Ongoing monitoring and optimisation of NIV

Troubleshooting and optimisation of NIV

Healthcare professionals should be aware of the individual factors that influence a patient’s adherence, the effectiveness of the ventilation and those patients who may be most at risk of ineffective NIV, for example patients with bulbar impairment.

On this page:

Potential problems with the mask

Potential problems causing poor tolerance of NIV

Potential problems with the ventilation

Good practice points

In the following clip Rosie Whitehead, a Respiratory Physiotherapist, describes some of the problems that can cause poor tolerance and to how to manage these.

Potential problems with the mask

Learn more about troubleshooting steps by clicking on the problems below.

Poor mask fit

Adjust mask straps
Inspect and replace mask straps if worn
Trial of alternative masks

Nose or face soreness

Optimise mask fit
Rotate different masks during a 24-hour period
Protective equipment such as gel plasters or dressings
Involve tissue viability specialist

Dry eyes or irritation

Assess for and address mask leak
Offer lubricating eye drops

Mask leak

Optimise mask fit
Consider a chin strap or neck collar
Seek senior support

Poor mask fit results in nose and face soreness, dry eyes, poor ventilation, discomfort and poor tolerance. If mask fitting is difficult, a face-to-face assessment may be appropriate, particularly as disease progresses.

Protective pad for masks

Potential problems causing poor tolerance of NIV

Excessive oropharyngeal or respiratory

Review medications that can cause excessive secretions, eg clozapine.
Consider pharmacological and non-pharmacological strategies to reduce secretions.
Offer an oropharyngeal suction machine.
Optimise cough, eg use of cough optimisation techniques, positioning.
Optimise swallow, eg positioning, collars.

Dry mouth or thickened oropharnygeal or respiratory sections

Review medications which can cause thickened or dry secretions, eg diuretics, anticholinergics.
Offer medication for thickened secretions (eg carbocysteine, nebulised saline) artificial saliva and good hydration for dry mouth.
Provide NIV humidification.
Offer an oropharyngeal suction machine.
Optimise cough and swallow.
Optimise oral hygiene.

Claustrophobia

Offer alternative masks including mouthpiece.
Optimise communication, eg consider the need for AAC.
Offer psychological therapies.
Discuss and plan for the likelihood of future deterioration with the patient, family, carers and multidisciplinary team.

Agitation

Consider whether respiratory failure is adequately treated.
Ensure adequate communication strategies in place.
Involve palliative care team.
Consider non-pharmacological strategies, eg psychological interventions.
Consider pharmacological strategies, eg anxiolytics.
Consider the patient’s current wishes and advance directives and prepare for further deterioration.

Increasing dependence on NIV

Ensure patient and carers have access to sufficient (and back-up) equipment to manage on a day-to-day basis and in the event of equipment or electricity failure, eg multiple machines, battery, masks, straps and tubes.
Offer alternative masks or mouthpieces to enable the mask to be removed for oral care.
Discuss and plan for the likelihood of future deterioration with the patient, family, carers and multidisciplinary team.
Consider offering pre-emptive prescribing or a ‘Just in case’ box.

Patient wearing a oronasal mask

Potential problems with the ventilation

New or poorly controlled symptoms of respiratory failure

New or poorly controlled symptoms of respiratory failure.
Monitor adherence using diaries and objective measures, eg telemonitoring.
Assess ventilation using overnight oximetry +/- telemonitoring +/- polysomnography.
Discuss and plan for the likelihood of future deterioration with the patient, family, carers and multidisciplinary team.

Hypoventilation

Address mask leak.
Seek expert support.

Low tidal volumes

Address mask leak.

Upper airway events

Consider obstructive sleep apnoea.
Change from an oronasal mask to a nasal mask.
Avoid neck flexion.
Offer a cervical collar.
Mandibular advancement device.
Seek expert support.

Premature expiratory effort

Address mask leak.
Seek expert support.

Auto-cycling asynchronies

Address mask leak.
Seek expert support.

Ventilator not triggering despite patient effort

Address mask leak.
Reduce trigger sensitivity.
Change to pressure-controlled mode.

Good practice points

Healthcare professionals should be aware of factors that influence a patient’s adherence to NIV and the effectiveness of the ventilation, as well as those patients who are at high risk.
Healthcare professionals should monitor patients regularly to check for problems and take steps to rectify them.
If necessary, healthcare professionals should seek senior support to rectify problems affecting patients.