Expanding horizons of NIV

Dr.M.Srinivas,MD,Dip.A&E
Sr consultant
Emergency & Critical care
Apollo speciality hospitals
Nellore
 Evolution of Mechanical Ventilation

TIME

1930’s to 1950’s 1960’s to 1970’s 1980’s to 1990’s 2000 to present

Technological developments of CPAP

OSA with lung problems Ventilatory Ventilatory

OSA
insufficiency Failure

CPAP Bi-Level Bi-Level Bi-Level

Pressure Pressure
support support
ventilators ventilators

1987 1990 1995 <1987 2000 <1987

Breathing with lung disease
Oxygen Therapy NIV

Invasive
NIV Ventilation
 Types of NIV
• Negative-pressure ventilation,
• Abdominal-displacement ventilation and
• Positive-pressure ventilation
 NPPV: Definition
NPPV
Noninvasive Positive Pressure Ventilation

International Conference Consensus AJRCCM 2001: NPPV is defined as any

form of ventilatory support applied without the use of an endotracheal tube.

British Thoracic Society Thorax 2002: Noninvasive ventilation (NIV) refers

to the provision of ventilatory support through the upper airway using a
mask or similar device.
 International Consensus Conferences in Intensive Care Medicine:
non-invasive positive pressure ventilation in acute respiratory failure.
The American Thoracic Society, the European Respiratory Society, the European Society of
Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise

AJRCCM 2001; 163: 283-291; ICM 2001; 27: 166-178

1. Clinical abnormalities
Moderate to severe dyspnea
RR > 24 b/min (> 30-35 b/min in ARF)
Use of accessory muscles, paradoxal breathing

2. Gas exchange abnormalities

PaCO2 > 45 mmHg, pH < 7.35
PaO2/FiO2 < 250 mmHg
AJRCCM 2001;163:283-91
 Goals of NIV
• Alleviate respiratory distress
• Improve gas exchange
• Achieve patient/ventilator synchrony
• Optimize patient comfort
• Reduce work of breathing
• Avert intubation
• Minimize risk
• Avoid complications
Does the Patient Meet Conditions for Successful NIV?

Minimal
Intact Upper Secretions
Airway Function or a Means to
Remove Them*

No Bollous Cooperative &

Lung Disease Motivated
 Potential indicators of success in NIV

Younger age Synchronous breathing

Lower acuity of illness Intact dentition
Able to cooperate Less secretions
Better neurologic score Better compliance
Less air leak Improvements in gas
PaCO2 45 - 60 mmHg
exchange and heart
respiratory rates within
pH 7.10 - 7.35
first 2 hours
 Exclusion Criteria for NIV
• Respiratory arrest or need for immediate intubation
• Hemodynamic instability
• Inability to protect the airway (impaired cough or
swallowing)
• Excessive secretions
• Agitated and confused patient
• Facial deformities or conditions that prevent mask from fitting
• Uncooperative or unmotivated patient
• Brain injury with unstable respiratory drive
• Untreated pneumothorax
 Contraindications
•Cardiac or respiratory arrest
•Non respiratory organ failure
•Severe encephalopathy (eg, GCS <10)
•Severe upper gastrointestinal bleeding
•Hemodynamic instability
• Unstable cardiac arrhythmia
• Facial or neurological surgery, trauma, or deformity
• Upper airway obstruction
•Inability to cooperate/protect airway
•Inability to clear secretions
•High risk for aspiration
NIV Machine
 BiPAP Technology
Blower

Patient
Circuit Air Filter

(airflow sensor)
Exhaust Ambient Air

(P v
ro al
po ve
rti )
on
al
CRITICAL CAREVENTILATOR VS NIV
NIV Interfaces
Harness

Plastic body

Elbow
Blue: dual limb
Transparent:
Single limb

Accesory port

Cushion part
Non vented mask
(non leak mask)

Leak Mask
(Vented mask)
 Which one to select?

*Guidelines for noninvasive ventilation in acute respiratory

failure, ISCCM, 2006
 Complications

Interface related • Air pressure/flow

related

Patient related
 NIV Terminology
BiPAP
• Bilevel positive airway pressure.

IPAP
• Inspiratory positive airway pressure.

EPAP
• Expiratory positive airway pressure.

Trigger
• The point where the Bipap unit transitions
from the low EPAP pressure to the higher IPAP
Cycle
pressure.
• The point where the Bipap unit transitions
from the higher IPAP pressure to the lower
Rate
EPAP pressure.
• The number of breaths per minute
 Terminology
Cycle Time
• The amount of time devoted to one complete breath
cycle as determined by the set breath rate. Divide 60
seconds by set rate to determine cycle time in seconds.
I Time
• Inspiratory time. How long the Bipap unit stays at the IPAP
pressure. This setting applies only to machine triggered
breaths.
Rise Time
• The length of time it takes the unit to transition from the
EPAP pressure to the IPAP pressure. This is set to patient
comfort
Sensitivity
• This refers to triggering and cycling of the device. There is no
setting for this as AutoTrak® handles this.

Pressure Support
• The difference between IPAP and EPAP settings. This is the
amount of assistance applied to the inspired breath.
 CPAP vs. NIV
CPAP
• Pressure greater than atm
applied to proximal airway
throughout resp cycle
– Splints airway
– Increases lung volume
– Raises intrathoracic pressures
– Does not offload resp muscles
NIV
• Greater pressure applied
during inspiration over and
above the baseline CPAP
– Unloads resp muscles
– Can provide complete resp
support
 CPAP
• A mode for invasive and noninvasive mechanical
ventilation
• Provides static positive airway pressure throughout
the respiratory cycle‐ both inspiration & expiration
• Facilitates inhalation by reducing pressure
thresholds to initiate airflow
A typical breath in NIV
 BIPAP
• Bi-level Positive Airways
Pressure
– Lower positive pressure EPAP
IPAP
during expiration (EPAP)
(equivalent to CPAP)
5-10cmH
12-20cmH2O2O
– Higher positive airways
pressure during
inspiration (IPAP)
• CPAP + Increases tidal
volume
 BiPAP Waveform

25

20 Rise time is a part of

I time
IPAP
Pressure

Cycle
15
Rise

Pressure Support
10

EPAP
5
Rise Time Inspiratory
Trigger Time

Time
 BIPAP
EPAP
• EPAP (PEEP)
– Recruits alveoli 5-10cmH2O

– Increases VQ matching
– Improves oxygenation

IPAP
• IPAP – EPAP (pressure support)
12-20cmH2O
– Increases tidal volume
– Reduces CO2
 IPAP (Inspiratory Positive Airway Pressure)

Is the pressure applied during the inspiratory phase

Pressure cmH2O

EXPIRATION
IPAP

EPAP

Time
INSPIRATION
 Role of IPAP
• IPAP
• Provides pressure support
• ↑ Vt
• ¯ RR
• Improves Ventilation and decrease work of breathing
• Decrease CO2

• Ý O2
 EPAP (Expiratory Positive Airway Pressure)
Also referred to as : PEEP (Positive End Expiration Pressure)

Is the pressure maintained during the expiratory phase

Pressure cmH2O

EXPIRATION
IPAP

EPAP

Time
INSPIRATION
 Role of EPAP
• EPAP
• prevent CO2 rebreathing
• Stabilises the upper airway
• Improves oxygenation,
• Decreases effects of intrinsic PEEP
(PEEPi, also known as auto-PEEP)
• Decreases ineffective efforts
• Reduces work of breathing
• As rule of thumb use 5 to 8 cm H20
• Different guidelines state between 3-6 is the ideal starting
pressure, and increasing beyond 8 should be done only in
selected cases
 Pressure Support (PS)

PS = IPAP – EPAP

Pressure support is the amount of pressure applied above the

EPAP during inspiration. This creates the “ventilation”.

IPAP

Pressure Support

EPAP

IPAP = 25 cm H2O EPAP = 5 cm H20  PS = 20 cm H2O

 Bi-level Modes of NIV
The following table summarizes the initiation of triggers and
cycles for each bi-level mode

Mode Trigger Limit Cycle

S Patient Pressure Patient/Device
S/T Patient/Device Pressure Patient/Device
PC* Patient/Device Pressure Device
T* Machine Pressure Device
 Spontaneous Mode (S)
• Therapy mode in which all breaths are spontaneous
 Spontaneous/Timed Mode (S/T)
• Therapy mode that is similar to S mode, but can also
deliver mandatory breaths.
• Also called as Assist control ventilation
 Timed Mode (T)
Times pressure support therapy mode with all mandatory
delivered breaths.
 Pressure Control Mode (PC)
Delivers assisted and mandatory breaths at a user-defined
pressure.
Proportional Assist Ventilation (PAV) : The
ventilator assists the patient by generating
volume and pressure in proportion to patient’s
effort creating a ventilatory pattern that
matches metabolic demands on a breath-by-
breath basis.
 iVAPS
•Intelligent. Automatic. Alveolar.
•iVAPS is designed to maintain a preset target alveolar minute ventilation
• Monitors delivered ventilation
Adjusts pressure support
• Provides an intelligent backup breath
 iVAPS
•Settings:
• EPAP – it can be auto-adjusted to maintain upper airway patency.
However, titration still needed to overcome intrinsic PEEP or to improve
lower airway recruitment
• Minute Alveolar Ventilation Target
• Can be set using Learn Targets – patient breathes for 20
minutes and machine Learns the Target
• Can be set using Va Calculator from Tidal Volume or Minute
Ventilation
• Can be set using ResScan Data on ST mode
• Ideal Respiratory Rate
• Patient Height (to approximate the dead space)
iVAPS
 What is AVAPS hybrid ventilation?
Average Volume Assured Pressure Support Ventilation

AVAPS automatically adapts pressure support to patient

needs to guarantee an average tidal volume

IPAP max
± 1 to 3-5* cmH2O
over 1 min

IPAP min
IPAP
EPAP
Target Vt
AVAPS-AE: Auto EPAP proactive analysis

Theory of Operation

Device
Pressure P search
opt

Ptherapy

Pcrit search

Upper Airway
Resistance
Auto-EPAP
TROUBLESHOOTING
 Weaning Algorithm
Does
patient meet
weaning guidelines?
❑ Clinically stable NO
YES
❑ RR < 24 Continue with
❑ HR < 110 NPPV therapy
Slowly titrate IPAP downward Trial off NPPV with ❑ pH > 7.35
in decrements of 2-3 cm H2O supplemental oxygen ❑ SpO2 >90%
on< 50% If patient status does not
improved consider
intubation

Does
patient demonstrate NO
clinical evidence Discontinue NPPV and place on
of respiratory supplemental oxygen
distress?

YES

Restart NPPV at
previous settings
 Predicting NIV failure in hypoxemic patients
HACOR score

• Heart rate
• Acidosis (pH)
• Consciousness (GCS)
• Oxygenation
• Respiratory rate

NIV failure of a HACOR score above 5 at 1 hour of NIV

 NIV Failure
• Patient intolerance / failure to co-ordinate
• pH < 7.20 despite optimal support
• pH 7.20 – 7.25 on 2 occasions 1 hour apart
• Hypercapnic coma (GCS < 8 and PaCO2 > 8 kPa)
• PaO2 < 6.00 kPa despite max tolerated FiO2
• New onset of other initial exclusion criteria,
particularly sputum retention, vomiting, or
pneumothorax
• Cardiorespiratory arrest
 Conclusion

NIV
“ ’Be the ‘choice’
Not the ’option’ ”

• NIV is an important tool to tide over an acute insult in

the hands of a experienced operator
• Key factors in success
– Evidence based application for selected etiologies
– Careful patient selection/rejection
– Skilled initiation & application
– Algorithmic approach in initiation & discontinuation
– Patient comfort & avoiding dyssynchrony
– Avoiding complications
 NIV
Expanding
Horizons

Routine
NIV Use

Thank you