NIPPV

1. Non-invasive positive pressure
ventilation in respiratory failure
Dr. Tajamul hussain
Department of Internal and Pulmonary Medicine

2. • Background
Definition of NIPPV
Indications /Contraindications
How to set up a ventilator in patients RF
Our experience
Examples

3. Back-Ground
 Concept of artificial ventilation --- 1700’s.
 1832- Dalziel developed ventilator based on
negative pressure.
 1928 - Development of Iron lung Drinker-Shaw
 In 1931 modified by Emerson
Emerson tank ventilator

4.  It was standard for ventilatory support during
that period.
 Played a crucial role in treatment of victims of
poliomyelitis.

5.  1950’s Concept of positive pressure
ventilation (PPV) was used to provide
ventilation.
Initially using ET or Tracheostomy.
 1980’s PPV was first time delivered non
invasively via Face mask
OSA, Respiratory failure due to neuromuscular
diseases.

6. Definition
 (NIPPV) Non invasive positive pressure
ventilation refers to positive pressure
ventilation delivered through non invasive
interface, rather than an invasive
interface.

8. Advantages of NIPPV
 Non invasiveness
 Avoids complication related to ET (trauma,
Infections)
 Allows intermittent application
 Reduces need for sedation
 Oral patency (preserves speech, cough,
swallowing)
 Decreases hospital stay and thus cost.
 decreases morbidity and mortality
 Decreases rate of intubation.

9. How dose it benefit ?
 Keeps the airway patent relieves obst ( OSA/OHS).
 Prevents the expiratory collapse of airways and
alveoli.( increases FRC, Adequate exhalation and O2).
 Increases the tidal volume (Increases the Alve0lar
ventilation, Decreases CO2 level).
 Recruits more and more alveoli (increases O2).
 Decreases the preload to heart (By increasing ITP).
 Decreases Work of breathing.(Improves Dyspnea)

10. All patients with respiratory failure
dose not need non invasive ventilation

11. Indications of NIPPV
 Patients with AECOPD complicated by hypercapnic
acidosis (PaCO2 >45 mmHg or pH <7.30) despite
maximum medical treatment, who do not require
emergent intubation with no contraindications to NPPV.
 The benefit was most pronounced in patients with
moderate to severe AECOPD
pH < 7.3, moderate to severe dyspnea
Use of Accessory muscles of respiration
• No benefit was observed in patient with less disease
severity.
• A systemic review of literature. Ann Int Med 2003.

12. What is the Evidence?
 Meta-analysis (15 RCT) indicate that NPPV improve
clinical outcome in patients with AECOPD
complicated with hypercapnic acidosis.
 NPPV + standard medical treatment(SMT) vs SMT
 decreased mortality (11 vs 23)
 decreased rate of intubation (16 vs 33)
 hospital stay and rate rehospitalization
 Decreases rate of Nosocomial pneumonia
Ram FS et al: Cochrane database Syst Rev 2004,and JAMA. Dec 10 2003;290

13. 2. Respiratory failure due to Acute
cardiogenic pulmonary edema or CHF.
Pulmonary vascular congestion
Interstitial edema
Alveolar edema
 CPAP more effective than BPAP
 Recruits more alveoli
 Decreases shunt (improves V/Q mismatch)
 decreases preload to heart

14. Cardiogenic pulmonary edema
 Meta analysis of (13 RCT) various trails
 Show that NPPV plus SMT in CHF
 Decreased rate of intubation
 Improved clinical parameters (HR, Dyspnea,
acidosis Hypercapnia).
 In hospital mortality ? (some studies)

15. Other indications of NIPPV
 Decompensation of OSA/ OHS
 Hypercapnic respiratory failure secondary to
Neuromuscular diseases (ALS, GB)
Chest wall deformity (Kyphoscoliosis, thoracoplasty)
 To prevent post extubation respiratory failure,
after weaning from Invasive ventilation.
 Post operative hypoxemia (Atelectasia, Edema).
 Intubation refusal
 Hypoxemic respiratory failure sec to
Pneumonia
ARDS
Acute severe asthma ( HDU or ICU)

16.  Asthma
a trial of NPPV prior to invasive mechanical
ventilation seems reasonable for patients
having a severe asthma exacerbation
despite initial bronchodilator therapy,
if they do not require immediate intubation
and have no contraindications to NPPV
Nowak R, Corbridge T. Noninvasive ventilation. J Allergy Clin Immunol 2009
Meduri GUet al. Noninvasive positive pressure ventilation in status asthmaticus. Chest 1996

17. ARDS
 Not as first line
 Use of NIV in selected patients
 Reduced intubation in 54% (147/79)
 Without Encephalopathy, hemodynamic
instability, severe hypoxemia, metabolic
acidosis, or multiple organ failure.
 Antonelli M et al. A multiple-center survey on the use in clinical practice
of noninvasive ventilation as a first-line intervention for acute
respiratory distress syndrome. Crit Care Med 2007

18. Predictors of successful noninvasive ventilation
 Younger age
 Lower acuity of illness (APACHE score)
 Able to cooperate, better neurologic score.
 Moderate hypercarbia (PaCO2 >45 mmHG,<92 mmHG)
 Moderate acidemia (pH <7.35, >7.10)
 Improvements in gas exchange and heart
respiratory rates within first 2 hours
 Less air leaking, intact dentition

19. Avoid use of NIPPV
 Cardiac or Respiratory arrest.
 Sever encephalopathy
 Upper GI bleed
 Hemodynamic ally unstable or Unstable
cardiac arrhythmia.
 Upper airway obstruction
 Inability to cooperate/ or Protect
airways
 High risk for aspiration

20. Complications
1. Facial and nasal
bridge injury
 Can be minimized by
Cover pressure points with
protective dressing.
Intermittent applicatiction of
NIV.
Use minimum strap tension to
avoid air leak.
Low potent steroids, doxy or
clindamycin

21.  Gastric distention  Rare
 Usually transient
 Can occur in patients
with IPAP of > 25 cm
H2O.
 Nasogastric tube can
increase air leak.

22.  Nasal congestion
and Dryness  Seen in patients on
extended ventilation
 Heated humidifier.

23. 4. Eye irritation, sinus pain, or sinus
congestion …. lower inspiratory pressure or a
facial mask rather than a nasal mask
5. Mask intolerance… explain
Full face mask
Hold the mask without
securing
6. Aspiration of Gastric contents
7. Barotrauma (less likely than invasive)
8. Hypotension ( by increase in ITP)

24. Modes of NIV
 NIPPV can be delivered using the same modes
that are used for invasive mechanical ventilation,
although certain modes are used more
frequently.
1. Bi-level positive airway pressure (BPAP).
2. Continuous positive airway pressure
(CPAP).

25.  CPAP maintains a generally constant pressure in
the upper airway throughout the respiratory
cycle.
 CPAP acts physiologically as a pneumatic splint,
inducing patency of the upper airway during
inspiration and expiration.
 Most commonly indicated in OA, CPE
 Corrects hypoxemia .

26. In Congestive cardiac failure
 CPAP benefits by
 Increase in Intrathoracic pressure
decreases venous return to heart
Decreases preload to heart
Improvement in symptoms


27.  Prevents alveolar collapse (increases FRC
by providing PEEP)

28. BPAP Bi-level positive airway pressure
 Delivers positive airway pressure at different
levels during inspiration and expiration.
 Level During inspiration is called the inspiratory
positive airway pressure (IPAP) and
 the level during expiration is called the
expiratory positive airway pressure (EPAP).
 IPAP – EPAP = Pressure support (PS).
 Tidal volume delivered depends on the degree
of PS.

29.  IPAP helps Augments inspiration , augments TV,
improves ventilation , decreases hyper-carbia
and decreases work of breathing.
 EPAP (PEEP) prevents airway and alveolar
collapse, recruits more alveoli, improves
oxygenation.

30. Interface
 Difference b/w Invasive and Non
Invasive.
 Various interfaces in NIPPV are
 Nasal mask
 Nasal pillows
 Full face mask, Oro-nasal mask
 Helmets
 Proper fitting of the mask or other
interface is key to successful
noninvasive ventilation.

33.  Face mask is preferred over Nasal mask or nasal
pillows during initiation of NIV.
Patients are mouth breathers
Large Air leak through mouth, and decrease in Vent.
Nasal passages provide higher resistance, require high IP
 The face mask conferred the greatest physiologic
improvement, but the nasal mask is better tolerated.
 A helmet interface improves patient tolerance.
 Allows patient to talk, drink through straw, read
 With less complications Skin necrosis, gastric
distention and eye irritation.
◦ Accumulation of CO2, Excessive noise.

34.  Can be administered in
◦ Emergency ward
◦ Respiratory care unit
◦ General medical ward
 Facilities for Intubation should be present.
Location of NIPPV Who can administer
 Physician .
 Trained Nurse.
 Respiratory
therapist.

35. Setting up an NIPPV
 Select the patient
 Proper place
 Select the mode of ventilation
 Select type of interface
 Initial ventilator setting
 Initial IPAP 8-10 cm H2o ( 5 cm H2O if CPAP)
 EPAP 5 cm H2O
 Increased by 2 cm H2o every 10 minutes
 Un-till therapeutic response
 Patients tolerability

36.  Breath rate
 Inspiratory time
 Rise time
 Ramp length
 Add O2 if SpO2 < 88 %
 Humidifier

37. Monitoring
 Make Clinical assessment and Blood gas analysis,
after 1 hour of NIV.
Clinical features GCS, PR,RR, BP, Grade
of Dyspnea and use of Accessory muscles.
 Adjust settings / FiO2 as required
 Look for complications
 If worsening …. Alternative management
 If no improvement …. Adjust
 If improvement ….. continue

38. If pCO2 remains high
 Too much O2….. adjust FiO2 (85-90%)
 Check for Excessive leakage
Adjust the mask fit
if Nasal mask in use , change to FFM
 Check circuits for leak.
 Consider increase in RR to increase MV
 Increase inspiratory time (increases TV)
 Increase IPAP

39. If pO2 remains low
 Increase FiO2
 Increase EPAP

40. Indications of termination
 Deterioration in patient’s condition
 Failure to improve or deterioration in arterial
blood gas tensions
 Development of new symptoms or complications
such as
pneumothorax, sputum retention, nasal bridge
erosion
 Intolerance or failure of coordination with the
ventilator
 Failure to alleviate symptoms
 Deteriorating conscious level
 Patient and carer wish to withdraw treatment

42. Our Limited experience
 NIPPV was used in 18 patients who
presented with acute respiratory failure
and fulfilled Clinical and blood gas criteria.
 Out of 18 (10M and 8 F)
 Age ranged from 42-87 years
 Mean age 62 years

43.  Out of 18 patients
 14 had COPD with AHRF (78%)
 2 had de-compensation of their OSA/ OHS
 2 had hypercapnia secondary to Chest wall
deformity
0
10
20
COPD AHRF OSA/OHS CHEST WALL TOTAL

44.  Commonest mode of ventilation used was
 BPAP followed by
 CPAP (in one patient)
• All patients received NIPPV in general
medical ward in addition to their SMT
• Interface used Oro-facial mask.

45.  Initial IPAP 10 cm H2o
EPAP 5 cm H2o
 Average IPAP 16 cm H2o
EPAP 10 cm H2o
 Maximum IPAP used was 28 cm H2O
( patient with OHS)

46. Monitoring
 Patients were monitored
 Clinically ( GCS, RR, PR, BP)
 Blood gases ( pH, Pco2, po2, SPO2 )
 one hour than 4-6 hours after NIPPV
 If patient showed response it was
continued with adjustment made as per
Clinical and Blood gas parameters.

47. PCO2 level Pre and Post NIPPV
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PCO2(before)
Pco2(after)

48. pH before and after NIV
6.8
6.9
7
7.1
7.2
7.3
7.4
7.5
7.6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
pH (before)
pH (after)

49. Out come
 All patients had improvement in Clinical
and blood gases.
 And where discharged home
 None of our patients required intubation.
 The most common and the only
complication observed was
Claustrophobia

50. Examples
42 year old male with Kyphoscoliosis
Presented with
Breathlessness and Altered con
Examination revealed
GCS 12/15, Tachypnea (28/m), features of CO2
retention, hemodynamically stable, PR 110
Blood Gas
 pH 7.06 pCO2 113, HCO3 23.8,

51. Started on NIV (BPAP)
 GCS improved to
15/15.
 Tachypnea improved
 Improvement in
other parameters

52. Case 2
 65 year female HTN , Hypothyroid, obese,
labelled OSA with
 Admitted with Breathlessness
Irritability
Examination
GCS 13/14, RR 27, PR 98, BP 110/70
Flap
Blood gas
Ph 7.3, pCO2 80, pO2 64, SpO2 88%
CXR no consolidation , ECG sinus tach RBBB

53. Started on BPAP (IPAP 28cm H2O)
 After 1 hour
Improvement in Clinical
and blood gas
parameters
NIV contd
Discharged home with
advice to use NIV at
home.

54. THANKYOU