nppv3

Non-Invasive Positive Pressure Ventilation

NPPV

Outlines • Definition.• Goals of NPPV.• Indication for NPPV.• Patient Selection & Exclusion Criteria for NPPV.• Contraindication of NPPV.• Equipment.• Modes.• Initiation of NPPV. • Complications of NPPV.• Monitoring and Management of NPPV.• Troubleshooting of NPPV.

NPPV is defined as “the application of positive pressure to the upper respiratory

tract via an interface (mask) for the purpose of augmentating alveolar

ventilation.

Goals of NPPVAcute care setting• Avoid intubation• Relieve symptoms• Enhance gas exchange• Improve patient-ventilator

synchronization • Maximize patient comfort• Decrease length of stay

Chronic care setting• Relieve or improve

symptoms • Enhance quality of life • Increase survival • Improve mobility

Indication for NPPV Acute Care setting • Acute Exacerbation of COPD • Asthma • Acute Cardiogenic Pulmonary Edema• Community-Acquired Pneumonia in COPD Patients• Hypoxemic Respiratory Failure• Immunocompromised state

Indication for NPPV chronic care setting • Restrictive Thoracic Disorders• Chronic Stable COPD• Cystic Fibrosis • Nocturnal Hypoventilation

Indication for NPPV Other indications• Do-Not-Intubate Orders • Postoperative Status • Facilitation of Weaning from invasive MV.

Patient Selection Criteria for NPPV

GOLD 2010 latest up date 2013

Patient Exclusion Criteria for NPPV

NPPV in COPD

• COPD is the most suitable condition for noninvasive ventilation.• Noninvasive ventilation is most effective in patients with moderate-

to-severe disease• Hypercapnic respiratory acidosis may define the best responders

(pH 7.20-7.30). The lowest threshold of effectiveness is unknown, but success has been achieved with pH values as low as 7.10.

• Obtunded COPD patients can be treated, but the success rate is lower.

• Improvement after a 1- to 2-hour trial may predict success.

Guy W Soo Hoo: Noninvasive Ventilation

Increased Raw and RR

Hyperinflation

Increased intrinsic PEEP

Increased WOB

Increased ventilatory demand

Muscle fatigue

In Acute COPD Exacerbation

Acute Cardiogenic Pulmonary Edema

• Noninvasive ventilation is well suited for patients with cardiogenic pulmonary edema.

• CPAP and BiPAP modalities both are effective, with CPAP possibly being more effective.

• The greatest benefits are realized in relief of symptoms and dyspnea.

• A decrease in intubation and mortality rates is not a universal experience.

• Patients with hypercapnic respiratory acidosis may derive the greatest benefit from noninvasive ventilation.

• Importantly, adjust to standard therapy, including diuresis.• Benefit may be seen with as few as 2 hours of support.


Increased fluid leak into the alveoli

Decreased lung compliance

Increased WOB

Reduced SaO2

Increased WOB

Increased oxygenation &

ventilatory demand

In ACPE Exacerbation

NPPV After Extubation

• Noninvasive ventilation is effective as a bridge support after early extubation.

• Noninvasive ventilation is an adjunct to weaning (substitutes noninvasive support for invasive support).

• Patients with underlying COPD are most likely to benefit from noninvasive ventilation after early extubation.

• Noninvasive ventilation is not as effective in patients with postextubation respiratory distress.

• COPD patients are a subgroup who may benefit in that situation.


NPPV in Asthma • Similar pathophysiology to COPD; limited reported experience

with noninvasive ventilation • Mostly case series with reported benefit • Prospective, randomized studies based on emergency

department settings • Improvement in spirometry main outcome measure • Fewer admissions with noninvasive ventilation; intubation not an

outcome measure • Hypercapnic asthma patients not represented in randomized

trials • Noninvasive ventilation probably beneficial, but experience

limitedGuy W Soo Hoo: Noninvasive Ventilation

NPPV in Postoperative Patients Postoperative hypoxemia related to atelectasis or

pulmonary edema Occurrence following multiple types of surgery (eg, lung,

cardiac, abdominal)

Randomized trials with postoperative continuous positive airway pressure (CPAP) demonstrate benefit

Applied as prophylactic support or with development of hypoxemia

Benefit noted with level CPAP levels in 7.5- to 10-cm water range

Lower intubation rates, days in ICU, and pneumonia


NPPV in Other Conditions • Neuromuscular respiratory disease– Nocturnal use may be especially effective for daytime

hypercapnia – Avoid in bulbar dysfunction or excess secretions – Effective in patients with muscular dystrophy,

kyphoscoliosis, and postpolio syndrome – Some may be able to be treated with negative-pressure

ventilators• Obesity-hypoventilation (or decompensated obstructive sleep

apnea) - Corrects hypercapnia, facilitates diuresis, and provides opportunity for restorative sleep


Contraindication of NPPV• Absolute contraindications Coma Cardiac arrest Respiratory arrest Any condition requiring immediate intubation


Contraindication of NPPV• Other contraindications (rare exceptions)Cardiac instability – Shock and need for pressor support – Ventricular dysrhythmias – Complicated acute myocardial infarction

GI bleeding - Intractable emesis and/or uncontrollable bleeding


Contraindication of NPPV• Other contraindications (rare exceptions) Inability to protect airway

– Impaired cough or swallowing – Poor clearance of secretions – Depressed sensorium and lethargy

Status epilepticusPotential for upper airway obstruction

– Extensive head and neck tumors – Any other tumor with extrinsic airway compression – Angioedema or anaphylaxis causing airway compromise


Equipment

Ventilators

• CPAP/BIPAP Machines • Pressure Targeted Ventilators• ICU Ventilators

CPAP/BIPAP Machines

Pressure Targeted Ventilators

ICU Ventilators

The Critical Care Ventilators Should Have NIV software

To be capable of compensating for high levels of air leak

LEAK COMPENATION?

Patient Interfaces

Patient Interfaces• Nasal Mask: The nasal mask covers the nose only, as

its name indicates.

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Patient Interfaces• The Nasal Pillow – also called nasal prong – usually

consist of silicone rubber and is introduced directly into the nostril. (rarely used in acute settings)

Patient Interfaces• Chin Strap for nasal masks

Patient Interfaces• The Full-Face mask: covers nose and mouth. For this

reason, this mask type is often called oronasal mask.

Patient Interfaces• The Total-Face mask: covers the entire face.

Patient InterfacesDisadvantages Advantages Interface

Mouth leak, Eye irritation, Ulceration over nose bridge, Nasal congestion, Increase resistance

through passages

Easy to fit and secure, Less feeling of claustrophobia, Patient can speak, eat, and cough and clear secretion, Low risk of aspirationLess mechanical dead space

Nasal Mask

Increased risk of aspiration, asphyxia, and dead spaceClaustrophobia, Difficult to fit and secure, Facial skin irritation, Ulceration over nose bridge Patient must move mask to eat, speak, or expectorate secretions

Less air leak Less airway resistance

Full-Face Mask

Patient must move mask to eat, speak, or expectorate secretionsClaustrophobiaIncreased risk of aspiration, and asphyxia

Same as full-face mask Less pressure sores or skin ulceration

Total-Face Mask

Continuous Positive Airway Pressure (CPAP)

CPAP Mechanisms of Action Increases gas exchange 2º to increased alveolar

ventilation Prevents alveolar collapse during exhalation by

maintaining a positive intra-alveolar pressure. Increases intrathoracic pressure, reducing

preload/afterload and improving cardiac output.

Time (sec)

Flow(L/m)

Pressure(cm H2O)

Volume(mL)

Spontaneous Breathing without CPAP

Time (sec)

Flow(L/m)

Pressure(cm H2O)

Volume(mL)

CPAP Level

Continuous Positive Airway Pressure (CPAP)

CPAP• Continuous Positive Airway Pressure.• The elevation of patient pressure base line. • Patient breathing spontaneously on continuous

positive pressure applied via nasal or face mask.• Decreases WOB.

Bi-level Positive Airway Pressure

(BiPAP)

BiPAP• Bi-level Positive Airway Pressure delivers both inspiratory positive

airway pressure (IPAP) and expiratory positive airway pressure (EPAP).

• IPAP controls ventilation, improve CO2 elimination.• EPAP has direct effect on oxygenation.• IPAP should be double the EPAP or more but not more than 20 cm

H2O.• BiPAP has three modes: 1. Spontaneous (S) 2. Spontaneous/Timed (S/T) most common 3. Timed (T)

Spontaneous (S) Mode• In this mode you only set EPAP, IPAP, Trigger, and

alarms based on the type of ventilator used. • Patient control his own rate and minute ventilation.• No backup rate.• Not suitable for patients with apnea episodes.• Breath characteristics: patient’s trigger, flow cycled,

and pressure limited. (spontaneous only)

Spontaneous/Timed (S/T) Mode

• In this mode you set IPAP, EPAP, RR, Trigger, and alarms based on the ventilator used.

• The S/T (spontaneous/timed) mode guarantees breath delivery at the user-set rate.

• It delivers pressure-controlled, time-cycled mandatory and pressure supported spontaneous breaths, all at the IPAP pressure level.

• Very comfortable and most commonly used.

Timed (T) Mode• In this mode you set IPAP, EPAP, RR, and alarms based

on the ventilator used.• The T (Timed) mode guarantees breath delivery at

the user-set rate.• It delivers pressure-controlled, time-cycled

mandatory and no pressure supported spontaneous breaths.

• May cause patient discomfort.

Advantages of BiPAP • Aids oxygenation and ventilation. • Aids in sleep apnea (Way) or ventilatory muscle

weakness (Way). • More comfortable than CPAP (Way).• Often prescribed if patient has problems tolerating

CPAP.

Other Modes of NPPV(PSV, PCV)

Other Modes of NPPV(PSV, PCV)

• Used in the ICU or acute settings.• Can be provided by ICU ventilators.• Not all ICU ventilators provide NPPV.• Ventilators must have the appropriate software

which allow for leak compensation.• Examples: Drager (Evita 4, or Evita XL), Maquet

(Servo i), Respironics V60 Ventilator, and others.

PSV Mode• NIV Pressure Support Ventilation. Pressure Support is a

spontaneous ventilation mode.• The patient initiates the breath and the ventilator delivers

support with the preset pressure level.• The patient regulates the respiratory rate and the tidal

volume with ventilator support.• If the mechanical properties of the lung/thorax and patient

effort change, delivered tidal volume will be affected. • The pressure support level must be regulated to obtain the

desired ventilation.

FEATURE_maq_niv_insert_050927

PCV Mode• The PCV (pressure-controlled ventilation) mode

delivers pressure-controlled mandatory breaths, either triggered by the ventilator (Timed) or the patient (Spont).

• In this controlled mode of ventilation, the ventilator delivers a flow to maintain the preset pressure at a preset respiratory rate and during a preset inspiratory time.

FEATURE_maq_niv_insert_050927

PCV Mode• The pressure is constant during the inspiratory time.

If for any reason the pressure decreases during inspiration, the flow from the ventilator will immediately increase to maintain the set inspiratory pressure.

• The volume may vary from breath to breath if the patient’s compliance and resistance changes, and depending on the leakage.

• Not commonly used during NPPV.

Application and Initiation

General Considerations• Capabilities and Limitations.• Identification of the Appropriate Patient.• Elimination of Immediate Intubation Need.• Equipment Available.• Area of Application. • The Experience and Expertise of Front-Line

Health Care Providers

ApplicationPatient

Assessment

pH < 7.3↑ PCO2 RR > 25

↓ SaO2 ↓ PO2 Distress

Establishing Patient Need

ApplicationPatient Care

PlanMode of NPPV Initial Settings

Given the Order

Initiat NPPV as following:BiPAP , IPAP 15 cm H2O, EPAP 7 cm H2O, FiO2 45% , backup rate of 10 BPM.To maintain the following;pH ≥ 7.3 and SaO2/SpO2 ≥ 90%

ApplicationTechnical

Application

Ventilator Patient Interface

• Pressure-Targeted Ventilators.

• Critical Care Ventilators.

• Nasal Mask

• Full-Face Mask

• Total-Face Mask

Monitoring Patient on NPPV

First 30 min. of NPPV necessitate Bedside presence of a

respiratory therapist or nurse familiar with this mode is essential.Providing reassurance and adequate explanation in order to have optimal

outcomeBe ready to intubate and start on invasive

ventilation

Initiation of NPPV

Place patient in an upright or sitting position. Carefully explain the procedure NPPV, including the goals and possible complication.

Make sure a mask chosen that is the proper size and fit.

Attach the interface and circuit to he ventilator. Turn on the ventilator and adjust it initially to low pressure setting.

Hold or allow the patient to hold the mask gently to the face until the patient become comfortable with it. Encourage the patient to use proper breathing technique.

Initiation of NPPV Monitor SpO2; adjust FiO2 or the O2 flow to maintain SpO2

above 90%.

Secure the mask to the patient. Do not make the straps too tight.

Titrate the pressures (IPAP and EPAP) to achieve patient comfort, adequate exhaled Vt, and synchrony with the ventilator. Do not allow Ppeak to be more than 20 cm H2O.

Initiation of NPPV Check for leaks and adjust the straps if necessary or the

interface fit and size.

Monitor RR, HR, level of dyspnea, SpO2, Minute Ventilation, and Vte.

Obtain blood gas values within 30 min to 1 hour.

Initiation of NPPV• Initial IPAP/EPAP settings Start at IPAP of 10 to 12 cm H2O/ EPAP of 5 cm H2O Pressures less than 8 cm water/4 cm water not advised as this

may be inadequate Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP

and/or EPAP)


Initiation of NPPV• Critical Care Ventilators: PSV PSV of 8 to 10 cm H2O PEEP of 5 cm H2O Trigger flow 2 to 5 L/min

• Critical Care Ventilators: PCV (A/C) PC adjust to maintain adequate Vte (8 to 10 cc/kg) RR 8 to 12 BPM PEEP 5 cm H2O Trigger flow 2 to 5 L/min

Complications of NPPV• Facial and nasal pressure injury and sores – Result of tight mask seals used to attain adequate

inspiratory volumes – Minimize pressure by intermittent application of

noninvasive ventilation – Schedule breaks (30-90 min) to minimize effects of mask

pressure – Balance strap tension to minimize mask leaks without

excessive mask pressures – Cover vulnerable areas (erythematous points of contact)

with protective dressings


Complications of NPPV• Gastric distension – Rarely a problem – Avoid by limiting peak inspiratory pressures to less than 25

cm water – Nasogastric tubes can be placed but can worsen leaks from

the mask – Nasogastric tube also bypasses the lower esophageal

sphincter and permits reflux


Complications of NPPV• Dry mucous membranes and thick secretions – Seen in patients with extended use of noninvasive

ventilation – Provide humidification for noninvasive ventilation devices – Provide daily oral care

• Aspiration of gastric contents – Especially if emesis during noninvasive ventilation – Avoid noninvasive ventilation in patient with ongoing

emesis or hematemesis


Monitoring Patient on NPPV Response• Physiological a) Continuous oximetry

b) Exhaled tidal volume c) ABG/VBG

• Objective a) Respiratory rate b) blood pressure c) pulse rate

• Subjective a) dyspnea b) comfort c) mental alertness

Monitoring Patient on NPPV• Mask

Fit, Comfort, Air leak, Secretions, Skin necrosis• Respiratory muscle unloading

Accessory muscle activity, paradoxical abdominal motion

AbdomenGastric distension

Management of NPPVTable 11 NPPV Adjustments Setting Adjustment Anticipated Result IPAP ↑

↓ Increased tidal volume; ↑ ventilation, ↓ PaCO2 Decreased tidal volume; ↓ ventilation, ↑ PaCO2

EPAP ↑ ↓

Increased FRC; ↑ PaO2, ↓ tidal volume (if IPAP kept the same) Improve synchronization if intrinsic PEEP is present Decreased FRC; ↓ PaO2, ↑ tidal volume (if IPAP kept the same) Possible rebreathing of CO2 if EPAP < 4 cmH2O

CPAP ↑ ↓

Increased FRC; ↑ PaO2 Improve synchronization if intrinsic PEEP is present Decreased FRC; ↓ PaO2

FiO2 ↑ ↓

Increased PaO2 Decreased PaO2

Controlled Rate ↑ ↓

Increased minute ventilation in timed modes, ↓ PaCO2 Decreased minute ventilation in timed modes, ↑ PaCO2

Management of NPPV• PSV & PCV: Increase PS or PC level to achieve adequate Vte and Exhlaed

Minute ventilation increase CO2 wash out and correct BG values.

Increase PEEP then FiO2 to improve oxygenation. In PCV mode you may increase RR to achieve adequate

Exhlaed Minute ventilation increase CO2 wash out and correct BG values.

Check for leaks

Troubleshooting of NPPVTable 12 NPPV Complication and Possible Remedies Interface related Discomfort Pressure sores Acneiform rash Claustrophobia Facial skin erythema

Minimize strap tension, assess pressure levels, change interface Minimize strap tension, check mask fit, apply artificial skin Administer topical steroids or antibiotics Use smaller mask, administer sedation (low dose) Minimize strap tension, check mask fit, apply artificial skin

Air pressure or flow related Nasal/oral dryness or nasal congestion Sinus or ear pain Eye irritation Gastric insufflation Abdominal distention/Aerophagia Air leak

Add or increase humidification, use decongestant Reduce pressure if the pain is intolerable Check mask fit, readjust strap Reassure the patient, administer simethicone, reduce pressure Assess patient, apply nasogastric tube, anti-vomiting medication Check mask fit, encourage mouth closure, try chin strap or try oronasal mask, if using nasal mask, reduce pressure

Troubleshooting of NPPVVentilator-patient interaction Failure to cycle to expiration Failure to trigger Inadequate pressurization CO2 rebreathing

Check leak, shorten inspiratory time, try oronasal mask Check leak, reduce trigger sensitivity, change to flow triggering Reduce pressure rise time, increase pressure Lower respiratory rate, add PEEP, exhalation valve, reduce dead space

Patient related Hypotension Aspiration Pneumothorax

Reduce inflation pressure, inotropic support Select patient carefully Chest tube, reduce pressure, switch to intubation and invasive mechanical ventilation

Termination of NPPV• Deterioration in patient's condition• Failure to improve or deterioration in arterial blood gas

tensions• Development of new symptoms or complications such as

pneumothorax, sputum retention, nasal bridge erosion• Intolerance or failure of coordination with the ventilator• Failure to alleviate symptoms• Deteriorating conscious level• Patient and/or family wish to withdraw treatment

Weaning ↓pressures

↑ Time off

Patient Stable maintaining good Oxygenation & Ventilation Status

Continue decreasing pressures and increainging time off as long as the patient is stable

Patient is weaned successfully maintain Ventilator By bedside for 12 hours reassess the patient and monitor him closely.

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