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Guideline 750.3 1 of 19 Uncontrolled if printed

750.3 USE OF NON-INVASIVE VENTILATION (NIV) OUTSIDE OF THE INTENSIVE CARE UNIT (ICU)

Acknowledgements This guideline has been adapted from the template policy from the British Thoracic Society (BTS) (2008). This guideline should be read in conjunction with:

Mental Capacity Act (2005)

Infection Prevention and Control Manual

Management of Medical Devices Training

Guideline 12 End of Life and Palliative Care Symptom Control

Guideline 26 Physiological Observations of Adult Non-Obstetric Inpatients

Guideline 92 Intensive Care Unit (ICU) – Operational Guideline

Guideline 244 Management of an Acute Exacerbation of COPD with Type 2 Respiratory Failure

Document name Use of non-invasive ventilation (NIV) outside of the Intensive Care Unit (ICU)

Guideline Number 750

Version 3

Effective Date August 2019

Review Date January 2020

Approvals:

Clinical Guidelines Subgroup 14th August 2019

Reviewed by Dr David Taylor, Respiratory Consultant Liz Staveacre, Consultant Nurse, Outreach Team

SDU(s)/Department(s) responsible for updating the guideline

Outreach Team

Uploaded to Intranet 21st August 2019

Buckinghamshire Healthcare NHS Trust

http://swanlive/policies-guidelines/mental-capacity-act-mca

http://swanlive/policies-guidelines/infection-prevention-control-manual

http://swanlive/sites/default/files/guideline_12.pdf






Contents

1. Introduction and key principles ................................................................................................. 2

1.1 Responsibilities ............................................................................................................... 2 1.2 Key principles .................................................................................................................. 3 1.3 Aim .................................................................................................................................. 3 1.4 Respiratory failure ........................................................................................................... 3

2. Patient selection for NIV and management plan ...................................................................... 3

2.1 Patient stratification ......................................................................................................... 4 2.2 NIV inclusion criteria ........................................................................................................ 4 2.3 NIV exclusion criteria ....................................................................................................... 4

3. Patient management ................................................................................................................ 5

3.1 Management and care of patient on NIV: ........................................................................ 5 3.2 Initial settings for NIV: ...................................................................................................... 5 3.3 Ongoing care ................................................................................................................... 5 3.4 Weaning from NIV ........................................................................................................... 6 3.5 Hospital discharge ........................................................................................................... 6

4. Equipment ............................................................................................................................... 6

4.1 Decontamination & cleaning ............................................................................................ 7 4.2 Equipment purchase ........................................................................................................ 7

5. Knowledge and skills ............................................................................................................... 7

6. Documentation ......................................................................................................................... 7

7. Monitoring for effectiveness ..................................................................................................... 7

8. References .............................................................................................................................. 7

Appendix 1: NIV Prescription Chart ................................................................................................. 8

Appendix 2: NIV Audit Proforma ................................................................................................... 10

Appendix 3: NIV Set Up Guide ...................................................................................................... 11

Appendix 4: NIV Troubleshooting Guide ....................................................................................... 12

Appendix 5: Competency Statement – Respironics BiPAP ........................................................... 14

Appendix 6: Core Nursing Care Plan ............................................................................................ 16

Appendix 7: NIV Consumables ..................................................................................................... 18

Appendix 8: Terminology and Settings for the FOCUS ................................................................. 19

1. Introduction and key principles

This guideline is for use by the multi-professional team (trained nursing staff, physiotherapists and medical staff) in the acute hospital setting.

Non-invasive ventilation (NIV) within both the intensive care unit (ICU) and the ward environment, has been shown in randomised controlled trials (RCTs) and systematic reviews to reduce intubation rate and mortality in chronic obstructive pulmonary disease (COPD) patients with decompensated respiratory acidosis (pH <7.35 and PaCO2 >6 kPa) following immediate therapy (Royal College of Physicians (RCP) 2008).

1.1 Responsibilities

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

Ward managers should keep records of nurse training and achievement of competence in the use of NIV.


1.2 Key principles

NIV is “the provision of ventilatory support through a patient’s upper airway using a mask or similar device” (RCP/BTS/ICS 2008). The choice of NIV therapy will depend on the patient’s underlying problem and may be:

Continuous positive airways pressure (CPAP), or

Bi-level positive airways pressure (BiPAP).

These treatments may be used as the sole treatment, a holding measure, a trial prior to intubation,

or the ceiling of treatment (BTS 2002) with the aim to produce: Decreased work of breathing.

Increased tidal volume.

Decreased respiratory rate.

CPAP is indicated for patients with acute hypoxaemic respiratory failure or cardiogenic pulmonary

oedema.

This guidance does not cover the intended use of CPAP within Buckinghamshire Healthcare NHS

Trust (BHT).

BiPAP is indicated in the ward environment for patients with COPD and alveolar hypoventilation

with hypercapnic respiratory failure. It can be used in specialist areas such as the ICU for other

indications, such as weaning from invasive ventilation.

NIV is generally contraindicated in patients with asthma and those patients who do not respond to

early treatment.

NIV has been used to support patient care in critical care areas (A&E, ICU and HDU) and ward areas for a considerable time. Recently there has been an increase in the use of NIV in ward

areas as the evidence for this therapy increases and the ward population becomes more acute.

For example, the National Institute for Health and Care Excellence (NICE) guidance for the management of COPD (2010) recommends that all acute units that admit patients with

exacerbations of COPD should have the capability to provide NIV 24 hours/day. These patients should be treated in designated level 2 facilities.

1.3 Aim

This guideline identifies the expected standard of care required for patients receiving NIV and identifies the minimum standard for:

Patient management

Knowledge and skills

Equipment

Documentation

Monitoring for effectiveness

1.4 Respiratory failure

Respiratory failure can be defined as the failure to maintain adequate gas exchange. This may be acute, chronic or acute on chronic.

i) Type 1 respiratory failure:

Arterial blood gas (ABG) analysis:

PaO2 <8 kPa with normal or low PaCO2

ii) Type 2 respiratory failure:

ABG analysis:

PaO2 <8 kPa with PaCO2 >6 kPa

ABG analysis is therefore essential before NIV is commenced to ensure that the appropriate choice of therapy is made. 2. Patient selection for NIV and management plan

NIV should be considered for all patients with acute exacerbation of COPD in whom a respiratory acidosis (PaCO2 >6 kPa, pH <7.35) persists despite immediate maximum standard medical


treatments on controlled oxygen for no more than one hour.

BiPAP is less effective with severe acidosis (pH <7.26) and specialist advice needs to be sought. BiPAP may still be considered in these patients if it is established that BiPAP is the ceiling of care.

The management of any patient admitted with neuromuscular disorders or obstructive hypopnoea syndrome should be discussed ideally with the respiratory physician or ICU registrar, especially out of hours.

Standard medical therapy (within first hour) should include:

Controlled oxygen to maintain oxygen saturations 88 - 92% (prescribed on patient’s drug chart).

Nebulised salbutamol 2.5 - 5 mg (on air).

Nebulised ipratroprium 500 micrograms (on air).

Prednisolone PO 30 mg.

Antibiotic agent (as per BHT guidelines).

Consider NIV.

All should be administered within one hour and response assessed - see Guideline 244 Management of an Acute Exacerbation of COPD with Type 2 Respiratory Failure.

2.1 Patient stratification

To assist the assessment process, the patient should be stratified into one of five groups, based on their pre-morbid state, the severity of physiological disturbance, the reversibility of the acute illness, the presence of relative contraindications and, where possible, the patient’s wishes.

This stratification is recorded in the patient’s health records. If appropriate, consultation with ICU medical staff should be made at an early stage - see Guideline 92 Intensive Care Unit (ICU) – Operational Guideline.

Five groups of stratification:

1. Patient requires immediate intubation and ventilation. 2. Patient is suitable for NIV and suitable for escalation to intensive care treatment/intubation

and ventilation if required. 3. Patient is suitable for NIV but not suitable for escalation to intensive care

treatment/intubation and ventilation. 4. Patient is not suitable for NIV but for full active treatment. 5. Palliative care agreed as the most appropriate patient management – see Guideline 12 End

of Life and Palliative Care Symptom Control.

2.2 NIV inclusion criteria

Type 2 respiratory failure.

Able to protect airway.

Conscious and co-operative.

No excessive respiratory secretions.

Potential for recovery to quality of life acceptable to the patient.

Patient’s wishes considered.

2.3 NIV exclusion criteria

Life threatening hypoxaemia.

Patient declines treatment.

Facial burns/trauma/recent facial or upper airway surgery.

Fixed upper airway obstruction.

Undrained pneumothorax.

Haemodynamically unstable requiring inotropes/pressors (unless in a critical care unit).

Severe co-morbidity.

Inability to protect airway (relative contraindication).

Copious respiratory secretions (relative contraindication).

Upper gastrointestinal surgery (relative contraindication).

Vomiting (relative contraindication as nasogastric (NG) tube can be considered in these patients if intubation is not an option).








Confusion/agitation (relative contraindication).

Bowel obstruction (relative contraindication).

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 2002). 3. Patient management

During daytime hours, patients identified as suitable for NIV using the NIV guidelines should be referred to the acute medical team (advice may be sought from the respiratory team). Out of hours, cases that do not fulfill the guideline criteria must be discussed with the on-call consultant or registrar.

BiPAP should be prescribed for type 2 respiratory failure using the tool in appendix 1.

Care of the patient requiring NIV should be limited to A&E, 2A Wycombe Hosptial (WH), cardiac and stroke receiving unit (CSRU), respiratory wards 4 and 7 at Stoke Mandeville Hospital (SMH), St. Andrew Ward, National Spinal Injuries Centre (NSIC) (and adult intensive care units). These clinical areas must ensure that staff are adequately trained and are competent in the use of NIV therapy are available at all times.

The clinical site manager/Critical Care Outreach Team, if not already aware, should be informed of the patient, their current condition, and the patient must be included in the Hospital at Night handover meeting.

Transfer from A&E to an appropriate ward may be delayed due to the patient requiring extended treatment in A&E ‘resus’ or a delay in providing a suitable bed as outlined above.

3.1 Management and care of patient on NIV

Continuous clinical assessment of the patient is needed including:

Respiratory rate

Continuous pulse oximetry

Heart rate and blood pressure (BP)

National Early Warning Score (NEWS)

Chest wall movement

Co-ordination of respiratory effort with the NIV machine

Increased use of accessory muscles

Chest pain/indicators of myocardial ischaemia

Patient comfort

Mental state

3.2 Initial settings for NIV

To allow acclimatisation of the patient to NIV, the initial settings should be:

Inspiratory pressure (IPAP): 10 cm H2O

Expiratory pressure (EPAP): 4 cm H2O

The IPAP should be gradually increased over the next 20 minutes to a target IPAP of 20 cm H2O to achieve a therapeutic response (or patient tolerability is reached). Further increases of EPAP are not recommended without obtaining expert advice.

Oxygen should be entrained into the circuit and adjusted to maintain the target saturation (usually 88 – 92%) as per BTS guidance (2008).

3.3 Ongoing care

Improvements in clinical parameters, e.g. respiratory rate and effort, are usually seen within 1 – 2 hours and are usually accompanied by improvement in neurological state. Therefore a full clinical and blood gas review should be made after approximately 30 - 60 minutes of treatment. A decision should then be made as to whether NIV is being effective.


Patient assessment and observations should be clearly documented using the prescription and observation chart (reviewing individualised core care plan as appropriate, see appendix 6).

If NIV is continued, ABG should be monitored until the pH is normal and PaCO2 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 unit).

If the treatment with NIV is not effective, see troubleshooting guide (appendix 4). If NIV has been optimised without an improvement in clinical or blood gas parameters it should not be continued. The patient should either have escalation of care to intubation, where appropriate, or conventional medical therapy alone, according to section 2.1.

The patient should have regular medical review (at least daily) to ensure NIV treatment remains optimal.

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 (see core care plan appendix 6).

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

NIV should preferably be interrupted for the administration of bronchodilators. If the patient is too unstable a ‘Misty T’ can be used in the circuit, between the expiration port and face mask, allowing nebulisation without a break in the circuit.

Change the filter every 24 hours and label.

3.4 Weaning from NIV

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, or if NIV is making no difference to the patient’s condition, weaning from NIV should be considered.

If effective, treatment will usually be required until the acute cause has resolved, commonly 3 days.

Principles of weaning:

Build period of time off NIV – continued oxygen therapy via a venturi mask, monitor for any signs of work of breathing (increased respiratory rate/decreased oxygen saturation, increased use of accessory muscles).

Recheck ABG approximately 2 hours after discontinuation of therapy.

Consider use of NIV overnight if nocturnal hypoventilation is present.

3.5 Hospital discharge

Patient’s respiratory medicines should be optimised.

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. 4. Equipment

Location of BiPAP machines is outlined in Table 1.

Table 1: Equipment location

Machine Hospital Ward/Dept

BiPAP® Focus™ x 1

Trilogy 202 x 2 (Philips Respironics)

SMH

A&E

BiPAP® Focus™ x 8 SMH Wards 4 and 7

Stellar™ 100 x 2

BiPAP® Synchrony™ x 6

ResMed S8 CPAP x2

ResMed S9 CPAP x3

SMH St Andrew

BiPAP® Focus™ x 1 WH CSRU

BiPAP® Focus™ x 1 WH Ward 2A

Consumables are available as stock on ‘top up’.


4.1 Decontamination and cleaning

Following use, the machine should be cleaned and decontaminated following infection control and manufacturer’s instructions. The device should labelled using the ‘yellow’ medical device label to clearly show it is ready for use.

For further details see set up guide in appendix 3 and troubleshooting guide (appendix 4).

4.2 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 procurement department to ensure a corporate approach to purchasing. 5. Knowledge and skills

All staff caring for a patient with NIV should be deemed competent in the use of NIV before caring for a patient (appendix 5: Competency framework).

Staff should attend a NIV workshop to gain theoretical/practical understanding of the therapy ensuring they understand the medical device used.

6. Documentation

The NIV prescription chart (appendix 1) should be used for all patients receiving NIV (outside the ICU) and used in conjunction with BHT observation chart incorporating the NEWS. See Guideline 26 Physiological Observations of Adult Non-Obstetric Inpatients.

Limitations on treatment, weaning regimen, 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 plan should be completed and evaluated (appendix 6). 7. Monitoring for effectiveness

The NIV service will be audited, in line with BTS guidelines, by the lead nurse in NIV in each clinical area (see audit proforma appendix 2). The audit form (attached to the prescription sheet) should be detached and collected from the patient records following completion of therapy. NIV will also be audited as part of the BTS National Audit. 8. References

1. Baudouin, S et al (2002) Non–invasive ventilation in acute respiratory failure. British Thoracic Society Standards of Care Committee. Thorax. 57:192-211.

2. Royal College of Physicians, British Thoracic Society, Intensive Care Society. (2008). Chronic obstructive pulmonary disease: non invasive ventilation with bi-phasic positive airways pressure in the management of patients with acute type 2 respiratory failure. Concise Guidance to Good Practice Series. No 11. London RCP.

3. Intensive Care Society (2009) Levels of Critical Care for Adult Patients. Standards and Guidelines.

4. NICE (2010) Chronic Obstructive Pulmonary Disease. Management of chronic obstructive pulmonary disease in primary and secondary care.

http://swanlive/sites/default/files/decontamination_policy_bht_pol_013_rvw_may_2020.pdf




Appendix 1 NIV Prescription Chart

(SMH bleep 566)


Appendix 2 Audit Proforma


Appendix 3

NIV Set Up Guide

Action Rationale

Ensure ward emergency equipment available. To provide a safe environment.

Patient discussed with nursing staff, medical staff (at all times) and physiotherapists (in hours).

To ensure NIV is the appropriate intervention and that support is available.

Ensure the NIV chart has been fully completed with an appropriate prescription.

To ensure the appropriate settings are maintained.

Check with medical staff that the patient has had a recent chest X-ray (CXR) which is clear of pneumothorax/pneumonia.

Pneumothorax must be discounted prior to starting NIV as positive pressure can cause lung barotraumas. If a patient already has a pneumothorax the size can be increased by NIV. NIV is unlikely to succeed if pneumonia is present.

Explain procedure to the patient positively and calmly. Gain verbal consent from patient. The patient will require reassurance throughout the procedure. Optimise the patient in an upright position.

To gain consent and co-operation. This is potentially a frightening and claustrophobic experience.

Set up the equipment as shown in the diagram. Ensure filter is connected to the port on the NIV machine prior to attaching the tubing.

To prevent contamination of the machine.

Carry out as much preparation as possible away from the bed area.

To prevent distressing the patient.

Use full face mask. Assess mask size using gauge on mask pack. It should fit firmly and not encroach on the upper lip and into corners of the eye.

To ensure seal and prevent air leaks which may reduce the effectiveness or cause complications, e.g. conjunctivitis.

Adjust the nasal clip on the bridge of the mask to ensure good fit. Check for any poor facial skin condition.

Bridge of patient’s nose is a very high risk pressure area. Existing poor facial skin condition may also be exacerbated.

Connect patient’s current O2 supply to second O2 supply.

Maintain O2 supply whilst preparing equipment.

Set mode to spontaneous/timed mode. Set IPAP, EPAP and back up BPM setting as per prescription.

To ensure the machine is functioning correctly and that back up rate is provided in the spontaneous/timed mode.

Turn on machine and connect entrained O2 supply.

To commence treatment and provide O2 supply.

Ask patient to breathe through nose and maintain a tight mouth seal. Hold mask to patient’s nose for a few minutes.

To reassure patient and acclimatize.

Attach head strap to mask and obtain a seal. The mask should be firm but not tight and small leaks may be acceptable. If leak below 7 l/min loosen straps a little.

To ensure there are no leaks. To prevent pressure sores.

Ensure that exhalation port is not blocked and is facing away from the patient.

To prevent build up of CO2.

Document a set of observations (including NEWS).

Provide baseline for assessing progress.

Watch chest wall movement and titrate settings to achieve therapeutic effect – increase chest wall movement and improved clinical signs.

Improving the tidal volume is the aim. An inadequate tidal volume is the cause of the patient’s ventilatory failure.


Appendix 4 NIV Troubleshooting Guide

Problem

Persistently elevated PaCO2

Is there an excessive mask leak? Check mask fit. Is the circuit set up correctly? Check connections and identify leaks. Is the expiratory port patent? Is the patient being over oxygenated? Especially consider aim of oxygen therapy during period off NIV. Consider the acceptable level of PaO2 to be aimed for. Consider increase in pressure support by increasing IPAP. 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 (>8 cm H2O).

Mask leaks Aim for leak >7 l/min. Small leaks are normal and acceptable but larger leaks may cause inefficient ventilation, eye irritation, noise, dry mouth and nasal symptoms. Be prepared to try different mask types. Check the mask fit and size is correct.

Asynchrony between patient and ventilator

This is rare if using Respironics® Focus™ machine due to its triggering sensitivity. Check correct tubing 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.

Hypocapnia/alkalosis Minute ventilation too high. 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. CXR may be required.

Nasal problems Nasal redness/nasal bridge sores? Check mask not fitted too tightly. Appropriate padding or change of mask may be necessary. Rhinitis/nasal crusting/bleeding? Ask about nasal symptoms. Consider short term use of 0.5% ephedrine nose drops every 6 - 8 hours for stuffiness. Anticholinergic spray (ipratropium bromide) every 8 to 12 hours or sodium chloride aqueous spray when necessary may be helpful for nasal streaming.

Dry mouth Regular mouth care is essential. Offer frequent drinks.

Gastric distension Check for abdominal pain or distension occurring during NIV. Try to reduce IPAP if possible. Consider nasogastric tube accepting a small leak will occur. Consider anti-emetics, e.g. metoclopramide PO 10 mg 8 hourly (max 5 days duration).


Problem

Persistent hypoxaemia Deteriorating clinical condition in the presence of hypoxaemia should lead to an urgent review of the patient and consideration of intubation and mechanical ventilation (if appropriate). CONTACT ICU. Check correct O2 entrainment into circuit of machine. If there is a definite atelectasis then increasing EPAP may help (remembering to increase IPAP by same level to maintain the same pressure support).

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

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 ABGs have corrected themselves before the agitation/confused state settles. This may be life-saving. Relatives may also be helpful to calm the patient.

SEDATION MUST BE AVOIDED WITHOUT SENIOR MEDICAL OR ANAESTHETIC INPUT.

Haloperidol PO 500 micrograms may be useful to decrease agitation and facilitate tolerance of NIV therapy. Avoid benzodiazepines.

▲


Appendix 5:

Competency Statement: Respironics BiPAP High Risk – STOP do not operate this device unless you have been trained to use it safely after advice/guidance from a trained user.

Date training received on: Self Assessment

Surname: Forename:

Title (Mr/Mrs/Miss/Dr, etc.) Assignment No. (stated on wage slip)

Job title/designation

Dept/ward and hospital Ext.

Self verification of competence is undertaken by assessment against the following statements: These statements are designed to indicate competence to use this device. Responsibility for use remains with the user, so if you are in any doubt regarding your competence to use the device, you should seek education to bring about the improvement. Discuss this with your Medical Devices lead.

Prior to carrying out a self assessment, read the relevant sections in the Equipment Library and Competencies Folder and Section 4 of the Infection Control Manual. You must be able to answer “yes” to all questions before considering yourself to be compliant. If you are not competent, instigate learning and then repeat self-verification.

Questions to ask yourself for self analysis: Are you safe using this device? Do you know:

Initial assessment date

Final assessment date

1. Identify appropriate patients for NIV and explain the basic physiology behind this decision.

2. Identify the contraindications for NIV.

3. Correctly assemble and prepare the equipment, including correct mask fitting technique.

4. Provide an explanation to the patient.

5. Demonstrate the ability to establish initial settings for a new patient and explain the rationale for doing so.

6. Explain and implement the safety measures required, including setting the back up rate and apnoea alarms.

7. Demonstrate how to accurately record the physiological observations of the patient whilst on NIV.

8. Explain how pressure support is determined.

9. What happens to pressure support if EPAP is increased, but IPAP remains the same? What impact will this have on delivered tidal volume?

10. Demonstrate knowledge of the prescribed ‘ceiling of treatment’ for the patient.

11. Discuss the process for device contamination following use.


Statement: Having answered “yes” to all questions above and taken into account my personal assessment of my competence with the product, I declare that: I am competent to use this product without further training. Signature: Date:

I require further training before I can use this product in a competent manner. Signature: Date:

Indicate how you plan to meet your learning needs:

When self-assessment complete, Ward Manager or nominated deputy to observe and supervise staff member setting up, dismantling and cleaning this equipment. To be completed by manager/deputy: I have observed (INSERT NAME) ………………………... setting up this equipment and, at the time of observation, found them to be competent. Name (Print) ………………………………… Job Title…………………………. Signature……………………….……….…… Date……………………………... Date for review………………………………

Form to be kept in your personal portfolio or training record and a copy to be kept by your manager.


Appendix 6

Core Nursing Care Plan for a Patient on Non-Invasive Ventilation

Date Problem Cause Goal Nursing Intervention

Ineffective breathing pattern Shown by breathlessness Resp rate, pulse, BP Abnormal arterial blood gas analysis: pH: …<7.35………. PaCO2 (>6.0 kPa): PaO2 (8.0 kPa): O2 saturation Identified need for NIV

Worsening COPD +/- acute respiratory infection

To promote normal and effective breathing patterns

□ □ □ □ □ □ □ □

Record BP, pulse, respiratory rate, temp, O2 sats, AVPU score and NEWS. Ensure equipment is correctly set according to guidelines. Check NIV prescription. Assess patient for type and size of mask. Ensure good fit and minimal leakage. Check hourly for pressure damage. Give O2 via mask as prescribed. Monitor O2 saturation continuously and report if it decreases. Record BP, pulse, respiratory rate, sats, temp, NEWS and AVPU score half hourly for first two hours then hourly thereafter. Report changes from baseline. Ensure blood gases are taken after first hour.

Signature …………………………………..

Receiving adequate ventilation

Worsening COPD +/- acute respiratory infection or chest wall deformity and BiPAP

To ensure patient receives optimal levels of IPAP and EPAP as defined in management plan

□ □ □ □ □

Start patient at IPAP 10 cm H20 and EPAP 4 cm H20. Competent practitioner to titrate to agreed IPAP level within 20 minutes of starting therapy. Check patient is not exceeding the set IPAP level. After first hour reassess respiratory rate, work of breathing and oxygen saturations. Medical staff to recheck ABG.

Signature …………………………………..

Reduced ability to clear airways shown by shortness of breath, increased respiratory rate, decreased O2

saturations

Worsening COPD +/- acute respiratory infection

To increase the ability to clear airways

□ □ □ □ □ □

Give nebulisers as prescribed. Ensure nursed in upright position. Encourage regular movement. Ensure adequate fluid intake. Ensure physiotherapy referral. Give antibiotics as prescribed.

Signature …………………………………..

Alteration in comfort shown by verbal expression, body language

Worsening COPD +/- acute respiratory infection and BiPAP

Promote comfort

□ □ □ □ □

Ensure NIV is fitted comfortably. Allow patient rest periods if necessary – starting with 5 minutes each hour. Ensure patient is given oxygen via nasal specs or venturi mask during rest period. Modify patient position if necessary. Protect nasal bridge and cheeks with duoderm, as appropriate.

Signature …………………………………..

Name Trust ID DoB

(Attach patient sticker)


Date Problem Cause Goal Nursing Intervention

Risk of dehydration shown by reduced tissue turgor, coated tongue, concentrated urine


To prevent or correct dehydration

□ □ □

Encourage hourly fluids orally during NIV rest periods. Accurate input and output fluid balance chart. Give IV fluids as prescribed.

Signature ………………………………….

Risk of skin damage shown by inability to change position


To prevent pressure damage

□ □ □ □

Ensure pressure risk assessment complete (Waterlow score). Patient to be nursed on profiling bed with suitable mattress. Position to be changed 2 hourly or more, depending on assessment of need. Ensure adequate nutrition hydration.

Signature ………………………………….

Anxiety shown by verbal expression, body language


To alleviate anxiety

□ □ □ □ □

Give clear, simple explanation of CPAP/BiPAP to patient. Ensure NIV is fitted comfortably and correctly. Allow rest period from NIV. Remain with patient if necessary. Where possible, involve relatives in care. Give NIV patient leaflet to family and/or patient.

Signature ………………………………….

Weaning from BiPAP

To plan weaning from BiPAP according to patient’s individual requirements

□ □ □ □

Plan weaning from BiPAP with multi-professional team. Agree aim of oxygen saturations. Stop BiPAP. Continue oxygen therapy via nasal specs or venturi mask.

Monitor for signs of respiratory distress/increased work of breathing.


Appendix 7 NIV Consumables

Item Bunzell code

Mask (single)

PerformaTrak™ S (small) 1012573

PerformaTrak™ M (medium) 1012574

PerformaTrak™ L (large) 1012635

Tubing: Dry circuit pack for Focus™ 9624C

Filter

Grey foam pollen filter (pack of 2) 1005964

Low resistance bacterial filters (box of 10) 1030663


Appendix 8 Terminology and Settings for the FOCUS™

IPAP

Inspired positive airway pressure – the device increases the pressure from EPAP to IPAP to assist the work of breathing and to ensure a tidal volume which eliminates CO2 retention. Recommended starting pressure 10 cm H2O.

EPAP

Expired positive airway pressure – the device returns to EPAP and holds the airways open at this pressure to ensure lung recruitment and increased functional residual capacity (FRC) to increase oxygenation. Recommended starting pressure 4 cm H2O.

Rise Time

The speed at which the flow from the device goes from EPAP to IPAP. This is for comfort. However, a patient with tachypnoea or obstructive lung disease may require a faster rise time (i.e. set at 1).

Pressure Support

A method of assisting spontaneous breathing, making it easier for them to take a bigger breath. It is the difference between IPAP and EPAP.

Inspiratory Time

This is the inspiratory time for each back up breath. This is normally set at a third of the back up breath rate. 10 bpm = 6 seconds (60 ÷ 10) 6 ÷ 3 = 2 seconds. Therefore the I-time = 2 seconds.

Ramp Time

Ramp is a feature by which the pressure gradually increases from EPAP or below to IPAP. The time range can be set from 0 - 45 minutes.

Ramp Start

This is the starting pressure for the RAMP feature. This can be set at the EPAP setting or below if the EPAP is set higher than 4 cm H2O.

use of niv outside of icu€¦ · antibiotic agent (as per bht guidelines). consider niv. all...

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