Not every patient reads the textbook, but you and I have to know where to start when managing our patients who have hypercapnic respiratory failure that we want to treat with non-invasive ventilation (or what you and I frequently call BiPAP). This NIV algorithm is taken from the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guidelines that were published in 2017.
Fortunately, they are free for you to download your own copy and put it up on your wall. This guideline recommends starting with an EPAP of 3. If I’m honest, everywhere I’ve been and the way I’ve been trained is to start at 5. Also, they recommend uptitrating the IPAP up to 20-30. In my practice, once I start kissing 20, I start thinking very seriously about intubating the patient. For those who are unfamiliar with the kilopascal units (as I certainly was), the equivalent PCO2 is 48.75mmHg. Note that you need to have acidosis and hypercapnia in COPD exacerbations to have any benefit from NIV. A hat tip to the authors. Hopefully your patients with benefit from the NIV algorithm.
-EJ
Click HERE to learn more about NIV and HFNC.
Citations for NIV Algorithm:
Ghosh D, Elliott MW. Acute non-invasive ventilation – getting it right on the acute medical take. Clin Med (Lond). 2019 May;19(3):237-242. doi: 10.7861/clinmedicine.19-3-237. PMID: 31092518; PMCID: PMC6542238.
Link to Article with FULL FREE Algorithm
Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foëx B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L; BTS Standards of Care Committee Member, British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group, On behalf of the British Thoracic Society Standards of Care Committee. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016 Apr;71 Suppl 2:ii1-35. doi: 10.1136/thoraxjnl-2015-208209. Erratum in: Thorax. 2017 Jun;72 (6):588. PMID: 26976648.
Link to the FREE FULL Guidelines
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