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Non-invasive ventilation | Signal

Reference number
1293 F
Issue date29 October 2010

This Signal is about patient safety issues related to non-invasive ventilation 

A sample incident reads:

….. Patient referred for physiotherapy …. known COPD with CO2 retention on BiPAP with 6 litres O2 ….. Therapist identified incorrect set-up of BiPAP circuit, instead of a BiPAP circuit being used, elephant tubing was in situ. As a result there was no CO2 expiratory port, the safety flap was down and the machine was unable to deliver the required support . ….

Non-invasive ventilation (NIV) is the umbrella term for a range of ventilation techniques supplying positive pressure ventilatory support to the airways through masks attached to a patient's nose or mouth, including Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP). NIV is commonly used to treat chronic obstructive airways disease but also other acute respiratory conditions, and may be used at night in the community by patients with obstructive sleep apnoea.

A search of the National Reporting and Learning System (NRLS) for incidents reported over four years identified 197 cases where problems with administering NIV were reported as causing at least moderate harm.

Key issues were:

  • shortage of staff skills or staff time to set up and monitor NIV for patients who require it;
  • equipment shortages that delayed or prevented the provision of NIV;
  • setting up the machine incorrectly, especially circuits and alarm thresholds;
  • tissue damage, mainly pressure damage under the NIV mask;
  • confusion between CPAP and BiPAP;
  • removing NIV so the patient could eat, or to take blood gases, and not reapplying.

Reports suggested some hospitals restrict NIV provision to one or two units, which ensured skilled staff were available and the likelihood of error was reduced. However, these units did not always have capacity to admit all patients who needed NIV. We recommend that services providing NIV review their policies and protocols to ensure the appropriate balance between restricting the service to those units where staff are competent and confident in its use, and ensuring NIV can be provided to all patients who would benefit.

Please contact us with your initiatives to reduce risks in these areas.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.