Non-invasive ventilation in palliative care
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Non-invasive ventilation (NIV) is a treatment to help someone's breathing. It can be used at home, but the patient will be under the care of a multidisciplinary (MDT) specialist team usually based in a local hospital. Here, we'll talk about what NIV is, which patients might need it, how it works and what to do if something goes wrong.
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What is non-invasive ventilation (NIV)?
Non-invasive ventilation (NIV) is a treatment to help someone's breathing. It uses a mask or nasal prong, and a small portable ventilator machine. It's called non-invasive because it does not use a tube that goes into someone's windpipe through the mouth or nose (endotracheal tube) or through a hole in their neck (tracheostomy tube).
You might hear NIV being called BiPAP, CPAP or Nippy. These are terms for different NIV machines or modes of delivery.
Who might need NIV?
Non-invasive ventilation (NIV) can be used for people who have medical conditions which affect the airways, lungs, or muscles or nerves involved in breathing. These include:
- neuromuscular disorders including motor neurone disease (MND)
- chronic obstructive pulmonary disorder (COPD)
- obstructive sleep apnoea
- amyotrophic lateral sclerosis (ALS).
Not everyone who has one of these conditions will need NIV. It depends on how much their underlying condition impacts on their breathing.
myBreathing , is a collection of educational resources for people living with these conditions. Share this site with the patient and their carers.
Watch a video from myBreathing about how NIV makes a difference to people's lives .
How NIV works
The patient either wears a tightly fitting face mask which may cover the nose, mouth, or both, or nasal pillows where small soft prongs fit into the nostrils. This is attached to a small ventilator machine by a plastic tube. The mask or nasal pillow fit tightly, creating a seal, so air does not leak out.
The machine pushes air into the lungs under high pressure. This opens the airways and allows the air to enter. Oxygen may also be given if indicated. The patient might use the machine all the time or just for parts of the day or night.
NIV helps a patient breathe by:
- reducing the effort of breathing
- increasing the amount of air taken in with each breath (tidal volume)
- increasing blood oxygen levels
- reducing carbon dioxide levels.
Different types of NIV
There are two main types of NIV:
- Continuous Positive Airway Pressure (CPAP)
- Bi-level Positive Airway Pressure (BiPAP).
CPAP provides continuous pressure to keep the airways open. It's commonly used for people who have obstructive sleep apnoea.
BiPAP sends two different pressures to the airways. When the person breathes in (inspiration), the machine sends a high positive pressure to the lungs. This increases the volume of air in the lungs.
When the person breathes out (expiration), the BiPAP machine sends a lower pressure to the lungs. This increases the amount of air that stays in the lungs when someone breathes out. This allows more oxygen into the blood.
NIV equipment
Patients will have:
- a ventilator machine they can move around with, which plugs into the mains electricity
- a face or nose mask, or a nasal pillow
- an adjustable headset for attaching the mask or nasal pillow
- tubes which attach the machine to the mask or nasal pillow.
Patients may also have:
- a battery pack – so they can travel with the machine, or in case the mains electricity supply stops
- a humidification unit – to loosen chest secretions
- an oxygen supply.
Not all patients will need oxygen. Read more about oxygen therapy.
How patients get NIV
If someone might need NIV, their doctor will refer them to a specialist team for assessment. NIV can only be provided by specialist teams.
The specialist team supplies patients with the equipment they need. The patient will usually start NIV in the hospital and stay in for a few days before going home. The specialist team will continue to support the patient when they go home. The team will create a care plan with the patient which includes:
- regular reviews
- ongoing access to clinical support from the specialist team
- plans for maintenance of the equipment
- 24-hour emergency and technical support.
The team will talk to the patient and those close to them about:
- their condition and how it may progress
- how the ventilator works – including how to connect it to the power supply, and what the different alarms mean
- how to connect the tube, machine and mask or nasal pillows, as well as oxygen if needed
- how to put the mask on and make sure there's a tight seal
- how to clean the equipment
- what to do if something goes wrong.
Common problems for patients on NIV
Some of the common problems patients may experience on NIV include:
- Dry mouth – NIV can dry out the mouth and nose. Patients needs good mouth care and to stay hydrated. Read more about good mouth care.
- Pressure sores – patients need support with good skin care, and their skin should be monitored for signs of pressure damage. Any damage should be reported to the manager immediately. Read more about preventing pressure ulcers.
- Distress – NIV can be distressing at first, and patients may require reassurance that it's helping them to breathe. Distractions like playing their favourite music, radio or TV can help. Read more about supporting someone with emotional distress.
Specialist help will be required if:
- the patient is struggling emotionally
- the patient is distressed
- the patient may be developing pressure sores
- the patient does not want to stay on NIV
- there's a problem with the equipment
- there are any other concerns about NIV.
Having contact details for the specialist is important.
Infection control and PPE
NIV is an aerosol generating procedure (AGP). This means it can cause airborne particles (aerosols) to be released from the respiratory tract. If the person has a respiratory infection (including coronavirus), this can spread the infection. You must always use the correct level of personal protective equipment (PPE).
If you're going to care for someone in their home, make sure you ask before you go if they use NIV. If they do, check with your manager that you have the right PPE to keep you, and others, safe.
End of life
As the patient approaches the end of their life, they may have to decide when to stop using NIV. Talking about this in advance and making a plan can help them to feel in control. Read more about planning ahead for the end of life.
Share this video from myBreathing on making decisions about end of life.
When to ask for help
If you need to care for a patient on NIV, it is vital that you speak to your manager.
NIV is a specialist treatment. You will need appropriate training to support someone with NIV.
Key points
- NIV is a treatment to help someone's breathing and improve the quality of their life.
- NIV can be used at home but it's managed by a specialist centre.
- NIV is an aerosol generating procedure and Health and social care staff must always wear the right PPE to keep them and others safe.
- Appropriate training must be undertaken by any Health and social care. professional before they care for someone with NIV. Ask your manager if there's any training you can attend.
Useful websites
Royal College of Nursing: caring for someone with MND
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Disclaimer
This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
