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Chapter 34. Noninvasive Ventilation on a General Ward

Mark W. Elliott

In any discussion about location of a noninvasive ventilation (NIV) service, it is important to note that the model of hospital care differs between countries and that there may be significant differences even between hospitals within the same country. There will be variations in staffing levels; the skills of doctors, nurses, and paramedical staff; and the sophistication of monitoring. The terms intensive care unit (ICU), high-dependency unit (HDU), and general ward have a different meaning to different people. Care therefore must be taken when extrapolating experience and results obtained in one environment to other hospitals and countries.

The United Kingdom’s King’s Fund panel1 defines intensive care as “a service for patients with potentially recoverable diseases who can benefit from more detailed observation and treatment than is generally available in the standard wards and departments.” The definition of HDU is less clear, with some HDUs allowing invasive monitoring, whereas in others only noninvasive monitoring is performed. In some countries, specific respiratory ICUs and intermediate ICUs have been developed.2,3 Specifically, within the King’s Fund definition is the consideration of intensive care as a service rather than a place; critical care is provided within a continuum of primary, secondary, and tertiary care, and patients are categorized on the basis of their needs4 (Table 34-1). Movement through the different levels usually means transfer from one location to another. Critical care outreach teams can advise on care as patients cross organizational boundaries and also facilitate transfer when this is needed.5,6 Although most acute NIV services are situated in a specific clinical area, a peripatetic model has been described and has some advantages.7,8

Table 34-1: Classification of Individual Patient Dependency
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Table 34-1: Classification of Individual Patient Dependency
  • Level 0: Patients whose needs can be met through normal ward care in an acute hospital
  • Level 1: Patients at risk of their condition deteriorating or patients recently relocated from higher levels of care whose needs can be met in an acute ward with additional advice and support from the critical care team
  • Level 2: Patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care, and those stepping down from higher levels of care
  • Level 3: Patients requiring advanced respiratory support alone or basic respiratory support, together with the support of at least two organ systems. This level includes all complex patients requiring support for multiorgan failure

For the purposes of this chapter, the following definitions are used:

  • Intensive care. High ratio of staff to patients, facility for invasive ventilation and sophisticated monitoring.
  • Intermediate respiratory ICU or HDU. Continuous monitoring of vital signs, with a staffing ratio intermediate between an ICU and a general ward, in a specified clinical area. Intubated patients (unless with tracheostomy) usually are not cared for ...

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