Bi-Level and Non-invasive

Intermittent Postive Pressure

Ventilation.
M.A . King
Respiratory Support & Sleep
Centre,
Papworth Hospital, Cambridge,
CB3 8RE, UK

Bi-level and NIPPV

Volumetric mechanical ventilation
is usually reserved for the
unconscious patient and is
delivered by an endotracheal tube.
Non-invasive Intermittent Positive
Pressure Ventilation is delivered by
a mask.
Bi-level and NIPPV

Plan

Avoid mentioning CPAP and Bi-Level in OSA !

Focus in non-invasive ventilatory support.
What is ventilatory failure?
Who needs this treatment?
What do the machines do?
What are the outcomes?
Discusion
: Do Sleep Technologists need to be involved
in these treatments?

Technological developments since the

invention of CPAP
OSA

CPAP

Ventilatory
insufficiency

OSA with lung

problems

Bi-Level

Bi-Level

Ventilatory
Failure

BiLevel

Pressure
support
ventilator
s
1987

1990

199
5

<198
7

Pressure
support
ventilator
s
2000

<198
7

Ventilatory Failure.
Lung Function = Ventilation and gas exchange
Minute Ventilation is a function of respiratory
rate and tidal volume
Ventilatory Failure causes a rise in CO2 and
drop in O2
Gas Exchange (respiratory) failure causes
hypoxia alone

Pump Failure.

Respiratory control centres.

Neurological system ( Nerves and
synapses)
Muscle
Mechanics ( Thoracic cage).

RESTRICTIVE VENTILATORY DEFECT

Restrictive defect.

Small lungs in a
rigid chest cage.
Normal lungs which
can not be
expanded.
Lung mechanics
are altered and
efficiencey lost.

Ventilatory Pump.
Cerebral cortex

Brainstem

WAKE

Sleep-wake

Respiratory muscles
Airflow resistance
Restrictive lung defect.

Chemoreceptors
Mechanoreceptors

Ventilation
Minute ventilation =
MV

Respiratory Muscle
Weakness

Begin AJRCCM 1997 156 133-139

pump

Contro
l

TV
work

RR

Muscle
fatigue

MV
reduced
Prolonged hypoventilation
+ or events (AHI),
Desats, Arousals, WASO,
poor sleep architecture.

Hypoxia
(hypersomnia)

Progressive and
insidious

Hypercapnoe
a
Acidosis
Ventilatory
Failure

TV
Contro
l

work

RR

NeuroMuscle
insult

CVA
Trauma
Neuro
disease

MV
reduced
Prolonged hypoventilation
+ or events (AHI),
Desats, Arousals, WASO,
poor sleep architecture.

Hypoxia
Infectio
n

Acute

Hypercapnoe
a
Acidosis
Ventilatory
Failure

Obesity epidemic hits Europe (not

France).

Nocturnal ventilatory
insufficiency

Reduced tidal volume and reduced

frequency.
Reduced minute volume =
hypercapnoea and hypoxia.

Indications for NIPPV.

Ventilatory pump failure.

Chronic or acute.
Reduced MV, hypoxia with
hypercapnoea.

( potential for normal gas exchange

single system failure).

Assessment.

Arterial blood gases (ABGs).

Overnight oximetry and CO2
Lung Function.( volumes and muscle
strength)
Medical exam ( cardio-vascular)
AHI and sleep stages have little
diagnostic or prognostic value.

Simple overnight oximetry.

What do the machines do?

Non-invasive ventilationobjectives
1.

2.
3.

Improve alveolar ventilation &

oxygenation.
Reduction of work of breathing.
Airway support.

Objective:Improve alveolar
ventilation & oxygenation.
The physiological mechanism is
complex & dependent upon the
pathology/disease mechanism.
1.
2.

paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQ
Increased Tidal volume and rate =
minute Ventilation.

Work of breathing
Work increases
when FRC reduced
or when TV = VC

Work of breathing
When FRC and lung compliance are reduced more work is
required to inflate the lung. By applying PEEP, the lung
volume at the end of exhalation is increased. The already
partially inflated lung requires less pressure and energy than
before for full inflation

TV

FiO2 & improved MV ( TV & RR)

Te
FiO2

TV

rco
RR

Ti

Mechanical Ventilatory
Support
Invasive endo-tracheal tube.
Non- invasive ventilation (NIV).
Negative Pressure NIV
Positive Pressure NIV *

Negative Pressure NIV precedes

positive pressure ventilation by 100
years.

- Patient lays inside a rigid cylinder with neck and

head outside cylinder.
A vacuum pump creates a negative pressure within
the chamber (outside of chest)
- this causes expansion of the patient's chest. This
change in chest geometry reduces intrapulmonary
pressure and ambient air flows into the lungs.
When the vacuum ends, the negative pressure
applied to the chest drops to zero, and the elastic
recoil of the chest and lungs results in passive
exhalation.
Pump Adjustable rate and adjustable negative
pressure.

Iron lung.

Limitations of Negative
Pressure NIV

Unsupported upper airwayobstruction induced with high

transluminal pressure gradients.
Can reduce cardiac OP and
peripheral oedema.
CONTROLLED ventilation.
Limited technologies.

Positive Pressure NIV

1. Delivery of positive pressure to lungs
without intubation.
2. Delivery of air is patient controlled
(with machine back up delivery).
3. Air is delivered via a nasal mask or
oro-naso mask ( full face mask).

NIPPV

Nomenclature of Positive pressure systems

CPAP
Bi-level
NIPPV
IPAP
EPAP
PEEP
Ventilating peak pressure (pressure
support)
Triggers - Cycling
Ti. Te, I/E ratio
Mode S, ST, T
Rise Time
Ramps

FiO2, tidal volume & rate.

FiO2 room air 20.8%, facility to add

oxygen. O2 % not measured.
TV Patient controlled breath enhanced
by delivery of air to a target pressure
level. Missed breaths recognised.
RR- apnoea recognised. Back up rate.
delivered. Tachypnea reduced by
control of inspiratory time and
expiratory time.

Improved alveolar ventilation &

oxygenation.
The physiological mechanism is
dependent upon the
pathology/disease mechanism.

paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQ
Increased Tidal volume and rate =
minute Ventilation.

Basic summary

Trigger level= spontaneous patient effort to

trigger a machine breath.
IPAP = expands the lungs more.
EPAP = supports small airways and allows
for PEEP.
PEEP= increases the volume held in the
lungs after passive recoil. Holds open alveoli
& improves gas exchange.Reduces work.
T or back up rate- ensures machine breaths
if the patient does not trigger.
Status/progress measured with CO2 & O2
measurements

FiO2 & improved MV ( TV & RR)

Te
FiO2

TV

rc
o
RR

Ti

Bi-level

Technology has developed from CPAP over

several years.
Splints upper airway.
Supplements Spontaneous breathing,
synchronisation, improves comfort.
Reduces work of breathing.
Time. Missed breaths delivered.
Range of features and settings added in recent
times. Alarms essentially a ventilator.NIPPV

Unrecognised ventilatory
insufficiency leads to big
problems

Problems with Home nocturnal

NIV

Cost of ventilator.
Choice of ventilator- locked settings.
Mask problems.
Compliance ( nights and hrs used)
Need to monitor efficacy and share
medical care with local doctor.
Rare diseases, physical disability,
mental disability, agitation, poor sleep.

Clinical Outcomes &

observational studies.
Physiology ABGs, TcCO2, SpO2.
Lung Function.
Psg AHI little value. WASO and better
sleep.
Quality of Life Activities of Living.
Health care utility (cost)
Survival

Post NIV

Mean overnight oximetry before and after NIV

Sleep Study
Baseline
Mean O2

100.0

95.0

Discharge
Mean O2
90.0

85.0

80.0

75.0

70.0

elective

Mode of Referral

Post exacerbation

NIV : Wake ABGs in Myotonic

Dystrophy

Nugent Chest 2002

121 459-464

Numerous publications: NIV in

Restrictive lung and neuromuscular
disease

No prospective randomised
controlled trials

Multiple case series and 2

withdrawal trials all showing similar
treatment effects

Should NIV be used in

COPD?

600,000 patients diagnosed with COPD in the UK

UK: 30,000 COPD deaths each year

By 2020 COPD is predicted to be the third biggest killer in the
world and will be responsible for the deaths of over six million
people
COPD is a major cause of medical admissions, particular in
winter. 308,355 emergency hospital admissions per year.
Of those that are admitted to hospital for COPD, 1 in 10 will
die in hospital, one in three will die within six months, and 43%
will die within twelve months of their admission to hospital

Cochrane Systematic Review

Nocturnal NIPPV for at least 3 months in
hypercapnic patients with stable COPD had no
consistent clinically or statistically significant
effect on lung function, gas exchange, respiratory
muscle strength, sleep efficiency or exercise
tolerance.
The small sample sizes of these studies
precludes a definite conclusion regarding the
effects of NIPPV in COPD.
More evidence is required.

Summary

Bi Level is needed for some OSA patients.

Bi-Level machines have some features of
pressure support ventilators but may not be
appropriate for all patients.
Ventilatory Failure is common in some
diseases.
Long term NIV is more effective for some
patient groups than others.
Potential for dramatic increase of Obesity
Hypopnoea Syndrome across Europe.

Should Psg technologists be

involved in NIV services?

Nocturnal (sleep related) Ventilatory

insufficiency.
Diagnostics. (type of abnormality)
Ventilatory Failure is not determined
by events (AHI)
Treatment medical speciality.
Outcomes. (efficacy of NIV)

Is our speciality led by

technologies ?
Bi-level
machines
CPAP
(OSA is one of
87 sleep
disorders)

Ventilator
y Failure

Equipment by disorder ( few patients with OSA

develop Ventilatory failure) Papworth,Cambridge,Sept 2006
Bi-level
machines used
for OSA and in
78 COPD
CPAP=3503
(OSA is one of
87 sleep
disorders)

Ventilatory
Failure = 385