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Non-Invasive Respiratory Support This page intentionally left blank Non-Invasive Respiratory Support: A Practical Handbook Third edition Edited by Anita K Simonds MD FRCP Consultant in Respiratory Medicine,Royal Brompton and Harefield NHS Trust,London,UK Hodder Arnold AMEMBER OF THE HODDER HEADLINE GROUP First published in Great Britain in 1995 by Chapman & Hall Second edition 2001 This third edition published in 2007 by Hodder Arnold,an imprint ofHodder Education and a member ofthe Hodder Headline Group, an Hachette Livre UK company, 338 Euston Road,London NW1 3BH http://www.hoddereducation.com © 2007 Edward Arnold (Publishers) Ltd All rights reserved.Apart from any use permitted under UK copyright law,this publication may only be reproduced, stored or transmitted,in any form,or by any means with prior permission in writing ofthe publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency.In theUnited Kingdom such licences are issued by the Copyright Licensing Agency:Saffron House,6–10 Kirby Street, London EC1N 8TS. Whilst the advice and information in this book are believed to be true and accurate at the date ofgoing to press,neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made.In particular (but without limiting the generality ofthe preceding disclaimer) every effort has been made to check drug dosages;however it is still possible that errors have been missed.Furthermore,dosage schedules are constantly being revised and new side-effects recognized.For these reasons the reader is strongly urged to consult the drug companies’printed instructions before administering any ofthe drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library ofCongress Cataloging-in-Publication Data A catalog record for this book is available from the Library ofCongress ISBN 978 0 340 92560 7 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Philip Shaw Project Editor: Heather Fyfe Production Controller: Karen Tate Cover Designer: Andrew Campling Typeset in 10 on 12 pt Minion by Phoenix Photosetting,Chatham,Kent Printed and bound in Malta What do you think about this book? Or any other Hodder Arnold title? Please visit our website:www.hoddereducation.com Contents Contributors vii Preface ix Abbreviations Used xi Getting the basics right 1 Overview of indications for non-invasive respiratory support 1 A K Simonds 2 Equipment for non-invasive ventilation: Ventilators, interfaces and accessories 9 A K Simonds 3 Setting up a non-invasive ventilation service 31 A K Simonds Acute indications for NIV 4 Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease 39 M W Elliott 5 Continuous positive airway pressure and non-invasive ventilation in acute hypoxaemic respiratory failure 57 A K Simonds 6 Acute non-invasive ventilation in neuromuscular disease, chest wall disorders and cystic fibrosis and bronchiectasis 73 A K Simonds 7 Starting non-invasive ventilation: Practical aspects 81 A K Simonds 8 Cough assistance and physiotherapy aspects of the patient requiring non-invasive positive pressure ventilation 99 M Chatwin 9 Problem-solving in acute non-invasive ventilation 113 S Heather, M Chatwin and A K Simonds Intensive care, emergency department and perioperative indications for NIV 10 Non-invasive ventilation and post-extubation respiratory failure 123 S Nava and A Carlucci 11 Weaning using non-invasive ventilation 133 B Schönhofer vi CONTENTS 12 Non-invasive ventilation in the emergency department, for transferring patients and during intercurrent procedures 143 A K Simonds Selection of patients and outcome of long term non-invasive ventilation 13 Assessment and selection of patients for home ventilation 155 A K Simonds 14 Home non-invasive ventilation in restrictive disorders and stable neuromuscular disease 175 A K Simonds 15 Home ventilation in progressive disorders, quadriplegia and palliative non-invasive ventilation 193 A K Simonds 16 Non-invasive ventilation in chronic obstructive pulmonary disease 209 M W Elliott 17 Home ventilation in cystic fibrosis, bronchiectasis and diffuse interstitial lung disease 221 A K Simonds Discharge planning and problem-solving in long term non-invasive ventilation 18 Discharging the ventilator-dependent patient and the home ventilatory care network 229 A K Simonds 19 Problem-solving and transitions in long-term non-invasive ventilation 249 A K Simonds Acute and chronic non-invasive ventilation in children 20 Non-invasive ventilation in acute respiratory failure in children 257 O Norregaard 21 Home ventilation in children 275 B Fauroux Continuous positive airway pressure therapy in adults and children 22 Continuous positive airway pressure therapy for sleep disordered breathing in adults 291 A K Simonds 23 Continuous positive airway pressure for sleep disordered breathing in children 323 A K Simonds Organisational, ethical and medico-legal aspects of long term ventilation 24 Organization of home mechanical ventilation in Europe 333 S J Lloyd-Owen 25 Ethical and medico-legal aspects of assisted ventilation 345 M A Branthwaite and J-P Garside Appendix One: Suppliers of ventilatory equipment 355 Appendix Two: Useful contact addresses and websites 357 Index 359 Contributors Margaret A Branthwaite MD FRCP FFARCS;Barrister London,UK Annalisa Carlucci Pneumologist, Respiratory Unit, Fondazione Salvatore Maugeri, Instituto Scientifico di Pavia,Italy Michelle Chatwin Bsc Physiotherapy Clinical Specialist Physiotherapist,Noninvasive Ventilation and Neuromuscular Disease, Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, London,UK Mark W Elliott MD FRCP (UK) Consultant Respiratory Physician, Department of Respiratory Medicine, St James’s University Hospital,Leeds,UK Brigitte Fauroux MD,PhD Professor in Pediatrics,Pediatric pulmonology department and research unit INSERM U 719 Armand Trousseau Hospital,Paris VI University,Paris,France John-Paul Garside Head of Complaints and Legal Services,Norfolk and Norwich University Hospital NHS Trust and Honorary Senior Lecturer,University ofEast Anglia Steve Heather Chief Respiratory Support Technician,Sleep and Ventilation Unit,Royal Brompton and Harefield NHS Trust,London Simon J Lloyd-Owen MBBChir FRCP Consultant Respiratory Physician,Sleep and Ventilation Centre,London Chest Hospital, Barts and The London NHS Trust,London,UK Stefano Nava Respiratory Unit, IRCCS Fondazione Salvatore Maugeri, Instituto Scientifico di Pavia, Italy Ole Norregaard MD Director ofDanish Respiratory Center West,Arhus University Hospital,Arhus,Denmark viii CONTRIBUTORS Bernd Schönhofer Pneumologist, Intensivist, Department of Pulmonary and Critical Care Medicine, Klinikum Hannover,Hannover,Germany Anita K Simonds MD FRCP Consultant in Respiratory Medicine, Clinical and Academic Department of Sleep and Breathing,Royal Brompton and Harefield NHS Trust,London,UK Preface Since the second edition ofthis book in 2001,the field ofnon-invasive ventilation (NIV) has continued to expand briskly. NIV is recognized as ‘gold standard’ therapy in acute hypercapnic exacerbations ofchronic obstructive pulmonary disease (COPD) and should be provided by all centres admitting acute COPD patients. Some dilemmas such as whether to use CPAP or NIV in acute pulmonary oedema,and the timing ofintroduction of NIV in chronic neuromuscular disease are now mostly resolved. Intensive care and paediatric applications have grown, and there is evidence that NIV is being used by experienced units in sicker patients with maintained success rates. A wider range of paediatric interfaces (commercial and customized) is now available. This is particularly important for long-term use,so that facial pressure sores and mid-facial hypoplasia can be avoided. The impact of NIV on childhood neuromuscular disease means that many of these children who would have previously died in infancy are now surviving to adulthood. Some problem areas remain,and new controversies have arisen.Just what is the role of NIV in post-operative patients with respiratory failure,and which COPD patients (ifany) benefit from long-term NIV? How much NIV is required – a few hours in the day or is overnight use essential in COPD? Does NIV have any role in individuals with acute pneumonia due to pandemic flu or severe acute respiratory syndrome (SARS),and if so, how can healthcare staff be best protected from droplet dissemination of these diseases during NIV use? What are the equivalent infection control risks from high-flow oxygen therapy or intubating patients? There is growing interest in the use of NIV to palliate symptoms in endstage disease, and a randomized controlled trial has now shown that NIV extends life expectancy in amyotrophic lateral sclerosis/motor neurone disease. Even in those with marked bulbar weakness there may be improvement in sleep-related symptoms. In this area clear goal setting is required so that the burden oftreatment does not outweigh benefit.Research in the last few years has clarified the mechanisms of action of NIV in chronic respiratory failure, and not surprisingly these seem to differ between those with obstructive lung disease and restrictive disorders. This edition has been expanded to address these areas, and new expert contributors recruited. I am very grateful to these colleagues and previous contributors, all at the forefront oftheir field,who have provided new chapters.We have again included coverage of continuous positive airway pressure therapy in obstructive sleep apnoea in adults and children as the obesity epidemic means that a growing proportion of sleep laboratory patients may require NIV.In the chapter on palliative use ofNIV,other palliative strategies are discussed,as the team providing NIV will need to combine this with other approaches. The emerging issue ofsleep disordered breathing in heart failure is also discussed. Not surprisingly numerous guidelines are now available and protocols for NIV set-up. These are explored and the advice given throughout this edition is in line with these and recent consensus conference guidance,so that teams can improve the process of delivery ofNIV,and competency training ofstaff.As in previous editions the aim is for practical,