What are the current noninvasive ventilation techniques practiced in the emergen

cy department?
Upper airway trauma, ventilator-induced lung injury, and increased risk for noso
comial infection are just a few of the possible complications of intubation and
mechanical ventilation. Noninvasive ventilation has been shown to prevent intuba
tion in select patients with acute respiratory failure. Continuous positive airw
ay pressure (CPAP) and bilevel positive airway pressure (BiPAP) are the primary
forms of noninvasive positive pressure ventilation (NPPV) used in the emergency
department.
By definition, CPAP delivers a constant level of positive pressure throughout th
e respiratory cycle. CPAP decreases the work of breathing by increasing mean air
way pressure, improving functional residual capacity, and opening collapsed alve
oli. However, CPAP can only be used in spontaneously breathing patients. The typ
ical starting pressure for CPAP is 5 cm H20, with titration to 15 to 20 cm H20 b
ased on patient response. It must be noted that increasing levels of positive pr
essure impair venous return, thereby causing a decrease in cardiac output.
BiPAP alternatively provides different levels of positive pressure during inspir
ation and expiration, and a back-up respiratory rate can also be set. The inspir
atory positive airway pressure of BiPAP is analogous to pressure support ventila
tion and works by increasing airway pressure. This improves tidal volume and dec
reases patient fatigue. Inspiratory positive airway pressure is typically set at
8 to 10 cm H20 and can be titrated to 20 cm H20 based on clinical response. Imp
ortantly, inspiratory positive airway pressure is the first parameter that shoul
d be adjusted in patients with hypercapnic respiratory failure. The expiratory p
ositive airway pressure is analogous to positive end-expiratory pressure and pre
vents airway collapse, thereby improving oxygenation. Expiratory positive airway
pressure is initially set at 4 to 5 cm H20 and can be titrated to 15 cm H20 bas
ed on patient response. To date, there is no convincing evidence that BiPAP is s
uperior to CPAP or vice versa.
Accurate patient selection is the most important step in successfully using NPPV
. Published markers indicating the need for ventilatory assistance include moder
ate to severe respiratory distress, tachypnea, accessory muscle use, partial pre
ssure of carbon dioxide in arterial blood (PaCO2) > 45 mm Hg, pH < 7.35, and par
tial pressure of oxygen in arterial blood/fractional inspired oxygen (PaO2/FiO2)
< 200 mm Hg. Primary contraindications include the inability to protect one's a
irway, excessive secretions, agitation, recent upper airway or esophageal surger
y, untreated pneumothorax, and hemodynamic instability. The best predictors of N
PPV success are a reduction in respiratory rate, improvement in pH, improvement
in oxygenation, and a reduction in PaCO2 within the first 1 to 2 hours of therap
y.
Evidence demonstrating the efficacy of NPPV is strongest for patients with acute
hypercapnic respiratory failure resulting from exacerbations of chronic obstruc
tive pulmonary disease (COPD). Numerous studies have demonstrated decreased rate
s of intubation, reduced hospital length of stay, and decreased mortality in the
se patients. In fact, NPPV is considered to be the ventilatory mode of choice in
patients with acute COPD exacerbations. Notably, NPPV should be started as soon
as patients demonstrate the need for ventilatory assistance.
Data on the use of NPPV in patients with acute hypercapnic respiratory failure f
rom conditions other than COPD is less robust. NPPV has been reported to improve
gas exchange, improve expiratory flow rates, and decrease length of hospitaliza
tion. Unfortunately, most of the studies of NPPV in acute asthma are uncontrolle
d and include small numbers of patients; thus, the routine use of NPPV in patien
ts with asthma cannot be recommended. A trial of NPPV can be attempted in patien
ts with asthma; however, patients must be monitored very closely for signs of de
terioration.
In addition to acute hypercapnic respiratory failure, NPPV has also been evaluat
ed in patients with acute hypoxemic respiratory failure. Overall, NPPV has fared
less favorably in acute hypoxemic failure. This is likely in part because of th
e heterogeneity of diseases in this broad category of respiratory failure, and b
ecause these diseases usually take longer to resolve. Nevertheless, NPPV can be
useful in the emergency department management of select conditions that cause ac
ute hypoxemic failure.
NPPV improves oxygenation, reduces the work of breathing, and improves cardiac p
erformance by decreasing both preload and afterload in patients with acute cardi
ogenic pulmonary edema (ACPE). Numerous studies and meta-analyses have reported
decreased rates of intubation and reduced mortality when NPPV is used early in t
he management of patients with ACPE. One recent study, however, has challenged t
he mortality benefit NPPV in ACPE, as it demonstrated no difference in 7-day mor
tality compared with standard therapy in more than 1000 patients. Although addit
ional studies are needed to evaluate mortality benefits, NPPV clearly improves d
yspnea, vital sign abnormalities, metabolic abnormalities, and likely intubation
rates in patients with ACPE.
The use of NPPV in patients with do not intubate/do not resuscitate orders is mo
re controversial. In terminally ill patients, dyspnea is reportedly one of the m
ost frequent and distressing symptoms to patients and their families. Recent stu
dies have evaluated the use of palliative NPPV to ameliorate dyspnea. To date, t
hese studies have reported significant improvements in dyspnea, although the ben
efit seems primarily confined to those terminally ill patients with acute COPD e
xacerbations or ACPE. Provided there is clear communication with the patient and
family about the palliative use of NPPV, a trial to alleviate dyspnea and provi
de patient comfort is reasonable.
Summary
NPPV is a useful tool in the armamentarium of the emergency physician when treat
ing critically ill patients with acute respiratory failure. NPPV should be used
early in the emergency department management of select patients with acute COPD
exacerbations or ACPE. A trial of NPPV can be considered in patients with an acu
te asthma exacerbation or as palliative therapy in patients with do not intubate
/do not resuscitate orders.