Non Invasive Positive Non Invasive Positive Pressure Ventilation (NIPPV)Pressure Ventilation (NIPPV)

Rabia KhalailaRabia Khalaila

RN, MPH, BSNRN, MPH, BSN

Mechanical ventilation

Non Invasive ventilation Invasive ventilation

NINPVCuirass

Ventilation

NIPPVCPAPBIPAP

Pressure ControlPressure ControlPCPS

Volume ControlVolume ControlSIMVCMVA/CASV

Respiratory Failure

Hypoxic Respiratory Failure

Hypercarbic Respiratory Failure

NON INVASIVE VENTILATION

NIV

Negative Pressure• Spontaneous• Mechanical (Noninvasive Biphasic Cuirass Noninvasive Biphasic Cuirass

VentilationVentilation )

Positive Pressure • Mechanical

Invasive (CMV, SIMV, PS, PC, A/C) Non Invasive (CPAP, BiPAP)

Invasive vs. Non-invasive Invasive vs. Non-invasive ventilationventilation

InvasiveInvasive Good Good controlcontrol of airway of airway Suitable for Suitable for higherhigher pressurespressures

Non-invasiveNon-invasive Avoidance of complications of Avoidance of complications of

intubationintubation Avoidance of complication of Avoidance of complication of

invasive ventilation (VAP, invasive ventilation (VAP, sinusitis…)sinusitis…)

If tolerated, more comfortable If tolerated, more comfortable to awake patients. to awake patients.

No sedation (or less sedationNo sedation (or less sedation))

Goals of NIVGoals of NIV

Short Term:Short Term:

1.1. Relieve symptomsRelieve symptoms

2.2. Reduce work of Reduce work of breathingbreathing

3.3. Improve or stabilize Improve or stabilize gas exchangegas exchange

4.4. Good patientGood patient--ventilator synchronyventilator synchrony

5.5. Optimize patient Optimize patient comfortcomfort

6.6. Avoid intubationAvoid intubation

Long Term:Long Term:

1.1. Improve sleep Improve sleep duration and qualityduration and quality

2.2. Maximize quality of Maximize quality of lifelife

3.3. Enhance functional Enhance functional statusstatus

4.4. Prolong survivalProlong survival

NNonon I Invasive nvasive PPositiveositive P Pressure ressure VVentilation (entilation (NIPPV)NIPPV)

• CPAP = PEEP

• BiPAP = CPAP + PSV

• ePAP = CPAP

• iPAP = CPAP + PSV

Indications for NIPPVIndications for NIPPV

(A) Acute respiratory failure.(A) Acute respiratory failure.

(B(B) ) Chronic Respiratory Failure.Chronic Respiratory Failure.

(C(C))Thoracic RestrictiveThoracic Restrictive

(D) Cerebral Hypoventilation Diseases.(D) Cerebral Hypoventilation Diseases.

(E(E) ) Patients 'not for intubation.Patients 'not for intubation.

))AA ( (Acute respiratory failureAcute respiratory failure

1.1. Hypercapnic acute respiratory failure :Hypercapnic acute respiratory failure :

Acute exacerbation of COPD Acute exacerbation of COPD

Post extubation Post extubation

Weaning difficulties Weaning difficulties

Post surgical respiratory failure Post surgical respiratory failure

Thoracic wall deformities Thoracic wall deformities

Cystic fibrosis Cystic fibrosis

Status asthmaticus Status asthmaticus

))AA ( (Acute respiratory failureAcute respiratory failure

2. Hypoxaemic acute respiratory failure :2. Hypoxaemic acute respiratory failure :

Cardiogenic pulmonary oedema Cardiogenic pulmonary oedema

pneumonia pneumonia

Post traumatic respiratory failure Post traumatic respiratory failure

ARDS ARDS

Weaning difficultiesWeaning difficulties

Respiratory FailureRespiratory Failure

))BB) ) Chronic Respiratory Failure: Chronic Respiratory Failure: ((neuromuscular disease, Obstructive lung disease)neuromuscular disease, Obstructive lung disease)

))CC))Thoracic Restrictive DiseasesThoracic Restrictive Diseases

(D) Cerebral Hypoventilation -(D) Cerebral Hypoventilation - (nocturnal (nocturnal hypoventilation Syndrome (OSA)hypoventilation Syndrome (OSA)

))EE) ) Patients 'not for intubationPatients 'not for intubation..

ContraindicationsContraindications

Respiratory arrestRespiratory arrest

unstable cardiorespiratory status-CPRunstable cardiorespiratory status-CPR

post MIpost MI

Uncooperative patientsUncooperative patients . .

Unable to protect airwayUnable to protect airway- - impaired impaired swallowing and coughswallowing and cough ..

FacialFacial//esophageal or gastric surgeryesophageal or gastric surgery

Craniofacial traumaCraniofacial trauma//burnsburns

Anatomic lesions of upper airwayAnatomic lesions of upper airway

Relative ContraindicationsRelative Contraindications

Extreme anxietyExtreme anxiety

Copious secretionsCopious secretions

Need for continuous or nearly continuous Need for continuous or nearly continuous ventilatory assistanceventilatory assistance

Advantages of NIPPVAdvantages of NIPPV

   Early ventilatory supportEarly ventilatory support

   Intermittent ventilationIntermittent ventilation

   Patient can eat, drink and communicatePatient can eat, drink and communicate

   Ease of application and removalEase of application and removal

   Patient can cooperate with physiotherapyPatient can cooperate with physiotherapy

   Improved patient comfortImproved patient comfort

Advantages of NIPPVAdvantages of NIPPV

Reduced sedation requirementsReduced sedation requirements

Avoidance of complications of intubationAvoidance of complications of intubation

possible Ventilation outside hospital setting.possible Ventilation outside hospital setting.

Correction of hypoxaemia without worsening Correction of hypoxaemia without worsening hypercarbiahypercarbia

Ease to teach paramedics and nursesEase to teach paramedics and nurses

DisadvantagesDisadvantages

  Mask is uncomfortableMask is uncomfortable//claustrophobicclaustrophobic

Airway is not protectedAirway is not protected

Facial pressure sores Facial pressure sores

No direct access to bronchial tree for No direct access to bronchial tree for suctionsuction

Complications and Side effectsComplications and Side effects

Air leak. Air leak.

Skin necrosisSkin necrosis- - particularly over bridge of particularly over bridge of nosenose . .

Nasal congestionNasal congestion

Retention of secretionsRetention of secretions

Upper airway obstructionUpper airway obstruction

Gastric distension Gastric distension

Failure to ventilateFailure to ventilate

Sleep fragmentationSleep fragmentation

Complications of PEEPComplications of PEEP

Barotrauma.(Pneumothorax)Barotrauma.(Pneumothorax)

HypotensionHypotension

Hyperinflation.Hyperinflation.

Decreased venous return (pre load) Decreased venous return (pre load)

Decreased Cardiac output.Decreased Cardiac output.

Arrhythmias.Arrhythmias.

Increase ICP.Increase ICP.

excessive ADH secretion and edemaexcessive ADH secretion and edema

Choice of VentilatorChoice of Ventilator

NIMV can be given by:NIMV can be given by:

1.1. conventional critical care ventilators.conventional critical care ventilators.

2.2. or portable pressure ventilators.or portable pressure ventilators.

3.3. or volume limit ventilatorsor volume limit ventilators ..

VentilatorsVentilators

Modes ofModes ofNNon on IInvasive nvasive PPositive ositive PPressure ressure

VVentilation entilation (NIPPV)(NIPPV)

CPAPCPAP&&

BIPAPBIPAP

CContinuousontinuous PPositiveositive AAirwayirway PPressure ressure (CPAP)(CPAP)

CPAP = PEEPCPAP = PEEP

provides positive airway pressure throughout provides positive airway pressure throughout spontaneous ventilation. spontaneous ventilation.

Spontaneous breathing on one pressure level.Spontaneous breathing on one pressure level.

Pressures are usually limited to 5-15 cm of Pressures are usually limited to 5-15 cm of H2O .H2O .

most frequently peep= 10 cm of water.most frequently peep= 10 cm of water.

Oxygen can be delivered at flow rates high Oxygen can be delivered at flow rates high enough to maintain O2 saturation above 90%enough to maintain O2 saturation above 90%. .

CContinuousontinuous PPositiveositive AAirwayirway PPressure ressure (CPAP)(CPAP)

Increases the FRC. Increases the FRC.

Decrease shunt and opens collapsed alveoli Decrease shunt and opens collapsed alveoli

reduces the work of breathing by improving reduces the work of breathing by improving atelectasis and V/Q ratios atelectasis and V/Q ratios

Effective for treatment of pulmonary edema- Effective for treatment of pulmonary edema- CHF.CHF.

Reduces preload and also afterloadReduces preload and also afterload

improves oxygenation, hypercapnia improves oxygenation, hypercapnia

BiBi-level -level PPositive ositive AAirway irway PPressure ressure ((BIPAP)BIPAP)

The bi-level ventilator was first introduced in 1990

simple to use, lighter weight and less expensive,

They also compensate for air leaks.

can be administered with standard critical care ventilator or bi-level portable devices. effective for (chronic respiratory failure, neuromuscular problems, obstructive sleep apnea ) )

BiBi-level -level PPositive ositive AAirway irway PPressure ressure ((BIPAP)BIPAP)

Bi-PAP = CPAP + PSV mode

provides two levels of positive pressureprovides two levels of positive pressure– iPAP (inspiratory positive airway pressure) =

CPAP + PSV– ePAP(expiratory positive airway pressure) =

CPAP

spontaneous / timed mode : : Cycling between inspiratory and expiratory modes may either be triggered by the patient's breaths or preset .

Technical AspectsTechnical Aspects

1.1. Bilevel positive airway pressure (BiPAP)Bilevel positive airway pressure (BiPAP)Example:Example:

IPAP:IPAP: 14-20 cm of H 14-20 cm of H2200 EPAPEPAP: 3-6 cm of H: 3-6 cm of H2200

Mode:Mode: ST (spontaneous/ timed) ST (spontaneous/ timed)Respiratory Rate:Respiratory Rate: Inspiratory Time:Inspiratory Time: depends on pt age and depends on pt age and

RRRRRise time:Rise time: speed of breath delivery speed of breath delivery

TYPES OF INTERFACESTYPES OF INTERFACES

Non-invasive - Preset air volume or Non-invasive - Preset air volume or pressure delivered by:pressure delivered by:

Nasal maskNasal mask

Full face mask (oral-nasalFull face mask (oral-nasal ))

Mouth pieceMouth piece

FACE MASKFACE MASK

Nasal MaskNasal Mask

Small Child Nasal Mask and Head Gear

mouthpiece to deliver ventilation mouthpiece to deliver ventilation during the dayduring the day..

masksmasks

Face masks and nasal masks are the Face masks and nasal masks are the most commonly used interfaces .most commonly used interfaces .

Nasal masks are used most often in Nasal masks are used most often in chronic respiratory failurechronic respiratory failure

while face masks are more useful in acute while face masks are more useful in acute respiratory failure. respiratory failure.

Predictors of Success

• Younger Age• Lower acuity of illness• Better Neurologic score• Cooperative and able to coordinate breathing with ventilator and• control their airway and secretionscontrol their airway and secretions• Adequate cough reflexAdequate cough reflex

• Haemodynamically stable Haemodynamically stable • Less air leaking; •Patient can breathe unaided for several minutes

Predictors of Success

– Hypercarbia; not too severe (PaCO2 > 45 and < 92 mm Hg)

– Acidemia, but not too severe (pH < 7.35, > 7.10)

– Improvements in gas exchange, HR and RR within first 2 h

Successful treatment will result Successful treatment will result inin

higher tidal volumes,higher tidal volumes,reduced respiratory rate,reduced respiratory rate,improved chest wall movementimproved chest wall movementand adequate synchronization of the and adequate synchronization of the patient’s own breaths with the respiratorpatient’s own breaths with the respirator. . reversal of hypoxemia and hypercapnia reversal of hypoxemia and hypercapnia patient’s hemodynamic stability patient’s hemodynamic stability mental status are likely to improve mental status are likely to improve

Treatment failureTreatment failure

Deterioration in the patient’s status can occur Deterioration in the patient’s status can occur even after 48 hours or moreeven after 48 hours or more

‘‘late failures’ are often associated with a poor late failures’ are often associated with a poor prognosis and high mortality prognosis and high mortality

criteria for a ‘late failure’ include :criteria for a ‘late failure’ include :

1. a rapid drop in arterial pH to below 7.34 1. a rapid drop in arterial pH to below 7.34

2. a possible 15-20% rise in PaCO2 2. a possible 15-20% rise in PaCO2

3. dyspnia 3. dyspnia

4. deterioration of the patient’s mental status 4. deterioration of the patient’s mental status