Non-Invasive Ventilation

Outline

What is NonInvasive ventilation

Why & How does it help

Definitions

Indications type 1, 2 RF, Postop, NMD, Bridging to intubation?

PathoPhysiology [UTD, west] hypoxemia, Hypercapnia

Modes & Settings

CPAP vs BIPAP (S/T (a backup rate is available to deliver IPAP for the set inspiratory time if the patient does not trigger an IPAP/EPAP cycle within a set time window) in
Respironic V60

PEEPi

Specific conditions clinical scenario to exemplify

COPD, Asthma, APO,

Weaning process

Complications [ccm]

256: SPONTANEOUS EYE HERNIATION ASSOCIATED WITH FLOPPY EYELID SYNDROME AND NON-INVASIVE POSITIVE PRESSURE VENTILATION (NPPV)

Definition
Positive pressure ventilation without bypassing upper airway
(ETT/LMA/Tracheostomy as with mechanical ventilation)

Ventilators
Conventional mechanical ventilators
Full monitoring / alarm systems
Inspiration & expiration tubing system

portable device
Lightweight
Limited alarm system

Single tubing system some rebreathing risk

Modes of NIV
Principal modes
CPAP
CPAP is a fixed positive pressure throughout the respiratory cycle

BIPAP
BiPAP is when the ventilator delivers different levels of pressure

during inspiration (IPAP) and expiration (EPAP)

Triggering & Cycling

Breaths are patient triggered in all modes
Volume method pt effort leads to certain vol. of gas to accumulate above
baseline flow

Shape signal method inspiratory effort distort the expiratory flow

waveform sufficiently

Cycling to exhalation:
Shape signal
Flow reaches the spont exhalation threshold
3s at IPAP level (timed backup safety mechanism)
When flow reversal occurs (due to leak)

Auto-Trak Sensitivity
V60 able to

recognize and compensate for leaks

Adjust its triggering & cycling algorithms to maintain optimum

performances

Shape Signal method

CPAP
Patient triggers all breaths and determining their timing, pressure, and size

BIPAP (S/T) mode

Clinical usage
use of NIV has more than doubled in the past 10 yr

Emerging as an alternative to mechanical ventilation

Strongest evidence for use of NIV
COPD
cardiogenic pulmonary oedema
Others clinical settings
Pneumonia, MND, chest trauma, post-extubation

Indications & Contraindications

Clinical Scenario
65 yo man, heavy smoker , presented with 3 days history of

worsening sob. RR 35, SaO2 85% RA. Cxray showed hyperinflated chest.
ABG: pH 7.29, pO2 55, pCO2 60, HCO3 29.

Initial management : Bronchodilators, steroid, O2 therapy,

IVAb

Acute Exacerbation of COPD

NIV should be considered in all patients with an acute

exacerbation of COPD in whom a respiratory acidosis persists despite maximum standard

management for no more than 1 hr

Patient selection

Immediate intubation or trial of NIV?

ICU or Respiratory ward

Ceiling of treatment?

Settings

Mode

Pressures

Guidelines
Clear benefits of NIV when compared with standard medical therapy
Initial approach
IPAP 10, EPAP 5
Titrate to response
Oxygen therapy, target SaO2 88-92%
bronchodilators
Escalation
Within 4 hrs
Duration of treatment
Those who benefit from NIV during the 1st 4 hrs should receive NIV for as
long as required
Weaning plan

Acute Cardiogenic Pulmonary Oedema

Evidence
Mechanism
CPAP increases intrathoracic pressure
During diastole, it reduces venous return reduced preload
During systole, it reduces cardiac transmural pressure reduced

afterload
Decreased WOB, re-expand flooded alveoli

NIV
CPAP as first line intervention

Pneumonia
Evidence is nowhere as conclusive as it is for COPD
Many trials tend to exclude patients with pneumonia
Comparing to other causes of AHRF, NIV is least effective in pneumonia

Current opinion:
Reasonable to trial NIV in critical setting with rapid access to

mechanical ventilation

Asthma
Use of NIV is contentious in asthma attack
Cochrane review failed to find robust evidence of benefit
yet to have large RCT

BTS guidelines
Insufficient evidence to recommend routine use in acute asthma

but a trial may be considered

Why?

noninvasive ventilation pressures, as they are currently used, may not be sufficient to overcome
this degree of obstruction and associated resistance that is manifested in acute severe asthma

Obesity Hypoventilation Syndrome

Reference
Uptodate
PMJBMJ
BTS guidelines
CEACCP
LITFL

Clinical review: Positive end-expiratory pressure and cardiac output @ CCM forum

PEEP increases the pressure around structures in the thorax and, to a lesser extent, in the abdominal cavity, relative to
atmospheric pressure. Because the rest of the circulation is at atmospheric pressure, this results in a pressure differential, with
most of the systemic circulation being under lower pressure than the left ventricle and the thoracic aorta [18]. Thus, increased
ITP, at constant arterial pressure, decreases the force necessary to eject blood from the left ventricle

 LV transmural pressure decreased with PPV, and Ptrans

better reflects afterload than aortic pressure PPV as mechanism to reduce LV

afterload.

Effect of Continuous Positive Airway Pressure on Intrathoracic and Left Ventricular Transmural Pressures in Patients With
Congestive Heart Failure - http://circ.ahajournals.org/content/91/6/1725.long

http://adc.bmj.com/content/80/5/475.full