Noninvasive Positive Pressure

Ventilation. A short Review.

Elisa
UKK Emergensi dan Rawat Intensif
Anak (ERIA)
No competing interests declared
 Learning Objectives
To understand the pulmonary insults of Acute
Respiratory Distress Syndrome
To understand the facts about non invasive
ventilatory (NPPV) support
To understand the difference between CPAP and
BPAP
To understand the indications and contraindications
for NPPV
 Multiple hit theory for
acquired Acute Respiratory Distress Syndrome
(ARDS).

Intensive Care Med (2013) 39:615

 Modern Mechanical Ventilators
1. Classic Invasive procedure
2. Advanced Invasive procedure
3. Noninvasive procedure (NPPV)
CPAP (Continuous Positive Airway Pressure)
BPAP (Bi-level Positive Airway Pressure)
 What is NPPV
NPPV is a means to support failing respiratory
function by delivering oxygen enriched gas
under pressure without requiring
endotracheal intubation
NPPV Pneumatic Design

Courtesy of Phillips Respironics

Intraalveolar Pressure during CPAP

Courtesy of Eric Strong MD

Intraalveolar Pressure during BPAP

Courtesy of Eric Strong MD

 Benefits of NPPV over invasive
mechanical ventilation
Avoids potential for trauma secondary to
endotracheal intubation ( e.g. vocal cord
dysfunction)
Avoids need for sedation
Allows patient to maintain ability to communicate
Allows for intermittent eating/drinking if mask
can be briefly removed and if aspiration risk felt
to be sufficiently low
Avoids risk of ventilator-associated pneumonia
 Indications to NPPV in Children
1. Acute Respiratory Failure
Hypoxemic respiratory failure
Hypercapnic respiratory failure
Acute lower airway obstruction
Acute upper airway obstruction
Parenchymal lung disease
2. Specific Circumstances
Postoperative respiratory failure
Facilitation of ventilation weaning/ rescue of
failed extubation
Immunocompromised children
Chest wall alteration
Neuromuscular diseases
Central hypoventilation
 Contraindications to NPPV
Cardiac or respiratory arrest
Hemodynamic or arrhythmic instability
Facial trauma or deformity
Severe upper GI bleed
Severe encephalopathy
Inability to cooperate and/or protect airway
Inability to clear secretions
Upper airway obstruction
High risk for aspiration
CPAP
Courtesy of Eric Strong MD
Neonates interface
Childrens Interface
 Side Effects
Air leak
Skin necrosis particularly over bridge of nose
Retention of secretions
Gastric distension
Failure to ventilate
Sleep fragmentation
 Major Complications
Delay of intubation and worsening of
prognosis
Major desaturation and cardiac arrest
Aspiration pneumonia
Pneumothorax
Hypotension
 Algorithm: Noninvasive Ventilation in Children
Deis, J, estrada, C.M, Abramo, T. Pediatric Emergency Medicine
practice, 2009. EBMedicine.net. June 2009

Hemodynamic instability?
Altered mental status?
Excessive secretions or vomiting? Intubate
Upper GI bleeding? YES (Class I-II)
Recent facial, upper airway, or upper GI
surgery?

NO

Explain procedure to patient.

Show patient the equipment and mask.
Ensure patient is on monitor and pulse
oximeter
Ensure adequate personnel to monitor
patient.
Apply mask to patient.
CPAP: Start with low pressures (5 cm H2O). Increase
in
increments of 1 cm H2O.
BPAP: Start with low setting. IPAP of 8-10 cm H2O
and
EPAP of 2-4 cm H2O. Tirate to effect.
Typical IPAP levels in children are 8-16 cm H2O,
and
typical EPAP levels are 4-8 cm H2O.
(Class Indeterminate)

Positive response to therapy? Worsening agitation?

Decreased respiratory rate? NO Poor mask fit?
Decreased work of breathing? Worsening hypoxia?
Improved oxygenation? Worsening respiratory distress?

YES YES

Continue noninvasive ventilation. Intubate.

(Class III) (Class II)
Predictors of Failure Najaf-Zadeh, A, Lederc, F. Annals of
Intensive Care 2011, 1:15
 Summary
NPPV is a major support therapy in management
of certain cases of respiratory failure in children,
some studies confirm its efficacy and safety.

To perform NPPV in children, a specific interface

is needed. The choice of the material could
improve patient tolerance and patient-ventilator
synchrony.

Predictive factors of NPPV failure have been

identified and a good understanding of
indications and contraindication is essential.