Initiation of NIV
When should patients be initiated on NIV?
Late initiation of non-invasive ventilation (NIV) is associated with a poor prognosis so it is vital that patients are not referred late in the course of their disease. 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 initiation of NIV.
Patients needing to start NIV without signs of severe respiratory failure should still be referred urgently and be seen within one week. 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.
There are many factors that can influence the timing of referral and initiation of NIV you should take steps to prevent delays.
My patient is experiencing respiratory secretions. Do they need Cough Assist?
All patients experiencing respiratory secretions should be referred to have a chest clearance assessment to assess the need for a Cough Assist device or secretion clearance manoeuvres. If a Cough Assist device is recommended, this should be explained clearly to the patient and set up by an expert.
How should sialorrhea be managed?
Sialorrhea should be managed using a trial of antimuscarinic medicine as the first-line of treatment. If the patient has cognitive impairment, glycopyrrolate should be considered as the first-line treatment for sialorrhea because it has fewer central nervous system side effects.
If first-line treatment is ineffective, not tolerated or contradicted, you should consider referring the patient to a specialist service for Botulinum toxin A.
How should I prepare my patient for NIV?
You should explain the process of setting up NIV clearly and in a positive and calm manner. You should provide patients and family members with information, training and guidelines so they understand that they are allowed to ask for help, when to ask for help and who to ask. You should assess the patient’s supportive environment to ensure that they have support at home available. You should also provide reassurance whilst setting up the NIV.
Can people living with MND use oxygen?
Oxygen use in MND can be very dangerous. Respiratory failure in MND causes a chronic increase in blood carbon dioxide and later, hypoxia. A sudden deterioration in breathing (such as during a pneumonia) can cause worsening hypoxia and respiratory distress.
In people with chronic respiratory failure, providing oxygen can overcorrect their hypoxia, reducing their body’s drive to breathe causing their breathing to become slower, more shallow or stop completely. They may become drowsy or die.
If oxygen is used it should be used in a controlled manner to target saturations of 88-92% and monitored very closely for signs of deterioration. Expert advice should be sought urgently and any advanced care or emergency plans should be consulted.
What should I discuss with patients when setting up NIV?
You should explain the procedure in a positive and calm manner, and provide reassurance. You should explain that hours of use is a significant prognostic factors and that perseverance may be required. You should encourage patients to use the NIV.
Where should patients be set up on NIV?
The most suitable place for set up will depend on patient choice, complexity, safety and the planned speed of initiation. It is important that staff initiating in a domiciliary setting are appropriately trained and equipped to detect and deal with emergencies arising such as respiratory collapse and aspiration.
Patients with signs of respiratory crisis require admission. Signs of respiratory crisis include
extremely rapid deterioration
severe respiratory infections
When initiating a patient on NIV, what equipment do they need?
All patients should be provided with at least one NIV machine with the option of having two machines, especially if the service does not provide an out-of-hours support service. Patients should be given a minimum of two mask interfaces and a battery-aided machine if using NIV for more than eight hours.
What mask interface should be used for initiating NIV?
This requires an individualised approach as the most appropriate mask will depend on patient choice, need and safety. Therefore, it is key that there are a range of mask interfaces available to choose from and these should be available in a range of sizes.
What settings should be used to initiation patients on NIV?
It is important that you seek senior support when deciding on the initiation settings to use. It is key that the settings are optimised at initiation to ensure good adherence and effective ventilation. You should make sure that the patient is synchronising with the machine. The settings to use will be influenced by individual circumstances such as age, weight and CO₂ levels.