NON-INVASIVE

VENTILATION
 What is Non-Invasive Ventilation?

• refers to positive pressure

ventilation delivered through a
noninvasive interface (nasal mask,
facemask, or nasal plugs)
Known by several terminologies among
them
Bilevel Positive Airway Pressure
IPAP and EPAP,
Biphasic Positive Airway Pressure
CPAP with inspiratory assist
Pressure Support with assist

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 Non-Invasive Ventilation?

• Conditions known to respond to

NIV include:
1. Exacerbations of chronic
obstructive pulmonary disease
(COPD) that are complicated
by hypercapnic acidosis
(arterial carbon dioxide tension
[PaCO2] >45 mmHg or pH
<7.30)
2. Cardiogenic pulmonary edema
3. Acute hypoxemic respiratory
failure 3
NIV In Asthma

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NPPV in Cardiogenic Edema

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 NPPV in Cardiogenic Edema

Berstein et al, NEJM, 1995;325:1825-30

■ 39 patients with CPE and severe ARF were
randomised to receive O2 supplementation
alone or CPAP
(10 cm H20) by face mask
■ The CPAP group has rapid improvement in
RR, pCO2, pH, PO2/FIO2 ratio, HR
■ 7 patients in the control group required ETT
compared to 0 in the CPAP group
■ Decreased LOS in the ICU and decreased
cost in the CPAP group

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 Contraindications to Non-Invasive
Ventilation

• Cardiac or respiratory arrest

• Inability to cooperate, protect
the airway, or clear secretions
• Severely impaired
consciousness
****Hypercapnic
encephalopathy
• Nonrespiratory organ failure
that is acutely life threatening
• Facial surgery, trauma, or
deformity
• High aspiration risk
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• Prolonged duration of
Advantages of NPPV

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Inspiratory Positive Airway
Pressure (IPAP)

■ Pressure Support Ventilation

■ Positive Pressure applied during
Inspiration
■ Increases lung volume
■ Reduces work of Respiratory Muscles

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Expiratory Positive Airway
Pressure (EPAP)

■ Minimizes or eliminates upper airway

resistance and small airway collapse
■ Positive pressure applied to the
airway during exhalation
■ Keeps the upper airway open and
avoids alveolar collapse

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Setting up
NPPV
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 Setting up NPPV

Add O2 1-2 liters (FiO2 settings) per minute if O2

saturation is less than 90% or pO2 is less than 60 mm Hg

Set an inspiratory pressure (IPAP) of around 10 to 14-

cm H20. Set EPAP at 4 to 5 cm H20 (Pressure
support goal of at least 7 cm)

Set a back-up rate of 10-12 per minute

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 Setting up NPPV

You may NOT strap the mask initially. Hold the mask over the
face and gently let the patient adjust to the sensation of the
pressurized air for a few minutes. You may then strap the
mask once the patient feels comfortable with the pressure.

Check O2 saturation continuously and an ABG after 30 to

60minutes. Increase inspiratory pressure by 2 cm H20
increments to reduce pCO2. Most individuals (except children
and those with neuromuscular disease who will need less) will
need an IPAP > 12 cm H20

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 Setting up NPPV

The EPAP may be increased to improve

oxygenation. Caution must be taken since high
levels of EPAP can reduce effective pressure
support and may be counterproductive.
Adjust O2 to keep O2 saturation > 90%

For adequate ventilatory support the delta

between IPAP and EPAP must be at least 5 cm
H20 (Pressure Support = IPAP-EPAP)

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Setting up NPPV

■ The delta max (PS) between IPAP

and EPAP is around 10-15 cm

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Monitoring the
Patient

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■ Will require intensive monitoring the first 30
minutes!
■ Continuous oximetry with alarms
■ Arterial line if with severe hypercapnia with
ABG taken after 1 hour, and as necessary
■ Subjective responses (dyspnea, mental
status, comfort)
■ Objective responses (RR, HR, use of
accessory muscles)
■ Monitoring for complications (facial skin
necrosis, abdominal distension, respiratory
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difficulties)
Discontinuati
on of NPPV
Predictors of Failure
When should NPPV be Discontinued and
Invasive MV be Started?

■ Inability to tolerate the mask because of

discomfort or pain.
■ Inability to improve gas exchange or dyspnea
within max of 2 hours.
■ Need for endotracheal intubation to manage
secretions or to protect the airways.
■ Hemodynamic instability.
■ ECG abnormalities with evidence of ischemia
or significant ventricular arrhythmia.
■ Failure to improve mental status 30 min.
after initiation of NPPV in patients with CO2
retention (lethargy) or hypoxemia (agitation)
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 Predictors of Failure

COPD Hypoxemic RF
■ Air leaking ■ ALI/ARDS
■ Severely ill ■ Severely ill
■ Asynchrony ■ Metabolic Acidosis
■ GCS <11 ■ P/F < 150 (175 for
■ Poor tolerance ARDS) after 1h of
■ pH <7.25 NPPV
■ Pneumonia
■ RR > 35/min
■ Shock

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Weaning
from NPPV
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General Guidelines

■ There is significant resolution of the

underlying disease which required
ventilatory support
■ O2 requirement is less than 40% with
pCO2 back to baseline level.
■ IPAP/EPAP delta may be decreased at a
decrement of 1-2 cm without worsening
of symptoms and blood gases
■ NPPV free time may be given (e.g. 30 min
every 4 hours and increased as tolerated
until patient is stable without NPPV
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Thanks!

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