Non-invasive Positive Pressure

Ventilation


Introdaction
* Nippv is recent phenomenon, mainly because of
advances in noninvasive interfaces and ventilator
modes

* NIPPV delivered o2 by nasal or oronasal mask

* The efficacy of noninvasive positive-pressure
Ventilation has been demonstrated for acute
pulmonary edema, for respiratory failure in
immunocompromised patients, and to facilitate
extubation in COPD patients.
* Patients who develop respiratory failure or who
refuse intubation are potentially good candidates for
noninvasive positive-pressure ventilation

*Several factors are vital to the success of noninvasive
positive-pressure ventilation: careful patient
selection; properly timed initiation; comfortable,
well-fitting interface; coaching and encouragement;
and careful monitoring.




*Noninvasive ventilation should be used to avert
endotracheal intubation rather than as an alternative to
it.
Definition
The application of positive pressure ventilation
without using an endotracheal tube.
or
As the provision of ventilatory assistance to the
lungs without an invasive artificial airway
History
Until the early 1960s, negative-pressure ventilation in the
form of tank ventilators was the most common type of
mechanical ventilation outside the anesthesia suite
With the introduction of nasal CPAP to treat obstructive sleep
apnea in the early 1980s,
NIPPV rapidly displaced negative-pressure ventilation as the
treatment of choice for chronic respiratory failure in patients with
neuromuscular and chest wall deformitie
The past 12 years, noninvasive ventilation has moved
from the outpatient to the inpatient setting, where it is
used to treat acute respiratory failure.

Non-invasiveVentialtion

1- Positive pressure


2-Negative Pressure


Advantage(NIPPV)
*Decreased direct upper airway trauma & bypass of
the upper airway defense mechanisms
*Allows patients to eat orally, vocalize normally, and
expectorate secretions.
* Noninvasive ventilation reduces infectious hospital
including pneumonia,sinusitis, and sepsis.
* lowers morbidity and mortality
* Shorten hospital length of stay, thus reducing costs.
Goals of NIV
Relieve symptoms
Reduce work of breathing
Offset the effect of i PEEP
Improve gas exchange
Minimize risk of barotrauma
Avoid intubation
Indication
Airway Obstruction
COPD
Asthma
Cystic fibrosis
Obstructive sleep apnea or obesity hypoventilation
Upper airway obstruction
Facilitation of weaning in COPD
Extubation failure in COPD
Indication
Hypoxemic Respiratory Failure
ARDS
Pneumonia
Trauma or burns
Acute pulmonary edema (use of CPAP)
Immuno compromised patients
Restrictive thoracic disorders
Post operative patients
Do-not-intubate patients
During bronchoscopy
Modes of Noninvasive Mechanical Ventilation




* volume ventilation, initial tidal volumes range from
10 to 15 mL.kg.

1-Pressure modes

2-volume modes
Pressure-cycled vents are better tolerated than volume-cycled vents
Pressure modes
**Continuous Positive Airway Pressure(CPAP)

Continuous positive airway pressure (CPAP) is a mode for invasive and
noninvasive mechanical ventilation.

It provides positive airway pressure throughout the respiratory cycle.
This static, positive pressure is maintained constantly during inhalation
and exhalation

CPAP is not a stand-alone mode of assisted mechanical ventilation. It is
equivalent to positive end-expiratory pressure (PEEP) and facilitates
inhalation by reducing pressure thresholds to initiate airflow.

This mode should never be used in patients who may have apneic
episodes because of the lack of a backup rate.
Pressure modes
Spontaneous Modes
In spontaneous mode, the airway pressure cycles between an inspiratory
positive airway pressure (IPAP) and an expiratory positive airway
pressure (EPAP).
This is commonly referred to as bilevel or biphasic positive airway
pressure (BL-PAP or BiPAP). The patient's inspiratory effort triggers the
switch from EPAP to IPAP. The limit during inspiration is the set level of
IPAP.
The inspiratory phase cycles off, and the machine switches back to EPAP
when it detects a cessation of patient effort, indicated by a decrease in
inspiratory flow rate, or a maximum inspiratory time is reached, typically
2-3 seconds.
Tidal volume (Vt) varies breath to breath and is determined by degree of
IPAP, patient effort, and lung compliance.
Spontaneous mode depends on patient effort to trigger inhalation. A
patient breathing at a low rate can develop a respiratory acidosis.



Spontaneous/timed (ST) mode


The trigger in the ST mode can be the patient's effort or an elapsed time
interval, predetermined by a set respiratory backup rate.

If the patient does not initiate a breath in the prescribed interval, then
IPAP is triggered. For machine-generated breaths, the ventilator cycles
back to EPAP based on a set inspiratory time.

For patient-initiated breaths, the ventilator cycles as it would in the
spontaneous mode.




Pressure modes
Conceptually:

One can consider BiPAP as PEEP with pressure support (PS).
The pressure during the inspiratory phase is termed IPAP and
is analogous to PS.

The pressure during the expiratory phase is termed EPAP and
is analogous to PEEP.

The IPAP is necessarily set higher than EPAP by a minimum
of 5cm H
2
O, and the difference between the two settings is
equivalent to the amount of PS provided
I nitiating Noninvasive Mechanical Ventilation
Either a face mask or a nasal mask can be used, but a nasal mask is
generally better tolerated.
A respiratory therapist must measure the patient to ensure a good fit and
seal.
Initially supply 3 to 5 cm H
2
O of CPAP with supplemental oxygen.
sequentially increase the CPAP pressure by 2 to 3 cm H
2
O increments
every 5 to 10 minutes (ABG-Pulse oximetry)
Recommended initial settings for BiPAP machines in the noninvasive
support of patients in respiratory distress or failure are IPAP of 8 cm H
2
O
and EPAP of 3 cm H
2
O, for a pressure support (IPAP minus EPAP) of 5
cm H
2
O.
The level of supplemental oxygen flowing into the circuit should be
governed by goal pulse oximetry and corroborated by ABG results as
necessary; it is appropriate to initiate therapy with 2 to 5 L/minute, but
this amount should be adjusted with each titration of IPAP or EPAP.


The intrinsic positive end-expiratory pressure
(PEEP
i
), or auto-PEEP, cannot be measured by
a noninvasive ventilator; therefore, EPAP
should generally be maintained below 8 to 10
cm H
2
O to be certain that it does not exceed
PEEP
i
in patients with obstructive lung disease.

The IPAP must always be set higher than EPAP
Conceptually:
Management Strategies
COPD
Main goal to decrease work of breathing (decreasing V/Q
mismatch) and provide adequate ventilation
Relatively low EPAP: 5-8cm H2O (assuming no obesity or
sleep disordered breathing)
Relatively moderate IPAP+EPAP: 10-14cm H2O
Goal to have at least a 5cm H2O differential between EPAP
and IPAP+EPAP; may need to go higher depending on
ventilation requirements
ie BiPAP 14/10 or 8/5
Management Strategies
CHF
Goal is to decrease work of breathing, decrease
afterload and decrease overall static pressure
Relatively moderate EPAP: 6-12 cm H2O
Relatively low IPAP+EPAP: 12-18cm H2O
Patient will benefit mostly with EPAP unless other
concurrent disease ( COPD, Obesity-
Hypoventilation)
Typical starting point: BiPAP 10/6
Management Strategies
Obesity-Hypoventilation Syndrome
Goal of therapy is to decrease work of breathing and
increase ventilation
Combined disease as >90% will also have concurrent
Obstraction sleep Apnea(OSA)
EPAP: usually on the higher side; enough to overcome
OSA and cardiopulm disease: ~10cmH2O, more for
bigger individuals
IPAP+EPAP: at least a 4cm H2O differential
Need to adjust according to ventilation requirements;
may benefit from back up rate
Management Strategies
Sleep Disordered Breathing
Most often post-op with known OSA or as a
complication associated with admit (CHF or
Obesity-Hypoventilation)
For elective admit with known OSA: usual
CPAP/BiPAP unless physiologic changes with acute
illness, surgery or narcotics.
Management Strategies
Neuromuscular Disease
Goal to decrease work of breathing, decrease
fatigue, assist ventilation
EPAP: usually low; 4-5cm H2O
IPAP+EPAP: at least 4cmH2O differential
May benefit from backup rate
Management Strategies
Other causes of respiratory failure
Pneumonia/ARDS
Cancer and respiratory failure
Post-op management
Settings depend on disease and other cardiopulmonary
disease
Most often used as a bridge to mechanical ventilation
or for pts DNR/DNI
Usually moderate settings: 12/8 or 14/8
Nasal masks are widely used for the administration of
CPAP or noninvasive ventilation, particularly for chronic
applications.

Nasal masks are usually better tolerated than full face masks for
long-term applications, because they cause less claustrophobia
and discomfort and allow eating,conversation, and expectoration.

The standard nasal mask is a triangular or cone-shaped
clear plastic device that fits over the nose and uses a soft cuff
that forms an air seal over the skin.

Full facemasks cover both the nose and the mouth
and are preferable to nasal masks in the acute
setting.
The efficacy of both nasal and oronasal masks in
lowering PaC02 and avoiding intubation is similar in the
acute setting,

but in a recent randomized,
patients tolerated the full facemask better because of reduced
air leakage through the mouth.
Selection of a comfortable mask that fits properly is key
to the success of noninvasive ventilation.

The full facemask
should be tried first in the acute setting, and if possible,

The mask straps are then tightened with the least tension
necessary to avoid excessive air leakage.
NIPPV masks
Nasal mask
NIPPV masks
Full face mask
NIPPV masks
Full face mask
Most of our patients!!
NIPPV machines
BiPAP
NIPPV machines
CPAP machine

Head straps hold the mask in place and are important for
patient comfort.


Straps attach at two to five points, depending
on the type of mask. More points of attachment add to
stability.
Head straps
OXYGENATION AND HUMIDIFICATION

Oxygen is titrated to achieve a desired oxygen saturation,
usually greater than 90% to 92%
Either by using oxygen
blenders on critical care and some bilevel ventilators or
By adjusting liter flow (up to 15 L/min) delivered via oxygen tubing connected
directly to the mask or ventilator circuit.

Bilevel ventilators
have limited oxygenation capabilities (maximal inspired oxygen fraction( %45 to
50)
so ventilators with oxygen blenders should be used for patients with hypoxemic
respiratory failure.

A heated humidifier should be used to prevent drying of the nasal passage and
oropharynx when the duration of application is anticipated to be more than a
few hours.
MONITORING

Once noninvasive ventilation is initiated, patients should be
closely monitored in a critical care unit or a step-down unit
until they are sufficiently stable to be moved to a regular
medical floor.
The aim of monitoring is

Relief of symptoms, reduced work of breathing, improved or stable
gas exchange, good patient-ventilator synchrony, and patient comfort

A drop in the respiratory rate with improved oxygen saturation or
improving pH with a lower PaCO2, reduce heart rate, within the first
1 to 2 hours portends a successful outcome.

The absence of these propitious signs indicates a poor response to
noninvasive ventilation
MONITORING OF PATIENTS RECEIVING
NON-INVASIVE VENTILATION IN ACUTE CARE SETTINGS
Location
Critical care or step-down unit
Medical or surgical ward if able to breathe unassisted for >20-30 min
"Eyeball test
Dyspnea
Comfort (mask, air pressure)
Anxiety
Asynchrony
Leaks
Vital signs
Respiratory and heart rates
Blood pressure
Continuous electrocardiography
Gas exchange
Continuous oximetry
Arterial blood gases (baseline after 2 h ,and as clinically indicated)
ADVERSE EFFECTS AND COMPLI CATI ONS in
NI V

The mask,
Discomfort and erythema or skin ulcers.

Airflow or pressure,
Conjunctival irritation. Ear pain. nasal or oral dryness .
Nasal congestion and discharge. Gastric insufflation.

Patient-ventilator asynchrony
Caused by high airflow is usually indicative of air leaking
through the mouth.