brighton and sussex university hospitals the use of non-invasive ventilation for acute ... ·...

Non-Invasive Ventilation policy

V.8 Approved Clinical Policies Steering Group: August 2018 of 37

Brighton and Sussex University Hospitals

The use of Non-Invasive Ventilation for acute hypercapnic respiratory failure

Version 8

Category and number C064

Approved by Clinical Policies Steering Group

Date approved August 2018

Name of author Nurse Consultant Critical Care & Non-Invasive Ventilation Group

Name of responsible committee / individual Non invasive ventilation group

Director responsible Nurse Director

Date issued August 2018

Review date August 2021

Target audience Clinical staff

Accessibility Electronically on the Infonet



Contents

Section Page

1 Introduction and key principles 3

2 Purpose 3

3 Definitions 3

4 Responsibilities, Accountabilities and Duties 3

5 Policy 4

6 Training Implications 10

7 Monitoring Arrangements 10

8 Due Regard Assessment Screening 10

9 Links to other Trust policies 11

10 Associated documentation 11

11 References 11

Appendices

Appendix 1 Summary of NIV 12

Appendix 2 NIV Pathway 13

Appendix 3 NIV audit tool 21

Appendix 4 Set up and Troubleshooting guide 22

Appendix 5 NIV Competency framework 29

Appendix 6 Ordering consumables 33

Appendix 7a Due Regard assessment 34

Appendix 7b Dissemination, Implementation and Access Plan 36



1. Introduction and key principles

This policy is for use by the multi-professional team (registered nursing staff physiotherapists and medical staff) in the acute hospital setting to guide the safe management of patients requiring non-invasive ventilation (NIV)

2. Purpose

NIV is the treatment of choice for persistent acute hypercapnic respiratory failure (AHRF) during exacerbations of Chronic Obstructive Pulmonary Disease (COPD) (despite maximal medical therapy), neuromuscular disease or obesity (British Thoracic Society (BTS) 2016).

This policy covers the use of Bi-Level positive airways pressure (BiPAP) also known as NIV. The aim of therapy is to

Decrease work of breathing

Increase tidal volume

Decrease respiratory rate.

To correct a respiratory acidosis The National Institute for Clinical Excellence (NICE) guidance for the management of COPD (2010) recommend that all acute units that admit patients with exacerbations of COPD should have the capability to provide NIV 24 hours/day. This policy identifies the expected standard of care required for patients receiving NIV and identifies the minimum standard. It does not include the use of Continuous Positive Airways Pressure (CPAP).

3. Definitions

Respiratory failure occurs when there is inadequate gas exchange (either oxygen or carbon dioxide or both) between the lungs and blood stream.

Hypercapnia is the increase in carbon dioxide levels in arterial blood. Hypoxaemia is the decrease in oxygen level in arterial blood.

Non-invasive ventilation (NIV) is the provision of ventilatory support through a patients upper airway using a mask or similar device

4. Responsibilities, Accountabilities and Duties 4.1 The Chief Executive

The Chief Executive is responsible for ensuring the requirements within this policy are fulfilled and operational responsibilities are in place when patients who are receiving NIV are nursed on general wards.

4.2 Nurse Director and Divisional Lead Nurses (DLN)

The Nurse Director is responsible for ensuring requirements within this policy are fulfilled and that this policy is disseminated to all the DLNs and matrons for appropriate action.

4.3 Medical director



The Medical director is responsible for ensuring that this policy is disseminated to consultants who supervise medical staff in training and that education and training facilities are available.

4.4 Service managers Business support managers will ensure that adequate resources are available within their division to make provisions within this policy feasible

4.5 Trust Board

The Trust Board is responsible for the overall patient management within the Trust. Assurance for the implementation of this policy is delegated to the Directorate Quality and Safety Committees.

4.6 NIV Group

The NIV group is responsible for developing the NIV policy and pathway according to national guidelines.

4.7 Divisional safety and quality group

This is responsible for receiving the reports on the safety and quality issues related to NIV.

4.8 Clinical Site Manager (CSM)

The CSM will allocate the appropriate bed for the patient requiring NIV and handover to critical care outreach team any patients admitted out of hours.

4.9 Ward manager Ward managers should keep records of staff training and achievement of competence in the use of NIV. 4.10 All staff : Nursing, Physiotherapy & Medical Teams

It is the responsibility of the individual nursing, physiotherapy and medical team to ensure that they are competent in the use of NIV devices if regularly caring for patients who require this therapy.

5. Policy 5.1 Indications

BiPAP is indicated in the ward environment for patients with COPD, neuro muscular disease (NMD), chest wall deformity (CWD) and obesity hypoventilation syndrome(OHS) with AHRF but can be used in specialist areas such as the intensive care unit (ICU) for other indications such as weaning from invasive ventilation. Patients not fitting these categories should be discussed with a senior respiratory or intensive care consultant.

5.2 Types of Respiratory Failure 5.2.1 Respiratory failure can be defined as the failure to maintain adequate gas exchange.

This may be acute, chronic or acute on chronic. 5.2.2 Hypoxic (Type 1) respiratory failure: Arterial blood gas (ABG) analysis: PaO2 <8 kPa with normal or low PaCO2.

Acute Hypercapnic (Type 2) respiratory failure:



Arterial blood gas (ABG) analysis: PaCO2 > 6.5 kPa with pH <7.35 ABG analysis is therefore essential before NIV is commenced to ensure that the appropriate choice of therapy is made.

5.3 Indications for NIV in AHRF 5.3.1 NIV should be considered for all patients with AHRF in whom a respiratory acidosis

(PaCO2 >6.5 kPa, pH <7.35) persists despite immediate maximum standard medical treatments on controlled oxygen for no more than one hour.

BIPAP may be less effective with severe acidosis (pH <7.26) but may still be considered in these patients if it is established that BIPAP is the ceiling of treatment.

The NIV pathway should be commenced (see Appendix 2). 5.3.2 Patients with acute exacerbation of COPD

Standard medical therapy (within first hour) should include:

Controlled oxygen to maintain oxygen saturations 88-92% (prescribed on patients drug chart and identified on the National Early Warning Score Version 2 (NEWS2) chart)

Nebulised salbutamol 2.5.-5mg (on air)

Nebulised ipratroprium 500mcgs (on air)

Prednisolone 30 mg

Antibiotic agent (as per BSUH microguide) All should be administered within one hour and response assessed. 5.3.3 Patients with neuromuscular disease (NMD) or chest wall deformity (CWD)

NIV should be considered for all acutely unwell patients with neuromuscular disease (NMD) or chest wall deformity (CWD) with hypercapnia (pCO2 >6.5). NIV should not be delayed even if acidosis is not present (BTS, 2016).

NIV should be considered in an acute illness when vital capacity (VC) is known to be <1L and RR>20, even if pCO2 is within normal range (BTS, 2016).

Controlled oxygen to maintain oxygen saturations 88-92% (prescribed on patients drug chart and identified on the NEWS2 chart)

Consider controlled ventilation as triggering may be ineffective.

Intubation and escalation to invasive mechanical ventilation should not be delayed if NIV is ineffective unless this is not desired by the patient or deemed to be inappropriate by the senior clinician responsible for the patient.

If the patient has communication difficulties and bulbar dysfunction, NIV delivery may be difficult or impossible (BTS, 2016).

5.3.4 Patients with obesity hypoventilation syndrome (OHS).

In patients with obesity hypoventilation syndrome (OHS), NIV should be used for AHRF (i.e pH <7.35 and pCO2>6.5).

NIV may also be indicated in some patients with OHS and daytime somnolence; sleep disordered breathing and/or right heart failure in the absence of acidosis.

Controlled oxygen therapy is recommended for OHS and AHRF (BTS, 2016) to maintain saturations of 88-92%.



Patients with OHS commonly require higher inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) settings (e.g. IPAP >30 and EPAP>8).

Fluid overload commonly contributes to ventilatory failure in patients with OHS. Forced diuresis may be useful.

The risk of NIV failure is greater in OHS and intubation may be more difficult, it is recommended to place these patients in HDU/ICU environment where appropriate (BTS, 2016).

5.4 Contra-indications for NIV in AHRF. 5.4.1 Absolute Contra-indications – where NIV delivery is impossible.

Severe facial deformity

Fixed upper airway obstruction

Facial burns 5.4.2 Relative Contra-indications

The presence of relative contra-indications necessitates a higher level of supervision, consideration of placement in High Dependency Unit (HDU)/ICU and an early appraisal of whether to continue NIV or convert to invasive mechanical ventilation (IMV). The presence of adverse features increases the risk of NIV failure, therefore requiring more caution and more intense monitoring.

GCS <8 where airway compromise does not warrant immediate endo-tracheal intubation and IMV.

Confusion, agitation or cognitive impairment – may make NIV more difficult to apply but should not preclude its use.

Acute pneumothorax – should be drained before applying NIV. However if too small to drain or suspected to be chronic, NIV may proceed with careful monitoring. If the patient deteriorates, NIV should be discontinued in case it is contributing the development of a tension pneumothorax and an urgent chest X-ray obtained (BTS, 2016).

Vomiting – NG tube placement may be required and NIV may be used if it can be rapidly removed, i.e. by the patient indicating the need to vomit.

Abdominal distension – the cause should be investigated and if deemed to be caused by COPD or morbid obesity, NIV may still be indicated.

Copious secretions – may increase the risk of NIV failure but NIV may also improve the ability to clear secretions and improve alveolar ventilation.

Significant arrhythmia, especially if causing hypotension may be preferred for endo-tracheal intubation and IMV as cardioversion may be required.

5.5 Patient management

To ensure that the patient is managed safely in the initiation, optimisation, maintenance and weaning of non-invasive ventilation the patient must be monitored carefully. This will require increased nursing time to support the patient, particularly in the first 4 hours of therapy. A patient requiring NIV is considered to be a level 2 patient (ICS, 2015). A staffing ratio of 1 nurse to 2 patients receiving NIV should be ideally provided (BTS, 2016).



5.5.1 During daytime hours, patients identified as suitable for NIV using the NIV guidelines should be referred to the respiratory team. Out of hours, cases that do not fulfil the guideline criteria must be discussed with the on call medical registrar and HDU/ICU team.

5.5.2 Care of the patient requiring NIV should be limited to emergency department (ED),

acute admissions unit, respiratory wards and adult critical care units. These clinical areas must ensure that staff are adequately trained and that staff competent in the use of NIV therapy are available at all times. The CSM / Critical Care outreach team (CCOT), should be informed of the patient, their current condition and the patient must be included in the Hospital at Night handover meeting.

5.5.3 Transfer from ED to an appropriate ward may be delayed due to the patient requiring extended treatment in ED “resus” or a delay in providing a bed as outlined above. 5.6 Management and care of patient on NIV

See appendix 1 and 2 NIV summary and pathway for the set-up of NIV 5.6.1 Continuous clinical assessment of the patient is needed including:

Continuous monitoring of oxygen saturation

ECG monitoring for all patients with HR>120, dysrhythmia or known cardiomyopathy.

Intermittent monitoring of CO2 and pH (i.e. serial ABGs)

Serial vital signs and NEWS2 score

Chest wall movement

Co-ordination of respiratory effort with ventilator

Increased use of accessory muscles

Chest pain / indicators of myocardial ischaemia

Patient comfort

Mental state. 5.6.2 Initial settings for NIV To allow acclimatisation of the patient to NIV the initial settings should be:

Inspiratory pressure (IPAP): 15 cm H2O Expiratory pressure (EPAP): 4 cm H2O (higher EPAP may be required if obstructive sleep apnoea known or suspected, but should not exceed 8 cm H2O without consultant review). The IPAP should be gradually be increased over the next 10-30 minutes to a target IPAP of 20-30 cm H2O to achieve a therapeutic response (or patient tolerability is reached). The need for higher pressure and more rapid escalation is indicated by patient size and more severe acidosis. Oxygen should be set on the machine using the same FiO2 (%) as was used through the venturi mask/humidified oxygen prior to starting NIV and adjusted to maintain the target saturation (usually 88 – 92%).

5.7 Ongoing care



5.7.1 Monitoring of the patient should include physiological measures and clinical assessment, these should be clearly documented using the NIV pathway and NEWS2 observation chart.

. Improvements in clinical parameters e.g. respiratory rate are usually seen within 1–2 hours, and are usually accompanied by improvement in neurological state. Therefore a full clinical assessment and blood gas review should be made after 1 hour of treatment. A decision should then be made as to whether NIV is being effective.

The patient should be monitored continuously using pulse oximetry and ECG monitoring (if heart rate >120 per minute or dysrthymia present) for the first 12 hours

Frequency of documented observations on initiation of NIV: First hour – every 15 minutes 1- 4 hours- every 30 minutes 4- 12 hours – hourly.

These observations should include respiratory rate, pulse oximetry, heart rate, level of consciousness, blood pressure, temperature and NEWS2 score - recorded on the NEWS2 chart, as well as noting chest wall movement, ventilator synchrony, accessory muscle use and comfort – recorded on the NIV pathway.

5.7.2 If NIV continues, arterial blood gases (ABG) should be monitored until the pH is

normal and pCO2 has stabilised. The need for an indwelling arterial line should be considered if frequent ABG sampling is being undertaken (this can only be managed in a critical care area). Capillary blood gas (CBG) sampling may be used to measure trends once the team have confirmed that BiPAP is effective. Diagnosis should only be based on an arterial sample.

5.7.3 If the treatment with NIV is not effective, see troubleshooting guide (Appendix 4). The

most common reason for failure of NIV are excessive mask leak, insufficient pressure support or patient / ventilator asynchrony If NIV has been optimised without an improvement in clinical or blood gas parameters it should not be continued. The patient should have escalation of treatment planned. i.e. to intubation, where appropriate, or conventional medical therapy alone.

5.7.4 The patient should have a minimum of daily consultant review whilst receiving NIV to

ensure that treatment remains optimal. 5.7.5 Other care:

Provide care to eyes and mouth.

Breaks from NIV should be made for drinks, drugs, physiotherapy, meals etc.

Assess and monitor oral and dietary intake

All patients receiving NIV therapy should have a fluid balance chart to assist hydration assessment

NIV should be interrupted for the administration of nebulised bronchodilators o Administration of in line nebulisers via a standard nebuliser device is

ineffective as the patient will only receive a small dose of the intended drug therapy

o If the patient is unable to tolerate a break in NIV for nebuliser therapy continue NIV and seek senior advice.

o Where an aerosol device is available (e.g. aeroneb in critical care) this may be used within the circuit as per manufacture guidelines.



5.7.6 Transfer of NIV patient between wards / departments

If a patient who is dependent on NIV requires transfer between departments please seek senior advice. The NIV machine must have adequate battery backup for transfer. The battery life will be used up faster the higher the leak around the mask. The patient must have staff with the appropriate skills to escort the patient and should be monitored appropriately before and during transfer.

5.8 Weaning from NIV 5.8.1 The patient should be assessed on an individual basis for suitability for weaning from

NIV. Generally once the patient is either showing signs of continued improvement (work of breathing falls and acid base balance normalises) * or if NIV is making no difference to the patient’s condition weaning from NIV should be considered and palliation measures adopted including referral to specialist palliative care team (see infonet for contact details).

5.8.2 Principles of weaning;

After 24 hours, if the patient is improving, build periods of time off NIV during the day; continue oxygen therapy via nasal specs or venturi mask, monitor for any signs of work of breathing (increased respiratory rate / decreased oxygen saturation, increased use of accessory muscles) If the patient shows signs of clinical deterioration during weaning, an ABG may be required and NIV resumed. Patient should have NIV overnight during weaning period. Wean off over 2-3 days. Consider use of NIV overnight if nocturnal hypoventilation is present

5.9 Hospital discharge

Prior to hospital discharge an ABG/CBG on room air should be performed and spirometry to aid future assessment please document this on the electronic discharge summary. All COPD patients should be seen by the COPD nurse prior to discharge (bleep 8453 or extension 3109). As part of ongoing rehabilitation, following successful weaning from NIV, patients should be assessed for suitability for pulmonary rehabilitation and if applicable smoking cessation support.

5.10 Equipment 5.10.1 Non specialist NIV equipment is stored in the equipment library and wards and is

maintained and managed by medical physics. Machines can be found in ED, respiratory wards, Acute Assessment Unit (AAU) and Critical care on both hospital sites. The NIV machine requires a dedicated tubing circuit with integral expiration valve and in line bacterial filter and vented face mask (this is a safety feature to enable the patient to breathe if the air flow in the machine is interrupted). The system is for single patient use. Consumables are to be purchased by each ward separately via IPROC NHS supplies.

(Appendix 5) 5.11 Decontamination & cleaning



The machine should be wiped over/ cleaned daily in accordance with Trust cleaning standards. Following use the machine should be cleaned and decontaminated following infection control and manufacturer’s instructions.

There is a reusable foam inlet filter, required to protect the ventilator from dirt and dust. This requires cleaning every week and replacing periodically (recommended every 6 months) and/or if damaged.

5.12 Equipment purchase

NIV equipment purchases should be agreed by all clinical teams involved in NIV management to reduce any error produced by unfamiliarity with equipment. Replacement machines will be co-ordinated by the medical devices committee to ensure a corporate approach to purchasing.

5.13 Documentation 5.13.1 The NIV pathway (Appendix 1) should be used for all patients on NIV outside the adult

intensive care units and used in conjunction with BSUH observation chart incorporating the NEWS2.

5.13.2 Limitations on treatment, weaning regime, further treatment proposals, response to

treatment and indications for the treatment following NIV must be clearly documented in the patient’s health records. The nursing care of NIV should be evaluated in the patient pathway (Appendix 1).

5.14 Patient safety All risk issues identified should be reported using the trust Datix system and

investigated. Lessons learnt should be shared with the relevant departments and ward areas caring for NIV patients.

6. Training Implications

6.1 Nursing Training: All staff caring for a patient with NIV must be competent in the use of NIV before caring for a patient (Appendix 5: Competency framework). Nursing Staff should attend the NIV study day to gain theoretical / practical understanding of the therapy ensuring they understand the medical device used (access via the practice educators acute floor and specialist medicine directorate).

6.2 Medical Training: Doctors initiating NIV should be experienced in using NIV and have suitable evidence within their portfolio of competency.

7.0 Monitoring Arrangements

The NIV service will be audited, in line with BTS guidelines by the respiratory registrar on each site (See audit tool Appendix 2).

Measurable Policy Objective

Monitoring / Audit Method

Frequency Responsibility for performing monitoring

Where is monitoring reported and which groups / committees will be responsible for progressing and reviewing action plans

To audit the use of NIV in

Audit using the BTS

Annual Respiratory consultant (NIV

Respiratory Safety and Quality Meeting



BSUH audit proforma

lead)

To audit the completion of competency of staff caring for NIV patients

Audit of training database

Annual Nurse manager / clinical educator

To respiratory safety and Quality meeting

8. Due Regard Assessment Screening BSUH NHS Trust has a statutory duty to assess and consult on whether policies and processes impact on service users, staff and other stakeholders with regard to age, disability, gender (sex), gender identity, marriage or civil partnership, pregnancy and maternity, race (including ethnicity, nationality), religion or belief and sexual orientation. This policy has been evaluated against the criteria and has been summarised in Appendix 7. 9. Links to other Trust policies Management of Medical Devices training Mental Capacity Act Policy Infection control Patient Observation policy

Resuscitation Policy 10. Associated documentation Summary of NIV (Appendix 1)

NIV pathway (Appendix 2) Set up and troubleshooting Guide (Appendix 4) NIV competency (Appendix 5) Guideline for Continuous Positive Airway Pressure (CPAP) in Cardiogenic Pulmonary Oedema in the Cardiac Care Unit (CCU) at Royal Sussex County Hospital (RSCH) and Princess Royal Hospital (PRH). (available on the Trust Infonet)

11. References British Thoracic Society/ Intensive care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. 2016. Guidelines for the ventilator management of Acute Hypercapnic Respiratory Failure in Adults. Thorax Vol 71 Supplement 2 Intensive Care Society. 2015. Guidelines for the Provision of Intensive Care Services. NICE. 2010. CG 101. Chronic Obstructive Pulmonary Disease. Management of chronic obstructive pulmonary disease in primary and secondary care. Patient safety Alert 2015 Risk of severe harm and death from unintentional interruption of non-invasive ventilation NHS/PSA/W/2015/003



Appendix 1 Summary of NIV



Appendix 2: NIV Pathway

Acute Non Invasive Ventilation Pathway – NIV (also known as BiPAP) This pathway is suitable for patients with acute hypercapnic respiratory failure (pH <7.35, PaCO2 >6.5) who fulfil the following criteria in ward areas.

If considering initiating NIV, inform a senior clinician now. The following steps will assist in the decision making and management of the patient. Step 1 Initial assessment Step 2 Management and escalation plan Step 3 Communication Step 4 Set up of NIV Step 5 Monitoring and weaning of NIV Daily record

Name of Doctor initiating NIV ………………………………………..

Grade :…………………….. Bleep : …….…

Step 1 : Initial assessment Time: Date: Please circle

Initial investigations ?

CXR checked : to exclude Pneumothorax ECG checked to exclude ischaemia / arrhythmias If HR >120, arrhythmia, or known cardiomyopathy attach patient to cardiac monitor.

Bloods taken (do not delay NIV initiation waiting for blood results)

YES YES

YES

NO NO

NO

ABG analysis

Does the patient have COPD, obesity or neuro-muscular disease? Is there a respiratory acidosis (i.e. pH <7.35, PaCO2 >6.5)?

OR Obesity and daytime PaCO2 >6 with drowsiness/reduced GCS? Neuromuscular disease, RR>20 with respiratory illness and usual VC <1L.

YES YES YES YES

NO NO NO NO

Name Trust ID DoB (Attach patient sticker)



FOR COPD patients: Is the patient on maximal medical therapy ?

Controlled oxygen via venturi mask (aim SpO2 88-92%)

Salbutamol Nebulisers 2.5mg

Atrovent nebulisers 500mcg (max 6 hourly)

Nebulisers given by air driven device

Steroids

Consider antibiotics (see anti-microbial formulary)

IV bronchodilators if indicated

YES YES YES YES YES YES YES

NO NO NO NO NO NO NO

Absolute Contraindications

Severe facial deformity, Facial or upper airway burns, Fixed upper airway obstruction – if YES, stop and seek senior clinician.

YES

NO

Relative Contraindications

metabolic acidosis, untreated pneumothorax, recent upper GI or craniofacial surgery, vomiting / aspiration risk (consider NGT), bowel obstruction, pH <7.15 (pH<7.25 and additional adverse feature), GCS <8, Confusion/ agitation, Cognitive impairment

– if YES to any of the above, STOP and seek senior clinician.

YES

NO

Are there any indications for ICU input?

AHRF with impending respiratory arrest Patient requiring IV sedation or need for closer monitoring. Possible difficult intubation as in OHS, NMD.

Refer to ICU (RSCH bleep 8413, PRH bleep 6010) Or if required 2222 for “anaesthetic emergency”

YES YES YES

NO NO NO

Consent

Does the patient have the mental capacity to provide consent for this procedure? Refer to Mental Capacity Act 2005 If YES, has the patient provided consent to commence NIV? If the patient does not have capacity to consent to NIV therapy consideration has to be given to whether this is a transient or permanent loss of mental capacity and what is the likely outcome from NIV support (i.e. improvement or intubation / invasive ventilation or NIV as ceiling of treatment).

Capacity assessment and best interest decision if lacking capacity

must be clearly documented in the patients’ health records Implementation of NIV should only then occur if there is expectation of survival to a reasonable level of independence consistent with what the patient’s previous expectations are understood to have been. Such expectations need to be considered with input from relatives, carers and friends.

Senior opinion is advisable in this situation.

State outcome of discussion:

YES YES

NO NO



Step 2: Management and escalation plan Management and escalation plan

If no contraindications to NIV – Has the patient been referred to the on –call medical SpR / Consultant Physician? If YES, with whom?....................................................

YES

NO

Escalation plan

Has a decision been made and documented about escalation of treatment if NIV fails? Is the patient for intubation if required? All patients requiring NIV must be discussed with ICU and the escalation plan agreed with ICU. If not accepted for ICU/HDU admission give rationale in patient health records

YES YES YES

NO NO NO

Resuscitation status FR DNACPR

Step 3: Communication Clinical handover to respiratory team & Critical Care Outreach Team All patients on NIV must be discussed with the respiratory team as soon as possible

Respiratory SpR - during daytime hours

RSCH bleep 8398 / 8060 PRH bleep 6048

Date / time respiratory team contacted :

RSCH daytime:

Critical Care Outreach bleep 8495

RSCH Out of hours:

Clinical Site Team bleep 8152 PRH 24/7:

Critical Care Outreach bleep 6331

Date & Time contacted:

Signature of doctor completing initiation of NIV pathway: ………………………………………………



Step 4: Set up of NIV Initiate NIV (BiPAP)

Position patient upright (use profiling bed to optimise position)

Ensure correct machine tubing (disposable, passive) selected, check filter and exhalation valve present.

Assess facial vented mask size (large, medium or small) – using package to measure patient’s face for correct mask fitting

Protect nasal bridge with duoderm (or equivalent ) as appropriate

The machine MUST be turned on and set up before attaching to patient

Use S/T mode for BiPAP. (See set up and troubleshooting guide on machine).

Set Back up respiratory rate (‘breath rate’) - minimum 10

Connect mask to patient, aim leak 25-40.

Increase IPAP in 2-3 cmH2O increments within the first 10-30 minutes to achieve target (see below).

Monitor SpO2 continuously; titrate FiO2 to achieve SpO2 88-92%

After 1 hour - Check ABG and 1 hour after any changes to settings (or earlier if clinically indicated) For subsequent samples consider using capillary blood gas samples. If ABG analysis is required more frequently consider referral to HDU to facilitate arterial line insertion.

Adjust IPAP to control PaCO2 (increase IPAP to reduce CO2 – max IPAP 30)

Adjust Oxygen to maintain SpO2 in range of 88-92 %

Avoid changing EPAP unless senior advice sought Red Flags – if present consider ICU review if appropriate.

pH<7.25 on optimal BiPAP settings RR persisting > 25

New onset confusion or patient distress Requiring EPAP > 6 Timed breaths (patient not spontaneously breathing)

Actions Check synchronisation, mask fit, exhalation port:

- give physiotherapy, bronchodilators, consider anxiolytic.



Blood gas trends (Arterial / Capillary)

Base-line

1 hour post NIV set up

Subsequent trends, consider using capillary samples.

ABG/CBG ABG ABG

Date

Time

pH

PaO2

PaCO2

HCO3

Base Excess

Oxygen Setting (%)

SpO2

IPAP Setting

EPAP Setting

Resp rate

Step 5: Monitoring and weaning of NIV Frequency of documented observations on initiation of NIV:

First hour – every 15 minutes 1- 4 hours- every 30 minutes 4- 12 hours – hourly.

Including respiratory rate, pulse oximetry, heart rate, level of consciousness, chest wall movement, ventilator synchrony, accessory muscle use and comfort. Other observations; BP, HR, Temperature, RR, oxygen saturations should be recorded on the BSUH NEWS2 chart.

NIV weaning guide Patients should be encouraged to use NIV as much as possible (i.e. 24 hours) initially. As blood gases improve this may be reduced. E.g. 2 hours off in the morning and evening one day, 4 hours off in the morning and evening the next, all day off the next day. During initial weaning the patient should have NIV continuously overnight If the patient requires oxygen whilst off NIV this should be administered via nasal specs or controlled venturi device according to target saturations.



Monitoring and weaning of NIV therapy

Day 0 : Date Medical review and plan:

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

IPAP

EPAP

Oxygen %

RR

MV (est)

TV (est)

Back up rate

Leak

Rise time

NIV Break

Oral care

Time

Nursing evaluation of NIV therapy

Time BiPAP initiated …..:…...

increase settings over 10-30 mins to IPAP 20-30, EPAP 4.

ABG due after 1 hour: ……:…..

Action Nurse to Sign & date/time every time BiPAP applied

Visually inspect circuit

Check settings

Check alarms

BiPAP prescribed

Air inlet filter change due: (every 6 months)

Clean weekly date:



01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

IPAP

EPAP

Oxygen %

RR

MV (est)

TV (est)

Back up rate

Leak

Rise time

NIV Break

Oral care

Time




Check settings

Check alarms

BiPAP prescribed


Clean weekly date:



01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

IPAP

EPAP

Oxygen %

RR

MV (est)

TV (est)

Back up rate

Leak

Rise time

NIV Break

Oral care

Time


Add additional pages as required



Check settings

Check alarms

BiPAP prescribed


Clean weekly date:

Appendix 3: NIV audit proforma – To be completed annually by respiratory team

Appendix 4 NIV Set up and Troubleshooting guide

TRILOGY BiPAP machine set-up - Checklist *BiPAP device should be visually inspected and all settings

checked before connecting patient to BiPAP*

Plug in (battery on charge). – KEEP ON CHARGE EVEN WHEN NOT IN USE. Check O2 connection. Switch on – check internal battery. Connect BiPAP hose (disposable adult passive circuit - REF 9624C; or Intersurgical 5804000)

Check Bacterial Filter attached (REF 1944000) (attach to machine, furthest from patient) Check expiration port present (nearest to patient)

Power Off : Use the RIGHT button to select ‘Yes’ ‘100% Oxygen’: This is to give a BOLUS of 100% Oxygen, this is not usually required to use for nurses using BiPAP on ward patients. ‘Leak’: Leak should be between 20-35L/min. A leak of <15L/min may mean the mask is unnecessarily tight, a leak of >50L/min may cause inefficient ventilation.

Settings and Alarms: Confirm settings and alarms before connecting patient.

Select MODIFY to change settings (The settings from the previous use will be saved unless the machine is ‘Reset’) Under MENU. Use DOWN button to highlight SETTINGS AND ALARMS. Use the RIGHT button to select.

Setting: Initial value Comments

Dual Prescription

OFF

Dual Prescription allows separate day and night prescriptions for the patient, not used acutely.

Mode

S/T Spontaneous and timed. Display shows ‘Passive S/T’

AVAPS OFF Average volume assured pressure support – not used for BiPAP.

IPAP Start at 15 Aim 20. Increase if pCO2 not falling. Increase by 2 up to max 30.

EPAP start at 4

Can increase - Senior review required.

Breath Rate

10 Only for backup breaths, if patient is not triggering.

Inspiratory time

e.g. 1.5 (Minimum 1 sec)

Only for backup breaths, if patient is not triggering.

FiO2

21 – 100 % As required

Aim target sats (usually 88-92%) Start at venturi mask requirement prior to BiPAP starting (e.g. 35%)

Trigger Type

Auto-trak Can be adjusted for complex patients, needs senior review.

Set Rise Time

3 Measured in 0.1 sec (i.e. 3 = 0.3 sec)

Ramp length

OFF - 45 min Increases IPAP over time set, may improve compliance with BiPAP

Nebulizer enabled

OFF It is not advised to use oxygen or air driven nebulisers within the BiPAP circuit. Only specialist aerosol driven nebs (e.g. aeroneb in critical care) can be used within the BiPAP circuit.

Alarm: Suggested value Comments

Circuit disconnect 30 sec

Apnoea 20 sec

Apnoea rate 10 Suggest half the patient’s pre-BiPAP respiratory rate

Low Vte (tidal volume) 200 Depends on patient ideal weight, adjust accordingly

High Vte (tidal volume) 800 Depends on patient ideal weight, adjust accordingly

Low minute volume 4.0 Minute volume = rate x tidal vol.

High minute volume 14.0 Minute volume = rate x tidal vol.

Low respiratory rate 10 Adjust accordingly

High respiratory rate 40 Adjust accordingly

Storage: Keep plugged in and on charge at all times, even when not in use. The batteries will self-discharge if not plugged in even if the machine is not switched on. The Trilogy BiPAP machine may be left plugged in to AC power without battery degradation. The Battery may take up to 8 hours to fully charge once fully discharged. Keep out of direct sunlight and do not store or use next to a heating appliance. Do not block the cooling air vents located on the base and at the rear of the device.

Cleaning:

Do not steam autoclave the device. Do not immerse in liquid or allow liquid into the enclosed device or inlet filter. Do not spray water or other solutions directly onto the device. Do not use abrasive cleaners or harsh detergents. Wipe clean with Clinell wipes between patients and when required during patient use. There is a reusable foam inlet filter to protect the ventilator from dirt and dust. This requires cleaning every week and replacing every 6 months and/or if damaged or visibly soiled.

Other info: The machine and all attachments are latex free. Settings may be completed without the machine starting by pressing and holding the ‘alarm silence’ button and the ‘down’ button for 5 seconds. Keypad lock: this may be used for confused patients to prevent the settings from being altered. In most acute settings the keypad lock should not be required. To lock the keypad, use MENU, select OPTIONS then select KEYPAD LOCK and ON. To unlock the keypad temporarily hold the right button for 5 seconds. To remove the keypad lock, use MENU, select OPTIONS, select KEYPAD LOCK and OFF.

BiPAP Troubleshooting:

Problem Suggestions:

Persistently elevated PaCO2

Is there an excessive mask leak? Check mask fit. Is the circuit set up correctly? Check connections and identify leaks. Is there rebreathing? Check the expiratory port is patent. Is the patient being over oxygenated? Aim sats 88-92% .Especially consider the aim of oxygen therapy during period off NIV. Consider the acceptable level of PaO2 to be aimed for. Consider increase in IPAP (max 30 unless senior review) – look at the Vte (tidal volume) this should be 6-8ml/kg ideal body weight. Is the patient spending sufficient time on BiPAP? Encourage more sustained periods of use (particularly during sleep). Address compliance issues. Consider decrease in EPAP if high level set

(>8cmH2O)

Persistent Apnoea Alarm Check patient, is the patient breathing? Is the patient conscious? CALL FOR HELP IF REQUIRED Check circuit connected. Check mask fitting and leak. Check trigger settings. (auto-Trak should be used.) Check backup rate (breath rate) if this is too high it may be preventing the patient breaths from triggering. Consider reducing the set breath rate (minimum 10 unless senior review).

Mask Leaks Small leaks (20-35L/min) are normal and acceptable but larger leaks (>50L/min) may cause inefficient ventilation, eye irritation, noise, dry mouth and nasal symptoms. Leaks <15L/min may mean the mask is too tight and may reduce compliance with BiPAP. Be prepared to try different mask types Use duoderm on nasal bridge for comfort and to protect skin against pressure damage. Consider facial hair. Consider position of NG tube

Asynchrony between patient and ventilator

Check correct tubing (disposable passive) is used in the circuit. The tubing should have a smooth interior to allow air flow to be detected accurately If the patient’s respiratory effort is inadequate the machine may not sense inspiration. An increase in EPAP may help. If the patient is very tachypnoeic increasing the IPAP may help: ensure rise time is as quick as possible (1).

Keypad Lock

To lock the keypad, use MENU, select OPTIONS then select KEYPAD LOCK and ON. To temporarily unlock the keypad on trilogy machine, hold the Right button for 5 seconds. An alarm noise indicates when the keypad is successfully unlocked.

Keypad Lock continued. The keypad will lock again after 30 seconds of inactivity. To remove the keypad lock, use MENU, select OPTIONS, select KEYPAD LOCK and OFF.

Hypocapnia / alkalosis Minute ventilation (MV) is too high. Reduce IPAP to reduce Tidal Volumes (Vte). Is BIPAP still required?

Difficulty inflating the chest

Poor expansion of the chest and desaturation may be due to bronchospasm, mucous plugging, pneumothorax, atelectasis / collapse, consolidation, pulmonary oedema or rarely circuit tube obstruction/ kinking. Clinical examination is required. Chest X-ray may be required.

Nasal problems Nasal redness / nasal bridge sores- Appropriate padding or change of mask may be necessary. Rhinitis / nasal crusting / bleeding- Ask about nasal symptoms.

Dry mouth Regular mouth care is essential; consider saline nebs during breaks from BiPAP. Consider humidified circuit – requires a different circuit, contact ICU or CCOT.

Gastric distension Check for abdominal pain or distension occurring during NIV Try to reduce IPAP if possible Consider nasogastric tube with a nasogastric tube guard accepting a small leak will occur. Small leaks should not cause a problem (20-35L/min) Consider anti-emetics.

Persistent hypoxaemia Check correct FiO2 setting on machine. If there is a definite OSA or atelectasis then increasing EPAP may help (remembering to increase IPAP by same level to maintain the same pressure support) Deteriorating clinical condition in the presence of hypoxaemia should lead to an urgent review of the

patient and consideration of intubation and mechanical ventilation. CONTACT ITU

Patient position The patient should be positioned upright with their head up Consider additional support if necessary (pillows, soft collar, rolled up towel)

Patient discomfort / poor compliance with BiPAP Patient discomfort / poor compliance with BiPAP continued.

Consider using the RAMP when starting – this will gradually increase the IPAP and may make BiPAP more tolerable. (e.g. 20 mins ramp to achieve target IPAP). Consider reducing the IPAP, if appropriate, discuss with senior nurse/doctor. Consider loosening the mask, aim for leak 20-35L/min. Allow regular comfort breaks, mouth care. Reposition patient. Consider mask size. Make sure the patient is properly fitted with the correct size mask. Use mask packaging to size patient.

Non co-operation / aggressive behaviour

Assess for patient agitation, confusion and not maintaining mask ventilation This may be due to hypoxaemia or hypercapnia. Ensure constant supervision as it may be necessary to hold the mask in place initially until ABG’s have corrected themselves before the agitation / confused state settles. This may be lifesaving. Relatives may also be helpful to calm the patient. SEDATION MUST BE AVOIDED WITHOUT SENIOR MEDICAL OR ANAESTHETIC INPUT. Haloperidol may be useful to decrease agitation and facilitate tolerance of NIV therapy. Avoid benzodiazepines.

IPAP not achieved If the measured IPAP is lower than the set IPAP by >0.5cmH2O (e.g. IPAP set at 18 but measured IPAP is showing as 17.4) consider changing the Rise Time to a lower setting. E.g. reducing from 3 to 2. Allowing a faster flow during inspiration.

Low Vte alarm Low estimated tidal volume, check alarm settings, Aim Vte (ml) = 6 – 8 x ideal body weight (kg) E.g. for 60kg ideal body weight, aim Vte 360-480ml. Check leak. Consider increasing IPAP (maximum 30 – unless senior review). Patients with OSA may tolerate higher IPAP.

High Vte alarm High estimated tidal volume, check alarm settings, Aim Vte (ml) = 6 – 8 x ideal body weight (kg) E.g. for 60kg ideal body weight, aim Vte 360-480ml. Consider decreasing IPAP (minimum 15 – unless senior review).

The Device does not turn on.

Chest AC power cord is plugged in and internal battery is charged. Contact EME if the device still does not switch on. Note: The device requires AC power to charge the internal battery. Keep plugged in even when not in use.

For issues with the machine please contact ward manager and EME.

For clinical issues using BiPAP please contact:

Respiratory SpR (daytime)- RSCH bleep 8398 / 8060. PRH bleep 6048.

Critical Care Outreach Team – RSCH (07:30-20:00) bleep 8495.

PRH (24/7)bleep 6331.

Clinical Site Team - RSCH bleep 8284. PRH bleep 6014.

Appendix 5: NIV competency Non Invasive Ventilation (NIV) competency Guidance for practice and assessment of NIV management

Nurses who work within a clinical setting which delivers NIV (BIPAP) therapy and who have identified this as a learning and developmental need should attend a NIV workshop/ undertake reading around the topic and consult the Critical Care Outreach Intranet site and practice with an experienced nurse, to develop theoretical understanding and practical skills of this therapy is recommended.

This competency is detailed, but can be assessed over a period of time, ideally within a one month time period from the delivery of teaching

Assessments for this competency can be completed by: NIV link nurses, Ward Leader, Critical Care Outreach Team (CCOT) or Practice Educators.

Ideally, practical elements of the assessment should involve at least two patients to reflect the diverse needs of those patients receiving this therapy

No. Key skills Assessment criteria Mentor’s signature

Nurse’s signature

Date achieved

1. Demonstrates an understanding of the anatomy and physiology of the respiratory system

Identify the main structures of the respiratory system. Discuss the position of these structures in relation to their function. Discuss the mechanics of normal breathing by negative pressure and explain how this changes with positive pressure therapy

Discuss the process of oxygen delivery Identify the difference between respiratory failure patients; hypoxic (type 1) & acute hypercapnic with acidosis (type 2) Discuss why some patients may be ‘oxygen sensitive’ and target sats.

2. Identify the contraindications for NIV (BiPAP)

Absolute

Patient declines treatment

Facial burns / trauma / recent facial or upper airway surgery

Fixed upper airway obstruction Relative

Undrained pneumothorax

Haemodynamically unstable (may require critical care unit)

Severe co-morbidity

Inability to protect airway

Copious respiratory secretions

Upper gastrointestinal surgery

Vomiting (NG tube can be considered )

Confusion / agitation

Bowel obstruction

3. Correctly assemble and prepare the equipment

Ensures the BiPAP machine is turned on and plugged in. Check and change filters Hose with HME filter attached Check exhalation valve Identify how to measure a patient for the correct sized mask Attach hose to mask Identify exhalation point on hose Check for mask leaks Ensures the mask is functioning correctly Demonstrate how to change BIPAP settings

4. Explain what is needed prior to starting NIV therapy, check capacity, check consent and check for medical escalation plan

Doctor has prescribed the therapy and there is a recorded medical plan for the patient in the medical notes Discusses issue of consent / does the patient have capacity? Preparation and explanation to the patient as required Doctor has prescribed oxygen Ensure Chest XRAY is ordered and reviewed by the doctor prior to commencing therapy, to rule out a Pneumothorax Ensure the patient has received maximum medical treatment prior to commencing BiPAP therapy (i.e. nebs, steroids, antibiotics as required)

5. Provide an explanation to the patient and to the next of kin

Explain step by step setting up and implementation of BiPAP, attaching mask and how it is going to feel for the patient. Explain time on machine at first and then plan time for breaks with patient Consider communication aids/call bell in reach/reassurance.

6. Explain and implement the safety measure required for BiPAP

Monitoring of patient Suction equipment checked and functioning Oxygen therapy prescription and administration No clutter around bed Understanding of machine alarms, i.e. battery failure, apnoea, etc.

7. Demonstrate the ability to commence the treatment (on a patient) and plan within the first hour, with underpinning rationale for actions

Discusses their understanding of acute hypercapnic with acidosis (type 2) respiratory failure Demonstrates an understanding of IPAP settings Demonstrates an Understanding of EPAP settings Explains the importance of pressure support and what it is Demonstrates how to set the IPAP and increase it to the optimum setting within 10-30 minutes Understands the link between EPAP, IPAP and tidal volume (TV) Demonstrates how to monitor the patient

Demonstrates how to monitor breathing pattern, respiratory rate and oxygen saturations Discuss how these observation alter in respiratory failure Takes and records the patients NEWS2 score accurately Explains the aim of BiPAP management within the first hour Demonstrates how to entrain prescribed oxygen

8. Accurately record the treatment of the patient, changes in the patient’s condition and maintains appropriate documentation throughout the patient’ treatment

Demonstrates how to use the NEWS2 Scoring system and when to escalate findings for urgent assistance Demonstrates how to record blood gas and BiPAP readings accurately Demonstrate the ability to evaluate the care given and patient’s progress Assess the effectiveness of the respiratory support delivered Clear legible timely documentation in line with NMC guidelines

9. Demonstrate the ability to assess, understand and discuss the indicators of successful therapy and indicators which suggest the therapy not to be improving the patients’ condition. Can explain the rationale for their actions/changes e.g. in settings

Discuss normal blood values and how they alter in respiratory failure Demonstrate the ability to evaluate the care delivered and patients’ progress Assess the effectiveness of respiratory support (BiPAP settings, ABG results and patient assessment).

10. Ensure medication is administered to the patient receiving BiPAP therapy and discuss actions to take if the patient desaturates on mask removal.

Demonstrate an understanding of adjunct therapies, i.e. actions of:- Nebulised Broncho-dilators and how to administer them successfully when the patient receiving this therapy Use of steroids Use of antibiotics Demonstrates ability to use an air compressor for nebulising salbutamol and ipatropium

11. Hydration & fluid balance Explain implementation of a plan, ensuring patient receives adequate hydration and Nutrition whilst receiving BIPAP therapy Facilitates patient breaks for drinks, drugs, physiotherapy, meals etc. Explain how to implement a plan for recording the patients’ fluid input and documenting their output, discussing the significance of this

12. Weaning

Identifies what factors indicate the patient to be ready for weaning off this supportive therapy

Assess suitability for weaning – i.e. patient improving or consideration of stopping NIV treatment. Recognises each patient should be assessed on an individual basis regarding their suitability for weaning from BiPAP. Explains principles of weaning ; increased periods off NIV, monitor for any signs of exacerbated work of breathing (increased respiratory rate / decreased oxygen saturation, increased use of accessory muscles) Understand why patient should continue to receive NIV therapy overnight

during the weaning period *Re-check ABG, prior to discharge.

13. List the potential complications and limitation of NIV therapy

Non Compliance / poor tolerance (discussed interventions to assist the patient in this circumstance Excessive sputum Patient coming to the end of their life – focus of care to change.

14. Decontamination Can discuss process for device decontamination following use

Can discuss what would indicate that a filter requires changing when a patient is receiving this therapy (if damaged, soiled, or every 7 days and between patients) BSUH policy on infection control decontamination Cleaning of machine Demonstrates how filters are removed and cleaned (as appropriate) Machine to be connected to power supply to recharge or switched off at rear of machine to preserve battery supply.

Appendix 6 – NIV consumables

Item NHS code

Vented Mask (single)

Performatrak S (small)

Performatrak M (medium)

Performatrak L (large)

FDD611

FDD613

FDD614

Tubing :

Intersurgical 22mm smooth bore bilevel breathing system with swivel CO2 leak port

OR Respironics Breathing Circuit

size 1.8m- 19mm (with bacterial filter)

5804000

REF 9624

Filter:

intersurgical filta-guard bacterial filter

1944000

Appendix 7a: Due Regard Assessment Summary

Yes/No Comments

1. Does the document/guidance affect one

group less or more favourably than another

on the basis of:

Age No

Disability No

Gender No

Gender identity No

Marriage and civil partnership No

Pregnancy and maternity No

Race No

Religion or belief No

Sexual orientation, including lesbian, gay

and bisexual people

No

2. Is there any evidence that some groups are

affected differently and what is/are the

evidence source(s)?

No

3. If you have identified potential

discrimination, are there any exceptions

valid, legal and/or justifiable?

N/A

4. Is the impact of the document/guidance

likely to be negative?

No

5. If so, can the impact be avoided? N/A

6. What alternative is there to achieving the

document/guidance without the impact?

N/A

7. Can we reduce the impact by taking

different action and, if not, what, if any, are

the reasons why the policy should continue

in its current form?

N/A

8. Has the policy/guidance been assessed in

terms of Human Rights to ensure service

users, carers and staff are treated in line

with the FREDA principles (fairness,

respect, equality, dignity and autonomy)

No

If you have identified a potential discriminatory impact of this policy, please refer it to the author together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Barbara Harris, Head of Equality, Diversity and Inclusion.

Appendix 7b: Dissemination, Implementation and Access Plan

To be completed and attached to any policy when submitted to Corporate Governance for consideration and TEC approval.

Dissemination Plan Comments

1. Identify:

Which members of staff or staff groups

will be affected by this policy?

All medical and nursing staff

How will you confirm that they have

received the policy and understood its

implications?

Available on intranet

How have you linked the dissemination

of the policy with induction training,

continuous professional development

and clinical supervision as appropriate?

Yes

2. How and where will staff access the

document (at operational level)?

Hospital Intranet and black book

Yes/No Comments

3. Have you made any plans to remove old

versions of the policy or related documents

from circulation?

Yes Plan to remove old policy

4. Have you ensured staff are aware the

document is logged on the organisation’s

register?

Yes It will be logged

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