Initiation of NIV
Timing of referral
NIV should be commenced at a time that’s right for the patient. Patients should be offered a trial of NIV when they develop signs or symptoms of respiratory failure.
Early initiation allows time for the patient and carer to acclimatise to the diagnosis of respiratory failure and the adapt to using NIV. This avoids the need for urgent initiation. Patients who are already in established respiratory failure have a high early mortality and may fail to gain benefit from NIV. In addition, they may need to be optimised quickly and this may not allow time for acclimatisation and promotion of good adherence.
Timing of initiation of NIV
Patients with a PaCO2 of >6kPa, hypoxia or signs or symptoms of severe respiratory failure, or rapidly deteriorating respiratory function should be considered for immediate inpatient initiation of NIV as they have a high mortality.
We recommend that patients needing to start NIV without signs of severe respiratory failure should still be referred urgently and be seen within one week.
We recommend that patients without respiratory failure should be referred to a respiratory specialist as soon as possible after diagnosis and seen by respiratory services within four weeks.
When making a referral, it is important to explain the reason for the referral to patients and their carers and consider ways in which they can be prepared to start NIV such as dealing with oropharyngeal and respiratory secretions, assessing carer burden and any psychological distress.
In the following clips, Debbie Freeman, a Respiratory Nurse, and Rosie Whitehead, a Respiratory Physiotherapist, describe the importance of early referrals and early initiation.
When initiating a patient on NIV, acclimatisation should occur over a short period (eg a couple of days) with patients encouraged to use NIV for as much time as possible, preferably all night. It is important that staff explain to patients that a minimum of four hours of NIV use per day is recommended as this has been associated with improved survival.
In the following clip, Rosie and Matt Cox, an Extended Scope Respiratory Physiotherapist, discuss the importance of patients needing to persevere with NIVB and that staff should emphasise the need for patients to get adequately ventilated as soon as possible.
However, for some patients, it may be necessary to perform initial acclimatisation during the day and gradually increase their use of NIV. This is highlighted in the following video where James explains that building up NIV steadily was the best approach for him.
Patients should also be allowed short breaks to encourage diet, drinks, oral hygiene, nebulisers and oral medication.
Good practice points
Patients should not be referred late, as this is associated with a poorer prognosis.
For an urgent referral, the patient should be seen immediately.
Healthcare professionals should consider the factors that influence the timing of referral and initiation of NIV and take steps to prevent delays.
Generally, acclimatisation should occur over a short period of time. However, for a minority a gradual acclimatisation period may be needed so an individualised approach should be taken.