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 PneumothoraxECG checked to exclude ischaemia / arrhythmiasIf HR >120, arrhythmia, or known cardiomyopathy attach patient to cardiac monitor.Bloods taken (do not delay NIV initiation waiting for blood results)

YESYES

YES

NONO

NO

ABG analysisDoes the patient have COPD, obesity or neuro-muscular disease?

Is there a respiratory acidosis (i.e. pH <7.35, PaCO2 >6.5)?ORObesity and daytime PaCO2 >6 with drowsiness/reduced GCS?Neuromuscular disease, RR>20 with respiratory illness and usual VC <1L.

YES

YES

YESYES

NO

NO

NONO

Name Trust IDDoB

(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

YESYESYESYESYESYESYES

NONONONONONONO

Absolute ContraindicationsSevere facial deformity, Facial or upper airway burns, Fixed upper airwayobstruction – if YES, stop and seek senior clinician.

YES NO

Relative Contraindicationsmetabolic 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 arrestPatient 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”

YESYESYES

NONONO

ConsentDoes the patient have the mental capacity to provide consent for this procedure? Refer to Mental Capacity Act 2005If 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 planIf no contraindications to NIV –

Has the patient been referred to the on –call medical SpR / Consultant Physician?If YES, with whom?....................................................

YES NO

Escalation planHas 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 possibleRespiratory SpR - during daytime hoursRSCH bleep 8398 / 8060PRH bleep 6048

Date / time respiratory team contacted :

RSCH daytime:Critical Care Outreach bleep 8495RSCH Out of hours:Clinical Site Team bleep 8152PRH 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 postNIV set up Subsequent trends, consider using capillary samples.

ABG/CBG ABG ABG

DateTimepH

PaO2

PaCO2

HCO3

BaseExcessOxygen Setting (%)SpO2

IPAP SettingEPAPSettingResprate

Step 5: Monitoring and weaning of NIV

Frequency of documented observations on initiation of NIV: First hour – every 15 minutes1- 4 hours- every 30 minutes4- 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 guidePatients 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 Action Nurse to Sign & date/time every time BiPAP

appliedVisually inspect circuit

Check settings

Check alarms

BiPAP prescribed

Air inlet filter change due: (every 6 months)

Clean weekly date:

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 rateLeak

Rise time

NIV BreakOral 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: ……:…..

Monitoring and weaning of NIV therapy

Day 1 : 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 rateLeak

Rise time

NIV BreakOral care

Time Nursing evaluation of NIV therapy

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:

Monitoring and weaning of NIV therapy

Day 2 : 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 rateLeak

Rise time

NIV BreakOral care

Time Nursing evaluation of NIV therapy

Add additional pages as required

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: