Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Interactive Course on
Dr Bernd Schönhofer
Respiratory and Critical Care Medicine
Klinikum Hannover
Podbielskistrasse 380
30659 Hannover, Germany
Bernd_Schoenhofer@yahoo.com
Aims
Dealing with NIV, the aim of this presentation is to characterize different types of ventilators and to
illustrate criteria how to choose ventilators. Additionally matching the respirator to patient and the
basic set-up in acute and chronic respiratory failure will be focused on.
Summary
Non-invasive mechanical ventilation (NIV) has a long tradition for the treatment of chronic respiratory
failure and more recently has also been applied in acute respiratory failure (ARF). Based on this
experience, negative pressure and positive pressure, critical care ventilators and portable, volume
targeted and pressure targeted ventilators in spontaneous (i.e. assist), spontaneous/timed
(i.e.assist/controlled) and timed (i.e. controlled) modes are used to perform NIV. The individual choice
of ventilator type should depend on the patient’s condition, but also on the expertise of attending staff,
the therapeutic requirements and finally on the location of care.
Many years volume targeted ventilators predominantly were applied to treat CRF; in the past decade
pressure targeted ventilators are surpassing the former. The majority of studies dealing with ARF have
used pressure targeted ventilation in the assist mode. Positive qualities of pressure support ventilation
(PSV) are leak compensation, good patient-ventilator synchrony and the option of integrated positive
end expiratory pressure to counteract the effect of dynamic hyperinflation. In this article some crucial
issues concerning PSV (i.e. triggering into inspiration, pressurisation, cycling into expiration and
CO2-rebreathing) and some corrective measures are discussed. The parameters which should be
monitored during NIV are presented.
25
Ventilator modes
Pressure targeted ventilation
Patients with ARF are often characterised by agitation, irregular breathing pattern and often
tachypnoea. They prefer ventilation modes which support spontaneous breathing. Compared to VTV
due to several significant advantages PTV are the preferred NIV devices in the treatment of ARF
(table 3). Accordingly, in the French epidemiologic survey ARF was treated in 67% with PSV with or
without positive endexpiratory pressure (PEEP), whereas in only 15% assist-control VTV were used 1.
PSV allows the patient to control inspiratory and expiratory times while providing a set pressure
which along with patient effort and respiratory mechanics determines the inspiratory flow and tidal
volume. Another positive quality of PSV is the improved patient-ventilator synchrony in terms of
triggering and cycle functions.
In order to compensate a significant leak a ventilator needs high flows. PTV have leak compensating
abilities with peak inspiratory flow rates of 120 – 180 L/min. However, based on a test lung model
recently it was found that leak compensating capabilities between six different devices differed
markedly 3. In volume targeted ventilators leak compensation is much more limited. Adding a leak to
the circuit of these ventilators caused a fall in tidal volume of more than 50% 4. Moderate leaks can be
compensated by increasing tidal volume.
The new generation of pressure targeted ventilators include higher maximal inspiratory pressure (up to
40 cm water), adjustable pressure rise time, adjustable minimum and maximum inspiratory times and
sophisticated monitoring and alarm systems. Especially in terms of efficacy and safety this new
generation has overcome the most concerns about the application of portable pressure ventilators as an
intervention in ARF. Some crucial issues of PSV and corrective measure are given in table 4. Failures
in the ventilator settings or other shortcomings may be perceived already during the adaptation period
in terms of insufficient improvement of gas exchange or adverse effects. During ventilation typical
problems may be persistent hypercapnia, hyoxemia, hypocapnia and air leaks. Table 5 deal with
possible causes and indicates some solutions.
COPD is characterised by dynamic hyperinflation and intrinsic PEEP which may cause patient-
ventilator asynchrony 5, 6 and consequent increase of work of breathing. PEEP, which is an integrated
option of PTV, is set to counteract the effect of intrinsic PEEP on ventilator triggering and therefore
increases the effect of the intervention and patient’s comfort. PEEP may also stabilize the upper
airway function during sleep, increase functional residual capacity or decrease micro- and
macroatelectasis.
26
Control and assist-control mode
The combination of triggering spontaneous breathing and controlled mechanical ventilation is
available in volume targeted ventilators as the assist-control (A/C) mode, which is called
“spontaneous-timed” (ST) mode in pressure targeted ventilators. Here the ventilator setting allows for
spontaneous patient triggering and improves the patient-ventilator synchrony. The backup rate is
usually set at slightly below the spontaneous breathing rate.
Patients with CRF, who mostly are cooperative and often start NIV with an elective indication, are
optionally offered controlled ventilation modes, which has been rarely studied 12. In ARF the pure
control modes have been rarely applied. However, if they are used, the breathing frequency of the
ventilator must be set higher than the spontaneous breathing frequency to avoid spontaneous efforts.
Furthermore inspiratory and expiratory times are set. Volume or pressure targeted controlled modes
may be preferred in patients with unreliable respiratory effort, unstable ventilatory drive or mechanics,
apnoea and hypopneas, massive overloaded respiratory muscles and failure of pressure support modes
augmenting spontaneous breathing before endotracheal intubation.
Practical Issues
In this chapter only respirator associated issues will be dealt with. Both in ARF and CRF adaptation to
NIV means to match the machine to the patient’s own pattern of breathing. Therefore asking the
following simple questions may be helpful: Are you getting a big enough breath ? Does the breath
lasts long enough ? Are the breaths coming too quickly ? Do you have enough time to breathe out ? Is
there enough time between the breaths ? Is the number of breaths adequate ?
Therefore in simple words every step should be explained to the patient in a calming manner. In order
to realize the most possible comfort and to reduce the probability of aspiration and gastro-esophageal
reflux the patient should be seated in an upright position (e.g., 45-60°). The duration of the first
27
continuous period of NIV depends on the well being and tolerance of the patient. Often it may be
helpful to interrupt the first period of NIV already after some minutes in order to get some feedback
and not to provoke an aversion against NIV. In case of dys-synchrony between patient and ventilator,
a short-term manual mask ventilation trial according to patients’ ventilator needs using an ambu-bag
may be helpful to induce acclimatization.
When NIV is started, the major aims are to reduce WOB and dyspnea. Regarding effectiveness of
mechanical ventilation, the physician must ensure an adequate inspiration in terms of pressure, volume
and timing. Normal tidal volume (VT) is about 5-9 mL/kg. Performing NIV with VTV the difference
compared to invasive mechanical ventilation is that a leak may cause a significant decrease in VT.
Therefore VT is set higher. VT about 10-15 mL/kg are large enough to compensate for leaks, resulting
in an effective, “leak compensated” VT of 5-9 mL/kg 20. With VTV in the controlled mode, the
inspiratory time is set directly (usually between 0.7 - 1.0 sec), or indirectly via peak inspiratory flow
rate which should be 40-60 L/min.
No scientific based data are available investigating the ideal peak inspiratory pressure. Concerning the
recommended pressure levels there is a tendency to set higher levels in some European countries
compared to USA. The fact that no patient could tolerate inspiratory pressures of higher than 15 cm
H2O in several US studies 21, 22 is in contrast to other studies, where pressures between 18 and 40 H2O
were applied 23-25. Also Bott et al used VTV in AC mode to treat ARF with peak inspiratory pressures
in excess of 30 cm H2O mostly without irritating patients 11. Independent of the applied time frame and
ventilator type compared to patients with neuromuscular diseases, in patients with chest wall disorders
and obesity hypoventilation (OHS) high levels of inspiratory pressure are chosen (up to 30 cm H2O
and sometimes even higher).
In more recently developed PTV respirators pressure rise time (i.e., the time to reach the preset
inspiratory pressure) can be set, in order to enhance patients’ comfort. In COPD, patients require a
rapid pressure rise time, e.g. 0.1 – 0.2 sec may be preferred. A relaxed patient, e.g. with NM, without
high ventilatory drive of breathing feels convenient with a slower rise time, e.g. 0.3-0.5 sec.
References
28
6. Nava S, Bruschi C, Fracchia C et al. Patient-ventilator interaction and inspiratory effort during
pressure support ventilation in patients with different pathologies. Eur. Respir. J. 1997;
10:177-183
7. Younes M. Proportional assist ventilation, a new approach to ventilatory support. Theory. Am.
Rev. Respir. Dis. 1992; 145:114-120
8. Ranieri VM, Grasso S, Mascia L et al. Effects of proportional assist ventilation on inspiratory
muscle effort in patients with chronic obstructive pulmonary disease and acute respiratory
failure. Anesthesiology 1997; 86:79-91
9. Wysocki M, Richard JC, Meshaka MD. Nonivasive proportional assist ventilation compared
with noninvasive pressure support ventilation in hypercapnic acute respiratory failure. Crit.
Care Med. 2002; 30:323-329
10. Lofaso F, Fodil R, Lorino H et al. Inaccuracy of tidal volume delivered by home mechanical
ventilators. Eur Respir J 2000; 15:338-341
11. Bott J, Carroll MP, Conway JH et al. Randomised controlled trial of nasal ventilation in acute
ventilatory failure due to chronic obstructive airways disease. Lancet 1993; 341:1555-1557
12. Schonhofer B, Sonneborn M, Haidl P et al. Comparison of two different modes for
noninvasive mechanical ventilation in chronic respiratory failure: volume versus pressure
controlled device. Eur. Respir. J. 1997; 10:184-191
13. Meecham Jones DJ, Paul EA, Grahame-Clarke C et al. Nasal ventilation in acute
exacerbations of chronic obstructive pulmonary disease: effect of ventilator mode on arterial
blood gas tensions. Thorax 1994; 49:1222-1224
14. Navalesi P, Fanfulla F, Firgerio P et al. Physiologic evaluation of noninvasive mechanical
ventilation delivered with three types of masks in patients with chronic hypercapnic
respiratory failure. Crit. Care Med. 2000; 28:1785-1790
15. Vitacca M, Rubini F, Foglio K et al. Non-invasive modalities of positive pressure ventilation
improve the outcome of acute exacerbations in COLD patients. Intensive Care Med. 1993;
19:450-455
16. Girault C, Richard JC, Chevron V et al. Comparative physiologic effects of noninvasive
assist-control and pressure support ventilation in acute hypercapnic respiratory failure. Chest
1997; 111:1639-1648
17. Restrick LJ, Fox NC, Braid G et al. Comparison of nasal pressure support ventilation with
nasal intermittent positive pressure ventilation in patients with nocturnal hypovention. Eur
Respir J 1993; 6:364-370
18. Kacmarek RM, Hill NS. Ventilators for noninvasive positive pressure ventilation: technical
aspects. In: Muir JF, Ambrosino N, Simon AK, eds. Noninvasive mechanical ventilation. Vol.
6. Sheffield: European Respiratory Monograph, 2001; 76-105
19. Kacmarek RM, Stanek KS, McMahon KM. Imposed work of breathing during synchronized
intermittent mandatory ventilation provided by five home care ventilators. Respir care 1990;
35:405-414
20. Leger P, Jennequin J, Gerard M et al. Home positive pressure ventilation via nasal mask for
patients with neuromuscular weakness or restrictive lung and chest wall deformities. Respir
Care 1989; 34:73-77
21. Casanova C, Bartolome R, Celli R et al. Long-term controlled trial of nocturnal nasal postive
pressure ventilation in patients with severe COPD. Chest 2000:1582-1590
22. Lin CC. Comparison between nocturnal nasal positive pressure ventilation combined with
oxygen therapy and oxygen monotherapy in patients with severe COPD. Am. J. Respir. Crit.
Care Med. 1996; 154:353-358
23. Elliott MW, Simmonds AK, Carroll MP et al. Domicilliary nocturnal nasal intermittent
positive pressure ventilation in hypercapnic respiratory failure due to chronic obstructive lung
disease: effects on sleep and quality of life. Thorax 1992; 47:342-348
24. Meecham Jones DJ, Paul EA, Jones PW et al. Nasal pressure support ventilation plus oxygen
compared with oxygen therapy alone in hypercapnic COPD. Am. J. Respir. Crit. Care Med.
1995; 152:538-544
25. Ambrosino N, Nava S, Bertone P et al. Physiologic evaluation of pressure support ventilation
by nasal mask in patients with stable COPD. Chest 1992; 101:385-391
29
Additional references dealing with technical issues
Schönhofer B. Choice of ventilator types, modes, and settings for long-term ventilation. Respir Care
Clin 2002; 8: 419-445
Schönhofer B and Sorter-Leger, S: Equipment needs for non-invasive mechanical ventilation 2002,
Eur Respir J 2002; 20:1029-36
****
Underlying pathophysiology
Invasiveness and degree of ventilator dependency
Convenience
Comfort
Individual needs and preference of the patient
Presence of artificial airway
Age and compliance of the patient
External PEEP
Leak
Portability
Necessary supplies
Economy
Reliability
Local expertise
Staff familiarity
Tab. 1: Some important factors which influence the decision what kind of ventilator is chosen
Table 2: Critical care (CC) ventilators versus portable ventilators, PSV: Pressure support
ventilation
30
Issue PTV VTV
Level of applied volume medium high
Level of applied pressure Medium/high high
Noise low low
Weight medium high
Alarm rare yes
Handling easy medium
Price medium medium/ high
Internal battery rare usual
Comfort high medium
Amount of reduced WOB medium high
Amount of leak compensation high medium
Mucosal dryness medium low
CO2 rebreathing low no
Trigger sensitivity high medium
EPAP (external PEEP) option yes optional
Tachypnoe tolerance high low
Effect on progressing illness low medium
Table 3: Pressure targeted ventilators (PTV) versus volume targeted ventilators (VTV),
WOB: Work of breathing, PEEP: Positive endexpiratory pressure
31
Crucial issue Potential cause Troubleshooting
Hypercapnia* Pressure support, Vt, Increase one of more of theses
fb or volume is too parameters
low
Air leak# Change mask type
VTV: increase Vt
Change from VTV to PTV
CO2 - rebreathing CO2 - rebreathing valve,
external PEEP
Low compliance Increase care and education
Hypocapnia Vt, fb, minute Reduce one of more of theses
ventilation and/ or parameters
IPAP too high
Air leak Nasal mask, open See Air leak#
mouth
Hypoxemia With hypercapnia See Hypercapnia*
Without Hypercapnia:
Atelectasis or
Intrinsic lung disorder Increase of external PEEP O2
(gas exchange) supplemantation
32
Slide 1 ___________________________________
Ventilators for NIV
How to choose, matching to patient, ___________________________________
basic set up
Bernd Schönhofer, MD, PhD
___________________________________
Respiratory and Critical Care Medicine
Klinikum Hannover ___________________________________
Germany
Slide 2 ___________________________________
Ventilators for NIV
___________________________________
How to choose ? ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
33
Slide 4 The choice of NIV-ventilators depends on (2): ___________________________________
Location
Local expertise ___________________________________
Staff familiarity
Training
Impact on nurse workload
___________________________________
Technical issues
External PEEP ___________________________________
Leak
Necessary supplies ___________________________________
Needs to follow-up
Handling
Portability ___________________________________
___________________________________
Slide 6 ___________________________________
Different techniques in NIV
___________________________________
• Negative and positive pressure
• Volume and pressure targeted ventilation ___________________________________
• Assisted and controlled mode
___________________________________
• Intensive care and home ventilators
___________________________________
___________________________________
___________________________________
34
Slide 7 Negative pressure ventilation ___________________________________
unloads respiratory muscles
___________________________________
___________________________________
Pes ___________________________________
Pmask
RC
___________________________________
EMG dia
Carrey, Chest 1990; 97: 150
___________________________________
___________________________________
___________________________________
___________________________________
volume
___________________________________
VTV PTV
___________________________________
___________________________________
35
Slide 10 VTV in CRF ___________________________________
First author, journal, year Diagnosis
Ellis et al, ARRD, 1987, Chest, 1988
Kerby et al, ARRD, 1987
RTD
RTD
___________________________________
Leger et al, Respir Care, 1989 RTD
Carroll et al, Thorax, 1988 RTD, COPD
Bach et al, Chest, 1987, 1990 NM ___________________________________
Heckmatt et al, Lancet 1990 RTD
Gay et al, Mayo Clin Proc, 1991 RTD, COPD
Goldstein et al, Chest 1991 RTD ___________________________________
Elliott et al, Thorax 1992 Miscell.
Piper, Sullivan, ERS, 1996 NM
Muir et al, AJRCCM, 1999 COPD ___________________________________
Restrictive thoracic disease: RTD
Neuromuscular disease: NM
Chronic obstructive disease: COPD
___________________________________
___________________________________
100
[%]
___________________________________
90
80
70
60
___________________________________
50
40
30 ___________________________________
20
10
0 ___________________________________
1990 1992 1994 1996 1998 2000
Volume targeted ventilators
Pressure targeted ventilators (PTV) in spontaneous mode
PTV in controlled or assist-controlled mode
___________________________________
___________________________________
36
Slide 13 VTV vs PTV – advantages/disadvantages
___________________________________
Issue Pressure Volume ___________________________________
Amount of leak compensation high low
Trigger sensitivity high low/medium
EPAP (PEEP) option yes rare ___________________________________
Volume constance medium high
Level of applied pressure medium/high high
Comfort high low/medium ___________________________________
Amount of reduced WOB medium high
Long duration batteries rare yes
Alarms rare yes ___________________________________
Air stacking no yes
High breathing drive +++ +
___________________________________
___________________________________
Leak +
___________________________________
VT % baseline
37
Slide 16 In a subgroup of patients with CRF ___________________________________
VTV may be more effective than PTV
___________________________________
[mmHg]
PCO2
70
60
___________________________________
50
40
___________________________________
30
4 weeks VTV 4 months VTV ___________________________________
4 weeks PTV
Schönhofer et al, ERJ, 1997; 10: 184 ___________________________________
___________________________________
Slide 18 ___________________________________
A/C vs PSV
Girault C, et.al: Chest 111:1639, 1997 ___________________________________
ACV SB PSV
Paw, cmH2O 6.9 0.4 4.6
___________________________________
∆Pes, cmH2O 6.0 21.4 9.8
pEMGdi 60.5 100 67.5 ___________________________________
WOBinsp,J 0.38 0.85 0.52
Comfort, VAS (0-100) 57 75 82 ___________________________________
Acute on chronic RF, Nasal mask, n=15
___________________________________
___________________________________
38
Slide 19 ___________________________________
Portable- vs ICU- ventilators
Results from bench studies: ___________________________________
Comparative or even better bench study
triggering, pressurization, and cycling ___________________________________
between home ventilators and ICU
ventilators ___________________________________
Bunburaphong et al, Chest 1997;111:1050
Patel and Petrini, Chest. 1998;114:1390-6
___________________________________
Tassaux et al, Intensive Care Med. 2002; 28: 1254-61
Richard et al, ICM, 2002; 28: 1049 - 1057 ___________________________________
___________________________________
Slide 20 ___________________________________
ICU- versus portable ventilators
Portable ICU ventilators ___________________________________
Leak compensation +++ +
Inspiratory trigger +++ less sophisticated
Expiratory trigger problem
Alarms
seldom
vital indication
often
disturbing
___________________________________
Monitoring no (yes) yes
Oxygen blender
Handling
seldom
simple
yes
complex
___________________________________
Compactness yes no
Hosts
CO2 rebreathing
light
potentially
heavy
no
___________________________________
Helmet compatible difficult yes
___________________________________
___________________________________
39
Slide 22 Bi-level portable ventilators
___________________________________
Technical options
___________________________________
Trigger ___________________________________
– Flow
– Pressure
Pressurization ___________________________________
Rise time
___________________________________
Inspiratory time
___________________________________
___________________________________
Slide 24 ___________________________________
What settings ?
___________________________________
___________________________________
___________________________________
Inspiration Switching Expiration
___________________________________
___________________________________
___________________________________
40
Slide 25 Flow vs Pressure trigger ___________________________________
- a matter of work of breathing
___________________________________
15 ___________________________________
10
___________________________________
5
___________________________________
A/C PSV PSV
pressure Flow trigger Flow trigger
trigger at 1L/min at 5L/min
Nava et al, Thorax, 1997: 52: 249
___________________________________
___________________________________
41
Slide 28 Effect of Expiratory Positive Airway
___________________________________
Pressure (EPAP) ___________________________________
Counter autoPEEP ___________________________________
Raise FRC, recruit lung
___________________________________
Reduce preload and afterload
Limit dynamic airway collapse ___________________________________
___________________________________
___________________________________
42
Slide 31 ___________________________________
Inspiratory pressure reduces WOB
___________________________________
Inspiratory PSV [cm H2O] 12 20 p
Decrease of RR [1/min] 3 16 <0.05
___________________________________
Decrease of pCO2 4 21 <0.05
Decrease of Pdi 7.2 11.2 0.08 ___________________________________
Brochard L, et al, NEJM, 1990; 323: 1523-30
___________________________________
___________________________________
___________________________________
80
60
___________________________________
40 ___________________________________
20
43
Slide 34 ___________________________________
Inspiratory time (Ti)
• Set by operator ___________________________________
– Based on respiratory rate during spontaneous
breathing ___________________________________
– Select I:E ratio
• In COPD: short inspiration (I:E, e.g. 1: 2.5)
• In Restriction: longer inspiration (I:E, e.g. 1:1.5) ___________________________________
• Calculation serve as guides
• Based on expiratory trigger ___________________________________
– Detect deceleration of flow at end of inspiration
___________________________________
___________________________________
Slide 35 ___________________________________
Set inspiratory time= time cycled
___________________________________
In case of cycling – problems
– Leakage
___________________________________
– Increased airway resistance
___________________________________
• Set inspiratory time window (“min/max”)
• Improves ventilator efficacy ___________________________________
___________________________________
___________________________________
___________________________________
Calderini et al, ICM, 1999; 25: 662
___________________________________
___________________________________
44
Slide 37 Back–up frequency
___________________________________
___________________________________
• Set in ST- or A/C mode
• Indications ___________________________________
–Central apneas
___________________________________
–Low spontaneous fb during sleep
Slide 39 ___________________________________
Many open questions
RE technical issues ___________________________________
___________________________________
?
___________________________________
___________________________________
___________________________________
___________________________________
45
Slide 40 Impact of home ventilator failure
___________________________________
Srinivasan S.et al. Chest 1998;114:1363-67
87/150 patients required assistance
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
46
Slide 43 ___________________________________
How To Start ?
___________________________________
Matching, Basic setting ___________________________________
___________________________________
Some practical issues
___________________________________
___________________________________
___________________________________
Slide 44 ___________________________________
Elective initiation of NIV
___________________________________
• Patient seated at about 45 degrees
• Apply mask briefly to face; reassure ___________________________________
• Then affix headgear
___________________________________
RE Interfaces, see separate presentation
___________________________________
___________________________________
___________________________________
47
Slide 46 Ask simple questions ___________________________________
• Tidal volumen
– Not enough, sufficient, too much ? ___________________________________
• Speed of air flow ___________________________________
– Too slow, adequate, too fast ?
___________________________________
• Breathing frequency
– Too low, adequate, too high ___________________________________
• Time to expiration
– Too short, adequate, too long
___________________________________
___________________________________
Physiol
___________________________________
-40
48
Slide 49 ___________________________________
Initiation of NIV in ARF
___________________________________
• Inspiratory pressure: 20-30 mbar
• Expiratory pressure: 5-8 mbar ___________________________________
• Tidal volume: 5-7 ml/kg
– Aim at adequate ventilation ___________________________________
• Breathing frequency : Close to
spontaneous fb
___________________________________
• FiO2: SaO2 guided
___________________________________
___________________________________
___________________________________
___________________________________
70 ___________________________________
60 Responder
___________________________________
Baseline 2 hr
49
Slide 52 ___________________________________
Troubleshooting (1)
Change
___________________________________
–Ventilator ___________________________________
–Mode
–Inspiratory pressure ___________________________________
–Breathing frequency
–I:E ratio ___________________________________
–In- expiratory trigger
___________________________________
___________________________________
50