AHRF Non-Invasive Ventilation Guidelines
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Josi JeremiaAHRF Non-Invasive Ventilation Guidelines
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Josi JeremiaCommon questions
Powered by AIIn cases of COPD with AHRF, key indicators for initiating NIV include a pH of less than 7.35, a PaCO2 level equal to or greater than 6.5 kPa, and a respiratory rate greater than 23 breaths per minute despite one hour of medical management .
Referral to the ICU is indicated for AHRF due to asthma, AHRF with impending respiratory arrest, failure of NIV treatment, an inability to maintain target SpO2 on NIV, the need for intravenous sedation, closer monitoring, or anticipated difficult intubation .
Absolute contraindications include undrained pneumothorax, facial burns, and fixed upper airway obstruction, as well as a period of at least two weeks post-esophagectomy. Relative contraindications account for pH below 7.15, GCS below 8, confusion, agitation, cognitive impairment, and vomiting (with consideration for an NG tube).
Weaning from NIV should begin after the patient stabilizes, using it as much as possible within the first 24 hours. Gradual reduction over the subsequent 48-72 hours is based on arterial blood gas results and clinical reviews. Patient-specific factors and improvements guide weaning decisions .
NIV is typically not indicated for asthma due to its pathophysiology, which may not respond well to the pressure-based support offered by NIV. Instead, asthma management primarily focuses on bronchodilator and anti-inflammatory therapies .
Initial NIV setup involves selecting an appropriate interface with exhalation port, starting IPAP at 10-15 cmH2O and EPAP at 4 cmH2O. Pressure adjustments should respond to ABG results: increase IPAP to improve tidal volume for high PaCO2 or increase EPAP/FiO2 for hypoxia, while regularly monitoring and adjusting settings accordingly .
To manage high PaCO2 levels on NIV, the strategy involves enhancing tidal volume by increasing the IPAP settings. Regular ABG assessments should guide further adjustments and optimize ventilation adequacy .
Adequate patient education and proper mask fitting are vital for ensuring patient comfort, compliance, and therapy effectiveness. Patients need to understand treatment goals, while correct mask fitting is essential to minimize air leaks and maximize comfort .
Continuous cardiac and SpO2 monitoring is crucial for at least the first 12 hours. PaCO2, PaO2, and SpO2 parameters must be set and regularly checked. Adjustments in NIV settings should occur upon PaCO2 assessment; increase tidal volume with changes in IPAP, or enhance EPAP/FiO2 for hypoxia. Re-evaluations using ABG tests should happen one hour post-adjustment .
For patients with neuromuscular disease, consider NIV if the respiratory rate is over 20 breaths per minute when the usual vital capacity is less than 1 liter, or if the pH is below 7.35 with PaCO2 equal to or greater than 6.5 kPa. This ensures support for impaired respiratory muscles due to underlying muscular weakness .