Intubation is a critical procedure, there is no doubt about it.
NIV does not have the glamour; it's not nearly as cinematic. But for the patient, to spend 30 minutes on a NIV mask is preferable to a couple of days on the ventilator. In this episode, I discuss some of the basic ideas and methods of NIV.
It is pretty simple as the mode only has 3 main settings:
FiO2 – set based on oxygen requirements, just like on the vent
PEEP/EPAP/CPAP – all the same thing, set this based on OXYGENATION needs. If the patient's sat is low, start at 5 cm H20 and titrate up to 15-17 as needed.
PSV/IPAP – this setting is for ventilation. If your patient does not have ventilation problems, they don't need PSV. If they do, start at 5 cm H20 and titrate to 15-17.
Yes, that's right, I did not tell you to put every patient at 10/5. Very few of your patients will have both ventilatory and oxygenation problems. Asthma and COPD need inspiratory support. APE, atelectasis, pneumonia patients need PEEP.
I also talk about sedation while a patient is on NIV.
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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thank you Dr. Weingart for NIV discussion. its really helpful for us also at upstair on floor.
thanks for the comment!!
scott
Hi Scott, I have just listened to your wonderful lecture. I tend to believe that here in this country, we at ED are not equipped with machines that are similar standard to that of in the ICUs. The ventilators that we have here are more of rudimentary…sort of. So many times I’ve encountered patients whom if we gave enough attention and if NIV get initiated aggrasively and timely , these patients might not need to be intubated at all. Even so, if NIV being given, the settings that we set to the patient were not proper and as such they… Read more »
Any good resources to read up on em noninvasive positive pressure ventilation that will not turn me comatose?
Any sentinel articles to look at? or just look it up on your em crit text?
these two are pretty good
Crit Care Med 2005;33(11):2651
Chest 2007;132:711
Dear Dr.W,
Iam a new ED educator at QHC. You are my Guru and resource.Yes, I do agree with the MD who wrote WWWD. You inspire me tremendously.I am always trying to bring the upstairs care downstairs.Thanks to you.
This is best comprehensive teaching on the fundamentals of NIV. Thank you very much.
Dr. Weingart, I am a newer paramedic in an urban service. I have always been a big believer in NIV, but your explanation and tips have helped me hone this skill even more. Our ventilators in the field are pretty terrible. We have very limited options, our choice is either to bag, CPAP, or intubate mostly. With someone that has no access to BiPap, NIV with a NC and a BVM has revolutionized by airway care! The service I work for only has Versed/Fentanyl to intubate with (which, as you know) can make for some pretty messy and difficult intubations.… Read more »
fantastic, Michael!
I was a Paramedic in 1979, prior to your birth probably. All we had was EOAs then EGTAs. And we came into the ER WITH ARTERIAL Phs of 7.25! Try to do that now, much less over 30years ago. They kicked our Assessment in School, we learned and saved lives more so than now with all the fancy BS THAT IS KEPT ON A UNIT. TRY DOING WHAT I DID 30+ YEARS AGO. WE EVEN HAD TO CARRY HANDGUNS WHILST ON DUTY IT WAS SOBAD AND 3 INCH WHITE AND ORANGE TAPE TO COVER UP THE BULLET HOLES! WE WERE… Read more »
Scott,
I listened to this 6 years ago and again last month. Understanding these concepts is fundamental to the practice of EM. I share it with our residents and fellows each July.
Thanks,
Eric J Wasserman, MD
EM Chair
Newark Beth Israel Medical Center
excellent
HFNC vs CPAP and BiPAP;How does it compare ?
Excellent explanation