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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) Page 1 of 5 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) Page 2 of 5 Patients who have had a Fontan Procedure performed Normal lungs 7.4 Prior to the Commencement of NIV 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 Phillips v60 machine NIV circuit NIV mask (sizing patient dependant) 7.5.3 Initial set up of CPAP machine (Phillips v60) 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) Page 3 of 5 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 (NIV) in the Cardiac Care Unit (CCU) Page 4 of 5 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) Page 5 of 5