Acute Noninvasive Ventilation Paediatric Guideline-2

Clinical Guideline
ACUTE NON-INVASIVE VENTILATION (NIV):

PAEDIATRIC GUIDELINE
SETTING Bristol Royal Hospital for Children PICU and Daisy ward
FOR STAFF Staff working with children requiring acute usage of NIV
PATIENTS Patients from birth up to 18 years old, requiring the acute usage of NIV.
Contents Page
Introduction 2
 Background
 Mechanism
 Advantages of NIV over invasive ventilation
 Disadvantages of NIV compared to invasive ventilation
 Think ‘ICEMAN’
Indications and contraindications 4
Equipment 5
 General equipment
 Interfaces
 Circuits
 Ventilators
Modes 11
Analysis of Failure – Troubleshooting 14

 Clinical monitoring
 P/F Ratio and S/F Ratio
 Monitoring of complications
 Failure troubleshooting
Next Steps 16
 Patient improving
 Patient deteriorating
Appendix 1. v60 set up guide 18
Appendix 2. Servo I and U set up guide 27
NB: Avoid using the V60 ventilator if at all possible

MHRA/NPSA ALERT (March 2022) –potential unexpected shutdown
V2 June 2022, review date June 2025 S. Coles, PICU Physiotherapist / C Stutchfield, PICU Consultant 1 of 33
Introduction
1.1 Background
Non-invasive ventilation (NIV) can be defined as ventilatory support using techniques that do not
require an endotracheal airway. These techniques are distinguished from those that bypass the
upper airway with a tracheal tube, laryngeal mask or tracheostomy and which are therefore
considered invasive.
1.2 Mechanism
 To increase functional residual capacity
 To decrease airway resistance and improve lung compliance, reducing work of breathing
and therefore reducing O2 consumption
 To improve alveolar ventilation therefore reducing V/Q mismatch and improving gas
exchange
 To decrease inspiratory muscle work and aid avoidance of respiratory muscle fatigue
 Supports respiratory musculature
 Beneficial effect on cardiac afterload and cardiac output
1.3 Advantages of NIV over invasive ventilation

 Physiological cough is maintained
 Physiological warming and humidification is partially maintained
 Reduced risk of ventilator associated pneumonia
 Patient can sometimes eat and drink
 Patients can communicate more easily
 Reduced need for sedation
 Can be managed in an HDU environment
 Increased opportunities for rehabilitation
 Less expensive
1.4 Disadvantages of NIV compared to invasive ventilation

 Effective suction can be more challenging
 Fewer ventilator strategies are available
 Limitations in pressure
 Can be difficult on occasion to successfully fit an interface
 Risk of pressure areas from the interface
 Long term use can cause facial bone changes
 Requires synchronisation with the machine from the patient
THINK ’ICEMAN’
I Indication and location of treatment

Identification Diagnose Acute respiratory failure (ARF)
Classify ARF
Contraindications: Cautions:
Need for airway protection Craniofacial trauma
Severe respiratory failure
Contraindication (Coma. GI bleed/vomiting)
C Severe ARDS Excessive secretions
Undrained
Pneumothorax
Recent GI surgery
Vomiting
ARF type Comfeel (Hydrocolloid

Age/Size dressing)
Material available Interface & head gear
Equipment
E Ventilator
Circuit
Humidifier
Nursing care Accessories
M Connect patient Set appropriately

Mode to ventilator
A Clinical monitoring
Monitoring of complications
Analysis of failure
Failure troubleshooting
Patient improving Weaning

N Next steps
Patient deteriorating Optimisation of care

Intubation and
ventilation
Indications and contraindications
2.1 Indication for Use
 Respiratory insufficiency
 Increased work of breathing and respiratory distress
 Respiratory acidosis (pH ≤ 7.3)
 Apnoeas with desaturations or bradycardia, particularly secondary to bronchiolitis
 Upper airway obstruction
 Neuromuscular illness (e.g. Guillain-Barre, SMA, muscular dystrophy)
 Elective post extubation in difficult to wean or high risk patients
 Rescue method to avoid re-intubation
 For children normally on long term ventilation
2.2 Precautions and Contraindications
2.2.1 Contraindications:
 Need for airway protection
 Coma
 Active gastrointestinal bleed / severe vomiting
 Severe PARDS: Acute respiratory failure with bilateral infiltrates and a PF ratio ≤100 or SF
ratio ≤150 (not explained by lung oedema).
 Haemodynamic instability (particularly if not responsive to initial fluid resuscitation)
 Fixed airway obstruction
2.2.2 Precautions (to individualise treatment, low threshold for intubation):

 Craniofacial trauma
 Severe respiratory failure
 Excessive secretions
 Undrained pneumothorax
 Recent GI surgery (except PEG insertion or previous home ventilation)
 Vomiting
Equipment
3.1 General equipment for NIV
 Hydrocolloid (Comfeel) dressings: we should aim to protect the patient’s skin prior to the
initial mask application to avoid pressure sores. Comfeel should be applied to the face
where the edges of the mask will sit.
o Oronasal masks are the most high risk, particularly over the bridge of the nose
o Full face masks have a wider distribution area of pressure, and therefore reduce the
risk of pressure areas. Comfeel is NOT required on those.
 Straps and head gear will depend on the type of interface used. They can be interchanged
if required and there are spare sets kept separately on PICU or with the LTV team. Do not
overtighten straps. You should be able to fit two fingers between the mask and the patients
face.
 Interfaces: Classification:
o Location: nasal, nasal prong, oro-nasal, full face mask, helmet
o Exhalation: vented (mask has a leak allowing for effective CO2 clearance) or non-
vented (they will need a CO2 exhalation port in the circuit or expiratory limb i.e dual
limb circuit).
o Safety: with or without an anti-asphyxia valve.
These masks contain valves which in the event of ventilator failure or power outage,
will open and allow you to breathe room air in, to prevent re-inhalation of CO 2 by the
patient.
They are essential for any patient that is not continuously cardiovascularly monitored,
on an NIV or home ventilator.

Please note: it is a safety feature, not a method of CO2 exhalation

In conventional ventilators, the valve can mistakenly drop and cause
asynchrony
Of note:
 Nasal masks are generally indicated for Type II chronic respiratory failure (CRF)
without acute deterioration. Can be a good option in patients who struggle to
tolerate oro-nasal or full face masks, and as option to cycle onto when devising a
weaning or progression plan. Also preferable in patients who normally use nasal
masks with LTV at home.
 Helmets, Full face masks and oro-nasal masks are best suited for Type I and
Advanced Type II Acute Respiratory Failure (ARF), in which the patient cannot
breathe through the nose alone, especially for dyspnoeic patients that tend to
breathe through the mouth. These masks offer more support for patients. They
should be considered as a first option in patients who are likely to require a higher
level of support or present with an acute deterioration.
3.2. Interfaces
3.2.1 Non-Vented Masks (SE elbow- standard elbow – BLUE ELBOW).
To be used with Servo I/U and Hamilton
 Performax Full Face Mask

 Available in sizes XXS, XS, S, L
 Sizing guide available
 Interface comes with cap (XXS, XS) or black head gear
(S,L)
 Elbows can be changed
 AF531 Oro-nasal Mask

 Available in sizes S, M, L
3.2.2 Non Vented masks with Anti-asphyxia Valve (EE elbow leak 1 – CLEAR ELBOW).
To be used with V60 or Trilogy
These masks contain valves which in the event of ventilator failure or power outage, will open and
allow you to breathe room air in, to prevent re-inhalation of CO 2 by the patient. They are a safety
feature, not a method of CO2 exhalation. If the valve opens, the patient will NOT BE VENTILATED.
 Performax Full Face Mask
 Available in sizes XXS, XS, S, L
 Interface comes with cap (XXS, XS) or black head gear (S,L)
 AF531 Oro-nasal Mask and Performatrack

 Available in sizes S, M, L
 Elbows can be changed in AF531, fixed in Performatrack
3.2.3 Nasal masks
 PN841 ‘Giraffe’ Nasal Mask

 Available in a range of mask sizes
 SE (blue elbow) can be used in Servo I,
Servo U, Hamilton, V60 and Trilogy
 EE (white elbow) can be used on home
ventilators and V60 if an adaptor is used.
Mask Fitting
 Optimal management is for all patients that require 24/7 NIV use to have two
different masks to avoid pressure areas developing (full face and oronasal).
 Remember the hats between the masks are interchangeable and you may need to
mix and match different sizes to achieve the best fit
 Use the sizing guides when fitting the masks to avoid opening masks you don’t
use
 To optimise fitting it should be a two person technique
 Comfeel should be applied to pressure areas on the face when oronasal is used
 You should always be able to fit two fingers between the mask and skin
 The masks do not need to be overtightened, it is ok to have a leak as long as the
pressures and tidal volumes are being achieved.
 The elbows are interchangeable so can keep the same mask if changing
ventilators
 Remove mask at least 4 hourly and check pressure areas
Please refer to specific ventilator set ups guides (in Appendix) for mask fitting information
3.2.4 CPAP for babies ≤4kg
For babies ≤ 4kg requiring CPAP only, Medin sets of nasal masks and nasal prongs are available.
They only fit on the neonatal ventilation circuit sets, but are compatible with both the Servo I and
Servo U ventilators. The pressure line is removed from the circuit when using the Medin sets. They
are for use in the Nasal CPAP NIV mode.
3.2.5 CPAP for babies ≤10 kg - Bubble CPAP
Bubble CPAP is also available for infants ≤ 1 year of age

and≤10kgs. Please refer to the following documents on the
UHBristol DMS:
 Continuous Positive Airway Pressure (CPAP) for Infants in
Paediatric Critical Care (Paediatric HDU/ICU)
 Bubble CPAP Competency Document
3.3 Circuits:
 Single limb for specific NIV ventilators- V60, Resmed, NIPPY, Stella, Trilogy, Astral
o Home ventilator circuits do not have a leak, use vented masks
o V60 circuits are single limb but have a standard exhalation device within the circuit –
always use non-vented masks in that case
 Dual limb for conventional ventilators- Servo I and Servo U
o Circuit doesn’t have an exhalation valve, exhalation occurs through the expiratory
limb - Use non-vented masks
3.4 Ventilators:
 NIV specific ventilator equipped with an oxygen blender - V60, Trilogy 202
 Conventional ventilator with a NIV option - Servo I and Servo U and Hamilton
 NIV specific home ventilators without oxygen blender – Trilogy 100, Astral, Stella, Nippy
(add O2 through a port; allow an FiO2 of up to 0.6)
 NIV specific ventilators will always be the optimum choice in bigger children, because they
compensate better for leaks, and the expiratory triggers are more sensitive than in
conventional ventilators.
 Maquet Servo I ventilator, NIV option
 Dual limb circuit
 Non vented mask
 FiO2 up to 1.0
 Use with SE elbow masks (blue)
 Maquet Servo U ventilator, NIV option

 Dual limb circuit
 Non vented mask
 FiO2 up to 1.0
 Hamilton T1(red)/MR1 (yellow)

 Dual limb circuit (looks like single!)
 Non vented mask
 FiO2 up to 1.0
AVOID USING V60 IF AT ALL

POSSIBLE
MHRA/NPSA ALERT (March 2022) –
potential unexpected shutdown
 V60 NIV specific ventilator

 Single limb circuit with expiratory port
 Requires non vented mask with anti-
asphyxia valve
 FiO2 up to 1.0
 Licenced >20kg
 Use with EE elbow masks (clear)
 Trilogy 202 NIV specific ventilator
 Single limb circuit
 Vented mask
 FiO2 up to 1.0
 Licenced >5kg
 Use with EE elbow masks (clear)
 There is a home ventilation model (100)
without blender.
 NIPPY NIV specific ventilator

 Vented mask
 O2 delivered in litres, not able to titrate
percentage
 FiO2 will be a mix from the air taken from
the air + the oxygen added
 Use with home ventilation masks! Mask
will have to be vented.
 Resmed Stella
 Vented mask
 O2 delivered in litres, not able to titrate
percentage
 FiO2 will be a mix from the air taken from
the air + the oxygen added
 Resmed Astral
 Vented mask
 O2 delivered in litres, machine will
calculate the percentage
 Up to 30L/min O2 can be added
MODE:
V2 June 2022, review date June 2025 S. Coles, PICU Physiotherapist / C Stutchfield, PICU Consultant 10 of
When programming NIV we should take into account:
 Age of the patient
o ≤3 months, likely asynchronous, consider CPAP as initial mode
o ≥ 3 months, more likely to synchronise, BLPAP can be used as first option.
 Type of respiratory failure we are supporting (although patients will usually have mixed
characteristics as the disease progresses):
o Type I acute respiratory failure (ARF): Characterized by V/Q mismatch without
alveolar hypoventilation. In paediatric patients it tends to occur with pneumonia, acute
pulmonary oedema, chest wall trauma, neonatal respiratory distress syndrome
(NRDS) and acute respiratory distress syndrome (ARDS).
o Type II ARF: Is characterized by alveolar hypoventilation. It tends to be associated
with conditions that affect the respiratory drive, as well as airway obstruction,
neuromuscular weakness, chest wall abnormalities and morbid obesity
 Degree of hypoxaemia:
Titrate FiO2
for SpO2 92-
Figure 1. Algorithm for NIV failure analysis based on S/F ratio for a target SpO2 92-97%.
MV: Mechanical ventilation; BLPAP: Bilevel positive airway pressure; CPAP: Continuous positive airway pressure; APO: Acute pulmonary oedema;
ARDS: Acute respiratory distress syndrome, S/F: oxygen saturation/fraction of inspired oxygen; HR: Heart rate; RR: Respiratory rate.
From: Medina A, Pilar J, Humphry A, Christopherson M, Garcia Cusco M, editors. Handbook of paediatric and neonatal mechanical ventilation.
Oviedo (Spain): Tesela ediciones; 2018
4.1 Setting up CPAP. Initial settings
 General concepts
o CPAP provides one level of pressure (PEEP/EPAP)
o It can be used in respiratory failure type I and apnoeas, particularly in asynchronous
patients (<3month age)
o The optimal PEEP for bronchiolitis is approximately 7cmH2O
 Setting up in conventional ventilators (Servo I/U)

o Can be delivered by providing Nasal CPAP in paediatric mode or NIV PS with a set
pressure support of 0 (although the ventilator might still support slightly)
 Setting up in specific NIV ventilators (v60)

o Select CPAP mode
o Start at low pressures (4cmH2O) and increase as required
o C-flex option is available: It drops pressure when exhalation starts, to improve comfort
and synchronisation. Use carefully in patients with borderline oxygenation.
4.2 Setting up BLPAP. Initial settings
 General concepts
o Provides two levels of pressure: PEEP/EPAP and PIP/IPAP
o Requires synchrony for its optimal delivery
 Setting up in conventional ventilators (Servo I/U)

o Worse leak compensation, sensitive triggers
o Select NIV PS
 Start at low pressures: PEEP 4, PS 4 (over PEEP) and increase later
 Inspiratory trigger is automatic and cannot be changed (quite sensitive)
 Inspiratory rise time should be adapted to patient’s “air hunger” and comfort,
starting at 0.15sec
 Expiratory trigger (inspiratory cycle off): If insufficient Ti, reduce the %; if
breaths are too long: increase %
 Please do not change to NIV PC unless discussed with NIV specialist staff
member
o In small babies that are asynchronous or uncontrollable leaks:
 Select NIV PC and try to “mimic” their breathing pattern. RR 5bpm below their
own rate and short Ti.
 NIV NAVA can also be used. Please refer to specific guideline.
(http://nww.avon.nhs.uk/dms/download.aspx?did=21942 )
o NOTE: The ventilators will default to a maximum PIP setting of 15cmH2O (alarm limit
20cmH2O but will cut out at 5cmH2O below this). This will need to be increased to
deliver pressure effectively, without the ventilator cutting out.
 Setting up in specific NIV ventilators (V60/Trilogy)

o Better leak compensation, less sensitive triggers
o Mask and exhalation ports used should be selected on the ventilator
o Select S/T (Spontaneous/Timed)
 Start at low pressures: EPAP 4, IPAP 8 and increase later
 The patient should be breathing spontaneously. The back up rate will only start
if there is no spontaneous patient effort. This is worked out by how many
breaths per minute you set as a back up- the V60 works out how many breaths
your patient should be taking. If the patient fails to trigger a breath within the
interval determined by the rate setting it will detect an apnoea and deliver a
mandatory breath. It is important to remember this when setting the back up
rate- if it is too high it will trigger unnecessarily It should be set as low as
possible to avoid this happening and to avoid asynchrony.
 The rise time will determine how long it takes the patient to reach the target
pressure during inspiration. Altering this can improve patient comfort and
synchronisation. Aim for a starting point of 3.
 Autotrack + is a feature to increase trigger sensitivity and expiratory cycle
sensitivity and can be used in younger patients, smaller patients and those that
find it harder to trigger i.e. patients with neuromuscular conditions.
Trigger sensitivity ranges from 1 being the least sensitive to 7 being the
most sensitive
The E-Cycle determines the expiratory cycle sensitivity. It determines the
threshold at which the ventilator will transition from inspiration to exhalation,
so lengthening or reducing the duration of inspiratory flow.
 Ramp can be used to allow the patient to become accustomed to respiratory
ventilatory therapy over time. Ramp will allow the pressure to linearly increase
over a user-set period. It would be advised to no set it no longer than a
maximum of 10minutes
Please refer to specific ventilator set ups guides (in Appendix) for clear navigation to access
these additional settings
ANALYSIS OF FAILURE / TROUBLESHOOTING:
5.1 Clinical Monitoring
Patients requiring NIV are critically ill and need monitoring, but we should aim to perform it as non-
invasively as possible, avoiding repeated blood gases.
 Heart Rate
 Respiratory Rate
 SaO2 Hourly
 FiO2
 SatO2/FiO2
 Chest X Ray- initially in hypoxemic patients (to rule out ARDS and pneumothorax) and if
clinical deterioration.
5.2 P/F Ratio and S/F Ratio
The P/F ratio is a measure of intrapulmonary shunting, and is obtained by comparing arterial to
inspired oxygen.
This value can be calculated by dividing the arterial oxygen tension (PO 2) by the fraction of inspired
oxygen (FiO2). S/F ratio is a correlation to P/F ratio and is calculated using the O 2 saturations
instead of the PO2. e.g.: SaO2 92/ FiO2 0.8 = 115
S/F ratios are a reasonable way of identifying early ALI and ARDS, e.g.:
o Acute lung injury S/F Ratio < 315
o Acute Respiratory Distress S/F Ratio < 23
SpO2/FiO2 (SF) ratio is a non-invasive, easily and continuously available figure that has been
shown to have a good correlation with the PaO2/FiO2 (PF ratio), that is a measure of shunt and a
predictor of mortality. According to this, a low SF ratio (below 150) would correspond to a severe
hypoxemic acute respiratory failure. SF ratio can only be calculated when SpO 2 is ≤97%. However,
as long as the oxygen saturation is kept between 93-97%, We can use FiO 2 required to estimate
the degree of respiratory failure.
P/F ratio S/F ratio (approx.)

PF 300 (mild) 300
PF 200 (moderate) 235
PF 100 (severe) 150
5.3 Monitoring of Complications:

 Skin irritation and skin sores- anti-sore dressings, alternating masks
 Conjunctivitis- minimise leak around the eyes
 Hypercapnia- big masks in small babies can lead to re-inhalation of CO2
 Gastric distention – Nasogastric tube
 Pulmonary hyperinflation
 Pneumothorax (rare)
5.4 Failure Troubleshooting
NEXT STEPS
(for medics and NIV trained physiotherapists and nurses)
6.1 Patient improving:
 Use assessment tools (auscultation, observations, ABGs, CXR, comfort, secretions) to

implement weaning plan
 Utilise MDT members to aid optimal progression
 Weaning plans are patient specific
6.2 Patient deteriorating (please escalate concerns to medic or NIV competent

physiotherapist or nurse)
Optimisation of care
Optimising airway patency

 Confirm that the treatment is adequate for respiratory failure of this aetiology
 Optimise secretion clearance with physiotherapy
 Clear Suction and positioning plan with nursing staff
Check for any new complications
 Pneumothorax
 Aspiration pneumonia
 Collapse
 Pleural effusions
Persistent hypoxaemia:
 Switch to a ventilator with oxygen blender, if not already on one
 Consider IPAP/ EPAP increase
 Increase FIO2
Persistent hypercapnia:
 Check for leakage in the interface
 Consider switching the interface
 Check the circuit
 Correct any re-breathing:
o Increase EPAP
o Switch to an interface with less dead space (if possible)
Prevent desynchronisation:
 Adjust the respiratory rate and I:E ratio
 Adjust inspiratory and expiratory trigger, if possible
 Adjust rise time and inspiratory flow, if possible
 Consider EPAP increase
Ensure adequate ventilation:
 Check chest wall expansion
 Increase IPAP or delivered volume
 Consider mode/ventilator change, CXR, Auscultation, Work of Breathing (WOB), etc.
If no improvement after optimisation
 Discuss with consultant in charge

 Make Sister in charge aware
 Prepare for intubation
 Use pre intubation checklist items
 Ensure adequate communication of plan to parents and MDT
Of note:
 Ensure stomach is vented with NGT (or PEG) on free drainage or regularly aspirated
 Always think about your patient position, particularly their airway
 The humidifier should always be set to the ‘non-invasive’ setting regardless of the circuit
 If you are cycling off NIV and turning the humidifier off, on turning it back on it will always
restart on the ‘invasive setting’
 Dummies can be used only after being risk assessed by NIV specialist (
RELATED  Continuous Positive Airways Pressure (CPAP) For Infants in Paediatric Critical Care
DOCUMENTS (Paediatric HDU/ICU)
 Bubble CPAP Competency Document
 Neurally adjusted ventilatory assist NAVA
AUTHORISING PIC Governance

BODY
SAFETY Wrong connection of equipment can lead to inability to ventilate or instability of the
patient. Please double check that correct equipment is used.
QUERIES Contact PICU Physiotherapists Ext 28101 / 28894 / Bleep 2720.

Out-of-hours – Senior Nurses / Medical Staff on PICU
APPENDIX 1
AVOID USING V60 IF AT ALL POSSIBLE
MHRA/NPSA ALERT (March 2022) – potential unexpected shutdown
SETTING UP THE V60 FOR NIV

Respironics single limb
circuit with exhalation port Humidifier Dome Interfaces-Masks
and pressure line
Sterile water for inhalation
Bacterial-viral Filter Temperature wires
Set –up
1. Connect your circuit to the ventilator.
Pressure line line
Intersurgical clear guard 3

bacterial/viral filter added
into circuit
Fill with sterile Pressure line

water for inhalation attached to
to black max line exhalation
2. Connect heated humidifier - set on NON INVASIVE SETTING port
3. Ensure temperature wires in place and circuit connected
Temperatur
e wires
Temperatur
Note: the circuit is a single limb circuit, with a CO2 exhalation port that MUST NOT BE
COVERED e probe
attached to
the
connector
below
CO2 the
elbow piece
exhalation
onport
the
mask
4. Turn V60 on, button located at the front of the machine
5. Check the right mode is selected i.e. CPAP or Batch S/T (BLPAP)
6. Check the alarm settings are appropriate for the patient and reset as required
Note… Alarms can be silenced, paused and reset using the touch screen options along the
top of the screen
7. Program in type of mask used by leak number- leak number can be found on elbow of the
mask, this allows the ventilator to compensate for the anticipated leak and tidal volumes for
the specific mask. Go to MENU, MASK/PORT, press arrows to get required LEAK
NUMBER then press ACCEPT
Once you input the mask and press accept it will also ask you for the type of CO2 clearance device.
Always select ‘DEP’ (disposable expiration port) unless you are not using our standard circuit and
set up
8. Doctors; physios or nurses who have successfully completed the ventilation weaning
course can program the appropriate ventilation settings for the patient
9. Once the V60 is on and the settings are correct then fit the mask to the patient (Note: the
mask should not be fitted until the V60 is set up and on)
MASK FITTING
Full Face Masks (EE leak 1 elbow):

 Check the mask is appropriately sized
 Check mask is fitted correctly. The mask should sit around the circumference of the face
Oro-nasal masks (EE leak 1 elbow):

 Check mask appropriately sized
 The mask should sit comfortably covering the nose and mouth
Note: Additional considerations

 Mask fitting is essential for optimising patient
outcomes on NIV: please see main guideline for
additional considerations and advice in regards to
mask fitting
 The V60 will compensate for a leak up to 60L/minute
 Aim if possible for a leak of up to 30L/minute
Oxygen delivery
Oxygen percentage is set using the touch screen function and is accessed from the main screen
To deliver 100% oxygen immediately for two minutes:
Select 100% O2 on main screen
To go into standby…
Only Doctors, nurses and physios who have successfully completed the ventilation
management course are able to alter the V60 ventilator settings
V60 modes: AVOID USING V60 IF AT ALL POSSIBLE
MHRA/NPSA ALERT (March 2022) –potential unexpected shutdown
Ventilation modes. The ventilator offers a range of conventional pressure modes:
 CPAP (continuous positive airway pressure),

 PCV (pressure-controlled ventilation)
 S/T (spontaneous/timed)
 The volume-targeted AVAPS (average volume-assured pressure support) mode combines the
attributes of pressure-controlled and volume-targeted ventilation
 The optional PPV mode provides pressure ventilation in proportion to the patient’s efforts.
Within the trust we mainly use two modes:
CPAP mode
 In the CPAP (continuous positive airway pressure)

mode, the ventilator functions as a demand flow
system, with the patient triggering all breaths and
determining their timing, pressure, and size.
 The optional C-Flex setting enhances traditional
CPAP by reducing the pressure at the beginning
of exhalation – a time when patients may be
uncomfortable with CPAP – and returning it to the set CPAP level before the end of exhalation.
S/T mode
 Spontaneous/Timed mode delivers BiLevel

pressure
 Things to look out for and some trouble shooting
to consider….
 The patient should be breathing spontaneously.
The back up rate will only start if there is no
spontaneous patient effort. This is worked out
by
how many breaths per minute you set as a back up- the V60 works out how many breaths your
patient should be taking. If the patient fails to trigger a breath within the interval determined by
the rate setting it will detect an apnoea and deliver a mandatory breath. It is important to
remember this when setting the back up rate- if it is too high it will trigger unnecessarily It should
be set as low as possible to avoid this happening and to avoid asynchrony.
 Observe spontaneous vs timed breath indicator in the top left hand corner of the screen. It
indicates if the breath is a spontaneous breath by the patient (blue) or if they are using the back
up mode (orange)
1. Trigger settings
a. Remember trigger sensitivity setting when programming the settings
1 being the least sensitive to 7 being the most

b. The E-Cycle determines the expiratory cycle sensitivity. It determines the threshold at
sensitive
which the ventilator will transition from inspiration to exhalation, so lengthening or
reducing the duration of inspiratory flow.
Follow pictorial guideline in the screen for breath

c. Altering both the trigger sensitivity and the E-Cycle will improve patient comfort and
length
synchronisation with the V60. It can significantly aid compliance and optimise ventilation
2. Monitor Tidal volume and the trend and ensure it is within acceptable range for your patient (6-
12mls/kg). e.g. 10kg patient would have an estimated TV of between 60-120mls
3. Observe Patient trigger in conjunction with respiratory pattern for feedback on respiratory effort
and synchronisation
4. The rise time will determine how long it

takes the patient to reach the target pressure during inspiration. Altering this can improve
patient comfort and synchronisation.
5. Ramp can be used to allow the patient to become accustomed to respiratory ventilatory therapy
over time. Ramp will allow the pressure to linearly increase over a user-set period. It would be
advised to no set it no longer than a maximum of 10minutes.
Shutting down the ventilator
1. Press and release the ON/Shutdown key. The Shutdown window opens.
2. Select Ventilator Shutdown.
Screen Lock
 Deactivates all buttons and tabs on the touchscreen except Alarm Silence, Alarm Reset, the
Alarm/Message button, and Help.
 Tabs are greyed out.
 This message bar is displayed at the top of the screen: To unlock the screen, press the
Accept button in the centre of the navigation ring.
APPENDIX 2
SETTING UP THE SERVO I FOR NIV
Dual limb ventilator circuit Humidifier Dome Interfaces-Masks
 Neonatal dual limb

ventilation circuit < 5
kgs
 Paediatric dual limb
ventilation circuit < 20
kgs
 Adult dual limb
ventilation circuit > 20
kgs
Sterile water for inhalation
Bacterial-viral Filter Temperature wires
Nasal CPAP interface
Required:
o Neonatal circuit and additional NIV connector
o A bonnet
o An interface → Medin nasal prongs or mask
 This interface will only fit on the neonatal circuit

 This is the only occasion where you need to remove the pressure line
 Use the biggest size prongs or mask you can for the patient
o Remember they also come in a ‘ wide’ fit for medium and large
 Ensure the mask fits adequately, particularly taking into account NGT/NJT
 Switch between mask and prongs for pressure relief
 Do not overtighten
Bonnets
 Use the smallest bonnet available for your patient

o They are very stretchy and gentle on the skin
 Ensure the MEDIN fixation label is on the outside to ensure the 2 ventilation limbs sit
securely within it
 The Velcro fixation straps will secure adequately to the bonnet
Set up:
1. Connect your circuit to the ventilator
2. Connect humidifier and fill- set to NON INVASIVE SETTING
3. Ensure temperature wires in place
4. Complete Pre-Use check
5. Select NIV mode on ventilator (screen will go ORANGE)
 Servo I
NOTE: Alarm settings on Servo

I will default to a maximum PIP
 Servo U of 20cmH2O, therefore causing
the ventilator to cut out and not
deliver a pressure above
15cmH2O- this alarm setting
will need to be changed prior to
commencing NIV
6. Ensure appropriate interface selected
BLPAP Interfaces
1. Full facemasks (SE elbow)

 Require:
o Paediatric or adult circuit
o Facemask appropriately sized (use
paper sizer)
 Full face masks range from XXS to Large. XXS fits approximately 3kg baby
 Requires a non-vented mask with a BLUE elbow
 Dual limb circuit therefore does not require expiratory port
 Bonnets come with the masks, there are spares in the store cupboard, and a
variety of sizes
 Attach as demonstrated
2. Oro-nasal masks (SE elbow)
 Require:
o Paediatric or adult circuit
o Mask appropriately sized
o Can be used on the Servo I/U
Note: Additional considerations

 Mask fitting is essential for optimising patient outcomes on NIV: please see main guideline
for additional considerations and advice in regards to mask fitting.

Acute Noninvasive Ventilation Paediatric Guideline-2

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Clinical Guideline

ACUTE NON-INVASIVE VENTILATION (NIV):

Indications and contraindications 4

Analysis of Failure – Troubleshooting 14

Appendix 1. v60 set up guide 18

Appendix 2. Servo I and U set up guide 27

NB: Avoid using the V60 ventilator if at all possible

1.3 Advantages of NIV over invasive ventilation

1.4 Disadvantages of NIV compared to invasive ventilation

I Indication and location of treatment

ARF type Comfeel (Hydrocolloid

M Connect patient Set appropriately

Patient improving Weaning

Patient deteriorating Optimisation of care

2.1 Indication for Use

2.2 Precautions and Contraindications

2.2.2 Precautions (to individualise treatment, low threshold for intubation):

 Performax Full Face Mask

 AF531 Oro-nasal Mask

 AF531 Oro-nasal Mask and Performatrack

3.2.3 Nasal masks

 PN841 ‘Giraffe’ Nasal Mask

3.2.5 CPAP for babies ≤10 kg - Bubble CPAP

Bubble CPAP is also available for infants ≤ 1 year of age

 Maquet Servo U ventilator, NIV option

 Hamilton T1(red)/MR1 (yellow)

AVOID USING V60 IF AT ALL

 V60 NIV specific ventilator

 NIPPY NIV specific ventilator

4.1 Setting up CPAP. Initial settings

 Setting up in conventional ventilators (Servo I/U)

 Setting up in specific NIV ventilators (v60)

4.2 Setting up BLPAP. Initial settings

 Setting up in conventional ventilators (Servo I/U)

 Setting up in specific NIV ventilators (V60/Trilogy)

5.2 P/F Ratio and S/F Ratio

P/F ratio S/F ratio (approx.)

5.3 Monitoring of Complications:

6.1 Patient improving:

 Use assessment tools (auscultation, observations, ABGs, CXR, comfort, secretions) to

6.2 Patient deteriorating (please escalate concerns to medic or NIV competent

Optimising airway patency

 Discuss with consultant in charge

AUTHORISING PIC Governance

QUERIES Contact PICU Physiotherapists Ext 28101 / 28894 / Bleep 2720.

SETTING UP THE V60 FOR NIV

Sterile water for inhalation

Bacterial-viral Filter Temperature wires

1. Connect your circuit to the ventilator.

Pressure line line

Intersurgical clear guard 3

Fill with sterile Pressure line

Full Face Masks (EE leak 1 elbow):

Oro-nasal masks (EE leak 1 elbow):

Note: Additional considerations

To deliver 100% oxygen immediately for two minutes:

Select 100% O2 on main screen

Ventilation modes. The ventilator offers a range of conventional pressure modes:

 CPAP (continuous positive airway pressure),

Within the trust we mainly use two modes:

 In the CPAP (continuous positive airway pressure)

 Spontaneous/Timed mode delivers BiLevel

a. Remember trigger sensitivity setting when programming the settings