NIV - Patient comfort and compliance
|Section||Recommendation||Grade of recommendation|
Assessment of patient comfort and pain is to be completed at least second hourly and documented (1).
Assessment of patient tolerance for higher levels of NIV is to be completed at least hourly until highest level of compliance reached (1).
Patients receiving NIV are to be positioned to achieve maximal chest wall movement and prevent upper airway obstruction (2).
A total face or oronasal mask provide a similar clinical outcome and are preferred over the nasal mask in the acute setting (1, 3).
The choice of mask is influenced by:
The total face mask could be considered; however due to the limited use in Australia and limited evidence of greater efficacy it is not the first line therapy. (4)
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 .
Patient comfort and enhanced compliance are key factors in determining successful application of non-invasive ventilation. Some of the factors that contribute to patient comfort and compliance include (2, 5, 6):
- choice of suitable interface
- levels of pressure applied
- position of the patient
- synchrony of ventilation
- pharmacotherapy for dyspnoea, anxiety and pain
- palliation of symptoms.
Choice of suitable interface
One of the factors contributing to the successful application of NIV and patient compliance is the choice of a suitable interface. There are four types of mask interfaces available for use with NIV; they are the oronasal mask, nasal mask, total face mask (TFM) and the helmet. A suitable interface is one that provides patient with a good fit and minimises the risk of excessive air leak and skin breakdown due to increased pressure from the interface, especially to the bridge of the nose. It is important to avoid excessively tightened straps and consider whether the patient feels claustrophobic. Regular mouth care is essential to prevent oronasal dryness. A comfortable interface will help avoid some of the adverse effects of NIV and improve patient compliance with therapy (5, 6).
Level of pressure applied
The patient is generally commenced on well-tolerated levels of IPAP and EPAP that can be gradually increased. An initial inspiratory positive airway pressure (IPAP) of 10cm H2O and expiratory positive airway pressure (EPAP) of 4–5cm H2O can be used. IPAP should be increased by 2–5cm increments at a rate of approximately 5cm H2O every 10 minutes until a therapeutic response is achieved or patient tolerability has been reached (2).
Position of patient
The patient should be in a sitting or semi-recumbent position in bed. Consider side lying position to remove pressure from a pendulous abdomen (obesity / pregnancy).
Synchrony of ventilation
Synchrony of ventilation should be checked frequently. Assess and monitor chest wall movement and accessory muscle use (2, 7). Use a visual analogue scale (0-10: 10 representing maximum comfort, as if you were breathing without a mask; 0 indicates maximum discomfort you could imagine). Frequent clinical monitoring of patients on NIV will enable the assessment of synchrony and aid in the achievement of desired pressure settings.
Pharmacotherapy for dyspnoea, anxiety and pain
Consider the use of appropriate pharmacotherapy to relieve and alleviate symptoms of dyspnoea, anxiety and pain (2).
Using NIV to provide palliation of symptoms is appropriate in some patients, where standard medical treatment fails and a decision has been made, and documented not to escalate to intubation and mechanical ventilation or where a patient chooses not to have interventional treatment.
If the patient gains symptom relief continued NIV may be appropriate for palliation of breathlessness but therapy would normally be withdrawn. Opiates and benzodiazepines can be used to treat breathlessness in this situation. The palliative care team should be involved and a suitable care pathway followed after discussion with the patient and family (2).
Grading of recommendations
Grade of recommendation
Body of evidence can be trusted to guide evidence
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation/s but care should be taken in its application
Body of evidence is weak and recommendation must be applied with caution
Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (8)
- Holanda MA, Reis RC, Winkeler GF, Fortaleza SC, Lima JW, Pereira ED. Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation. J Bras Pneumol. 2009;35(2):164-73.
- 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.
- 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.
- Patroniti N, Foti G, Manfio A, Coppo A, Bellani G, Pesenti A. Head helmet versus face mask for non-invasive continuous positive airway pressure: a physiological study. Intensive Care Med. 2003;29(10):1680-7.
- Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374(9685):250-9.
- 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.
- Vargas F, Thille A, Lyazidi A, Campo FR, Brochard L. Helmet with specific settings versus facemask for noninvasive ventilation. Crit Care Med. 2009;37(6):1921-8.
- NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: Commonwealth of Australia; 2010.
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.