Proforma for use of

NIV in acute Type II Respiratory Failure

Please complete this document for every patient started on NIV

Date: __________ Time: ________

Patient name: Or sticker
Ward: _____________
Requesting Dr: ___________________
Grade: _________________________
Hospital number:
Consultant: ______________________
Ventilator number:

The decision to commence NIV should be made by a doctor of

CT2+ or above, or other competent designated healthcare
professional locally agreed, who is competent to do so, e.g. CCOT
Please complete the table below if you write in this document:

Name Position Initials Signature

 NIV for Acute Type II Respiratory Failure.

Diagnosis: Patient name: Or sticker

□ COPD previous FEV1: _____ (%pred) FEV1/FVC: ____ (%)
□ Chest wall deformity
□ Neuromuscular disease
Hospital number:
□ Obesity Hypoventilation (OHVS)
□ Cardiogenic pulmonary oedema
□ Other: __________________________
Criteria for considering NIV:
Decompensated respiratory acidosis (pH< 7.35, PaCO2>6 kPa), despite previous
maximum standard medical treatment for no more than 1 hour.

Criteria for inclusion of NIV Criteria for exclusion of ward-based NIV

 Able to protect airway
 Conscious and cooperative
 Potential for recovery to
quality of life acceptable to the
patient
 Patient’s wishes considered
 Acute asthma or pneumonia
 Undrained pneumothorax / life threatening
hypoxaemia
 Inability to protect the airway/ vomiting
 Copious respiratory secretions or patient
moribund
 Confusion/agitation/severe cognitive
impairment
 Facial burns/trauma, recent facial or upper
airway surgery
 Fixed upper airway obstruction / Bowel
obstruction
 Upper gastrointestinal surgery
 Haemodynamically unstable requiring inotropes
(unless on ITU)

Performance status before Care plan (please tick):

exacerbation (please tick):
□ Unrestricted
□ Strenuous activity limited
□ Limited activity but self-caring
□ Limited activity and limited
self-care
□ Confined to bed/chair, no self-
care
□ Patient requiring immediate intubation and
ventilation
□ Patient suitable for NIV and suitable for
escalation to ITU treatment/intubation and
ventilation if required
□ Suitable for NIV but not suitable for escalation to
ITU treatment/intubation and ventilation
□ Not suitable for NIV but for full active medical
management
□ Palliative care agreed as most appropriate
management

1. DNAR form completed if appropriate

2. Patient or relatives involved in above decision
Step 1 - Baseline ABG.

Patient information leaflet given

to patient? 

- Use Full face mask and ensure tight fit with no air leak
- Initial IPAP of 10 cmH2O, EPAP of 4-5 cmH2O
- Increase IPAP by 5 cmH2O every 10 min to a minimum Target pressure: 20
cmH2O (may need to be higher particularly in OHVS), or therapeutic response
achieved, or patient tolerability reached
- There should be no breaks in NIPPV in the first hour
- Target SpO2 88-92% (with supplemental oxygen if required)
- Ensure Critical Care Outreach informed of patient
- Continuous pulse-oximetry for the first 12 hours and ECG monitoring if HR
>120, dysrhythmia or cardiomyopathy.
- Monitor the patient every 15 min for the first hour → Go to Step 2

Step 2 - ABG after 1 hr of NIV therapy

- If ABG improved, RR stable or improved and SpO2>88-92%:

o Continue NIV and repeat ABG in 4 hours
o Monitor the patient every 30 minutes in the 1-4 hour period, and
1 hourly in 4-12 hourly period
o → Go to Step 3 (refer to Harrowden A Respiratory team)

- If ABG worse: (pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%) → Go to

Step 2b
 - If NIV Fails: decreasing conscious level
Patient name: Or sticker
(GCS<8), pH <7.20, pO2<6 kPa →
Contact ITU if appropriate.

Hospital number:

Step 2b - If ABG worse after 1 hr of NIV

(pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%):
- If CO2↑: Try to increase IPAP, patient may need IPAP above 20 cmH2O
- If O2↓, CO2 stable: ↑FiO2 to achieve >88-92% SpO2
- Check mask fitting
- After above changes, monitor every 15 minutes, repeat ABG in 1 hour
- If ABG still worse despite optimal settings in the first 4 hours of treatment, consider
escalation if appropriate, or withdrawal and palliative treatment
- COPD patients with pH <7.26 managed with NIV require more intensive monitoring
with a lower threshold for intubation if appropriate.

1 2 3 4
Date
Time
Signature /
Initials
pH
pCO2
pO2
HCO3-
BE
SaO2
FiO2
IPAP
EPAP
RR
HR

Stick ABG results here if needed:

 Step 3 - ABG after 4 hr on NIV

- If ABG worse: (pH 7.20-7.25, pO2 or pCO2 worse, SpO2<88%) go back to step 2b

- If ABG improved: Monitor every hour, and perform ABG in 12 hours, reduce monitoring
to 2 hourly if >12hours on NIV and if acidosis resolved

- Please use the chart on page 8

- Patients who benefit from NIV during the first 4 hours of treatment should receive NIV for
as long as possible (minimum of 6 hours) during the first 24 hours

- If NIV is successful (pH > 7.35 achieved, resolution of the underlying cause and
symptoms, RR normalized) following the first 24 hours or longer, it is appropriate to start a
weaning plan

Weaning plan:
DAY 2:
Continue NIV for 16 hours (Refer to Harrowden A Ward Respiratory team)
Weaning should be during the day, with extended periods off the ventilator for meals,
physiotherapy, nebulized therapy, etc

DAY 3:
Continue NIV for 12 hours, including 6-8 hrs overnight use

DAY 4:
Discontinue NIV, unless continuation is clinically indicated

Pre-discharge checklist:

□ Spirometry performed if COPD suspected and no recent result available (< 1 year)
FEV1 ______ L FEV1 % predicted ______ FEV1/FVC _______
□ Appropriate sleep study booked if suspected new diagnosis of OHVS/OSA.
Communications for the NIV ward round
 Acute exacerbation of T2RF management guideline

Deliver the following within one hour

 Take ABG to confirm T2RF

 Controlled O2 therapy to maintain saturations 88-92% - use
Has the respiratory acidosis resolved after 1 hour?
venturi mask and ensure oxygen prescribed
 Nebulised salbutamol 2.5-5mg on air – do not stop oxygen
 Nebulised ipratropium 500mcgs on air
 Prednisolone 30-40mg for 7 days Yes No *Escalate to senior doctor
 Antibiotic agent (as per hospital guidelines)

Continue as above Consider whether intubation is more appropriate?

 GCS <8 • Reversible factors

 PaO2 <6.5kPa despite optimal O2 therapy • Haemodynamic instability
 ph <7.25 despite optimal medical therapy • Good performance status

Yes No

Refer to ITU team

Bleep 766 Consider whether NIV is appropriate?
(Must be CT2+ or above, or CCOT to prescribe NIV)
Document ceiling of treatment +/- DNAR form

Yes No
 Use NIV proforma (available from intranet or HAW) and operational policy
 Ensure correct mask size
 Start NIV with IPAP 10 and EPAP 5 Consider palliative care if:
 Increase IPAP by 5 cm increments every 10 mins to achieve IPAP 20  End stage disease
This should be achieved in first 20mins of treatment  Patient’s wishes
 Ensure no breaks in NIV in the first hour  Failure to respond to NIV
 ABG after 1 hour
 Make CCOT aware (bleep 654, leave message if out of hours)
 Refer to respiratory team and transfer to Harrowden A ward
 Review observation frequency

Has ABG improved?

Yes No
 If CO2↑: Increase IPAP
Continue NIV and repeat ABG in 4 hours  If O2↓ and CO2 stable: ↑FiO2 to achieve SpO2 88-92%
 Check mask fitting
 Escalate to senior doctor
 Consider whether intubation is more appropriate?
 Repeat ABG in 1 hour
Has ABG improved?

Yes No

Continue NIV and repeat ABG in 12 hours

If acidosis is resolved follow weaning plan
in NIV proforma