Fundamental Critical Care Support Skill Station

Noninvasive Positive Pressure Ventilation

Instructor Guide
Estimated completion time: 45-60 minutes
Equipment needs: Ventilator capable of providing noninvasive positive pressure ventilation (NPPV), variety of masks (if available) for demonstration,
mask to use for participants, alcohol or chlorhexidine pads to wipe mask, board or flip chart
This skill station represents the practical application of the concepts presented in the Diagnosis and Management of Acute Respiratory Failure and Mechanical
Ventilation chapters in the text. The instructor will provide case material but also function as facilitator, supervisor, and demonstrator. Furthermore, the instructor
should carefully review the parts of the station to be demonstrated so as to be very familiar with that equipment. Case scenarios are presented to create a
framework for emphasizing the essential concepts in the use of NPPV in the management of the patient with respiratory failure. The pitfalls of NPPV, particularly in
regard to inappropriate patient selection, must be understood. Whenever possible, interject for discussion of the indications, contraindications, advantages,
disadvantages, and complications of the various activities conducted.
The cases presented here are intended to represent common problems encountered when caring for critically ill patients. Do not allow more advanced participants
in your group to overshadow others and limit their opportunity to learn the more basic elements. Discussions should be redirected to emphasize the fundamental
concepts that every participant must understand. Remind participants that trained personnel should make adjustments to ventilators. Many of the parameters and
alarms are interconnected, and any change may require adjustments or create changes in other settings.
At the conclusion of the session, please collect a Participant Evaluation Form (Form 02.07 in Course Letters and Forms online) from each attendee. Initial in the
appropriate space on that form to prove attendance and return the form to the participant.
Station Goals
The goals of this station are to:
Identify appropriate candidates for noninvasive ventilation.
Understand how to initiate and adjust noninvasive mechanical ventilation.
Interpret arterial blood gases correctly.
Participant Objectives
After completing this skill station, the student should be able to:
List diagnoses for which NPPV may be an appropriate therapy.
List characteristics of a patient who is a good candidate for NPPV.
Discuss the contraindications to NPPV.
Describe techniques to facilitate patient acceptance of NPPV.
Summarize the monitoring requirements for a patient treated with NPPV.

Noninvasive Positive Pressure Ventilation Instructor Guide

Updated February 2013, Version 5.4

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2013 Society of Critical Care Medicine

Case Scenario 1
A 70-year-old man with chronic obstructive pulmonary disease (COPD)
presents with a complaint of increasing dyspnea and cough for the last
several days. He is on home oxygen (3 L/min nasal cannula) and has
been using his home nebulizer every 2 hours for the past day without
relief. His vital signs on presentation reveal: T 36C (96.8F), P 125
beats/min, R 28 breaths/min, BP 155/90 mm Hg, SpO2 92% on oxygen at
5 L/min by nasal cannula. He is breathing with the use of accessory
muscles and is only able to speak in 1- to 2-word answers before
becoming acutely short of breath. His chest radiograph demonstrates
hyperinflation without infiltrates. His arterial blood gas data reveal: pH
7.23, PaCO2 75 mm Hg (9.9 kPa), PaO2 65 mm Hg (8.7 kPa), HCO3 30
mmol/L.
Detection
Q. What factors are important in your assessment of the patients
respiratory status? What information is missing that is important to
his assessment?
[Chapter 1, Assessment]
Q. How would you interpret the arterial blood gas information?
[Chapter 6, Monitoring]

Q. Is this patient an appropriate candidate for NPPV?

Ask for patient characteristics that would make him an appropriate
candidate for NPPV.
[Chapter 5, Mechanical Ventilation]

Critical Elements
Notes
Consider using flip chart or board to list vital signs and arterial blood gas
data to work through acid-base status and for comparison to subsequent
data.

Vital signs (especially respiratory rate, oxygen saturation), use of

accessory muscles, ability to speak, arterial blood gas, chest radiograph.
Level of consciousness is missing (lethargy, confusion).
A. Work through on board/flip chart using the traditional approach:
pH indicates acidemia
Respiratory or metabolic? Elevated PaCO2 indicates respiratory process;
HCO3 is elevated, which does not suggest a metabolic process.
Acute or chronic respiratory process? Formulas for acute and chronic
respiratory acidosis reveal that current pH is between expected changes
for an acute or chronic process, suggesting an acute-on-chronic
respiratory acidosis.
A. Yes. Discuss respiratory conditions that are likely to respond to NPPV and
patient characteristics that make the patient a good candidate for NPPV. This
patient has a potentially reversible respiratory process (COPD exacerbation)
that is often responsive to NPPV; his work of breathing is excessive, indicating
a need for respiratory support. NPPV offers the potential of reducing his work
of breathing and providing time for bronchodilators, corticosteroids, and other
interventions to work while avoiding intubation.
[Chapter 5, Table 5-3]
Patient characteristics that make him a good candidate: awake, cooperative
(answers questions), and hemodynamically stable (tachycardic but good blood
pressure). Discuss other patient characteristics that need to be considered
before initiating NPPV.
[Chapter 5, Table 5-5]

Noninvasive Positive Pressure Ventilation Instructor Guide

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Q. Why not just proceed to intubation immediately in this patient?

Intervention
Q. How would you initiate NPPV in this patient?
Type of ventilator
Type of interface
Mode
Inspiratory positive airway pressure (IPAP)
Expiratory positive airway pressure (EPAP)
FIO2
[Chapter 5, Mechanical Ventilation; text and Table 5-4]

Q. What are the determinants of the patients tidal volume and

minute ventilation?
Reassessment
Q. NPPV is initiated via a full face mask with IPAP set at 10 cm H2O,
EPAP 5 cm H2O, and FIO2 40%. What parameters should be
monitored to assess the patients response to NPPV?

Noninvasive Positive Pressure Ventilation Instructor Guide

Updated February 2013, Version 5.4

A. NPPV avoids many of the complications associated with invasive

mechanical ventilation, such as pneumonia, upper airway injury, etc.
It also avoids the need for sedation, allows easier communication with patient,
and improves mortality.
[Chapter 5, Table 5-2]
A. Type of ventilator: ICU ventilator (may or may not have adaptation for
delivering NPPV), NPPV ventilator. Discuss advantages and disadvantages.
Note which type of ventilator is being used in skill station. Demonstrate
features of the ventilator to include breathing circuit with a mandatory
expiratory valve (allows exhaled gases to escape), monitoring parameters
(respiratory rate, tidal volume, minute volume), and alarm settings (leak, low
minute volume).
Type of interface: face mask (oronasal) is most commonly used in acute
respiratory conditions due to tendency for mouth breathing. Discuss (show)
other types of interfaces and headgear for securing device.
Mode: Spontaneous; volume ventilation is another option but not as
comfortable for patients.
IPAP: 10 cm H2O
EPAP: 5 cm H2O
Patients initiated on NPPV should have the head of the bed elevated at 30 to
45, and many patients prefer to be sitting upright. Oral intake should be
restricted until the patient stabilizes, and sedation should only be considered
with great caution.
Have volunteer experience NPPV with face mask and 2 levels of pressure
(IPAP and EPAP). Lower pressures will usually be needed due to the normal
respiratory status of the volunteer. You can also take this opportunity to
demonstrate the difference between continuous positive airway pressure and 2
levels of pressure. Ask volunteer which is preferred. As time allows, have other
participants experience NPPV. Wipe mask with alcohol or chlorhexidine
between volunteers.
A. Tidal volume is determined by the patients effort, lung compliance, and the
difference between IPAP and EPAP. The minute ventilation is determined by
the patients respiratory rate and tidal volume.
A. Point out monitoring parameters on ventilator: tidal volume, minute
ventilation, and respiratory rate. Other clinical parameters that should be
monitored include vital signs, pulse oximetry, mental status, and patient
comfort. Arterial blood gas measurements (ABG) may also be relevant,
particularly in this patient where effective ventilation is a concern.

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Q. What adjustments would you make if the tidal volume/minute

ventilation is too low?
Q. What adjustments would you make if oxygen saturation is low?

Effective Communication and Teamwork

Q. Successful initiation of NPPV hinges on patient acceptance of
the face mask and device. What can be done at NPPV initiation to
improve patient acceptance and tolerance?

The patient now appears more comfortable and his ABG data show pH
7.31, PaCO2 65 mm Hg (8.7 kPa), and PaO2 105 mm Hg (13.9 kPa).
[Chapter 6, Monitoring]

Reassessment
Q. The on-call hospitalist evaluates the patient and decides to admit
him to a general medical unit. Is this an appropriate care location
for this patient?

Q. How would you determine if NPPV has failed and intubation with
invasive mechanical ventilation is needed?

Noninvasive Positive Pressure Ventilation Instructor Guide

Updated February 2013, Version 5.4

A. Increase IPAP (increase the difference between IPAP and EPAP). If tidal
volume is too high, IPAP should be decreased to use the lowest pressure
needed to achieve adequate ventilation and optimize patient comfort.
A. EPAP can be increased to improve oxygenation (similar to positive endexpiratory pressure), and/or the FIO2 can be increased. To maintain the
difference between EPAP and IPAP, some ventilators require that IPAP be
increased by the same amount as the EPAP.
A. Teaching and coaching the patient can result in improved acceptance. The
patient should understand the reasons for the device and, before mask
placement, should be told what to expect with regards to air pressure and
coverage of the mouth/nose. One technique, which can be of great value, is
asking the patient to lightly place the mask on his/her face for familiarization
before strapping the mask in place. Patients must also be taught how to
remove the mask in the event of intolerance or emesis.
Notes
Compare ABG data to initial ABG. Ask participants to identify the changes:
lower PCO2 and increased pH with increased PaO2. Note that the increase in
pH is secondary to an acute respiratory alkalosis. The anticipated change in
pH can be calculated from the formula: Increase in pH = 0.08 (change in
PaCO2)/10 = 0.08 (75-65)/10 = 0.08 1= 0.08.
A. No. Providers must recognize that the patient is on a mechanical ventilator
and requires a high level of nursing supervision and monitoring for his acute
respiratory condition. NPPV does not reduce the need for close monitoring. A
disposition to a critical care unit or intermediate care unit would be more
appropriate as patients on NPPV may decompensate precipitously with little or
no warning.
A. Indications to proceed to intubation include failure to significantly improve
within 1-2 hours, inability to achieve therapeutic goals within 4-6 hours, patient
intolerance of NPPV, or a change in the patients condition that makes him a
poor candidate for NPPV (eg, hemodynamic instability).

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Case Scenario 2
A 55-year-old homeless man presents with fever and cough productive of
copious thick green secretions. He is confused and resists attempts of
care. His vitals on presentation reveal: T 39.2C (102.5F), P 140
beats/min, R 40 breaths/min, BP 90/45 mm Hg, SpO2 95% on high-flow
oxygen. His chest radiograph confirms a multilobar pneumonia. Arterial
blood gas results are as follows: pH 7.32, PaCO2 38 mm Hg (5 kPa),
PaO2 70 mm Hg (9.4 kPa), HCO3 19 mmol/L
Detection
Q. Is this patient an appropriate candidate for NPPV?
Q. What characteristics make him a poor candidate for NPPV?

Q. How would you interpret the arterial blood gas data?

Intervention
Q. What interventions should be instituted?

Noninvasive Positive Pressure Ventilation Instructor Guide

Updated February 2013, Version 5.4

Critical Elements
Notes
Consider listing vital signs on board or flip chart for discussion.

A. No
A. He has a lung condition (pneumonia) that is less likely to respond to NPPV.
Other concerning findings are copious secretions, altered mental status, and
hemodynamic instability.
A. Work through on board/flip chart using the traditional approach:
pH indicates acidemia.
Respiratory or metabolic? HCO3 is decreased, which suggests a
metabolic acidosis, and near normal PaCO2 does not suggest a
respiratory process.
Is respiratory compensation appropriate? Use formula to calculate
expected PaCO2, which is close to expected.
Anion gap? Unable to calculate with current information.
Presence of metabolic acidosis is another concerning finding that would
suggest sepsis and weigh against using NPPV.
A. Intubation and mechanical ventilation.

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