Teach NIV scenario

starting NIV in COPD context

candidate brief

You have just seen a patient with COPD exacerbation with one of the ED SHOs. They ask if you can do some teaching on starting NIV for patients like this.

examiner brief

  • Introduce self
  • Check student's identity and level of experience
  • Sets learning objectives - patient population ?
  • Provides positive pressure support in a spontaneously breathing patient via tight-fitting mask
  • Indications for NIV: if, despite optimal medical treatment, patient still has:
    • pH < 7.35 on ABG
    • pCO2 > 6.5
    • RR >23
  • NOT indicated for pneumonia or asthma → these patients may require invasive positive pressure ventilation instead
  • Lists contraindications for NIV
    • Absolute: facial injury, fixed upper airway obstruction, severe facial deformity
    • Relative: Agitation, pH <7.15, GCS <8
    • ICU: Need for closer monitoring/IV sedation, treatment failure e.g. sats 85-88% on NIV; NIV not augmenting chest wall movement/reduce pCO2
  • Considerations before starting - escalation plan for patient/ceiling of care
  • Initial settings: EPAP 3, IPAP 15
    • OSA → higher EPAP
    • Backup rate
    • Use as much as possible in the 1st 24h
  • Uptitrate over 10-30 mins until IPAP 20-30 → Improve chest wall movement and slow RR (and TV?)
  • Escalate if IPAP >30
  • Check effectiveness with ABG
  • Can only be started in... (resus, RSU...)
  • Invites questions
  • Thanks student

#osce-answer-questions #respiratory #mrcem-osce

BTS guidelines

Acute respiratory failure
initiating NIV scenario