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Western-Health-Covid19-Collaboration / wh_covid19_app

Volunteer developed app containing information for frontline medical staff around COVID-19
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Build out ICU cross skilling - Breathing - Non invasive ventilation #254

Open fabiendade opened 4 years ago

fabiendade commented 4 years ago

Under ICU cross skilling Breathing section we need to instruct non ICU medical staff safely initiate non invasive ventilation which will hopefully prevent patients from having to be anaesthetised and put on the ventilator.

Format would be an intro section highlighting that this is a potentially dangerous treatment for staff looking after the patient, and an introduction of the concept.

Along the top I was thinking swipe tab format with the following structure and text

fabiendade commented 4 years ago

Title of section

Non invasive Mechanical Ventilation (NIV)

4 Tabs

  1. Non-invasive mechanical ventilation
  2. Indications
  3. Initiation
  4. Troubleshooting

Bold text the title of each box within the tab.

Tab 1

Non-invasive Mechanical ventilation (NIV)

Do NOT institute in COVID-19 patient unless discussed with Intensivist

This is an aerosol generating procedure

Closed circuit positive pressure ventilation via sealed face-mask

Can avoid requirement for intubation

Tab 2 - Indications

Types and indication

· CPAP – T1RF · BiPAP / CPAP + Pressure Support (PS) – T2RF

Caution

· COVID-19 suspected/confirmed – AGP – Discuss with Intensivist · Agitation / intolerance · Recent Upper GI surgery - Discuss with Surgical team · Haemodynamic instability · Pneumonia – no evidence NIV improves outcome– don’t delay intubation for trial of NIV

Contraindications

· Severe Hypoxic respiratory failure · T2RF + pH < 7.1 · Decreased GCS – not protecting airway · Severe vomiting / haematemesis · Facial surgery / Base of skull fracture · Pneumothorax · ARDS – high failure rate – of COVID-19 – discuss with Intensivist

Tab 3 – Initiation

Set up

· Terminology differs depending on ventilator · ABG prior to starting – do not delay NIV if difficult to get gas + consider arterial line

Outside ICU

· EPAP – Expiratory Positive airway pressure – (CPAP) total cmH20 · IPAP – Inspiratory Positive airway pressure (total cmH20)

ICU ventilators

· CPAP – continuous positive airway pressure · Pressure support ( Pressure above PEEP delivered on inspiration)

Initial settings

· CPAP / EPAP – 5cmH20 · IPAP 10 cmH20 · PS 5cmH20

Monitoring

Clincial – 5 min intervals initially – increase pressures until satisfactory response

1 hour post starting NIV – ABG

Titrate NIV

· T1RF -increase / decrease PEEP by 2cmH20 – according to Sp02 / PaO2 · T2RF – increase / decrease IPAP/PS by 2cmH20 – according to PaCO2 / pH
· RR + WOB should improve · If improved rapidly – wean or trial off NIV 1 hour

Tab 4 – Troubleshooting

Troubleshooting

Main issues

· Leak - ?Not tolerating / poor fit / beard · Non-compliance · Asynchrony · Not responding · Gastric insufflation · Pressure injuries to face · Claustrophobia · Check adequate Air flow

Tips

· Do not delay intubation in those requiring it · Barrier tape / cushioning - improve comfort and leak · Consider light anxiolytic if no contraindication – improve tolerance · Communicate with patient – explain why and apologise for discomfort · If worsened on NIV – ESCALATE IMMEDIATELY

lukesleeman commented 4 years ago

@greggmiller We now have the "breathing" section in Quick ICU training. Can we close this issue down, or is this something else ?