PURPOSE:Intermittent Noninvasive Mechanical Ventilation (NIV) was developed for the management of chronic hypercapnea.á Subsequently, its spectrum of use has expanded to critical care applications such as COPD and Asthma exacerbations, Pulmonary Edema and respiratory failure in Sleep Apnea.á In several of our consortium's institutions, use of NIV without clear clinical indication or anticipated benefit has been noted, often with little documentation of efforts made to optimize its use. We have identified some questionable uses of NIV, their prevalence and the situations iná which they occur.
METHODS:After numerous educational sessions (including presentation of an evidence based practice guideline) the charts of all patients treated with NIV during a 6 month period were reviewed.á The presence of documentation of the indication for NIV, of its benefit and of efforts to optimize its comfort and effectiveness were recorded, as were the presence of orders defining ventilator settings, use schedules and safety precautions (e.g. head elevation).
RESULTS:The charts of 90 patients (62 female and 28 male, aged 58±9 years) were reviewed.á 19% did not document the reason for NIV use.á 19% had surrogate DNR/DNI orders because of severe chronic dementia.á These patients required restraints for the treatment but their charts contained no indication of its anticipated benefit.á 60% did not document titration of therapy or an evaluation of its effect. 50% lacked adequate orders regarding ventilator use or safety precautions.
CONCLUSION:1) There were substantial deficiencies in recorded decision making and communication between all care givers. 2) There was little effort made to optimize the comfort or the effectiveness of this treatment. 3) NIV was used concurrently with therapies (e.g. restraints) which render its use hazardous. 4) In several cases NIV was used to circumvent surrogate DNR/DNI orders whose purpose was to avoid discomfort and indignity (both of which are caused by NIV).
CLINICAL IMPLICATIONS:The decision to use NIV and the process of its application must be better understood and taken much more seriously by all caregivers.
DISCLOSURE:William Marino, No Financial Disclosure Information; No Product/Research Disclosure Information