The purpose of this video is to provide general information and education about the care of
a critically ill child. It is in no way a substitute for the independent decision-making
and judgment by a qualified health care professional. The information contained in this video should
not be used to make a diagnosis or to overrule the advice of a qualified health care provider,
nor should it be used to provide advice for emergency medical treatment.
Non-invasive Ventilation: Complications, by Dr. Robert Graham.
Please note that in this video we will be following the guidelines used at Boston Children's
Hospital. Some of this information may need to be modified based on the equipment, guidelines,
and practices in place in your institution.
Hi, I'm Dr. Robert Graham. I'm an associate in the Division of Critical Care Medicine.
I'm with the Department of Anesthesia at Children's Hospital Boston.
Today I'm going to talk to you about complications of non-invasive ventilator support. There
are complications, as we've sort of talked about, when considering non-invasive ventilation.
Skin integrity is definitely a concern. And there are a variety of types of interfaces.
And I often would recommend that people consider alternating between interfaces: 12-hour periods
alternating, every other day alternating.
When you have something that's pressure on your face, either just a nasal mask, a full
nasal mouth mask, or the full hockey mask-- there are actually non-invasive ventilations
that encompass the entire face-- that the pressure points over the skin can cause skin
breakdown-- actually decubitus ulcers, if you will-- that are nice nidus for infection.
This is definitely a concern, especially for our immunocompromised patients, and something
that we watch for very closely. You can sometimes circumvent these by placing different types
of barriers and different types of skin care underneath, or simply, as I said, alternating
the mask and loosening or tightening appropriately.
Gastric distension is definitely a concern. Almost anyone who's on non-invasive ventilation
will have a degree of aerofagia, where they are swallowing air in addition to inflating
their lungs. This leads to gastric distension and the potential for discomfort, as well
as vomiting. So if you have a patient who has a nasogastric tube in for venting-- that's
very helpful-- or if they have an implantable gastrostomy tube, I would recommend venting
that to allow air to escape so that you're not pushing up on the diaphragm, decreasing
your functional residual capacity, and also increasing the risk of burping and aspirating
any gastric contents.
Nasopharyngeal dryness in the past has been a concern, but most of our BiPAP machines
and our ventilators that are BiPAP adaptable now have humidification. So that's no longer
really an issue.
And vasomotor rhinitis, conversely, as someone comes off the BiPAP and their nasopharynx
vessels vasodilate after being on BiPAP, patients would complain of rhinitis. Again, because
of the humidification, this is rarely an issue these days.
Aspiration risk we've talked about. Full face masks, either the circumferential face or
the nasal oral face mask do place patients at risk for aspiration if they vomit into
the mask. It is because of this in some of the smaller patients that we usually recommend
just a nasal mask. If someone who's either too weak to pull a mask off, too weak to alert
a provider that they vomited, or too weak to pull the mask off, nasal masks are nice
alternative. And we'll talk a little bit further about how to adapt for someone who's got a
nasal mask with an oral leak.
So air leaks are definitely a concern, either in the circuit, so make sure your circuits
are connected properly. Air leaks from the pleural space are unlikely to be caused by
non-invasive ventilation, partially because there's definitely a dampening of the pressure
dial in to the ventilator as it transmitted through the upper airways. And you're unlikely
to develop significant air leak as a result of that.
Now, the air leak, as it were, from the mouth, if you have someone just on a nasal interface,
the air is being blown in through the nasopharynx. Some of it is being transmitted into the lungs,
some of it to the stomach. And then some of it will actually be exiting through the mouth
as the lower pressure gradient.
A way to compensate for that is actually to either increase your flows and pressures,
or sometimes you will use a chinstrap, a little bit of a jaw thrust, and other positioning
just to help with that. Remarkably, most patients, regardless of their sort of level of consciousness
and their development, can usually coordinate that the oral leak is minimal.
Acute airway obstruction actually may be exacerbated by the use of non-invasive ventilation and
is definitely something to watch for. When you apply a full face mask or the circumferential
mask with the bonnet and the straps that go along with it, you may, in fact, actually
displace the mandible backwards. As you put the mask on, there's pressure that's applied
the mandible. And you may actually be forcing it back.
And with that goes the tongue. And you may actually create a significant amount of retro
pharyngeal airway obstruction. The way to test that is, again, to do a jaw thrust. And
that will help you identify the problem and then really sort of address it.
Again, you may be able to just loosen the straps a little bit or transition to a nasal
mask. If in fact you can't provide the amount of support needed with just a nasal mask,
or it's not practical to provide continuous jaw thrust, you may need to consider transitioning
to a translaryngeal airway or other types of support.
Airflow-induced arousal or sleep disturbance. This is more of an issue for long-term patients
on non-invasive ventilation. But certainly in a critically ill patient who's agitated,
because of the BiPAP, this is not necessarily tenable either.
Long-term facial and sinus development is, again, of concern for the very smallest of
children, patients with central hyperventilation, or long-term lung disease, chronic airway
obstruction where they're wearing masks 12-hours a day for months and months at a time at a
very young age as the face develops, you can actually contribute to midface hypoplasia
over time.
There are times where people are not able to trigger the ventilator. Again, this is
really dependent upon the type of BiPAP machine that you have or CPAP machine that you have
and the type of interface. The more sophisticated models actually have spontaneous and timed
modes or combined spontaneous and timed modes with varying degrees of flow or volume trigger
and also mandatory rates. This is not an issue so much anymore, that you can actually usually
adapt the machine to meet the patient's needs, independent of their size or degree of weakness.
That concludes our video on Non-invasive Ventilation: Complications. Thank you.
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