NIV

(NON-INVASIVE VENTILATION)
DR.S.MAGIMAIGUBERAN
 DEFINITION
 Noninvasive ventilation is the delivery
of ventilatory support without the
need for an invasive artificial airway
(E.T.Tube,Tracheostomy).
 TYPES
 TECHNIQUES OF APPLICATION:

 NonInvasive Negative Pressure

Ventilation (NNPV)

 NonInvasive Positive Pressure

Ventilation (NPPV)
NEGATIVE PRESSURE VENTILATION
 These devices create negative
pressure around the chest wall and
increase the tidal volume.
 Devices:Iron lung
 It can be used in patients after

surgery for CHD and pediatric

patients with respiratory
dysfunctions
 Currently NPV is replaced by PPV
NON INVASIVE POSITIVE PRESSURE
VENTILATION(NIPPV)

 DuringNIPPV, air enters the nose,

mouth or both through the interface,
which in turn is connected, to Positive
Pressure Ventilator.
 NIPPV
  INTERFACES

 Devices that connect ventilator tubing

to the face, allowing the entry of
pressurized gas to the upper airways
 Masks are usually made from a non-

irritant material such as silicon rubber

 It should have minimal dead space

and a soft inflatable cuff to provide a

seal with the skin.
 NIPPV
 Types of interfaces:
 Nasal interfaces:Nasal masks, nasal

cannulae
 There are two basic forms of nasal

interface tubes;nonsealing nasal

interface tubes for supplemental
oxygen therapy and sealing nasal
interface tubes for PAP ventilation
 Oral interfaces
 Combined oral and nasal interfaces
 NIPPV
  Helmet:

 Allows prolonged continuous

application of NIV
 Lesser complications like skin

necrosis, gastric distension, and eye

irritation
 MECHANISM OF ACTION OF NPPV

 Improvement in pulmonary mechanism and

oxygenation:
 It increases alveolar ventilation and allows

oxygenation without raising the PaCO2

 Partial unloading of respiratory muscles:

 NIV reduces respiratory muscle work and

diaphragmatic electromyographic activity

 This leads to increase TV,MV and decrease RR
MECHANISM OF ACTION OF NPPV
 Resetting of respiratory centre:
 By maintaining lower nocturnal PaCO2

during sleep by NIV, it is possible to reset

the respiratory control centre to become
more responsive to an increased PaCO2 by
increasing the neural output to the
diaphragm and other respiratory muscles
 These patients are then able to maintain a

more normal PaCO2 throughout the

daylight hours without the need for
mechanical ventilation
 MODES
 Hypoxaemia = CPAP

 Hypercapnia and hypoxaemia= BiLevel

PAP
 C PAP
 CONTINUOUS POSITIVE AIRWAY PRESSURE
 Constant positive airway pressure

throughout cycle
 Improves oxygenation
 Decreases work of breathing by alveolar

recruitment
 Decreases hypoxia by alveolar recruitment

and reduces intrapulmonary shunt

 Usual settings are 5, 7.5 or 10 cmH 0
2
 CPAP is commonly used in acute

pulmonary oedema after medical

management has failed
 BIPAP
  Combination of IPAP and EPAP

 Inspiratory PAP = Pressure Support

 Expiratory PAP = CPAP

 BIPAP
 It delivers two different airway pressures are
inspiratory pressure and an expiratory pressure.
 The expiratory pressure (EPAP) is analogous to
PEEP on CPAP and is usually set between 4-6
cmH2O
 The inspiratory pressure (IPAP) is a higher
pressure which aims to increases the patient’s
inspiratory effort
◦ Common settings for IPAP are 12 cmH 20 and it can go up
to 20 cmH20 if needed.
 It is used to treat type 2 respiratory failure and is
commonly used in exacerbations of COPD but only
after full medical management in appropriate
patients.
RESPIRATORY EFFECTS OF BIPAP
 EPAP

 Provides PEEP
 Increases Functional Residual Capacity
 Reduces FiO2 required to optimise SaO2

 IPAP

 Decreases work of breathing + oxygen

demand
 Increases spontaneous tidal volume
 Decreases spontaneous respiratory rate
 INDICATIONS OF NIPPV
A.Acute respiratory failure
 Hypercapnic in acute respiratory failure
 Acute exacerbation of COPD
 Post extubation
 Weaning difficulties
 Post surgical respiratory failure
 Chest wall deformities/neuromuscular disease
 Cystic fibrosis
 Status asthmaticus
 Acute respiratory failure in obesity

hypoventilation
 INDICATIONS OF NIPPV
 Hypoxemic in acute respiratory failure
 Cardiogenic pulmonary edema
 Community acquired pnemonia
 ARDS
 Weaning difficulties

B.Chronic respiratory failure

C.Immuno-compromised patients
D)Do not intubate patients
CONTRA-INDICATIONS OF NIPPV
  Inability to protect airway
 CVA,confused agitated patients
 Hemodynamic instability:

 Recent MI, arrhythmias, high dose

inotropes
 Inability to fix the interface:

 facial -abnormalities, burns, trauma

 CONTRA-INDICATIONS OF NIPPV
 Severe GI symptoms
 Life threatening hypoxemia
 Copious secretions
 Conditions where NIV has not been

found effective
 Non availability of trained medical

person
 NIV IN COPD
 Significantly reduce
mortality,compared to standard
medical therapy
 First line therapy
 Growing evidence that maybe

applicable to patient with:

 Severe acidaemia (Ph<7.25)
 Hypercarbic Coma
 NIV IN OBESITY
 Assc with certain respiratory
syndrome
 Chronic alveolar hypoventilation
 Obstructive sleep apnoea
 Type 2 respiratory failure

 If presenting in early stage, NIV initial

treatment of choice
 Post operative period
 NIV in Asthma:

 Controversial
 Trial of NIV in acute asthma should only be

carried out in CRITICAL CARE areas

 NIV in Cardiogenic Pulmonary Oedema:
 Reduction in both preload & afterload

and improved oxygenation and reduced

work of breathing

 NIV in Pneumonia:
 Controversial
 Benefits in Pneumonia in underlying

COPD or Immunocompromise mortality

 Trial of NIV Should be done in CRITICAL

CARE areas.
 NIV in Lung Contusion/Chest Trauma:
 Respiratory failure due to chest

trauma or contusion responds well to

NIV
 Combine with effective analgesic

regimen:
 Favourable outcome
 Reduce mortality & infective

complications
Requirements for successful
noninvasive support
A co-operative patient who can
control their airway and secretions
with an adequate cough reflex.
 Hemodynamically stable patients
 Blood pH >7.1 and PaCO2 <92 mmHg
 The patient should ideally show

improvement in gas exchange, H.R

and R.R within first two hours
SELECTION CRITERIA OF NIPPV
A) ACUTE RESPIRATORY FAILURE:
 Atleast 2 of the following criteria must

be present
 Respiratory distress with dyspnoea
 Use of accessory muscles of respiration
 Abdominal paradox
 Respiratory rate > 25/min
 ABG shows pH< 7.35 or PaCO2 >45

mmHg or PaO2/FiO2 <200

SELECTION CRITERIA OF NIPPV
B) CHRONIC RESPIRATORY FAILURE
 Fatigue,Excessive sleep, dyspnoea
 ABG shows Ph<7.35. Paco2>55 mmHg
 Oxygen saturation <88%

C) THORACIC RESTRICTIVE/CEREBRAL
HYPOVENTILATION DISEASES
 Fatigue,morning headache,Excessive

sleep,enuresis, dyspnoea
 ABG shows PaCo2 >45 mmHg
 Nocturnal SaO2 <90% for more than 5

minutes sustained
 INTUBATION DURING NIV
 No improvement in gas exchange or
dyspnoea progressively increases
 Deterioration or no change in the

mental condition of the hypercapnic

patients
 Need for airway protection
 Hemodynamic instability
 Fresh MI or arrhythmias
 Patient unable to tolerate the mask
 APPLICATIONS OF NIV
 Choose the correct interface
 Explain therapy and its benefit to the

patient in detail
 Also discuss the possibility of

intubation
 Start with very low settings.Start low

IPAP of 6-8 cm H2O and EPAP of 2-4

cm H2O.The difference between IPAP
and EPAP should be atleast 4 cm H2O.
 APPLICATIONS OF NIV
 Administer oxygen at 2 liters per
minute
 Hold the mask with hand over face. Do

not fix it
 Increase EPAP by 1-2 cm,till all the

inspiratory efforts are able to trigger

the ventilator
 Most of the pt require EPAP of about 4

to 6 cm H2O
 APPLICATIONS OF NIV
 when the patients efforts are triggering
the ventilator leave EPAP at this level
 Now start increasing IPAP in increments

of 1-2 cm H2O up to a maximum

pressure, which the patient can tolerate
without discomfort
 Now secure interface with head straps.

Avoid excessive tightness

 After titrating pressure increase oxygen

to bring SaO2 to around 90%.

 Patient Monitoring:
 The most useful indicator is patient’s
comfort. ABG is useful to assess
ventilatory parameters
 If the patient is getting increasingly

tired, or ABG deteriorates despite

optimal settings, then mechanical
ventilation is necessary. It must be
recognized early
 ADVANTAGES OF NPPV
 Avoidance of complications
 Related to Intubation, i.e. adverse effects from induction

drugs, risk of failed intubation, risk of aspiration of gastric

content and airway trauma
 Related to tracheal tube, i.e. need of sedation, risk of

endobronchial intubation, difficult communication, reduced

ciliary activity and more risk of ventilator associate pneumonia
 Long term complications like tracheal stenosis, sinusitis and

vocal cord damage

 Preservation of airway defense mechanism

 Early ventilatory support and intermittent ventilation is

possible
 Patient can eat, drink, communicate and cooperate with

physiotherapy
 ADVANTAGES OF NPPV
 Easy of application and removal with
improved patient comfort
 Pneumothorax is very rare
 Correction of hypoxia with out

worsening hypercarbia
 It can be instituted outside the ICU

because of nonrequirement of muscle

paralysis
 Customized purpose-built machines

available with different NIV modes for

domestic use
 DISADVANTAGE OF NPPV
 NIV is not appropriate for all patients and
is ineffective in those who are severely ill
 There are problems of air leaks, skin

damage and sore from mask pressure

 NIV may increase the risk of aspiration as

airway is not protected

 Mask uncomfortable
 No direct access to bronchial tree for

suction in excessive secretions

 Gastric distension
 SIDE EFFECTS
 Air leak
 Skin necrosis- particularly over bridge

of nose
 Gastric distension
 Failure to ventilate
 Sleep fragmentation
 Upper airway obstruction
THANK YOU