Non-invasive positive pressure ventilation management by medical and surgical inpatient services
CCCF ePoster library. Attalla M. 11/13/19; 283366; EP129 Disclosure(s)(s): I have no disclosures.
Dr. Mirna Attalla
Dr. Mirna Attalla
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Topic: Quality Assurance & Improvement

Attalla, Mirna1; D'Arsigny, Christine L.2
Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Canada; 2Department of Critical Care Medicine and Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Canada

Introduction: With increasing co-morbidities and aging of the general population, non-invasive positive pressure ventilation (NIPPV) is now commonly managed by non-critical care or respirology physicians. Evidence has shown the feasibility of NIPPV management on a medical ward with careful patient selection, staff education and collaboration with intensive care or respirology.1 In Canada, there is significant practice variation in the indication for NIPPV and the discipline of the requesting and managing physicians. Pulmonary edema and COPD remain the most common indications for NIPPV. Across 11 academic centers, emergency and critical care physicians, followed by respirology, most commonly initiate NIPPV.2
Objective: The objective of this project was to evaluate the barriers to providing effective NIPPV management on medical or surgical inpatient services.
Methods: A prospective chart review of incident NIPPV patients admitted to an open intensive care unit (ICU) under medical and surgical specialties was conducted over 6 weeks with a 30-day follow-up period. Data was collected about acid-base disturbances, medical management, indications and contraindications for NIPPV, ventilator management, and adverse events.
Population: 36 patients were reviewed; the indication for NIPPV was increased work of breathing in 12, type 2 respiratory failure in 20, and hypoxia in 4. 23 patients had a starting arterial pH of <7.25. The admitting service was internal medicine for 33 patients; thoracic surgery for 1, neurology for 1 and cardiac surgery for 2. Consultations were requested from ICU for 7 patients, and Respirology for 10 patients.

Patient outcomes: The average time to weaning was 3 days; 5 patients could not be weaned off NIPPV, and 3 were transitioned to symptom directed management and died. 15 patients (42%) experienced one or more adverse events: 10 reported dry nose/throat or pooled secretions; 16 reported impaired sleep; 2 developed nasal lesions; 1 developed conjunctivitis; and 1 was hyperventilated with an abrupt CO2 drop.

Management barriers: Of the 20 COPD patients, only 14 were receiving their regularly prescribed inhalers. 26 patients had ≧1 relative contraindications for NIPPV, without a change in frequency of blood gases or reassessment of patients and/or ventilator setting; 14 were agitated or unable to cooperate, 8 had cardiac ischemia or arrhythmia, 6 were hemodynamically unstable, 5 had an impaired cough and/or swallow, 1 had an upper GI bleed and 1 had a pneumothorax. 58% had delayed nutrition and 42% developed worsened mobility while being treated with NIPPV.
Conclusion: Although initial indications for NIPPV may be appropriate, a portion of patients develop relative contraindications for NIPPV, become intolerant to the settings and/or have nutrition, exercise and bronchodilators restricted. These developments should trigger reassessment by the managing team. Patients with contraindications or complications should be reassessed early for desynchrony and other causes for their respiratory failure, regardless of whether their blood gases are normal or improving. Physiotherapists and dieticians should be involved early, as worsening mobility and nutrition are among the most common and concerning complications.3 Consultation with Respirology or ICU should be considered if contraindications, complications or difficulty weaning develops.

  1. La Regina et al. Non-invasive mechanical ventilation in Internal Medicine Departments: A Pilot Study. Italian Journal of Medicine 2013; 7
  2. Digby GC et al. Non-invasive ventilation practice patterns for acute respiratory failure in Canadian tertiary care centres: a descriptive analysis. Canadian Respiratory Journal 2015;22(6):331-40
  3. Terzi N et al. Initial nutritional management during noninvasive ventilation and outcomes: a retrospective cohort study. Critical Care 2017;21:293
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