Non Invasive Positive

)Pressure Ventilation )NIPPV

Rabia Khalaila
RN, MPH, BSN
 Mechanical ventilation

Non Invasive ventilation Invasive ventilation

Pressure Control Volume Control

NINPV NIPPV SIMV
Cuirass CPAP PC
PS CMV
Ventilation BIPAP A/C
ASV
 Respiratory Failure

Hypoxic Respiratory Failure

Hypercarbic Respiratory Failure

NON INVASIVE VENTILATION
NIV
Negative Pressure
• Spontaneous
• Mechanical (Noninvasive Biphasic Cuirass
Ventilation )

Positive Pressure
• Mechanical
­ Invasive (CMV, SIMV, PS, PC, A/C)
­ Non Invasive (CPAP, BiPAP)
 Invasive vs. Non-invasive
ventilation
Invasive
Good control of airway
Suitable for higher pressures
Non-invasive
 Avoidance of complications of
intubation
 Avoidance of complication of
invasive ventilation (VAP,
sinusitis…)
 If tolerated, more comfortable
to awake patients.
 No sedation (or less sedation)
 Goals of NIV
Short Term: Long Term:
 Relieve symptoms  Improve sleep
 Reduce work of duration and quality
breathing  Maximize quality of
 Improve or stabilize life
gas exchange  Enhance functional
 Good patient- status
ventilator synchrony  Prolong survival
 Optimize patient
comfort
 Avoid intubation
 Non I nvasivePositive Pressure
Ventilation ))NIPPV

• CPAP = PEEP
• BiPAP = CPAP + PSV
• ePAP = CPAP
• iPAP = CPAP + PSV
 Indications for NIPPV

(A) Acute respiratory failure.

(B) Chronic Respiratory Failure.
(C)Thoracic Restrictive
(D) Cerebral Hypoventilation Diseases.
(E) Patients 'not for intubation.
 A) Acute respiratory failure)
1. Hypercapnic acute respiratory failure :
Acute exacerbation of COPD
Post extubation
Weaning difficulties
Post surgical respiratory failure
Thoracic wall deformities
Cystic fibrosis
Status asthmaticus
 A) Acute respiratory failure)
2. Hypoxaemic acute respiratory failure :
Cardiogenic pulmonary oedema
pneumonia
Post traumatic respiratory failure
ARDS
Weaning difficulties
 Respiratory Failure

)B) Chronic Respiratory Failure:

(neuromuscular disease, Obstructive lung disease)
)C)Thoracic Restrictive Diseases
(D) Cerebral Hypoventilation - (nocturnal
hypoventilation Syndrome (OSA)
)E) Patients 'not for intubation.
 Contraindications

Respiratory arrest
unstable cardiorespiratory status-CPR
post MI
Uncooperative patients .
Unable to protect airway- impaired
swallowing and cough .
Facial/esophageal or gastric surgery
Craniofacial trauma/burns
Anatomic lesions of upper airway
 Relative Contraindications

Extreme anxiety
Copious secretions
Need for continuous or nearly continuous
ventilatory assistance
 Advantages of NIPPV

Early ventilatory support

Intermittent ventilation
Patient can eat, drink and communicate
Ease of application and removal
Patient can cooperate with physiotherapy
Improved patient comfort
 Advantages of NIPPV

Reduced sedation requirements

Avoidance of complications of intubation
possible Ventilation outside hospital setting.
Correction of hypoxaemia without worsening
hypercarbia
Ease to teach paramedics and nurses
 Disadvantages

Mask is uncomfortable/claustrophobic
Airway is not protected
Facial pressure sores
No direct access to bronchial tree for
suction
 Complications and Side effects
Air leak.
Skin necrosis- particularly over bridge of
nose .
Nasal congestion
Retention of secretions
Upper airway obstruction
Gastric distension
Failure to ventilate
Sleep fragmentation
 Complications of PEEP
Barotrauma.(Pneumothorax)
Hypotension
Hyperinflation.
Decreased venous return (pre load)
Decreased Cardiac output.
Arrhythmias.
Increase ICP.
excessive ADH secretion and edema
 Choice of Ventilator
NIMV can be given by:
 conventional critical care ventilators.
 or portable pressure ventilators.
 or volume limit ventilators .
Ventilators
 Modes of
Non Invasive Positive Pressure
Ventilation )NIPPV)

CPAP
&
BIPAP
 Continuous Positive Airway
P ressure((CPAP
CPAP = PEEP
provides positive airway pressure throughout
spontaneous ventilation.
Spontaneous breathing on one pressure level.
Pressures are usually limited to 5-15 cm of
H2O .
most frequently peep= 10 cm of water.
Oxygen can be delivered at flow rates high
enough to maintain O2 saturation above 90%.
 Continuous Positive Airway
P ressure((CPAP
Increases the FRC.
Decrease shunt and opens collapsed alveoli
reduces the work of breathing by improving
atelectasis and V/Q ratios
Effective for treatment of pulmonary edema-
CHF.
Reduces preload and also afterload
improves oxygenation, hypercapnia
 Bi-level Positive Airway Pressure
(BIPAP)
The bi-level ventilator was first introduced
in 1990
simple to use, lighter weight and less
expensive,
They also compensate for air leaks.
can be administered with standard critical
care ventilator or bi-level portable devices.
effective for )chronic respiratory failure, neuromuscular
problems, obstructive sleep apnea )
 Bi -levelP ositiveA irwayPressure
((BIPAP
Bi-PAP = CPAP + PSV mode
provides two levels of positive pressure
– iPAP )inspiratory positive airway pressure) =
CPAP + PSV
– ePAP)expiratory positive airway pressure) =
CPAP
spontaneous / timed mode : Cycling between
inspiratory and expiratory modes may either be
triggered by the patient's breaths or preset .
 Technical Aspects
• Bilevel positive airway pressure (BiPAP)
Example:
IPAP: 14-20 cm of H20
EPAP: 3-6 cm of H20
Mode: ST (spontaneous/ timed)
Respiratory Rate:
Inspiratory Time: depends on pt age and RR
Rise time: speed of breath delivery
 TYPES OF INTERFACES

Non-invasive - Preset air volume or

pressure delivered by:

Nasal mask
Full face mask )oral-nasal )
Mouth piece
FACE MASK
Nasal Mask
Small Child
Nasal Mask and
Head Gear
mouthpiece to deliver ventilation
.during the day
 masks

Face masks and nasal masks are the

most commonly used interfaces .
Nasal masks are used most often in
chronic respiratory failure
while face masks are more useful in acute
respiratory failure.
 Predictors of Success

• Younger Age
• Lower acuity of illness
• Better Neurologic score
• Cooperative and able to coordinate breathing
with ventilator and
• control their airway and secretions
• Adequate cough reflex
• Haemodynamically stable
• Less air leaking;
•Patient can breathe unaided for several minutes
 Predictors of Success

– Hypercarbia; not too severe )PaCO2 > 45 and

< 92 mm Hg)

– Acidemia, but not too severe

)pH < 7.35, > 7.10)

– Improvements in gas exchange, HR and RR

within first 2 h
Successful treatment will result
in
higher tidal volumes,
reduced respiratory rate,
improved chest wall movement
and adequate synchronization of the
patient’s own breaths with the respirator.
reversal of hypoxemia and hypercapnia
patient’s hemodynamic stability
mental status are likely to improve
 Treatment failure
Deterioration in the patient’s status can occur
even after 48 hours or more
‘late failures’ are often associated with a poor
prognosis and high mortality
criteria for a ‘late failure’ include :
1. a rapid drop in arterial pH to below 7.34
2. a possible 15-20% rise in PaCO2
3. dyspnia
4. deterioration of the patient’s mental status