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Non Invasive Positive Non Invasive Positive Pressure Ventilation (NIPPV)Pressure Ventilation (NIPPV)
Rabia KhalailaRabia Khalaila
RN, MPH, BSNRN, MPH, BSN
Mechanical ventilation
Non Invasive ventilation Invasive ventilation
NINPVCuirass
Ventilation
NIPPVCPAPBIPAP
Pressure ControlPressure ControlPCPS
Volume ControlVolume ControlSIMVCMVA/CASV
Respiratory Failure
Hypoxic Respiratory Failure
Hypercarbic Respiratory Failure
NON INVASIVE VENTILATION
NIV
Negative Pressure• Spontaneous• Mechanical (Noninvasive Biphasic Cuirass Noninvasive Biphasic Cuirass
VentilationVentilation )
Positive Pressure • Mechanical
Invasive (CMV, SIMV, PS, PC, A/C) Non Invasive (CPAP, BiPAP)
Invasive vs. Non-invasive Invasive vs. Non-invasive ventilationventilation
InvasiveInvasive Good Good controlcontrol of airway of airway Suitable for Suitable for higherhigher pressurespressures
Non-invasiveNon-invasive Avoidance of complications of Avoidance of complications of
intubationintubation Avoidance of complication of Avoidance of complication of
invasive ventilation (VAP, invasive ventilation (VAP, sinusitis…)sinusitis…)
If tolerated, more comfortable If tolerated, more comfortable to awake patients. to awake patients.
No sedation (or less sedationNo sedation (or less sedation))
Goals of NIVGoals of NIV
Short Term:Short Term:
1.1. Relieve symptomsRelieve symptoms
2.2. Reduce work of Reduce work of breathingbreathing
3.3. Improve or stabilize Improve or stabilize gas exchangegas exchange
4.4. Good patientGood patient--ventilator synchronyventilator synchrony
5.5. Optimize patient Optimize patient comfortcomfort
6.6. Avoid intubationAvoid intubation
Long Term:Long Term:
1.1. Improve sleep Improve sleep duration and qualityduration and quality
2.2. Maximize quality of Maximize quality of lifelife
3.3. Enhance functional Enhance functional statusstatus
4.4. Prolong survivalProlong survival
NNonon I Invasive nvasive PPositiveositive P Pressure ressure VVentilation (entilation (NIPPV)NIPPV)
• CPAP = PEEP
• BiPAP = CPAP + PSV
• ePAP = CPAP
• iPAP = CPAP + PSV
Indications for NIPPVIndications for NIPPV
(A) Acute respiratory failure.(A) Acute respiratory failure.
(B(B) ) Chronic Respiratory Failure.Chronic Respiratory Failure.
(C(C))Thoracic RestrictiveThoracic Restrictive
(D) Cerebral Hypoventilation Diseases.(D) Cerebral Hypoventilation Diseases.
(E(E) ) Patients 'not for intubation.Patients 'not for intubation.
))AA ( (Acute respiratory failureAcute respiratory failure
1.1. Hypercapnic acute respiratory failure :Hypercapnic acute respiratory failure :
Acute exacerbation of COPD Acute exacerbation of COPD
Post extubation Post extubation
Weaning difficulties Weaning difficulties
Post surgical respiratory failure Post surgical respiratory failure
Thoracic wall deformities Thoracic wall deformities
Cystic fibrosis Cystic fibrosis
Status asthmaticus Status asthmaticus
))AA ( (Acute respiratory failureAcute respiratory failure
2. Hypoxaemic acute respiratory failure :2. Hypoxaemic acute respiratory failure :
Cardiogenic pulmonary oedema Cardiogenic pulmonary oedema
pneumonia pneumonia
Post traumatic respiratory failure Post traumatic respiratory failure
ARDS ARDS
Weaning difficultiesWeaning difficulties
Respiratory FailureRespiratory Failure
))BB) ) Chronic Respiratory Failure: Chronic Respiratory Failure: ((neuromuscular disease, Obstructive lung disease)neuromuscular disease, Obstructive lung disease)
))CC))Thoracic Restrictive DiseasesThoracic Restrictive Diseases
(D) Cerebral Hypoventilation -(D) Cerebral Hypoventilation - (nocturnal (nocturnal hypoventilation Syndrome (OSA)hypoventilation Syndrome (OSA)
))EE) ) Patients 'not for intubationPatients 'not for intubation..
ContraindicationsContraindications
Respiratory arrestRespiratory arrest
unstable cardiorespiratory status-CPRunstable cardiorespiratory status-CPR
post MIpost MI
Uncooperative patientsUncooperative patients . .
Unable to protect airwayUnable to protect airway- - impaired impaired swallowing and coughswallowing and cough ..
FacialFacial//esophageal or gastric surgeryesophageal or gastric surgery
Craniofacial traumaCraniofacial trauma//burnsburns
Anatomic lesions of upper airwayAnatomic lesions of upper airway
Relative ContraindicationsRelative Contraindications
Extreme anxietyExtreme anxiety
Copious secretionsCopious secretions
Need for continuous or nearly continuous Need for continuous or nearly continuous ventilatory assistanceventilatory assistance
Advantages of NIPPVAdvantages of NIPPV
Early ventilatory supportEarly ventilatory support
Intermittent ventilationIntermittent ventilation
Patient can eat, drink and communicatePatient can eat, drink and communicate
Ease of application and removalEase of application and removal
Patient can cooperate with physiotherapyPatient can cooperate with physiotherapy
Improved patient comfortImproved patient comfort
Advantages of NIPPVAdvantages of NIPPV
Reduced sedation requirementsReduced sedation requirements
Avoidance of complications of intubationAvoidance of complications of intubation
possible Ventilation outside hospital setting.possible Ventilation outside hospital setting.
Correction of hypoxaemia without worsening Correction of hypoxaemia without worsening hypercarbiahypercarbia
Ease to teach paramedics and nursesEase to teach paramedics and nurses
DisadvantagesDisadvantages
Mask is uncomfortableMask is uncomfortable//claustrophobicclaustrophobic
Airway is not protectedAirway is not protected
Facial pressure sores Facial pressure sores
No direct access to bronchial tree for No direct access to bronchial tree for suctionsuction
Complications and Side effectsComplications and Side effects
Air leak. Air leak.
Skin necrosisSkin necrosis- - particularly over bridge of particularly over bridge of nosenose . .
Nasal congestionNasal congestion
Retention of secretionsRetention of secretions
Upper airway obstructionUpper airway obstruction
Gastric distension Gastric distension
Failure to ventilateFailure to ventilate
Sleep fragmentationSleep fragmentation
Complications of PEEPComplications of PEEP
Barotrauma.(Pneumothorax)Barotrauma.(Pneumothorax)
HypotensionHypotension
Hyperinflation.Hyperinflation.
Decreased venous return (pre load) Decreased venous return (pre load)
Decreased Cardiac output.Decreased Cardiac output.
Arrhythmias.Arrhythmias.
Increase ICP.Increase ICP.
excessive ADH secretion and edemaexcessive ADH secretion and edema
Choice of VentilatorChoice of Ventilator
NIMV can be given by:NIMV can be given by:
1.1. conventional critical care ventilators.conventional critical care ventilators.
2.2. or portable pressure ventilators.or portable pressure ventilators.
3.3. or volume limit ventilatorsor volume limit ventilators ..
VentilatorsVentilators
Modes ofModes ofNNon on IInvasive nvasive PPositive ositive PPressure ressure
VVentilation entilation (NIPPV)(NIPPV)
CPAPCPAP&&
BIPAPBIPAP
CContinuousontinuous PPositiveositive AAirwayirway PPressure ressure (CPAP)(CPAP)
CPAP = PEEPCPAP = PEEP
provides positive airway pressure throughout provides positive airway pressure throughout spontaneous ventilation. spontaneous ventilation.
Spontaneous breathing on one pressure level.Spontaneous breathing on one pressure level.
Pressures are usually limited to 5-15 cm of Pressures are usually limited to 5-15 cm of H2O .H2O .
most frequently peep= 10 cm of water.most frequently peep= 10 cm of water.
Oxygen can be delivered at flow rates high Oxygen can be delivered at flow rates high enough to maintain O2 saturation above 90%enough to maintain O2 saturation above 90%. .
CContinuousontinuous PPositiveositive AAirwayirway PPressure ressure (CPAP)(CPAP)
Increases the FRC. Increases the FRC.
Decrease shunt and opens collapsed alveoli Decrease shunt and opens collapsed alveoli
reduces the work of breathing by improving reduces the work of breathing by improving atelectasis and V/Q ratios atelectasis and V/Q ratios
Effective for treatment of pulmonary edema- Effective for treatment of pulmonary edema- CHF.CHF.
Reduces preload and also afterloadReduces preload and also afterload
improves oxygenation, hypercapnia improves oxygenation, hypercapnia
BiBi-level -level PPositive ositive AAirway irway PPressure ressure ((BIPAP)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 ) )
BiBi-level -level PPositive ositive AAirway irway PPressure ressure ((BIPAP)BIPAP)
Bi-PAP = CPAP + PSV mode
provides two levels of positive pressureprovides 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 AspectsTechnical Aspects
1.1. Bilevel positive airway pressure (BiPAP)Bilevel positive airway pressure (BiPAP)Example:Example:
IPAP:IPAP: 14-20 cm of H 14-20 cm of H2200 EPAPEPAP: 3-6 cm of H: 3-6 cm of H2200
Mode:Mode: ST (spontaneous/ timed) ST (spontaneous/ timed)Respiratory Rate:Respiratory Rate: Inspiratory Time:Inspiratory Time: depends on pt age and depends on pt age and
RRRRRise time:Rise time: speed of breath delivery speed of breath delivery
TYPES OF INTERFACESTYPES OF INTERFACES
Non-invasive - Preset air volume or Non-invasive - Preset air volume or pressure delivered by:pressure delivered by:
Nasal maskNasal mask
Full face mask (oral-nasalFull face mask (oral-nasal ))
Mouth pieceMouth piece
FACE MASKFACE MASK
Nasal MaskNasal Mask
Small Child Nasal Mask and Head Gear
mouthpiece to deliver ventilation mouthpiece to deliver ventilation during the dayduring the day..
masksmasks
Face masks and nasal masks are the Face masks and nasal masks are the most commonly used interfaces .most commonly used interfaces .
Nasal masks are used most often in Nasal masks are used most often in chronic respiratory failurechronic respiratory failure
while face masks are more useful in acute while face masks are more useful in acute respiratory failure. 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 secretionscontrol their airway and secretions• Adequate cough reflexAdequate cough reflex
• Haemodynamically stable 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 Successful treatment will result inin
higher tidal volumes,higher tidal volumes,reduced respiratory rate,reduced respiratory rate,improved chest wall movementimproved chest wall movementand adequate synchronization of the and adequate synchronization of the patient’s own breaths with the respiratorpatient’s own breaths with the respirator. . reversal of hypoxemia and hypercapnia reversal of hypoxemia and hypercapnia patient’s hemodynamic stability patient’s hemodynamic stability mental status are likely to improve mental status are likely to improve
Treatment failureTreatment failure
Deterioration in the patient’s status can occur Deterioration in the patient’s status can occur even after 48 hours or moreeven after 48 hours or more
‘‘late failures’ are often associated with a poor late failures’ are often associated with a poor prognosis and high mortality prognosis and high mortality
criteria for a ‘late failure’ include :criteria for a ‘late failure’ include :
1. a rapid drop in arterial pH to below 7.34 1. a rapid drop in arterial pH to below 7.34
2. a possible 15-20% rise in PaCO2 2. a possible 15-20% rise in PaCO2
3. dyspnia 3. dyspnia
4. deterioration of the patient’s mental status 4. deterioration of the patient’s mental status