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CLINICAL GUIDELINE Document No:

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TITLE

TITLE Clinical Guidelines for Non-Invasive Ventilation (NIV) in Acute Respiratory Failure

Version: Version 2 (July 2012)

Approved by: Clinical Standards Sub Group Date:

Author/lead responsible for guideline:

Dr Steve Chay / Dr Isabel Gonzalez (Critical Care Services) On behalf of the NIV group

Date issued: July 2012 Review date: July 2014 Target audience: All staff Amendments and Additions

Update evidence base and references Modified algorithms Added appendices

Replaces/supersedes: Previous version Associated Policies: Nil Equality Impact Assessment Y/N Date: Yes 13th July 2012

Clinical guidelines for non-invasive ventilation in acute respiratory failure

Dr Stephen Chay, Critical Care Services, on behalf of NIV Working Group, South Tees Hospitals Foundation Trust, July 2012. Review date: 24 months.

1

Division of Acute Medicine

Clinical Guidelines for Non-Invasive Ventilation in

Acute Respiratory Failure.

Summary: Non-invasive ventilation (NIV) is increasingly being considered as a treatment

option in acute respiratory failure. This guideline reviews some of the common

clinical conditions where NIV may be considered. The evidence (or lack of) for

the use of NIV under such circumstances is discussed. Some of the

contraindications to NIV are discussed. A series of simple flow diagrams are

introduced to guide clinical carers in the use of NIV. A similar series of flow

diagrams are also introduced to help carers wean their patients from NIV.



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Introduction Non-invasive ventilation (NIV) is an increasingly popular treatment option in

varied clinical situations in patients presenting with acute respiratory failure

(Caples & Gay 2005). NIV differentiates itself from other techniques which

bypass the upper airway with a tracheal tube, laryngeal mask or tracheostomy

– the invasive forms of ventilation. The advantages of NIV relate to the

disadvantages of invasive ventilation – the potential for upper airway trauma,

ventilator-associated pneumonia, impaired speech and swallowing and the

relatively high costs and resource utilisation. NIV should complement the use

of invasive ventilation and should not be regarded as its replacement. Careful

patient selection and regular, well-timed bedside clinical assessments are

keys to success. Failure of NIV should be recognised early as it can only

delay more definitive therapy with invasive ventilation.

Definitions Respiratory failure is defined as a failure to maintain adequate gas exchange.

This manifests itself as abnormalities in arterial blood gas tensions. Type 1

failure is defined by a PaO2 <8 kPa and a normal or low PaCO2. Type 2 failure

is defined by a PaO2 <8 kPa and a PaCO2 >6 kPa (BTS 2002).

In acute hypercapnic respiratory failure, the arterial blood gas tensions will

show a high PaCO2, low pH (pH < 7.35) and normal bicarbonate levels.

In chronic hypercapnic respiratory failure, the arterial blood gas tensions will

show a high PaCO2, normal pH (pH 7.35 – 7.45) and high bicarbonate levels.

In acute-on-chronic hypercapnic respiratory failure, the arterial blood gas

tensions will show a high PaCO2, low pH (pH < 7.35) and high bicarbonate

levels.

Therefore, in clinical use, it is usually the low pH and not an elevated PaCO2 that determines the presence of acute respiratory failure and the

need to consider NIV. An understanding of arterial blood gases is vital to the

provision and management of patients with respect to NIV.



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Non-invasive ventilation is defined as respiratory support delivered via a non-

invasive interface – this is typically a face mask or nasal mask. However,

other less common interfaces may be deployed e.g. nasal plugs/pillows, oral

mouthpieces and full head helmets. Respiratory support may be delivered

using continuous positive airway pressure (CPAP) devices or those that

deliver bi-level positive airway pressure (BiPAP§). For the purposes of this

document and for simplicity we will be using the acronym NIV for both CPAP

and BiPAP, and the acronym BiPAP for bilevel positive pressure ventilation.

We recognised that CPAP is a mode of respiratory support rather than pure

ventilation.

CPAP is often likened to breathing with your head stuck out of a moving car. It

aims to deliver a continuous, single positive pressure throughout both the

inspiratory and expiratory phases of breathing. It improves oxygenation by

opening up collapsed airways, improving functional residual capacity (FRC)

and improving preload and afterload in cardiogenic pulmonary oedema

(Bersten et al 1991, Lin et al 1995). CPAP may also help by reducing the

efforts required for breathing by improving lung compliance by preventing

alveolar collapse (liken to the fact that to blow up a balloon that is already

partially inflated is easier than a balloon that is collapsed) and by

counteracting against the excessive intrinsic PEEP (positive end expiratory

pressure) seen in obstructive lung conditions such as chronic obstructive

pulmonary disease (COPD) (BTS 2002).

BiPAP (BTS 2002) aims to deliver two levels of positive airway pressure

support. The lower level is similar to CPAP although it is more commonly

called expiratory positive airway pressure (EPAP or PEEP, depending on

equipment) as it is present only at the expiratory phase of breathing. The

higher level of pressure is present at inspiration and is called the inspiratory

positive airway pressure (IPAP or Pinsp, depending on equipment). This higher

level of pressure is triggered when the machine senses the patient’s

inspiratory effort and aims to assist inspiration. The size of the breath (tidal

volume) generated in a particular patient is dependent on the difference

between EPAP and IPAP settings – the larger the difference between EPAP

§ BiPAP (small i) is a registered trademark of Respironics, Inc. Some of the current bi-level ventilators in use at South Tees Hospitals NHS Trust are from Respironics™. The term BiPAP is used in this document to describe bi-level positive pressure ventilation. This is not an endorsement of Respironics bi-level ventilators over similar products made by other manufacturers. Please also notice that BIPAP (capital I) is a registered trademark of Draeger™ ventilators.



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and IPAP settings, the larger the pressure difference between expiration and

inspiration, resulting in a larger breath. In spontaneous mode (S Mode in

Respironics™), the cycling from IPAP to EPAP and back to IPAP is under total

patient control and is synchronised with the patient’s own inspiratory and

expiratory cycles. In timed mode (T Mode in Respironics™), the cycling from

the different pressure levels is independent of the patient and is dependent on

the number of breaths set. The two modes may be combined (S/T Mode in

Respironics™) where the patient’s breathing is ventilator-assisted (S Mode) –

if the patient does not breath a set minimum number of breaths per minute,

the ventilator will supply those additional breaths (T Mode). It is envisage that

the S/T Mode will be the appropriate mode of ventilation under most clinical

circumstances. Depending which ventilator make is in use spontaneous, timed

and spontaneous/time mode may have different names, please refer to the

instructions of the equipment in use and ensure staff using the equipment has

been trained for its use.

Indications The indications for NIV depend upon the goals of therapy in the patients

presenting with acute respiratory failure. These may be improving gas

exchange resulting in enhanced oxygenation, better carbon dioxide

elimination and normalising acidaemia; reducing cardiac workload and

improving haemodynamics; unloading respiratory muscles, thereby

decreasing respiratory rate and improving patient comfort and avoidance of

invasive ventilation (BTS 2002). NIV may be used:

1. As an early intervention to assist ventilation in order to prevent the

development of acute respiratory failure. This is usually at an earlier

stage than that at which invasive ventilation would be considered.

2. As a trial with a view to tracheal intubation if NIV fails.

3. As the maximum ceiling of treatment in patients deemed inappropriate

for tracheal intubation.



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A decision about intubation must be made in all patients commenced on NIV.

If at all possible, this must involve a discussion between the clinician and the

patient. This should be done early, ideally prior to starting NIV, but may be

delayed to allow for consultations with relatives, carers and other health

professionals. In practice, the delay should be no longer than 4 hours in most

cases (BTS 2008). The decision should be made by an appropriately

experienced clinician and agreed upon by all the patient’s carers. The

decision regarding intubation may be reviewed as necessary and changed if

appropriate.

The “do not attempt resuscitation” (DNAR) status is a different issue

altogether and a decision regarding the DNAR status of a patient must be

made separate to that of the intubation status. A DNAR order does not

necessarily preclude a trial of NIV.

Best practice is expected in terms of cardiovascular and fluid optimisation,

management of any suspected infection, pain and distress management,

prophylaxis against deep venous thrombosis and the provision of adequate

nutrition.

Patient selection A key to successful NIV is careful stratification, selection and matching of

patients to the most appropriate treatment modality (BTS 2002, Caples 2005).

Acute exacerbations of chronic obstructive pulmonary disease (COPD) This group of patients are the most frequently studied in trials of NIV. When

they present with acute respiratory failure, arterial blood gas analysis shows

an acute respiratory acidosis with a moderate degree of hypoxaemia. There is

good evidence to support the use of BiPAP in this group, particularly in those

whose blood pH is between 7.26 to 7.35, in terms of lowering the rates of

tracheal intubation and subsequent mortality (Bott et al 1993, Brochard et al

1995, Plant et al 2000). Reduction in mortality rates up to 50% have been

reported (Ram et al 2004), with a NNT of approximately 10.



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Guidelines for the management of acute respiratory failure during

exacerbations of COPD endorsed by the British Thoracic Society, The Royal

College of Physicians London and the Intensive Care Society were published

in 2008 (BTS 2008). They suggested that BiPAP should be considered in all

COPD patients with a persisting acidosis after standard medical therapy

(30mg prednisolone, 2.5 – 5 mg nebulised salbutamol, 0.5 mg nebulised

ipratropium, controlled oxygen targeted to maintain SpO2 between 88 – 92%,

antibiotics if indicated) given in the first one hour. Patients with COPD

presenting with acute hypercapnic respiratory failure but with signs of

consolidation on chest radiograph should be considered to be in pneumonia

group (see below) – the benefits of NIV in these patients are considerably less

(Honrubia et al 2005).

There is no good evidence that CPAP is beneficial in this group. The benefits

of BiPAP may have rendered the use of CPAP in this group an irrelevance

(BTS 2002). However, a trial of CPAP may be justified with some patients in

this group when BiPAP is unavailable (Miro et al 1993).

Hypoxaemic respiratory failure/pneumonia (non-COPD) Historically, this group of patients have been thought to be poorly responsive

to NIV (Wysocki et al 1995, Honrubia et al 2005). However, current evidence

suggests that BiPAP can reduce the rate of tracheal intubation, reduce ICU

stay and increase survival rate (Ferrer et al 2003, Keenan et al 2004). CPAP

is now increasingly being used to support immunocompromised patients with

opportunistic chest infections (Hilbert et al 2001, Confalonieri et al 2002). In

this situation, CPAP can improve oxygenation, reduce respiratory rate and

lessen dyspnoea. Therefore, a trial of NIV may be warranted in the patient

with single organ (respiratory) failure (Antonelli M et al 1998, Caples & Gay

2005). Possibly more than the others, this group of patients needs to be

monitored closely for failure of treatment as continuing hypoxaemia can lead

to rapid cardiovascular collapse and arrest. If the patient is considered

appropriate for tracheal intubation in the event failure of NIV, then the ideal

environment to care for such a patient should be one that can facilitate this



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treatment (Garpestad & Hill 2005). Tracheal intubation should be considered

in the face of deteriorating hypoxaemia despite NIV, the failure to achieve

acceptable gas exchange indices within 2 hours or if there is instability in

other organ systems. Delay in tracheal intubation can lead to an overall poorer

outcome for the patient (Keenan et al 2004).

Cardiogenic pulmonary oedema CPAP has been associated with a lower intubation rate and a survival benefit

in this group of patients (Bersten et al 1991, Lin et al 1995, Peter et al 2006).

Some trials with BiPAP in patients presenting with acute pulmonary oedema

had shown an excess of acute myocardial infarctions when compared to

CPAP (Mehta et al 1997, Rusterholtz et al 1999) – criticisms have been made

of a compromised randomisation procedure resulting in more patients with

chest pain being allocated to the BiPAP group (Caples & Gay 2005).

Furthermore, the use of BiPAP for the treatment of acute pulmonary oedema

in the accident and emergency department appeared to be associated with

higher hospital mortality when compared with CPAP (Crane et al 2004). A

recent meta-analysis supports the use of both CPAP and BiPAP in reducing

the need for invasive ventilation when compared with standard medical

management. Furthermore, there was no evidence of mortality differences

between CPAP and BiPAP (Peter et al 2006). The recent Three Interventions

in Cardiogenic Pulmonary Oedema (3CPO) Trial (Gray et al 2008) showed no

excess of acute myocardial infarctions in patients receiving BiPAP over

CPAP. Both NIV modalities were equally effective and achieved better results

at 1 hour in dyspnoea scores, heart rate, acidosis and hypercapnia when

compared with standard oxygen therapy. However, there were no differences

in intubation rates and 7-day mortality between the NIV and the standard

oxygen groups. Therefore, in acute cardiogenic pulmonary oedema, NIV may

be used as an adjunct with standard pharmacologic treatment especially in

the presence of severe respiratory distress - CPAP should be the support of

choice and BiPAP should only be used when CPAP fails or in the presence of

acute hypercapnia (BTS 2002, Peter et al 2006).



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Asthma BiPAP has been used successfully to support and reduce the rate of tracheal

intubations in patients admitted with status asthmaticus and acute respiratory

failure (Meduri et al 1996, Soroksky et al 2003). Bronchodilator and anti-

inflammatory treatment must already be optimised (BTS/SIGN 2005).

However, there is little consensus in recommending its routine use in acute

severe asthma. There is also no evidence for the use of CPAP in acute

asthma (BTS 2002). Like hypoxaemic respiratory failure, tracheal intubation

should be considered if there is no rapid improvement in gas exchange

indices with BiPAP (Caples & Gay 2005).

Chest wall deformity/neuromuscular disease There are reports of good outcomes with the use of BiPAP in decompensated

ventilatory failure in this group of patients (Elliott et al 1990). The decision to

use BiPAP will need to take into account pre-existing co-morbidities, the

severity of ventilatory failure and the presence or absence of bulbar

involvement. There is no evidence for the use of CPAP in this group (BTS

2002).

Chest trauma There is some evidence to support the use of CPAP in patients with isolated

chest trauma and mild to moderate hypoxaemia ( Hurst et al 1985, Bollinger &

Van Eden 1990). Therefore, a trial of CPAP may be indicated in patients who

remain hypoxic despite adequate analgesia and high flow oxygen. These

patients must be adequately monitored for the possibility of developing a

pneumothorax with CPAP (BTS 2002).

Postoperative respiratory failure There is evidence that the early use of CPAP for the treatment of hypoxaemic

respiratory failure following uncomplicated abdominal surgery can reduce the

need for tracheal intubation (Squadrone et al 2005). BiPAP has been used

with similar results following lung surgery (Auriant et al 2001).



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Weaning from invasive ventilation The evidence for the use of NIV as an adjunct to facilitate weaning from

invasive mechanical ventilation is conflicting (Hilbert et al 1998, Nava et al

1998, Kilger et al 1999, Keenan et al 2002, Esteban et al 2004). Delays in

reintubation may be responsible for some of the adverse results in some trials

(Keenan et al 2002, Caples & Gay 2005). There is some evidence that

patients intubated following an acute exacerbation of COPD may benefit from

early extubation to NIV (Hilbert et al 1998, Nava et al 1998).

Predictors of outcome of NIV There is no one good objective predictor of NIV success available.

Stratification of patients into the groups as outlined above and careful

matching of patient to treatment modality can improve success rates (Caples

& Gay 2005). Predictors of success include those with mild to moderate

hypercapnia and acidaemia (pH 7.25 – 7.35) with mild hypoxaemia, a good

level of consciousness and rapid improvements (<2 hours) to physiological

parameters following the start of NIV (BTS 2002, Mehta & Hill 2001). Factors

associated with a poorer response to NIV includes the more severely sick

patient, the presence of pneumonia on chest radiograph, poor conscious level

(Glasgow coma score <11), respiratory rate >30 breaths per minute, copious

respiratory secretions, poor nutritional status and poor fitting of the face mask

(Ambrosino et al 1995, BTS 2002, Confalonieri et al 2005). Defining the goals

of NIV at the start can help target treatment and can also identify the patient in

whom NIV is failing so that more definitive treatment such as invasive

ventilation can be considered (Caples & Gay 2005).

Contraindications to NIV The clinical conditions for which NIV is being used continue to increase. There

are no absolute contraindications to the use of NIV (BTS 2002) but there are

some conditions where the use of invasive ventilation may be preferable.



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Invasive respiratory support may be preferable in:

• Recent facial trauma/burns including recent extensive facial surgery

where the fitting of the interface may be compromised, painful or

compromise the underlying surgery.

• Recent base of skull fracture with continuing CSF rhinorrhoea.

Although not contraindicated, careful consideration of the risk-benefit ratio

must be taken in the following conditions prior to starting NIV. In patients for

whom invasive intubation are deemed inappropriate, then NIV may be

suitable in spite of the presence of these problems.

• Recent upper airway or gastrointestinal tract surgery.

• Fixed obstruction of the upper airway.

• Inability to protect the airway.

• Life threatening hypoxaemia.

• Haemodynamic instability.

• Severe co-morbidities.

• Impaired conscious levels.

• Confusion or agitation.

• Vomiting.

• Bowel obstruction.

• Copious secretions.

In the patient with recent upper airway or gastrointestinal (particularly

oesophageal) surgery, the use of NIV must be discussed with the surgical

team involved prior to its commencement.

In patients with a severe respiratory acidosis (pH < 7.2) associated with type 2

respiratory failure, BiPAP may be started in conjunction with the appropriate

medical therapies. If further escalation of support is deemed appropriate in the

event of failure of NIV, then it is recommended that the Intensive Care Unit be

contacted early. Close monitoring and frequent analyses of blood gases are

recommended in the early stages as a failure to show rapid improvements

may be an early sign that NIV may not be ultimately successful.

An undrained pneumothorax by itself is not a contraindication to NIV.



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However, under most circumstances, it would be expected that an intercostal

pleural drain will be inserted before the start of NIV (BTS 2002). In the event

that NIV is started without the prior insertion of an intercostal drain, the patient

must be monitored closely for an expanding pneumothorax and personnel and

equipment must be immediately available should it become necessary to do

so.

Monitoring Clinical monitoring (BTS 2002) is essential and is not replaced by

physiological monitoring. Clinical monitoring should include looking at the

coordination of the patient’s respiratory efforts with the ventilator, the degree

of chest expansion, respiratory rate and its trend, heart rate and its trend,

patient comfort and mental state and a clinical examination of the chest. The

fitting of the chosen interface and the degree of air leak should also be noted.

All patients on NIV should have continuous ECG, automated BP set to

appropriate intervals and continuous pulse oximetry monitoring as a minimum.

The alarm limits for the monitors should be appropriately set. Arterial blood

gas analysis should be performed an hour after the start of NIV – earlier, if

clinically indicated. Arterialised capillary blood gas measurements (Pitkin et al

1994) may be used as a surrogate to arterial blood gas analysis, particularly if

it has been referenced to an earlier arterial blood gas measurement. The use

of an indwelling arterial cannula is not essential but may be more likely in the

HDU/ICU setting.

Treatment failure The conclusion that NIV has failed depends on the objectives set at the start

of the treatment. Some factors to consider when arriving at such a conclusion

may be a general deterioration in the patient’s condition, inability improve the

respiratory failure and normalise oxygenation and carbon dioxide elimination,

intolerance and inability to coordinate respiration with that of the ventilator, the

development of new symptoms or complications and a wish to withdraw

treatment.



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Care must be taken that all the NIV settings and the fitting of the interface are

optimised (BTS 2002). A management plan in the event of NIV failure will

usually have already been made and this should be commenced.

Withdrawal/weaning of NIV One of the advantages of NIV is that breaks can be instituted for meals,

physiotherapy and other activities. In the first 24 hours of treatment, the

patient should be ventilated for as long as possible and for as long as

tolerated (Kramer et al 1995). Thereafter, the decision to wean NIV will be

made based upon the assessment of the general improvements and stability

of the patient’s condition. A good sign is when a patient independently

decides to stop the use of NIV. Generally, weaning of NIV should be in a

stepwise fashion, reducing daytime ventilation before night-time ventilation

(Brown et al 1998), with the rate of withdrawal based upon the preservation of

favourable clinical and physiological parameters such as the patient’s general

condition, respiratory rate, heart rate, mental state and indices of gas

exchange.

In the event that NIV is being withdrawn due to failure to improve and the

patient is deemed unsuitable for further escalation of treatment, then the

stepwise method may be omitted. An assessment of palliative needs must be

made prior to stopping NIV. The decision to start end-of-life care does not

require the withdrawal of NIV – NIV may still be a reasonable component

within the end-of-life care package (Shee & Green 2003). Under such

circumstances, all relevant and involved parties must understand that the

continuation of NIV may prolong the terminal illness. However, usual practice

would be to withdraw NIV and to manage any symptoms of breathlessness

with opiods and benzodiazepines.



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NIV initiation pathway

Optimise/continue medical support. • Controlled oxygen. • Regular and frequent nebulised

bronchodilators – prescribed and administered.

• Steroids if indicated. • Antibiotics if indicated. • Full treatment of cardiac failure

(diuretics, nitrates). • Effective analgesia if indicated.

Assessed by/discussed with experienced/senior doctor or Critical Care. No contraindications to NIV. Agreed management plan in case of NIV failure.

Acute type 2 respiratory failure or

at risk of acute type 2 respiratory failure.

(pH < 7.35, PaO2 < 8 kPa, PaCO2 > 6 kPa)

Acute type 1 respiratory failure or

at risk of acute type 1 respiratory failure

(pH > 7.35, PaO2 < 8 kPa, PaCO2 < 6 kPa)

BiPAP CPAP

Respiratory failure despite optimisation of medical support?

No

Yes



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CPAP pathway

Start CPAP using body weight as a guide:

• < 60 Kg: 5 cm H2O pressure/CPAP valve • 60 – 90 Kg: 7.5 cm H2O pressure/CPAP valve • > 90 Kg: 10 cm H2O pressure/CPAP valve

Appropriate oxygen to maintain SpO2 > 92% (88% - 92% in patients known to be sensitive to oxygen).

Minimum monitoring: • Continuous ECG and pulse oximetry • Automated non-invasive BP • Full EWS observations

Blood gas analysis in 1 hour or earlier if indicated.

Improvements in clinical parameters (e.g. respiratory rate, heart rate, mental state) and/or physiological parameters (blood gas analysis)?

Continue and repeat blood gas

analysis in 2 hours or earlier if indicated.

Type 2 respiratory failure or

at risk of Type 2 respiratory failure (PaO2 < 8 kPa, PaCO2 > 6 kPa)

or patient tiring

Consider BiPAP.

Increase oxygen by 10% and/or CPAP by 2.5 cm H2O increments. • Perform blood gas analysis 1 hour after each

intervention or earlier if indicated. • Inform ICU if CPAP > 10 cm H2O; maximum CPAP

15 cm H2O. • Ask for ICU/experienced help early if requiring

increasing levels of support without improvements.

• Senior help must be sought when maximum support levels are reached.

Yes No

Yes No



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BIPAP pathway

• Commence BiPAP on S/T mode, IPAP 12 cm H2O, EPAP 5 cm H2O, 12 backup breaths, inspiratory time 1.6s, rise time 0.1s.

• Increase IPAP by 2-5 cm H2O every 5-10 minutes, until usual target pressure of 20 cm H2O or a good response is achieved or to limits of patient tolerance.

• Appropriate oxygen to maintain SpO2 > 92% (88% - 92% in patients known to be sensitive to oxygen).

Minimum monitoring: • Continuous ECG and pulse-oximetry • Automated non-invasive BP • Full EWS observations

Blood gas analysis in 1 hour or earlier if indicated.


Continue and repeat blood gas analysis in 2 hours or earlier if indicated.

Check: • Medical therapy optimum & has been given? • Complications (pneumothorax, gastric aspiration)? • Interface fitting well and circuit correctly set up? • Ventilation (chest expansion, minute/tidal volumes)

adequate? • Good synchronisation with ventilator?

Correct and/or treat.


PaCO2 high – increase IPAP by 2 cm H2O increments. Consider increasing respiratory rate. PaO2 low – increase oxygen by 10% or 4L/min increments. Consider increasing EPAP by 2 cm H2O increments – IPAP must be increased by a similar amount. Maximum levels of support are IPAP 28 cm H2O, EPAP 10 cm H2O, 90% oxygen, respiratory rate 20 bpm. • Ask for ICU/experienced help early if requiring increasing levels of support

without improvements. • Senior help must be sought when maximum support levels are reached. • If appropriate, consider intubation early, especially if there are no

improvements after 1-2 hours, continuing deterioration, or persistent hypoxaemia.

Yes No

Yes

No



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CPAP weaning pathway

Pre-conditions: • Primary illness treated or under medical control. • Targets in clinical and physiological parameters (respiratory rate, heart rate,

mental state, blood gas parameters) achieved and stable for ≥ 12 hours. • CPAP ≤ 10 cm H2O pressure/CPAP valve.

Reduce CPAP by 2.5 cm H2O every 4-6 hourly. Minimum CPAP = 5 cm H2O pressure/CPAP valve.

Stable clinical and physiological signs/parameters?

CPAP = 5 cm H2O pressure/CPAP valve for 4-6 hours?


Controlled oxygen via face mask to maintain SpO2 > 92% (88% - 92% in patients known to be sensitive to oxygen).

Stable clinical and physiological signs/parameters for 4-6 hours?

Continue with medical treatment and controlled oxygen.

Increase CPAP by 2.5 – 5 cm H2O pressure/CPAP valve and review pre-conditions.

Restart NIV (see NIV pathway) and review pre-conditions.

Yes

No

Yes

Yes

Yes

No

No

No

Notes: • Some patients may be suitable for weaning even when CPAP > 10 cm H2O – discuss with

experienced doctor/ICU. • The rate of weaning in this pathway is a guide only – some patients can be weaned faster,

others more slowly. • The weaning process may be interrupted overnight in order to promote rest. • Some patients (e.g. with post-operative lung collapse) may continue to require CPAP support

overnight in order to overcome nocturnal hypoventilation. • The PaO2 should not be used as the sole weaning parameter with the Boussignac system as

the delivered oxygen is uncontrolled and typically in excess of 60%. • This pathway is not suitable for patients for whom NIV is being withdrawn and palliative-only

management started. •



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BIPAP weaning pathway

Pre-conditions: • Primary illness treated or under medical control. • Targets in clinical and physiological parameters (respiratory rate, heart rate,

mental state, blood gas parameters) achieved and stable for ≥ 12 hours. • IPAP ≤ 18 cm H2O, EPAP ≤ 8 cm H2O, total respiratory rate ≤ 24 bpm.

Reduce IPAP by 2 cm H2O and EPAP by 2 cm H2O every 4–6 hourly. Reduce rate to 12 bpm. Minimum IPAP = 12 cm H2O, EPAP = 4 cm H2O.


IPAP = 12 cm H2O and EPAP = 4 cm H2O for 4-6 hours?


Controlled oxygen via face mask to maintain SpO2 > 92% (88% - 92% in patients known to be sensitive to oxygen).

Stable clinical and physiological signs/parameters for 4-6 hours?

Continue with medical treatment and controlled oxygen.

Restart NIV (see NIV pathway) and review pre-conditions.

Increase IPAP by 4 cm H2O and/or EPAP by 2 cm H2O and review pre-conditions. Consider CPAP.

Yes

Yes

Yes

Yes

No

No

No

No

Notes: • The rate of weaning in this pathway is a guide only – some patients can be weaned

faster, others more slowly. • The weaning process may be interrupted overnight in order to promote rest. • Some patients may be weaned from BiPAP onto CPAP, before being weaned

completely off NIV. • Some patients (e.g. with post-operative lung collapse) may continue to require CPAP

support overnight in order to overcome nocturnal hypoventilation. • This pathway is not suitable for patients for whom NIV is being withdrawn and palliative-

only management started.



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10. Brochard L, et al (1995). Noninvasive ventilation for acute

exacerbations of chronic obstructive pulmonary disease. N Engl J Med

333:817-822.

11. Brown J, et al (1998). Using nasal intermittent positive pressure

ventilation on a general respiratory ward. J R Coll Physicians Lond

32:219-224.

12. Caples SM & Gay PC (2005). Noninvasive positive pressure ventilation

in the intensive care unit: a concise review. Crit Care Med 33:2651-

2658).

13. Confalonieri M, et al (2002). Noninvasive ventilation for treating acute

respiratory failure in AIDS patients with Pneumocystis carinii

pneumonia. Intensive Care Med 28:1233-1238.

14. Confalonieri , et al (2005). A chart of failure risk for non-invasive

ventilation in patients with COPD exacerbation. Eur Resp J 25:348-

355.

15. Crane SD, et al (2004). Randomised controlled comparison of

continuous positive airways pressure, bilevel non-invasive ventilation,

and standard treatment in emergency department patients with acute

cardiogenic pulmonary oedema. Emerg Med J 21:155-161.

16. Elliott MW, et al (1990). Non-invasive mechanical ventilation for acute

respiratory failure. BMJ 300:358-360.

17. Esteban A, et al (2004). Noninvasive positive pressure ventilation for

respiratory failure after extubation. N Engl J Med 350:2452-2460.

18. Ferrer M, et al (2003). Noninvasive ventilation in severe hypoxaemic

respiratory failure: a randomized clinical trial. Am J Respir Crit Care

Med 168:1438-1444.

19. Garpestad E, Hill N (2005). Noninvasive ventilation for acute

respiratory failure. But how severe? Chest 128:3790-3791.



20

20. Gray A, Goodacre S, et al, on behalf of the 3CPO Trialist (2008).

Noninvasive ventilation in acute pulmonary edema. NEJM 359:142-

151.

21. Hilbert G, et al (1998). Noninvasive pressure support ventilation in

COPD patients with postextubation hypercapnic respiratory

insufficiency. Eur Resp J 11:1349-1353.

22. Hilbert G, et al (2001). Noninvasive ventilation in immunosuppressed

patients with pulmonary infiltrates, fever and acute respiratory failure. N

Engl J Med 344:481-487.

23. Honrubia T et al (2005). Noninvasive vs conventional mechanical

ventilation in acute respiratory failure. A multicenter, randomized

controlled trial. Chest 128:3916-3924.

24. Hurst JM, et al (1985). Use of CPAP mask as the sole mode of

ventilatory support I trauma patients with mild to moderate respiratory

insufficiency. J Trauma 25:1065-1068.

25. Keenan SP, et al (2002). Noninvasive positive-pressure ventilation for

postextubation respiratory distress: A randomized controlled trial.

JAMA 287:3238-3244.

26. Keenan SP, et al (2004). Does non-invasive positive pressure

ventilation improve outcome in acute hypoxaemic respiratory failure? A

systematic review. Crit Care Med 32:2516-2523.

27. Kilger E, et al (1999). Effects of non-invasive positive pressure

ventilatory support in non-COPD patients with acute respiratory

insufficiency after early extubation. Intensive Care Med 25:1374-1380.

28. Kramer N, et al (1995). Randomized, prospective trial of non-invasive

positive pressure ventilation in acute respiratory failure. Am J Respir

Crit Care Med 151:1799-1806.

29. Lin M, et al (1995). Reappraisal of CPAP therapy in acute pulmonary

edema: short-term results and long-term follow up. Chest 107:1379-

1386.

30. Meduri GU, et al (1996). Noninvasive positive pressure ventilation in

status asthmaticus. Chest 110:767-774.



21

31. Mehta S, et al (1997). Randomized prospective trial of bilevel versus

continuous positive airway pressure in acute pulmonary oedema. Crit

Care Med 25:620-628).

32. Mehta S, Hill NS (2001). Noninvasive ventilation. Am J Respir Crit Care

Med 163:540-577.

33. Miro AM, Shivaram U, Hertig I (1993). Continuous positive airway

pressure in COPD patients in acute hypercapnic respiratory failure.

Chest 103:266-268.

34. Nava S, et al (1998). Noninvasive mechanical ventilation in the

weaning of patients with respiratory failure due to chronic obstructive

pulmonary disease. A randomized controlled trial. Ann Intern Med

128:721-728.

35. Peter JV, et al (2006). Effect of non-invasive positive pressure

ventilation (NIPPV) on mortality in patients with acute cardiogenic

pulmonary oedema: a meta-analysis. Lancet 367:1155-1163.

36. Pitkin AD, et al (1994). Arterialised earlobe blood gas analysis: an

underused technique. Thorax 49:364-366.

37. Plant PK, Owen JL, Elliot MW (2000). Early use of non-invasive

ventilation for acute exacerbations of chronic obstructive pulmonary

disease on general respiratory wards: a multicentre randomised

controlled trial. Lancet 355:1931-1935.

38. Ram FSF, Picot J, et al (2004). Nin-invasive positive pressure

ventilation for treatment of respiratory failure due to exacerbations of

chronic obstructive pulmonary disease. Cochrane database of

systematic reviews 2004 issue 3.

39. Rusterholtz T, et al (1999). Non-invasive pressure support ventilation

(NIPSV) with face mask in patients with acute cardiogenic pulmonary

edema (ACPE). Intensive Care Med 25:15-20.

40. Soroksky A, et al (2003).A pilot prospective, randomized, placebo-

controlled trial of bilevel positive airway pressure in acute asthma

attack. Chest 123:1018-1025.



22

41. Shee CD & Green M (2003). Noninvasive ventilation and palliation:

experience in a district general hospital and a review. Palliative

Medicine 17(1):21-26.

42. Squadrone V, et al (2005). Continuous positive airway pressure for

treatment of postoperative hypoxaemia: a randomized controlled trial.

JAMA 293:589-595.

43. Wysocki M, et al (1995). Noninvasive pressure support ventilation in

patients with acute respiratory failure. Chest 107:761-768.

The NIV clinical guidelines revision group comprises: Dr Steve Chay, Associate Specialist, Critical Care Services Dr Isabel Gonzalez, Consultant in Critical Care Dr Andrew Adair, Consultant in Emergency Medicine Dr Kevin Whitfield, Consultant Acute Medicine Dr Ramamurthy Sathyamurthy, Consultant in Respiratory Medicine Dr Cristoph Muench, Consultant in Anaesthesia and Intensive Care Phil Howard, Senior Physiotherapist, Critical Care Services Maureen Tiernan, Senior Clinical Educator Lindsay Garcia, Clinical Manager, Critical Care Services

APPENDIX 1

LEVEL 1 (GENERAL WARD AREAS)

WARDS EQUIPMENT MODES FiO2

AAU (Ward 1 &15)*

Ward 9 (Respiratory support unit)*

ST 30, FOCUS, Harmony and Synchrony (Respironics™)

NIPPY™ 2 & 3

ResMed™

Bi-level (BIPAP) if type 2 respiratory failure

CPAP if type 1 respiratory failure

Up to 0.5

A patient needing FiO2 greater than 0.5 for more than 2 h to keep adequate SpO2 should be transferred to higher level of care (if escalation appropriate)

• None of this areas have facilities for arterial line and ABGs monitoring, they depend on intermittent arterial puncture or capillary blood gases

• Any patient requiring more than 50% oxygen to maintain target pO2 needs critical care discussion. Ward based equipment will not deliver more than 40-45% oxygen in any case (max oxygen enrichment advised by equipment companies is 10 l/min oxygen)

• Any patient requiring increasing pressure support to keep target pH/pCO2 needs critical care discussion (particularly if pH remains less than 7.25 after 2 hours of initiation of NIV)

• If type 1 respiratory failure is due to cardiac failure there should be a referral to Cardiology SpR/Consultant for assessment

• Discussions about limitation of therapy should be done ideally before starting of non-invasive respiratory support, but definitely within 4 hours of its initiation *Staff need to be trained and assessed competent in NIV (DH competencies Acutely Ill Patient) and equipment in use

LEVEL 2 (CRITICAL CARE AREA)

AREAS LEVEL 2 EQUIPMENT MODES FiO2

Generic HDU* Surgical HDU*

Spinal HDU* Cardiothoracic HDU*

Coronary Care Unit* NeuroHDU**(CPAP)

All level 1 equipment as above Carina (Draeger™)

Vision (Respironics™) Whisper-flow™

Draeger™ bellows High Flow Nasal Therapy

All modes, all interfaces, except for ETT

Unlimited (consider escalation to level 3 if FiO2 persistently above 0.7 and appropriate for escalation)

**Neuro HDU at present limited to Whisper-flow CPAP until further training

*Staff need to be trained and assessed competent in NIV (DH competencies Acutely Ill Patient) and equipment in use This guidance must be adhered to unless agreement with consultant in acute medicine, emergency medicine, respiratory medicine, cardiology or critical care consultant. It only relates to ACUTE respiratory support and not LONG TERM VENTILATION patients or patients admitted with own machines for overnight CPAP/BIPAP.

LOCATION OF PATIENTS FOR ACUTE RESPIRATORY SUPPORT AT JAMES COOK UNIVERSITY HOSPITAL

APPENDIX 2

Non Invasive Ventilation audit and observation tool: A3 booklet, code number for ordering MICC 2665


25

APPENDIX 3 RESPIRATORY SUPPORT UNIT: ADMISSION POLICY AND NIV SPECIFIC GUIDANCE FOR COPD PATIENTS

RS / DB / LG / IG RSU Admission policy / July 2012

Respiratory Support Unit (RSU) / Ward 9

Admission policy for patients on Non Invasive Ventilation (NIV)

1. All patients requiring admission to the RSU for NIV must be discussed

and accepted by the Respiratory Consultant on call or medical registrar

on call.

2. All patients referred to RSU should have a Non-Invasive Ventilation

observation chart commenced.

3. Documentation regarding escalation of therapy including a Stratified

Treatment Escalation Plan (STEP) form should be evident within the

patient Health Care records.

4. Do Not Attempt Resuscitation (DNAR) status should be clearly

documented within the patient Health Care Records.

5. Information provided to relatives must be clearly documented within the

patient Health Care Records.

6. Approved clinical guidelines for non-invasive ventilation are to be

followed.

7. Any deviation from approved clinical guidelines must be clearly

documented as part of the NIV observation chart or within the patient

Health Care Records with a clear rationale provided.

8. Clinical handover of care must be clearly documented within the medical

and nursing Health Care Records including an ongoing medical

management plan.


27

Respiratory+Support+Unit:+Non2Invasive+Ventilation+guidance+for+COPD+patients++

+ Sathyamurthy)Ra

mam

urthy)/)RSU)specific)guidelines)/)Ju

ly)201

2)++

AB

G o

n ai

r or

titr

ated

oxy

gen

(spe

cify

)

pH =

7.2

5 –

7.35

pO2 <

8kPa

pCO

2 >

6.5k

Pa

HC

O3 >

25m

mol

/L

Star

t NIV

(P

leas

e us

e N

IV o

bser

vati

on c

hart

)

IPA

P at

10

cm H

2O a

nd in

crea

se to

15

cm H

2O in

15

min

utes

EPA

P a

t 4 c

m H

2O

O2 f

low

1L

– 1

5 L

to k

eep

SpO

2 bet

wee

n 88

- 92%

+ Che

ck A

BG

in 1

hou

r

pH ↑

, p

CO

2↓,

pO

2 >8

= k

eep

on s

ame

setti

ngs

and

rech

eck

CB

G in

4 h

ours

unl

ess

chan

ge in

clin

ical

si

tuat

ion

pH →

or ↓,

P

CO

2 ↑

or →

=

↑

IPA

P to

20

cm

H2O

pH ↓

, P

CO

2 ↓,

PO

2 <

8 K

Pa

=

↑E

PAP

to 5

cm

H

2O o

r in

crea

se O

2 flo

w r

ate

if R

R >

20 b

reat

hs /

min

If a

ny o

f the

indi

ces

not i

n ra

nge

cons

ult d

octo

r. If

H

CO

3 < 2

0, c

onsi

der c

oexi

stin

g m

etab

olic

aci

dosi

s.

Che

ck in

dica

tions

and

con

trai

ndic

atio

ns a

s pe

r NIV

ob

serv

atio

ns c

hart

.

Do

ches

t x-r

ay, 1

2 le

ad E

CG

, ren

al a

nd li

ver f

unct

ion

test

s an

d fu

ll bl

ood

coun

t.

Exp

lain

to r

elat

ives

, pat

ient

the

purp

ose

of N

IV a

nd

the

criti

cal n

atur

e of

the

cond

ition

.

Prov

ide

NIV

leaf

let t

o pa

tient

and

rela

tives

.

Doc

umen

t pla

n fo

r Esc

alat

ion

and

Res

usci

tatio

n st

atus

.

Ass

ess

need

for i

ntra

veno

us f

luid

s, in

trav

enou

s an

tibio

tics

if in

fect

ive

exac

erba

tion,

pre

dnis

olon

e or

ally

and

neb

uliz

ed b

ronc

hodi

lato

rs th

roug

h an

air

co

mpr

esso

r

Mon

itor o

bser

vatio

ns a

s pe

r E

WS

scor

e: in

itial

ly

hour

ly u

ntil

stab

ility

ach

ieve

d, d

ecre

ase

to a

m

inim

um o

f 4

hour

ly if

sta

ble

Con

tinuo

us c

ardi

ac m

onito

ring

Hou

rly

urin

e ou

tput

/inpu

t cha

rt

Blo

od c

ultu

res

and

use

seps

is 6

pat

hway

if s

igns

of

seps

is.

Che

ck f

or e

xces

sive

air

leak

Che

ck p

atie

nt s

ynch

rony

with

the

mac

hine

.

Sudd

en d

eter

iora

tion

on N

IV –

che

ck m

achi

ne a

s pe

r m

anua

l, co

nsid

er p

neum

otho

rax,

cir

cula

tory

col

laps

e,

arrh

ythm

ias.

Any

cha

nge

in s

ettin

gs c

heck

CB

G in

1 h

our

If n

o im

prov

emen

t on

IPA

P 20

and

EPA

P 5

cm H

2O

cons

ult d

octo

r.

If n

ot to

lera

ting

high

er p

ress

ures

, con

sult

doct

or a

nd

keep

on

tole

rate

d pr

essu

res.

+

Weaning

'protocol'

Start+the+weaning+process+once+ABG+normalized+at+

0900+am.+

Day+1+2+223+hour+breaks+during+meal+time+during+the+

day,+continue+overnight+NIV+

Day+2+2+Daytime+break+if+improving,+continue+overnight+

NIV+

Day+3+–+assess+without+NIV+

Faster+weaning+process+suitable+in+some+patients+–+

consultant+to+write+up+plan+in+those+circumstances.+


28

APPENDIX 4 Non Invasive Ventilation Patient Information Leaflet

Non Invasive Ventilation (NIV) is a way of helping you breathe using a machine attached to a tight fitting mask that you wear over your face. It is not the same as a nebuliser which you might have used before and delivers a medication to the lungs. It is used usually when you are having a severe flare-up of your breathing problem.

x At this time your breathing

gets hard work and your muscles can become tired.

x This sometimes leads to a build-up of waste gas (carbon dioxide) and not enough oxygen getting into your blood.

x NIV supports your breathing to give your muscles a rest and allow them time to recover.

x It doesn’t breathe for you, but

gently assists each breath that you take.

x This can help to get your

oxygen and carbon dioxide levels back to normal.

In the past a machine to help breathing needed to be connected to a tube placed inside the windpipe of the patient and had to be done in the intensive care unit. Instead using this new type of ventilator you will need to wear a facemask, which fits firmly but not too tightly.

As you take a breath in you will feel a flow of air from the machine, then as you breathe out there will be a little resistance to help keep your lungs open.

It can feel a bit strange to start with, however most people find that they get used to it fairly easily.

The physiotherapist or nurse will set the machine up and make sure that it is as comfortable for you as possible.

x The nursing staff will check on

you frequently so if you do find it uncomfortable they can help.

x You will have your buzzer near by to call for help at any time.

To start with, you need to wear the mask as much as possible for the first 24 hours. It can be removed for short periods to enable you to eat and drink as normal and for your medicines and nebulisers. To monitor your progress, a peg-like probe will be placed on your finger to measure the oxygen level in the blood.

Also a blood test will need to be taken after the first hour to check that your oxygen and carbon dioxide levels are getting better.

Your normal treatments for your breathing condition, such as nebulisers, antibiotics and steroids will continue alongside using the NIV. x Generally people need to stay

on NIV for a few days, but everybody is different.

x After the first 24 hours you will

usually be asked wear it for 2 hours in the morning and afternoon as well as overnight and then we will cut it down to overnight only.

x Your doctor will discuss your

treatment with you. The length of time you need it will depend on how quickly the oxygen and carbon dioxide levels in your blood improve.

If you have any further questions please do not hesitate to ask any of the people involved in your care and they will be happy to help.

NIV: The Treatment Explained

A document planned for our patients as a result of patient

consultation, support and action.


29

APPENDIX 5 Equality Impact Assessment

This is a preliminary impact assessment (step 1) which is a quick and easy screening process and will help identify any policies, procedure, services, functions or strategies which will require a full Equality Analysis (step 2).

Title of Policy / Procedure / Service: NIV guidelines Date of Assessment: 13/07/2012

Name of member of staff/s completing the equality analysis:

Lindsay Garcia / Dr Isabel Gonzalez

Division / Directorate which the policy / procedure / service belongs:

Critical Care Acute Medicine

Manager responsible for the policy / procedure / service:

Lindsay Garcia

Please state if the Equality Impact Assessment (EqIA) has been carried out due to the policy / procedure / service being new, revised or has it been identified due to another source:

Due to the guidelines

1. What are the aims and purpose of the policy / procedures / services? To deliver a protocolised approach to non-invasive ventilation determined by the best available evidence. 2. Who does this policy / procedure / service target / benefit? Patients that require non invasive ventilation 3. What are the desired outcomes of this policy / procedure / service? To guide all clinicians on the safe application and delivery of non invasive ventilation regardless of the patient location. 4. What factors may cause the policy / procedure / service to not meet the desired outcomes? The guidelines assist in ensuring the desired outcomes are met. 5. Thinking about each of the groups below, does, or could the policy, procedure or service have a negative impact on members of the equality groups below? (If you answer ‘yes’ or ‘unclear’ to any of groups below, a full EqIA will need to be completed – Step 2)

Group Yes No Unclear Age

Disability

Race

Gender

Transgender


30

Sexual Orientation

Religion or Belief

Marriage & Civil Partnership

Pregnancy & Maternity Leave

Relationship between groups

Other socially excluded groups (e.g. homeless / travellers)

6. Does, or could, the policy, procedure or service help to promote equality of members of the equality groups below?

Group Yes No Unclear

Age

Disability

Race

Gender

Transgender

Sexual Orientation

Religion or Belief

Marriage & Civil Partnership

Pregnancy & Maternity Leave

Relationship between groups

Other socially excluded groups (e.g. homeless / travellers)

7. Has there been any consultation with the groups identified above during the formulation of the policy, procedure or service? Not applicable – motivated by the best interests of patients 8. Does any monitoring take place that looks at the impact on these groups? Describe any additional or improved monitoring that would help to explain the impact of this policy / function / service Not applicable 9. Does this policy, procedure, function / service require a full Equality Impact Assessment? Please outline how the decision was made with regards to the requirement for a full EqIA to be completed? No 10. Can any adverse impact that you have identified be justified on grounds that outweigh equality issues? No adverse impact


31

Full Equality Analysis 1. In step 1 (initial screening) which equality target groups were identified as being disadvantaged by the policy, procedure or service? None 2. Summarise the impacts for each group identified NA 3. Could you minimize or improve any negative impact? E.g. Can changes be made to the function or policy or can the policy or function be implemented in a different way? NA 4. Is it possible to consider a different policy, which still achieves your aim, but avoids any adverse impact? NA 5. What consultation has taken place, or will take place with each equality target group, either externally or internally and what were the consultation outcomes? NA 6. If there are any gaps in your previous or planned consultation and research, are there any experts / relevant groups that can be contacted to get further views or evidence on the issues? Please list them and explain how you will obtain their views NA 7. Have you involved your staff (who have or will have direct experience of implementing the service / procedure) in taking forward this impact assessment? If yes how? Yes 8. What practical actions are required to reduce or remove and adverse/ negative impact? No adverse effect 9. Give details of the monitoring arrangements NA

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