Governance for NIV adults

Recommendations

SectionRecommendationGrade of recommendation

44.

Any health facility that provides NIV should have a policy/procedure stating patient selection criteria and management plan/s for patients recovery, NIV including initial settings and escalation strategies (1).

Consensus

45.

The frequency of documentation for NIV is to be at least hourly in the acute phase and then may be reduced to 2-4 hourly once the patient is stable or is in a specialised respiratory unit.

Consensus

46.

Patients receiving NIV must be located in a ward area where there are appropriate numbers of competent staff able to provide monitoring and titration of therapy consistent with all aspects of patient care required.

Consensus

47.

Organisations providing NIV are to have formal education processes relating to NIV and a competency assessment package for new graduates and staff working in these areas.

Consensus

48.

Where hospitals wish to monitor the outcomes of patients receiving NIV, minimum data for collection could include:

  • Patient outcome (survival/death)
  • ICU and or specialist ward and hospital LOS
  • Length of ventilation
  • Treatment complications
  • Machine used and settings
  • Clinical data (diagnosis, PaO2, PaCO2)
  • Quality of life assessment/EOLCP
  • Dyspnoea scores (Borg)

Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

Environment (location of care)

To date, no studies have directly evaluated outcomes of acute NIV delivered in ward areas compared to therapy commenced in critical care locations. However, two meta-analyses of NIV in patients with COPD and acute respiratory acidosis found no significant difference in outcomes analysed in relation to location of care (1, 2). Nevertheless, severity of acidosis at presentation has been shown to be a key factor influencing outcome with NIV (3, 4), with pH <7.25 significantly increasing the likelihood of NIV failure (5), especially if pH remains below this threshold following two hours of therapy (4). As the benefits of NIV are modified by the severity of the presenting respiratory acidosis, pH is a useful and readily accessible metric for stratifying the risk of NIV failure and identifying the best location to perform therapy. The experience and familiarity of staff using NIV also has implications for the success of therapy, with longitudinal studies demonstrating the ability to manage more severely ill patients over time without increasing the risk of treatment failure (6). Therefore, cases of mild to moderate respiratory acidosis (7.25-7.35) and single organ failure may be effectively and safely managed in a dedicated ward area, provided sufficiently trained and experienced staff are available to initiate and monitor therapy. Patients with a pH <7.25 or those that are less acidotic but have significant concurrent clinical problems, are better nursed in critical care areas where higher staffing ratios and complex interventions are available.

With the exception of acute cardiogenic pulmonary oedema (7), the evidence for using NIV for other conditions leading to hypoxemic respiratory failure is either weak or lacking (8, 9). Given the potential for more rapid deterioration and adverse consequences related to accidental disconnection from ventilator support, patients with hypoxemia are more safely managed in more highly monitored and staffed critical care areas.

Staffing

The need for patients managed with NIV to be closely monitored by trained clinicians has been highlighted in a number of studies (2, 3). Although one of the advantages of NIV is that it can be used with success outside of critical care areas thereby reducing the demand on ICU beds, there still needs to be sufficient staff available to initiate therapy, monitor and troubleshoot problems in order for positive outcomes and patient safety to be achieved. Nurse to patient ratios of 1:1 to 1:2 reported in studies of NIV carried out in critical care areas permit close monitoring and timely intervention as needed and are appropriate for patients with greater acuity of illness (10). When reported, staffing levels in ward-based studies have been considerably lower, ranging from 1:2.6 to 1:13 (3, 8). Lower staffing ratios in ward areas have the potential to adversely affect outcome in patients that are not appropriately selected. Although studies have shown NIV does not significantly increase routine bedside nursing workload (3, 11); it should be appreciated that additional time is required to initiate and fine tune NIV settings, especially during the first eight hours of treatment (11). In patients with moderate to severe acidosis, failure to spend time individualising and troubleshooting NIV may lead to poorer outcomes (3). Conversely, patients with milder acidosis may be less tolerant of NIV (8) and without ongoing encouragement use therapy less than is required to gain the full benefits (12). Failure to identify patients not responding adequately to NIV can cause inappropriate delays in intubation (13) and even if invasive ventilation is commenced morbidity and mortality is increased (14). Therefore, nurse-patient ratios of no more than 1:2 in critical care areas and 1:4 in a ward settings is recommended to ensure patient safety and rapid response to deterioration.

Grading of recommendations

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (15)

References

  1. McCurdy B. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Ontario Health Technology Assessment Series. 2012;12(8):1.
  2. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004;3.
  3. Plant P, Owen J, Elliott M. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. The Lancet. 2000;355(9219):1931-5.
  4. Confalonieri M, Garuti G, Cattaruzza M, Osborn J, Antonelli M, Conti G, et al. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. European Respiratory Journal. 2005;25(2):348-55.
  5. Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPDA Systematic Review and Metaanalysis. CHEST Journal. 2008;133(3):756-66.
  6. Carlucci A, Delmastro M, Rubini F, Fracchia C, Nava S. Changes in the practice of non-invasive ventilation in treating COPD patients over 8 years. Intensive care medicine. 2003;29(3):419-25.
  7. Weng M-H. The effect of protective treatment in reducing pressure ulcers for non-invasive ventilation patients. Intensive and Critical Care Nursing. 2008;24(5):295-9.
  8. Keenan SP, Sinuff T, Burns KE, Muscedere J, Kutsogiannis J, Mehta S, et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. Cmaj. 2011;183(3):14.
  9. Ram FS, Wellington S, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2005;20(3).
  10. Roberts CM, Brown JL, Reinhardt AK, Kaul S, Scales K, Mikelsons C, et al. Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure. Clin Med. 2008;8(5):517-21.
  11. Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. American journal of respiratory and critical care medicine. 1995;151(6):1799-806.
  12. Pastaka C, Kostikas K, Karetsi E, Tsolaki V, Antoniadou I, Gourgoulianis KI. Non-invasive ventilation in chronic hypercapnic COPD patients with exacerbation and a pH of 7.35 or higher. European journal of internal medicine. 2007;18(7):524-30.
  13. Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, et al. Evolution of mechanical ventilation in response to clinical research. American journal of respiratory and critical care medicine. 2008;177(2):170-7.
  14. Chandra D, Stamm JA, Taylor B, Ramos RM, Satterwhite L, Krishnan JA, et al. Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008. American journal of respiratory and critical care medicine. 2012;185(2):152-9.
  15. NHMRC. NHRMC additional levels of evidence and grades for recommendations for developers of guidelines: Pilot Program 2005-2007. October 10 2006.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.