respiratory failure
Caution advised • ARDS • Pneumonia
Patient meets gas exchange and physiologic criteria
Patient has no exclusions for NPPV
Hypercapnic respiratory failure/COPD • pH <7.35 • PaCO2 >45 mmHg kPa • RR >24 bpm
• Cardiac/respiratory arrest • Systolic BP <90 (despite fluids) • Uncontrolled arrythmias • High risk for aspiration • Unable to clear respiratory secretions • Facial surgery, trauma, or deformity • Severe UGI bleeding • Unable to cooperate • Unable to fit mask • Undrained pneumothorax • Multiorgan system failure
Hypoxemic respiratory failure • PaO2 /FiO2 <200 • RR >35
Use of heated humidification can improve patient comfort and compliance with therapy
Initiate NPPV • Bilevel ventilator • Critical care ventilator in PSV mode
Choose and fit appropiate interface • Full face mask (first choice for initiation) • Nasal mask (if full face mask is not tolerated) • Other
Choose alternative therapy
Adjust EPAP or PEEP, and IPAP or PSV
Monitoring • Vital signs, notably respiratory rate • Neck muscle activity • Amount of air leaking • Comfort/tolerance • Patient/ventilator synchrony • Continuous oximetry • Blood gas initially, after 1 hr and as needed subsequently • Reassess alarms and ventilator settings
Adjust IPAP or PSV If persistent • Elevated PaCO2 or respiratory distress
If • Inadequate oxygenation • Obstructive airway • Significant Auto-PEEP
Then • Increase IPAP by 2-3 cmH2O every 5 minutes
Then • Increase EPAP in increments of 1-2 cmH2O to eliminate airway obstruction • Titrate oxygen to maintain SpO2 >90% • May lower EPAP back to level required to eliminate airway obstruction if intolerant
If patient is intolerant • Check leakage • Check mask fit • Adjust rate (if available) • Consider lower inspiratory pressures Optimise patient-ventilator synchrony
Titrate to ventilation needs High level of monitoring required during the first hour of titration
Monitor in ICU or stepdown
• • • •
Unless patient is able to tolerate >30 mins of unassisted breathing.
S/T or PSV mode IPAP/EPAP= 12-14/4 PSV/PEEP= 8-10/4 Rate = 12 (if available)
Consider nasogastric tube only if high aspiration or vomiting risk.
• Optimise Vt (>8 ml/kg) • Adjust rise time, insp time (if available) • Minimise excessive neck muscle use • If synchrony remains poor, consider conscious sedation
* Note: When increasing EPAP, increase IPAP by same amount to maintain same level of pressure support
Assess if patient meets weaning criteria • Clinically stable • RR <24 • HR < 110 bpm • Compensated pH >7.35 • SpO2 >90% on <50% FiO2 on 5 lpm O2
Respiratory symptoms and gas exchange
No improvement after 2–3 hours
Weaning • Trial off NPPV • Remove mask and continue same level of oxygen or • Slowly titrate IPAP or • PSV downward in decrements of 2 cmH2O
Restart NPPV at previous settings
Does patient demonstrate clinical evidence of respiratory distress?
Discontinue NPPV or consider long-term NPPV
Strongly consider use of invasive mechanical ventilation
Conversion table to set the inspiratory time for controlled breaths Set breath rate (BPM)
I/E 1/3, Ti 25%
I/E 1/2, Ti 33%
I/E 1/1, Ti 50%
15 16 17
Conversion table to set the target tidal volume:
Target Vte if 8 ml/kg
1.50 m / 4' 11"
1.55 m / 5' 1"
1.60 m / 5' 3"
1.65 m / 5' 5"
1.70 m / 5' 7"
1.75 m / 5' 9"
560 ml 600 ml
1.80 m / 5' 11"
1.85 m / 6' 1"
1.90 m / 6' 3"
Chronic respiratory insufficiency patients (patient >18 kg)
Chronic respiratory insufficiency patients. Adult or paediatric (patient >10 kg)
Chronic respiratory insufficiency patients, non-invasive and invasive ventilation. Adult or paediatric (patient >10 kg)
Chronic respiratory insufficiency patients, invasive and non-invasive ventilation (adults and paediatric >5 kg)
Above data have been calculated with an ideal Body Mass Index of 23 kg/m2 (BMI=weight/height2)
Set the inspiratory time in seconds: Ti (second) = 60 / respiratory rate x % Ti
For more information, go to www.philips.com/respironics