The document provides guidance for using non-invasive ventilation (NIV) to treat acute type 2 respiratory failure. It outlines criteria for considering and excluding NIV use, as well as steps for monitoring a patient's condition and blood gases over time to determine if NIV is effective or if escalation is needed.
The document provides guidance for using non-invasive ventilation (NIV) to treat acute type 2 respiratory failure. It outlines criteria for considering and excluding NIV use, as well as steps for monitoring a patient's condition and blood gases over time to determine if NIV is effective or if escalation is needed.
The document provides guidance for using non-invasive ventilation (NIV) to treat acute type 2 respiratory failure. It outlines criteria for considering and excluding NIV use, as well as steps for monitoring a patient's condition and blood gases over time to determine if NIV is effective or if escalation is needed.
The document provides guidance for using non-invasive ventilation (NIV) to treat acute type 2 respiratory failure. It outlines criteria for considering and excluding NIV use, as well as steps for monitoring a patient's condition and blood gases over time to determine if NIV is effective or if escalation is needed.
The decision to commence NIV should be made by a doctor of
CT2+ or above, or other competent designated healthcare professional locally agreed, who is competent to do so, e.g. CCOT Please complete the table below if you write in this document:
Name Position Initials Signature
NIV for Acute Type II Respiratory Failure.
Diagnosis: Patient name: Or sticker
□ COPD previous FEV1: _____ (%pred) FEV1/FVC: ____ (%) □ Chest wall deformity □ Neuromuscular disease Hospital number: □ Obesity Hypoventilation (OHVS) □ Cardiogenic pulmonary oedema □ Other: __________________________ Criteria for considering NIV: Decompensated respiratory acidosis (pH< 7.35, PaCO2>6 kPa), despite previous maximum standard medical treatment for no more than 1 hour.
Criteria for inclusion of NIV Criteria for exclusion of ward-based NIV
Able to protect airway Acute asthma or pneumonia Conscious and cooperative Undrained pneumothorax / life threatening Potential for recovery to hypoxaemia quality of life acceptable to the Inability to protect the airway/ vomiting patient Copious respiratory secretions or patient Patient’s wishes considered moribund Confusion/agitation/severe cognitive impairment Facial burns/trauma, recent facial or upper airway surgery Fixed upper airway obstruction / Bowel obstruction Upper gastrointestinal surgery Haemodynamically unstable requiring inotropes (unless on ITU)
Performance status before Care plan (please tick):
exacerbation (please tick): □ Unrestricted □ Patient requiring immediate intubation and □ Strenuous activity limited ventilation □ Limited activity but self-caring □ Patient suitable for NIV and suitable for escalation to ITU treatment/intubation and □ Limited activity and limited ventilation if required self-care □ Suitable for NIV but not suitable for escalation to □ Confined to bed/chair, no self- ITU treatment/intubation and ventilation care □ Not suitable for NIV but for full active medical management □ Palliative care agreed as most appropriate management
1. DNAR form completed if appropriate
2. Patient or relatives involved in above decision Step 1 - Baseline ABG.
Patient information leaflet given
to patient?
- Use Full face mask and ensure tight fit with no air leak - Initial IPAP of 10 cmH2O, EPAP of 4-5 cmH2O - Increase IPAP by 5 cmH2O every 10 min to a minimum Target pressure: 20 cmH2O (may need to be higher particularly in OHVS), or therapeutic response achieved, or patient tolerability reached - There should be no breaks in NIPPV in the first hour - Target SpO2 88-92% (with supplemental oxygen if required) - Ensure Critical Care Outreach informed of patient - Continuous pulse-oximetry for the first 12 hours and ECG monitoring if HR >120, dysrhythmia or cardiomyopathy. - Monitor the patient every 15 min for the first hour → Go to Step 2
Step 2 - ABG after 1 hr of NIV therapy
- If ABG improved, RR stable or improved and SpO2>88-92%:
o Continue NIV and repeat ABG in 4 hours o Monitor the patient every 30 minutes in the 1-4 hour period, and 1 hourly in 4-12 hourly period o → Go to Step 3 (refer to Harrowden A Respiratory team)
- If ABG worse: (pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%) → Go to
Step 2b - If NIV Fails: decreasing conscious level Patient name: Or sticker (GCS<8), pH <7.20, pO2<6 kPa → Contact ITU if appropriate.
Hospital number:
Step 2b - If ABG worse after 1 hr of NIV
(pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%): - If CO2↑: Try to increase IPAP, patient may need IPAP above 20 cmH2O - If O2↓, CO2 stable: ↑FiO2 to achieve >88-92% SpO2 - Check mask fitting - After above changes, monitor every 15 minutes, repeat ABG in 1 hour - If ABG still worse despite optimal settings in the first 4 hours of treatment, consider escalation if appropriate, or withdrawal and palliative treatment - COPD patients with pH <7.26 managed with NIV require more intensive monitoring with a lower threshold for intubation if appropriate.
1 2 3 4 Date Time Signature / Initials pH pCO2 pO2 HCO3- BE SaO2 FiO2 IPAP EPAP RR HR
Stick ABG results here if needed:
Step 3 - ABG after 4 hr on NIV
- If ABG worse: (pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%) go back to step 2b
- If ABG improved: Monitor every hour, and perform ABG in 12 hours, reduce monitoring to 2 hourly if >12hours on NIV and if acidosis resolved
- Please use the chart on page 8
- Patients who benefit from NIV during the first 4 hours of treatment should receive NIV for as long as possible (minimum of 6 hours) during the first 24 hours
- If NIV is successful (pH > 7.35 achieved, resolution of the underlying cause and symptoms, RR normalized) following the first 24 hours or longer, it is appropriate to start a weaning plan
Weaning plan: DAY 2: Continue NIV for 16 hours (Refer to Harrowden A Ward Respiratory team) Weaning should be during the day, with extended periods off the ventilator for meals, physiotherapy, nebulized therapy, etc
DAY 3: Continue NIV for 12 hours, including 6-8 hrs overnight use
DAY 4: Discontinue NIV, unless continuation is clinically indicated
Pre-discharge checklist:
□ Spirometry performed if COPD suspected and no recent result available (< 1 year) FEV1 ______ L FEV1 % predicted ______ FEV1/FVC _______ □ Appropriate sleep study booked if suspected new diagnosis of OHVS/OSA. Communications for the NIV ward round Acute exacerbation of T2RF management guideline
Deliver the following within one hour
Take ABG to confirm T2RF
Controlled O2 therapy to maintain saturations 88-92% - use Has the respiratory acidosis resolved after 1 hour? venturi mask and ensure oxygen prescribed Nebulised salbutamol 2.5-5mg on air – do not stop oxygen Nebulised ipratropium 500mcgs on air Prednisolone 30-40mg for 7 days Yes No *Escalate to senior doctor Antibiotic agent (as per hospital guidelines)
Continue as above Consider whether intubation is more appropriate?
GCS <8 • Reversible factors
PaO2 <6.5kPa despite optimal O2 therapy • Haemodynamic instability ph <7.25 despite optimal medical therapy • Good performance status
Yes No
Refer to ITU team
Bleep 766 Consider whether NIV is appropriate? (Must be CT2+ or above, or CCOT to prescribe NIV) Document ceiling of treatment +/- DNAR form
Yes No Use NIV proforma (available from intranet or HAW) and operational policy Ensure correct mask size Start NIV with IPAP 10 and EPAP 5 Consider palliative care if: Increase IPAP by 5 cm increments every 10 mins to achieve IPAP 20 End stage disease This should be achieved in first 20mins of treatment Patient’s wishes Ensure no breaks in NIV in the first hour Failure to respond to NIV ABG after 1 hour Make CCOT aware (bleep 654, leave message if out of hours) Refer to respiratory team and transfer to Harrowden A ward Review observation frequency
Has ABG improved?
Yes No If CO2↑: Increase IPAP Continue NIV and repeat ABG in 4 hours If O2↓ and CO2 stable: ↑FiO2 to achieve SpO2 88-92% Check mask fitting Escalate to senior doctor Consider whether intubation is more appropriate? Repeat ABG in 1 hour Has ABG improved?
Yes No
Continue NIV and repeat ABG in 12 hours
If acidosis is resolved follow weaning plan in NIV proforma
