Non Invasive Ventilation ;

A Respiratory Muscle Aid

Anitta FS Paulus
Physical Medicine & Rehabilitation
Persahabatan Hospital - National Respiratory Referral Hospital
October 21,2018
High Cervical
SCI

Amyotrphic lateral
scleraosis (Lou Gehrig’s
disease)
Introduction

  Respiratory muscle weakness occurs in

neuromuscular disease (NMD) especially in
progressive diseases.

  It is not even only from NMD but in any

condition causes increased work of
breathing that further results in respiratory
muscle fatigue.
Objectives to learn

  Ventilatory regulation

  Respiratory muscles ‘ rule in ventilation

  What conditions cause ventilatory failure

  Why non invasive ventilation

  Is it an aid? Is it a treatment?

  Assessment of hypoventilation
Ventilatory
regulation
 Central
Ventilatory Control
regulation Brain
stem
Cortex

Spinal Cord

Effector
Sensors
s

Chemoreceptor
Respiratory
Mechanoreceepto
muscles
r
Respiratory muscle
Weak Respiratory
involvement in muscle is easily
Ventilatory Regulation Chemo-
fatigue
mechano
Or
stimulant
Is not able to
compensate

Effectors Ventilatory
compensation Ventilstory
decompensation

Respiratory
Respiratory Rate Ventilstory/
muscles Tidal volume failure
cahnge
 Conditions with alveolar hypoventilation
that can use respiratory muscle aid

  Myopathy: muscular dystrophy, ICU-associated, medication,

inflammation, etc

  Endocrine

  Mixed connective tissue disease

  Motor neuron diseases

  GBS

  CNS disorders

  Central hypoventilation syndrome

  Restrictive lung disease/ increased work of breathing

 Conditions with alveolar
hypoventilation……cont’d

  High cervical SCI

  Obesity hypoventilation

  Kyposcoliosis

  Lung resection/TB, vocal cord paralysis,

congenital diaphragmatic hernia

  COPD, CF
How to support
Weak Respiratory
ventilation in respiratory
muscle is easily
muscle dysfunction Chemo-
fatigue
mechano
Or
stimulant
Is not able to
compensate

Effectors Ventilatory
compensation Ventilstory
Respiratory
decompensation
muscle aid to
assist
ventilatory
Respiratory pump, to replace
Respiratory Rate respireotry
Ventilstory/
muscles Tidal volume muscle function
failure
cahnge
What is the orthosis to assist

Mechanical Ventilation

  Should it be invasive by endotracheal tube or

non invasively?

Assessment determines decision

 Contraindications to NIV
  Apnea Absolute Relative

  Shock
  Nausea and vomiting
  Inability to protect airway

  Altered mental status

  Agitation

  Pneumothorax   Cardiac arrhythmias

  Gastric, laryngeal, oesophageal surgery   Cardiac ischaemia or
  Significant facial fracture acute myocardial
infarction
  Inability to cooperate with interface
  Significant chest trauma
  Rapid deterioration
How to assess

  Knowing the disorder’s affect to respiratory muscles

  Symptoms indicate hypoventilation syndromes : CO2

retention affects brain performance : sleepiness,
lethargy, difficulty in learning and focus Exertional
dyspnea in ambulatory patient, morning headache,
fatigue, anxiety, sleep disturbances, inability to
asleep, hypersomnolonce

  Bulbar muscle involvement contraindicates to non

invasive ventilation
Lung and chest wall compliance

  Maximum Inspiratory Pressure (MIP),

Maximum Expiratory Pressure (MEP)

  Diaphragm movement

  Spinal alignment
Assessment …..(cont’d)

  Vital Capacity

  Peak cough flow

  Maximum Insufflation Capacity

  Blood gas analysis : invasive and non

invasive method
 Blood gas analysis (BGA)

  Non invasive BGA

  Invasive
  End tidal
  Arterial blood gas capnography or
analysis transcutaneous
capnography
  Need skill for arterial
blood sample take   Advantages: easy and
simple
  Disadvantages : risk
of injection; pain,   no risk of injection;
infection, night pain, infection, night
arousal arousal
Day and night monitoring

  Alveolar hypoventilation is more often occurs at

night

  Duration of hypoventilation will be longer

related to disease progression

  Serial monitoring should be done at day at night

  Result of monitoring will determine the

application of non ventilation support
Nocturnal NIV

  Patient with nocturnal alveolar

hypoventilation will be managed with NIV at
night time

  Progressive neuromuscular weakness will be

worsening respiratory muscles that further
will be lengthening the duration of NIV, in
most ALS a 24 hours application is not
uncommon
Intermittent Positive Pressure Ventilation

Respiratpry muscle weakness

Both inspiratory and expiratory

2 respiratory phases dysfunction

Respiratory muscles aid for both phase

Intermitent Positive Pressure

 Take me home

  Weak or fatigue respiratory muscles need

support to do ventilatory function

  It is non invasive ventilation to assist or

replacing respiratory muscle’s function

  It is applicable broadly in many conditions

where the disease affects work of breathing
and affects respirator muscle function
 Take me home

  Supported ventilation results in increase

physical capacity or exercise tolerance and
increase functional level

  It is rehab! NIV is rehab business, making

people - disable becomes functioning
  Thank you