Neuromuscular Compromise and Respiratory Failure — Noninvasive Management Strategies — Pulmonary Floor — Clinical Pathway: Inpatient and PICU

Neuromuscular Compromise and Respiratory Failure Clinical Pathway — Inpatient and PICU

Noninvasive Management Strategies — Pulmonary Floor

Initial Management

Recommendations Additional Considerations
  • Do not initiate settings lower than patient’s baseline to meet this criteria.
  • Consider NIV with no supplemental O2 with settings:
    • IPAP: 12-20 cmH2O
    • IEPAP: 3-8 cmH2O
  • Assess patient and begin first-line airway clearance (CPT, MI-E, suction Q2 and PRN).
  • Use SpO2 as a guide for use of MI-E and other secretion clearance techniques — wean until FiO2 returns to 0.21.
  • NIV
    • IPAP
      • Set at a pressure high enough to see visible chest rise.
    • EPAP
      • Set at the lowest level possible to facilitate passive exhalation.
      • Settings are individualized to achieve adequate inspiratory chest wall expansion and air entry, SpO2 > 92% in room air, normal or baseline PaCO2 levels, improved WOB and baseline respiratory rate for the patient.
    • Mode
      • Spontaneous timed (S/T) (unless patient maintained at home on different mode of ventilation) with set a backup rate:
        • Use S/T mode with a backup rate to match the patient’s respiratory rate.
        • Consider transition to PC mode if spontaneous breaths are small.
        • Set I-time and rise to achieve set inspiratory pressures.
    • The IPAP/EPAP settings should not be decreased until the patient’s FiO2 is 0.21 or at baseline FiO2.
  • Interface
    • Use nasal mask or home interface.
  • MI-E (CoughAssist)
    • Use as often as needed to clear lower airway secretions.
    • Use if SpO2 < 92%.
    • May need to be frequent to help clear tracheal mucus and prevent atelectasis from distal secretion movement.
  • Postural Drainage
    • Consider Trendelenburg for 15 minutes as tolerated followed up again using MI-E (CoughAssist) and suctioning if CPT and MI-E (CoughAssist) are not effective.

Acute SpO2 Desaturations

Recommendations Additional Considerations
  • If SpO2 drops to < 92% acutely:
    • Perform MI-E
    • Assess if the patient needs an extra treatment
    • If in room air and SpO2 remains ≤ 92%: continue MI-E (CoughAssist) Q2 and PRN
    • If patient is on oxygen therapy continue with Q2 MI-E (CoughAssist) and PRN
  • Avoid/minimize use of supplemental oxygen.
  • Supplemental O2 indicates a V/Q mismatch and need for further airway clearance.
  • Nursing should contact Respiratory Therapy for any increases in FiO2.
  • Postural Drainage
    • Consider Trendelenburg for 15 minutes as tolerated followed up again using MI-E (CoughAssist) and suctioning if CPT and MI-E (CoughAssist) are not effective.

Once Stable in Room Air or Baseline FiO2

Recommendations Additional Considerations
  • Wean airway clearance regimen as airway secretions decrease working toward a Q6 schedule or less
  • Begin trials off NIV (in room air)
  • Goal is nocturnal support until the illness resolves or until the patient’s prior baseline has been achieved.
  • BID 2 hour sprints, and increase length (30-60 min BID) as tolerated. If desaturation is present, trial cough assist. If persisting desaturation is noted after cough assist the sprint should be stopped and BIPAP reapplied.