Download Guideline for Non Invasive Ventilation (NIV) in the

Guideline for Non Invasive Ventilation (NIV) in the Cardiac Care Unit (CCU)
Guideline code: Cardiac Services DG-CC2.6.1
Effective date: February 2016
Last review date : September 2012
Next review date: February 2019
Section: Continuity of Care
Sub-Section: Care Planning
1. Overview
This guideline outlines the safe and effective use of Non Invasive Ventilation (NIV)) in patients with Acute Pulmonary
Oedema (APO) in the Cardiac Care Unit (CCU):

The initiation NIV can be medically or nurse initiated in CCU.

Improvements should be seen within 5 – 10 minutes upon commencement of CPAP

If the patient shows no signs of improvement within 20 minutes, intubation should be considered
2. Applicability
This procedure applies to all Western Health Medical and Nursing staff involved with the ongoing care of patients receiving
NIV in the CCU.
3. Responsibility
The Director of Cardiology, the Nurse Unit Manager of CCU and the Clinical Nurse Educators, CCU are responsible for
ensuring that relevant clinical staff are aware of and comply with this procedure.
4. Authority
Exception to the clinical Guidelines described can only be authorised by the Director of Cardiology or other Senior Medical
Officer ( consultant or ICU registrar)
5. Associated Documentation
In support of this guideline, the following Manuals, Guidelines, Instructions, Guidelines, and/or Forms apply:
Code
Name
Respiratory DP-AC1.1.1
Admission and Discharge to the Intermediate Respiratory Care Unit
Physiotherapy Led Ward Based CPAP Clinical Practice Guidelines
Non Invasive Positive Pressure Ventilation Information Package (2008)
6. Definitions and Abbreviations
6.1 Definitions
For purposes of this guideline, unless otherwise stated, the following definitions shall apply:
Non Invasive Ventilation (NIV)
NIV effectively unloads the respiratory muscles, increasing tidal volume,
decreasing the respiratory rate, and decreasing the diaphragmatic work of
breathing, which translates to improvement in oxygenation, a reduction in
hypercapnia, and an improvement in dyspnoea.
CPAP
Continuous Positive Airway Pressure
NIPPV
Non Invasive Positive Pressure Ventilation
PEEP
Positive End Expiratory Pressure
PS
Pressure Support
Acute Respiratory Failure
Any condition that cause the PaO2 < 60mmHg and / or PaCO2 levels >
50mmHg
Hypoxaemia
Low PaO2 with normal PaCO2 (<60mmHg)
Hypercapnoea
High PaCO2 with normal PaO2 (> 45mmHg)
Cardiac Services DG-CC2.6.1 Guideline for Non Invasive Ventilation
(NIV) in the Cardiac Care Unit (CCU)
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6.2 Abbreviations
For purposes of this guideline, unless otherwise stated, the following abbreviations shall apply:
ABGs
Arterial Blood Gases
APO
Acute Pulmonary Oedema
BP
Blood Pressure
CCU
Cardiac Care Unit
CCVT
Centre for Cardiovascular Therapeutics
CM
Centimetre
CNS
Central Nervous System
C02
Carbon Dioxide
CPAP
Continuous Positive Airway Pressure
Fi02
Fraction of Inspired Oxygen
FRC
Functional Residual Capacity
H2O
Water
ICU
Intensive Care Unit
L
Litre
MIN
Minute
mmHg
Millimetres of Mercury
Sa02
Oxygen Saturation
7. Guideline Detail
7.1 Non Invasive Ventilation In the Cardiac Care Unit
In APO the increase in lung water is accompanied by alveolar filling, atelectasis, loss of lung volumes, decreased lung
compliance, and disordered gas exchange.
CPAP is the application of a single level of positive pressure non-invasively, CPAP is the same as PEEP, except it is called
Peep when it is applied to invasive modes of ventilation.
Pressure support is, following a patient initiated breath, the application of a pre-set pressure above CPAP
Application of positive airway pressure recruits collapsed alveoli and improves functional residual capacity (FRC). This
improves gas exchange, hence oxygenation, and increases lung compliance, which reduces the work of breathing. Together
these effects relieve respiratory distress.
Positive airway pressure also has potential benefits for cardiac output. The associated increase in intrathoracic pressure
decreases venous return and preload. Left ventricular afterload reduction can occur due to the reduction in the transmural
gradient developed across the left ventricle during systole.
7.2 Indications for NIV
Indications:
 Decreasing Sa02 < 90% and/or Pa02 < 60mmHg with High flow humidified oxygen.
 Acute hypoxaemia in the setting of the clinical signs and symptoms of Acute pulmonary oedema (APO), including:
- Tachypnoea or increased respiratory effort; and/or
- Increasing oxygen requirements > 60% FiO2 (either via Hi Flow or Hudson Mask)
- Chest X-ray: Bilateral alveolar infiltrates (grade 2).
Care should be taken in patients with chronic type 2 respiratory failure (C02 retention). In such patients a target oxygen
saturation of 90 to 92%. While higher oxygen saturations should be avoided, reversal of hypoxia is paramount and oxygen
should not be withheld in the presence of hyerpcapnia.. Higher oxygen saturations may worsen V/Q mismatch and increase
the carbon dioxide tension inducing narcosis.If oxygen-induced C02 narcosis is suspected, oxygen should not be withdrawn
suddenly, as dangerous hypoxaemia will result. a.
7.3 Contra-indications
Contra-indications:
 Altered conscious state
 Poor airway protection
 Upper airway obstruction related to a foreign body
 Fractured base of skull
 Chronic restrictive lung disease
 Pneumothorax
 Unilateral lung disease
 Raised intracranial pressure
 Barotrauma
 Pre-existing hyperinflation
 Compromised cardiac output related to hypovolaemia
Cardiac Services DG-CC2.6.1 Guideline for Non Invasive Ventilation
(NIV) in the Cardiac Care Unit (CCU)
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

Patients who have had a Fontan Procedure performed
Normal lungs
7.4 Prior to the Commencement of NIV
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Obtain medical clinical review of patient on commencement of NIV.
Record baseline vital signs including CNS assessment.
Commence continuous cardiac monitoring (if not already insitu).
Commence continuous pulse oximetry monitoring.
Check NIV circuit to ensure no leaks.
Explain NIV therapy to patient and reassure short term therapy only.
Explain to the pt what the therapy involves
Mask is tight
Mask smells
May be difficult to breathe initially
They won’t be able to talk effectively
If they think they want to vomit, to let you know ASAP
Only to be used until their breathing improves
Hold the mask on the face initially
Only strap the mask to the head if you are sure the pt. is tolerating the therapy
Can consider use of ramp function for patient comfort gradually increasing the pressure support if the
patient’s condition allows.
7.5 Commencing NIV
7.5.1 Pressure levels/flow


The recommenced initial level of PEEP in the CCU is 5cm H20. The recommended initial level of pressure support
is 5 cmH2O, The amount of PEEP and PS is dependent on the clinical situation, and discretion of a senior medical
officer (Cardiology/ ICU registrar or consultant)
Patients requiring levels of PEEP greater than 5 cm H20 is at the discretion / prescription of senior medical officer in
conjunction with an appropriate clinical plan.
Evidence suggests that if the pressures are too low then the incidence of intubation is high.
Evidence also suggests that if the pressures are too high then this can severely compromise haemodynamic stability and
thus myocardial blood flow.
If NIV is being used and the patient is not achieving an adequate tidal volume, then increasing the PS in relation to the PEEP
may improve it:

Flow is delivered either by O2 alone or combining O2 and air.

The NIV Machine (Phillips V60) can deliver O2 flow in a greater amount than what can be achieved from a standard
wall flow meter and Hudson mask. i.e. 15 – 50litres. The NIV Machine can also deliver air to increase the flow in
combination with O2. The O2/air ratio determines how the volume is expressed in a percentage. E.g. flow of 30L /
mins with O2 of 60% is 15L of O2 and 15L of air.
 As a general rule, the faster the RR the higher the flow that needs to be delivered to the patient.
 Generally 40-50L/min flow is required for patients receiving CPAP in the acute phase and should be titrated
according to patients Spo2 and arterial blood Gases (ABGs).
 This may need to be achieved via a combination of O2 and air. The O2 concentration delivered depends on SaO2
and PaO2 levels.
7.5.2 Equipment
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Phillips v60 machine
NIV circuit
NIV mask (sizing patient dependant)
7.5.3 Initial set up of CPAP machine (Phillips v60)
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Connect the power cord into power outlet and turn on
Attach O2 hose to wall outlet ( no air connection is required)
Attach V60 patient breathing circuit (CPAP circuit) with filter and pressure monitoring line to the v60
Select modes button and select CPAP/PSV button
Select settings Button. Here you can set the CPAP and pressure support required by using the up/down arrows to
set the desired levels (recommended initial level 5cm H2O). then select the % O2 required to be delivered to the
patient
Using the Ramp time function if the patient’s condition allows – the ramp time function helps your patient adapt to
the NIV by gradually increasing the pressure support (CPAP) from sub therapeutic to user set pressures over a set
Cardiac Services DG-CC2.6.1 Guideline for Non Invasive Ventilation
(NIV) in the Cardiac Care Unit (CCU)
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

interval. To use the ramp function
Select the ramp time button in the settings window
This will allow you to be able to set a time frame that you wish the V60 to achieve a pre-set level of pressure
support (CPAP cm H20) set. You can adjust this time from 5 - 45 minutes. (dependant on patient condition)
7.6 During CPAP Administration
During administration:
 The nurse patient ratio is 1:1 whilst CPAP is being delivered, due to patient acuity.
 Continuous pulse oximetry.
 Ensure CPAP mask is fitted to patient’s face to provide effective seal.
 Ensure patient sitting in upright position.
 Ensure CPAP pressure is being delivered by checking pressure on screen
 Monitor vital signs 5-10minutely on commencement until stable and then q30mins whilst CPAP insitu.
 Patient remains nil orally whilst CPAP in use.
 Consider administering anti-emetic if morphine administered concomitantly.
 Obtain arterial blood gases (ABGs) after commencement to identify hypoxaemia status and repeat as required to
ensure effective treatment.
7.7 Potential Complications
Complications:
 Aspiration pneumonia.
 Hypotension (if hypovolaemic).
 Gastric distension (routine gastric decompression is unnecessary).
 Increased work of breathing due to inadequate inspiratory flow, evidenced by increased restlessness, agitation or
dyspnoea following CPAP application. Consider increasing inspiratory flow to overcome “air hunger”.
 Potential C02 retention due to increased dead space, if inspiratory flow insufficient.
 Facial and nasal pressure injury and sores
Result of tight mask seals used to attain adequate inspiratory volumes
Minimize pressure by intermittent application of NIV.
Schedule breaks (30-90 min) to minimize effects of mask pressure ( if clinically able)
Balance strap tension to minimize mask leaks without excessive mask pressures
Cover vulnerable areas (erythematous points of contact) with protective dressings
 Dry mucous membranes and thick secretions
Seen in patients with extended use of NIV.
Consider humidification for NIV devices for prolonged use.
Provide daily oral care
 Barotrauma
 Sinus pain (sinusitis)
 Eye irritation
7.8 Indications to withdraw CPAP
Indications:
 Clinical improvement usually indicated by:
Decrease in work of breathing observed, e.g. no longer using accessory muscles, orthopnoea , dyspnoea
settling;
Respiratory rate < 30/minute, heart rate < 100/minute, BP systolic < 160 mmHg;
Diuresis commenced;
Chest auscultation improved, e.g. bilateral basal crackles only, reduced from midzone crackles;
Sp02 > 90%- 94%
Anxiety, restlessness and agitation settling
 Clinical deterioration usually indicated by:
- Decreased conscious state;
- Hypotension (BP < 90mmHg despite inotropes);
- Increasing agitation;
- Increasing hypoxaemia (Pa02 , 60mmHg, or Sa02 < 90% on Fi02 > 1.0); and
- Worsening orthopnoea despite CPAP.
 Should these circumstances exist, a MET call or Code blue should be considered.
Cardiac Services DG-CC2.6.1 Guideline for Non Invasive Ventilation
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7.9 Weaning CPAP
Weaning:
 Weaning depends on the clinical circumstances
 Generally, Commence weaning when Sa02 is persistently >90% and the patient is clinically improved (see
above).
 As a general rule, both the FiO2 and the pressure levels (PEEP and PS) should be reduced at regular time
intervals until they are able to obtain an adequate FiO2 off the therapy
 It is safer to reduce one element at a time i.e. FiO2 or pressure level/s.
 Once the pt is weaned off NIV it may be necessary to increase the O2 level as the patient is no longer receiving
pressure support, which has assisted greatly in gaseous exchange
 Initially alternating periods between high flow oxygen (Fi02 1.0, 30 l/min delivered by nasal CPAP prongs) and
face CPAP may be required.
 Some patients may not require any weaning.
8. Document History
Number of revisions: 2
Issue dates: May 2004 and September 2012
Documents superseded and/or combined:
Code
Cardiac Services DP-CC2.1.5
Name
Management of a Patient with Continuous Positive Airways Pressure (CPAP) in
the Cardiac Care Unit (CCU)
9. References
Keenan, S. et al. Clinical practice guidelines for the use of non-invasive positive-pressure ventilation and non-invasive
continuous positive airway pressure in the acute care setting. CMAJ 2011; 183(3): E195-E214.
Masip, J. et al. Non-invasive ventilation in acute cardiogenic pulmonary edema: Systematic review and meta-analysis. JAMA
2005; 294: 3124-30.
Thompson, P. (2011) Coronary Care Manual (2nd Ed) Sydney: Churchill Livingstone.
Koninkklijke Philips Electronics N.V, Respironics V60 Ventilator User Manual. 2009- 2010
10. Sponsor
Director of Cardiology
11. Authorisation Authority
Divisional Director Perioperative and Critical Care Services
Cardiac Services DG-CC2.6.1 Guideline for Non Invasive Ventilation
(NIV) in the Cardiac Care Unit (CCU)
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