NON-INVASIVE VENTILATION POLICY

Transcription

1 NON-INVASIVE VENTILATION POLICY

2 Policy Title: NON INVASIVE VENTILATION Executive Summary: This policy sets out the procedure for the use of Non - Invasive Ventilation in the treatment of acute hypercapnic respiratory failure. Supersedes: Version 3.0 Description of Update of Non Invasive Ventilation Equipment Amendment(s): This policy will impact on: Clinical Practice carried out by Medical and Nursing Staff. Financial Implications: Ward 4 budget / financial resources for Medical Business Unit. Policy Area: Ward 4 M.D.G.H. Document ECT Reference: Version Number: 4.0 Effective Date: October 2016 Issued By: Respiratory Consultant Review Date: October 2018 Author: Advanced Respiratory Specialist Practitioner (Integrated Respiratory Team) Impact Assessment Date: October 2016 APPROVAL RECORD Committees / Group Date Consultation: Respiratory Consultants SQS (Medicine) September 2016 October 2016 Ward 4 Staff, Medical Nurse October 2016 Practitioners, Medical Staff Respiratory Nurse Specialists Received for information: OCF/Trust Board/Team Brief October

3 NON INVASIVE VENTILATION CONTENTS Page 1.0 Introduction Inclusion / Exclusion Criteria Indication for Intubation Patient Selection Training Equipment required Assembly Initiation Initial Settings Post Initiation Monitoring Continued Monitoring Failure to Improve Continuing Care Weaning Infection Control References 10 Equality Analysis (Impact Assessment) 11 3

4 1.0 INTRODUCTION Non Invasive Ventilation (NIV) in the management of acute Type II respiratory failure in patients with Chronic Obstructive Pulmonary Disease (COPD) represents one of the major technical advances in respiratory care over the last decade (Royal College of Physicians 2008). The National Institute for Health and Clinical Excellence (NICE) recommends that NIV be available in all hospitals admitting patients with COPD (2004). NIV, within both the intensive care unit and the ward environment, has been shown in randomised controlled trials and systematic reviews to reduce intubation rate and mortality in COPD patients with decompensated respiratory acidosis following immediate medical therapy (Plant et al 2000). NIV should be considered within the first 60 minutes of hospital arrival in all patients with an acute exacerbation of COPD (RCP 2008). Acute hypercapnic respiratory failure (AHRF) is the term now used for the above. It is defined by ph <7.35 and pco2 >6.5kPa. More severe acidosis (ph <7.25) has conventionally been used as the threshold at which invasive mechanical ventilation (IMV) in ITU should be considered. NIV can be performed on a Respiratory Ward and does not necessitate the patient being managed in an Intensive Care Unit (ICU) or High Dependency Unit (HDU) environment (Gibbons and Milner 2002). NON INVASIVE VENTILATION IS EXCLUSIVE TO WARD 4 ONLY FOR FURTHER ADVICE ON THE MANAGEMENT OF THE PATIENT WITH RESPIRATORY FAILURE, PLEASE CONTACT The RESPIRATORY CONSULTANTS on either Extension 3211 or 1350 Or The Integrated Respiratory Team; Tel; , between 8 6 pm daily. 4

5 2.0 INCLUSION CRITERIA Acute hypercapnic respiratory failure in the acute or acute on chronic patient who does not require/ not suitable for tracheal intubation with; Or; ph < 7.35 pc02 > 6.5 kpa Increased respiratory rate despite optimisation with oxygen therapy Acute hypercapnic respiratory failure with chest wall deformity, neuromuscular disorder, bronchiectasis or decompensated obstructive sleep apnoea. AHRF in the context of asthma should precipitate URGENT review by the critical care team Type I respiratory failure and tiring, may be suitable for CPAP or NIV but must be implemented in a HDU setting. Patients weaning from mechanical ventilation Patients where you might wish to avoid tracheal ventilation EXCLUSION CRITERIA ph > 7.35 Or; Inability to protect airway/ fixed upper airway obstruction Metabolic acidosis Life threatening hypoxia/ impending respiratory arrest: Patients to be referred to ICU unless decision has been made not to escalate care. Undrained pneumothorax Patient refusal Facial injuries / burns / deformities or chest wall trauma Severe pneumonia on the background of stable disease / good quality of life. Relative contra-indications: Vomiting Impaired consciousness /confusion /agitation Inability to clear own secretions despite physiotherapy Hypotension monitor closely 2.1 INDICATIONS FOR INTUBATION/ ITU referral (If decision has been taken to escalate care) Respiratory arrest HR below 50 Respiratory rate > 35 despite trial of NIV Patient requiring sedation, nursing management becomes difficult ph <7.15 ph <7.25 and any of the following adverse prognostic indicators: 5

6 o Late acidosis (post admission) o Copious secretions o Consolidation on CXR o GCS <8 o Failure to improve ph/respiratory rate at 4h 2.2 PATIENT SELECTION Statement on ceiling of treatment / resuscitation status required with management plan clearly stated in the patients notes Referral to on-call Anaesthetist, for assessment of patient, for suitability of Invasive Ventilation if NIV fails Able to maintain own airway Able to expectorate Able to comprehend procedure and comply with instructions as well as tolerate mask Patients with impaired conscious levels may be considered as long as there is adequate respiratory effort 2.3 TRAINING Patients who require NIV must be transferred to ward 4 prior to initiation. NIV will be set up by the Trained Nurses on the Respiratory Ward. Other personnel involved in the monitoring of the patients are Junior and Senior Medical staff. Training on initiation, monitoring and weaning of NIV will be provided for all junior medical and Nursing staff on commencement on Ward 4, and a database of nursing and medical staff who have had training will be kept as evidence of competence. This will be kept by the Trainer. Nurses will undergo annual NIV updates, database to be kept by Ward Manager 2.4 EQUIPMENT REQUIRED Resmed Stellar 100 Bi-level ventilator Fisher Paykel masks Fisher Paykel humidifier Pack containing Armstrong breathing circuits x 2, humidification chamber and delivery system for distilled water Oxygen tubing 2.5 ASSEMBLY (See Manufacturers Instructions) Ventilator connection point to oxygen tubing to flow meter tubing humidifier tubing mask 2.6 PRE-VENTILATION CHECKS Factory Reset Learn circuit prior to connection of mask 6

7 3.0 INITIATION In all patients with AHRF, controlled oxygen therapy should be used to target O2 saturations to 88-92%. NIV is appropriate when optimised therapy (consisting of nebulisers, controlled oxygen and steroids) have failed to improve/correct acidosis. ABGs should be checked 1h after initiation of medical therapy, and NIV should be commenced if acidosis persists at this time. Setting up is time intensive, but extra staffing is not required once the patient is established and stable. Give full explanation of procedure to patient and how they will benefit, show patient the machine and masks etc. Assemble ventilator as above with humidifier. Select appropriate sized mask and headgear, according to patient s size and measurement guide. Ensure correct fitting and comfort of patient. Allow patient to feel positive pressure on their hand. Humidifier must be filled with sterile water via infusion Set humidifier at 4 and adjust according to patient comfort (if excess condensation is noted reduce setting, if patient s secretions are thick and tenacious setting may need to be increased) 3.1 INITIAL SETTINGS Set Inspiratory Positive Airway Pressure (IPAP) at 15cmH20 (A higher starting pressure may be required but this is at the discretion of the Respiratory Consultant / Registrar) Set Expiratory Positive Airway Pressure (EPAP) at 4 cmh20 (or higher at the discretion of the Respiratory Consultant/ Registrar) The EPAP is responsible for splinting the airways open on expiration in order to increase oxygen levels. In the presence of persisting hypoxia, the EPAP should be increased to a maximum of 8cmH2O (10 in patients with OSA). The pressure support (the difference between the IPAP and the EPAP) should be targeted for no less than 15cmH20 once patient is established on NIV. If the EPAP is increased, then the IPAP should also be increased. Pressure support increases the tidal volume breathed by the patient, which helps to reduce the CO2 levels. Ideally, IPAP should be increased by 2 cm increments at a rate of approximately 2 cmh2o every 10 minutes, with a usual pressure target of 20 cmh2o or until a therapeutic response is achieved or patient tolerability has been reached. Back up breath rate defaults to 10 breaths per minute for all patients. Back up breaths are delivered automatically by the ventilator if the patient becomes tachypnoeic or has feeble respiratory effort. The Inspired time (Ti) ranges from seconds and is pre-set on the ventilator Add l / min of oxygen (or greater if needed) to achieve Sa02 levels between 88-92% 7

8 Set rise time / ramp to a setting that the patient finds comfortable (low / medium or high) The IPAP should not be higher than 20cmH20 unless stated by the Respiratory Consultant / Specialist Registrar. 3.2 POST INITIATION Ensure that oxygen therapy is prescribed as per BTS guidelines and that target saturation range is stated. Aim for oxygen saturations between 88-92%, monitor continuously Perform ABGs 1 hour post initiation, these results should be reviewed and settings increased as appropriate. Once the ABGs are stable, repeat at 4h to ensure there is sustained response/absence of respiratory acidosis. If changes are made to settings, repeat ABGs after 1 hour The aim is to gradually increase the pressures by 2cms at a time, in accordance with the results, i.e. if the CO2 is still high then increase the IPAP, if the 02 is still low increase both the IPAP and EPAP. Observe for signs of CO2 retention Observe for any changes to Track and Trigger Score if patients scoring increases contact Medical Staff as per protocol If sharp rise in pco2 noted, repeat ABGs If the patient is struggling to tolerate NIV, this is usually due to high pressures. Reduce pressures to maximum settings tolerated: some NIV is better than none! 4.0 MONITORING Monitoring should include a mixture of physiological measures and clinical parameters. These parameters should be used to assist in formulating a management plan and within the first 4 hours of NIV assist in the decision as to the need to escalate to intubation. Staff involved in the care and monitoring of NIV patients should be appropriately trained and experienced. The following should be recorded and be used to formulate an iterative management plan: Baseline observations: Arterial blood gas (ABG) Respiratory rate heart rate Continuous pulse oximetry Repeat ABGs: after 1 hour of NIV therapy and 1 hour after every subsequent change in settings After 4 hours, or earlier in patients who are not improving clinically Frequent clinical monitoring of acutely ill patients: 8

9 i.e. every 15 minutes in the first hour, every 30 minutes in the 1 to 4 hour period, hourly in the 4 to 12 hour period Observations including: respiratory rate, heart rate level of consciousness, patient comfort chest wall movement, ventilator synchrony, accessory muscle use, general patient comfort. 4.1 CONTINUED MONITORING Respiratory muscle co-ordination Synchronisation with the machine Mask leak Mental state If signs of drowsiness CHECK ABG s N.I.V. should remain in situ as long as possible with minimal interruptions within the first hours (RCP2008). Remove only for meals, Nebuliser therapy, physiotherapy, personal care etc Check for improvement in ph, reduction in pc02, if so continue Review NIV requirement daily with Respiratory Consultants / Respiratory Registrars Daily ABG s are required to assess effectiveness of treatment. 5.0 FAILURE TO IMPROVE Seek Medical advice from Respiratory Physicians or Respiratory Registrars 6.0 CONTINUING CARE Allow minute breaks every 3-4 hours for meals, drinks and medications (ensure patient using controlled 02 therapy via nasal cannulae) Check for pressure sores from mask regularly, apply Granuflex/ Duoderm if required 7.0 WEANING Consider weaning when patient is no longer acidotic and ABGs have returned to within normal parameters (or as per patients previous A.B.G.s when stable) SpO2 above 85% on air or 90% on l/min via nasal cannulae Respiratory rate below 25 breaths per minute No use of accessory muscles Able to complete sentences Begin weaning process by either discontinuing NIV for periods of 2-3 hours at a time, whilst carefully monitoring the patient or discontinue daytime use and use only overnight, as the patient s condition improves. Patients naturally hypo-ventilate overnight, so during weaning, NIV should be continued overnight as much as possible until fully weaned. Recommended weaning strategy: Continue NIV for 16 hours on Day 2 Continue NIV for 12 hours including 6-8 hours overnight use on Day 3 9

10 Discontinue NIV on Day 4, or at the discretion of the Respiratory Physician (RCP 2008) Note that some patients may: a) Show at an earlier stage that they no longer require NIV and self-wean b) Improve rapidly, prompting a clinical decision to wean early c) Require long-term nocturnal support, indicated following assessment by the respiratory team. 8.0 INFECTION CONTROL Humidifier tubing and ventilator tubing single patient use / disposable All face masks/nasal masks single patient use / disposable Follow manufacturer s recommendations for servicing and cleaning (Medical Engineering) Superficial cleaning only of ventilator Ensure filter changed every month every 3 months by Medical Engineering 9.0 REFERENCES British Thoracic Society & Intensive Care Society (2016) Guidelines for the Ventilatory Management of Acute Hypercapnic Respiratory Failure in Adults Thorax; Vol 71 Royal College of Physicians, British Thoracic Society, Intensive Care Society 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, British Thoracic Society (2008) Guidelines for Emergency Oxygen use in adults Thorax; Vol 63 Gibbons, D. Milner, P. (2002) Non Invasive Positive Pressure Ventilation for COPD patients, Professional Nurse 17: National Institute for Clinical Excellence (2004) Chronic Obstructive Pulmonary Disease: Management of COPD in adults in Primary and Secondary Care Clinical Guideline 12 Royal College of Physicians (2008) Non Invasive Ventilation in COPD: management of acute type 2 respiratory failure National Guidelines Plant, P.K. Owen, J.L. Elliott M.W. (2000) Early use of Non Invasive Ventilation for acute exacerbation of COPD on general Respiratory wards: a multi-centre randomised controlled trial The Lancet; Vol 355 Revised: Aug 2016 Review: Aug

11 Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Non Invasive Ventilation Details of person responsible for completing the assessment: Name: Jackie Bayliss Position: Advanced Respiratory Specialist Practitioner Team/service: Integrated Respiratory Service State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) Non Invasive Ventilation (NIV) is the gold standard treatment in the event of Acute Hypercapnic Respiratory Failure seen in patients with exacerbation of Chronic Obstructive Pulmonary Disease (COPD).The aim of the policy is to act as a protocol for the management of these patients and to provide guidance in the use of the equipment. Evidence Base NICE guidance in:- Chronic Obstructive Pulmonary Disease : Management of COPD in adults in Primary and Secondary Care Clinical Guideline 12 Royal College of Physicians, British Thoracic Society, Intensive Care Society Chronic obstructive pulmonary disease: non-invasive ventilation with bi-phasic positive airways pressure in the management of patients with acute type 2 respiratory failure (2008) British Thoracic Society Standards of Care Committee (2002) Guidelines on Non Invasive Ventilation in Acute Respiratory Failure. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document 11

12 Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester 12

13 Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester No Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No 2.3 Does the information gathered from indicate any negative impact as a result of this document? 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes Explain your response: If the patients first language is not English, then full explanation of the treatment can be given and consent gained via telephone interpretation. All staff should be aware of the trust s interpretation and translation policy. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? No Explain your response: No differential impact identified regarding gender DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes 13

14 Explain your response: Following an initial equality impact assessment the Learning Disabilities group of patients may need to be excluded from the proposal, depending on the level of severity, due to the potential complexity of their needs and ability to comply with the treatment. If the patient is visually impaired or blind, then any written information regarding the procedure would need to be translated or put in large print. During the treatment, full explanations would need to be given before each step as the patient may not be able to see what is happening. If the patient is Deaf, then a British Sign language interpreter may be used, or the new Sign translate on line BSL interpretation system, when this is rolled out across all areas. For a hearing impaired person. Staff can use a portable induction loop if the patient wears a hearing aid or a hand held communicator if not (these can be located in ward communications boxes). There are picture communication books in the boxes to assist people with limited understanding. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? No Explain your response: The procedure would be carried out regardless of age groups for any adult patient. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? No Explain your response: The procedure would be carried out regardless of sexual orientation. Staff have access to equality and diversity training as part of stat/mandatory programme. RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes Explain your response: For Muslim women wearing a burkha, they should be attended to by females only, where possible, as it would offend their religious beliefs if seen uncovered by a male. If the patient is conscious, then staff should ask the patient their preference. In an acute emergency, safety of the patient is paramount. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? No Explain your response: If a carer / relative is in attendance, they would also need a full explanation as to the reason for the procedure OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? No Explain your response: The procedure would be carried out regardless of other status. The Staff has access to equality and diversity training as part of stat/mandatory programme. 14

15 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children Adult policy only 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Respiratory Consultants, Integrated Respiratory Team, Medical Nurse Practitioners, Critical Care Outreach Practitioners, Peri-operative Practitioners, Night Nursing Sisters and Respiratory / MAU Ward Staff 6. Date completed: Oct 2016 Review Date: Oct Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: October