Non-invasive Ventilation in Medical Retrieval
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1 Non-invasive Ventilation in Medical Retrieval Dave Tingey Retrieval Paramedic Practitioner (Candidate in Training) MedSTAR Emergency Medical Retrieval
2 Questions > How are we using non-invasive ventilation? > Does the transport platform have any impact? > What effect has improved technology had?
3 Disclaimer > I have no financial interest in any of the products mentioned in this presentation!
4 Background Retrievals in SA > Pre-2009 RAH Mediflight - adult FMC adult / paeds / neonates WCH paeds / neonates > Jan 2009 MedSTAR Emergency Medical Retrieval SA Health state-wide retrieval service Adults / paeds / neonates Primary / inter-hospital
5 Data > RAH Mediflight > MedSTAR > Operational data > Clinical data (limited) > Adult IHT / all primaries
6 Data > patients > 362 on NIV prior to arrival > 252 transported on NIV
7 NIV Pre/Post Retrieval Num ber of cases NIV Pre-Retrieval NIV Post-Retrieval Year
8 NIV by Working Diagnosis Other / unknow n Other neurological CVA (not SAH) Other infection Pre-Retrieval Post Retrieval Other respiratory Pneumonia +/- shock COAD Asthma Other cardiac Myocardial Infarction Pulmonary Oedema / CCF
9 Respiratory Outcomes Saturations % Respiratory Rate Arrival Delivery Saturations Respiratory Rate
10 Reasons for NIV > Best practice / definitive care > Avoidance of invasive ventilation > Trial with a view to intubation if fails > Ceiling with a plan not to intubate > Bridging to further care > Pre-oxygenation (e.g. prior to RSI)
11 Patient Selection > Underlying pathology > Likely clinical course > Co-morbid issues > Access in transport Monitoring Intubation
12 NIV for COPD Exacerbation > Cochrane review of 14 RCTs Decreased mortality Decreased need for intubation Reduction in treatment failure Rapid improvement in ph, PaCO2 and respiratory rate Reduction in treatment complications Reduced length of hospital stay > Cochrane Database (2009) 104/frame.htm
13 NIV for Asthma > Cochrane database One RCT, 30 pts > Significant improvements in Hospitalisation rate Number of ED discharges FEV1, FVC, PEFR and RR > The application of NPPV in patients suffering from status asthmaticus still remains controversial. Further studies are needed to determine the role of NPPV in the management of severe acute asthma. > Cochrane database (2005) tml
14 NIV - Bariatric Patients > Reduction in WOB > Improved oxygenation > Improved ventilation > Avoidance of intubation
15 NIV By Weight NIV All Pts Pt weight >110kg Pt weight >110kg Pt weight <110kg Pt weight <110kg Weight Category NIV % All transports % Pt weight <110kg % % Pt weight >110kg 57 21% % Total
16 Platforms PC-12 Ambulance BK117 B412
17 % NIV By Transport Platform Defence asset Lear jet Chartered Jet All Transports NIV Transports Other / unknown B412 BK117 Pilatus PC12 Road ambulance 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
18 Pilatus PC-12
19 Bell 412
20 BK117
21 Ventilator Selection > Work of breathing was halved with a highperformance ventilator > the effort required to trigger the ventilator represents 10-20% of the breathing effort. > turbine-based ventilators perform as well as the best conventional ICU ventilators. Thille, A. et al (2009) A bench study of intensive-care-unit ventilators: new versus old and turbine-based versus compressed gas-based ventilators, Int. Care Med., 35:
22 Oxygen Requirements > 2x transport time (mins) x [MVxFiO2] > + ventilator driving gas > + leak compensation > Ellis, D; Hooper, M; 2010, Cases in Pre-hospital and Retrieval Medicine, Elselvier.
23 Prehospital CPAP > Boussignac
24 Oxylog 2000 > Gas powered > NIV: CPAP > No leak compensation > [O2] 60/100%
25 Oxylog 3000 > Gas driven + battery <4 hours > NIV: PS PCV +/- PS CPAP +/- PS > Leak compensation > [O2] % > Trigger sens lpm
26 ResMed Elisee 350 > Electric turbine 6hrs > NIV: PS +/- TV CPAP +/- PS > Leak compensation > [O2] % > Trigger sens. 1-5 lpm > Triggering delay <50ms > Synchronised nebulisation
27 ResMed Elisee 350
28 Conclusions > The use of NIV has increased significantly over the last few years. > NIV can be used safely in medical retrieval > Patient screening is important > Technology has allowed improved provision of NIV > Data recording could be better > Further multi-centre research is required
29 Thank you
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