this is compiled & created to discuss the basic modes and initiation of NIV the author is thankful to the previous authors,teachers who helped to conceptualize the NIV .

1. Non Invasive Ventilation
Initiation & Modes
Dr. Chandan Kumar Sheet
MD (Pulmonary Medicine)
Pulmonologist, Calcutta Heart Clinic & Hospital

2. NIV Terminology
 PPV-
Positive pressure ventilation
 BIPAP-
Bi-level positive airway pressure
 CPAP –
Continuous positive airway pressure
 EPAP-
Expiratory positive airway pressure
 IPAP-
Inspiratory positive airway pressure
 PEEP-
Positive end expiratory pressure
 RATE-
- Number of breaths per minute
- Determined by the patient in NIV

3. NIV Terminology
 RISE TIME-
- Time taken to reach to IPAP from
EPAP
- This is set for patient comfort
 INSPIRATORY TIME-
How long BIPAP unit stays at IPAP
 PRESSURE SUPPORT-
- Difference between IPAP & EPAP
- This is the amount of assistance applied
to the inspired breath.
- Determines the tidal volume
- Higher the pressure support larger the
breath

4. NIV Terminology
 TRIGGER-
- Point where the BIPAP unit transitions from EPAP to the IPAP
- Initiation of inspiration or initiation of IPAP in BIPAP
- In BIPAP initiation of inspiration is patient trigger
 CYCLE-
- Point where the BIPAP unit transit from IPAP to EPAP
- Beginning of EPAP & end of inspiration
 SENSITIVITY –
- Refers to triggering & cycling of the device
- Sense inspiratory effort to trigger IPAP

5. BIPAP Waveform

6. Titration – Set Rise Time
 Rise time- Time from EPAP to IPAP
 Obstructive airway disease- Short rise time
 Restrictive disease- Prolonged rise time
 CAUTION- Long rise time with high respiratory rate not compatible

7. NIPPV MODES
Timed mode (T)
Spontaneous mode (S)
Spontaneous / timed mode (S/T)

8. NIPPV MODES
SPONTANEOUS (S)
 Machine provides ventilatory support in response to the patients
breathing effort but not backup safety rate
 The breath rate will be determined by the patient
 Ti Min and Ti Max are set to ensure appropriate cycling
 Usually the first mode of preference for spontaneously breathing
patients – who do not have any issues with initiating a breath
 This mode allows for the best synchronization between the
ventilator and the patient
 When this mode is used, it is important to monitor the ventilator
settings to ensure that there is good synchronization

9. Mode S (spontaneous): Pressure Support
P
Vt
F

10. NIPPV MODES..cont
Spontaneous / Timed mode (S/T)
 The machine provides ventilatory support in response to the patients
breathing effort but provides backup safety rate
 Main stay of mode in NIV in ICU
 In NIV, Patent initially put on this mode

11. NIPPV MODES
TIMED MODE(T)
 There is no patient effort required
 Ventilator provides full ventilatory support.
 On NIV machines this is referred to as ‘timed’ mode (t)
 Usually a patient required timed mode is not a candidate for NIV

12. Bi-level Positive Airway
Pressure [BIPAP]

13. BIPAP
INDICATIONS
 Acute respiratory failure
(PH<7.35,PaCO2>50,PaO2<55mmHg)
 Acute exacerbation of COPD
 Acute cardiogenic pulmonary edema
CONTRAINDICATIONS
 Facial trauma
 Claustrophobia
 Mouth breather
 Lack of teeth
 Provides IPAP & EPAP
 BIPAP can by converted to CPAP when IPAP=EPAP
 The patient who have acute respiratory distress should not be treated with NIV ,as this strategy
may delay endotracheal intubation & initiation of mechanical ventilation.
 Delay to implement invasive ventilation may lead to poor patient outcome

14. Titration of BIPAP
Bi-Flex
 Method of delivering of BIPAP
 The airflow during inhalation and exhalation is “soften”
 This makes the breathing more natural and comfortable
 This provides pressure relief at the end of inhalation &
start of exhalation
Three levels of patient adjustable Bi-Flex (1,2,3) are available
 Each higher level provides progressively increased pressure relief

15. Continuous Positive Airway
Pressure [CPAP]

16. CPAP
INDICATION
 OSA-Treatment of choice
 Cardiogenic pulmonary edema
CONTRAINDICATION
 Apnea due to neuromuscular
causes
 Progressive hypoventilation
 Fatigue of respiratory muscles
 Facial trauma
 Claustrophobia
 A constant Positive airway pressure applied throughout the reparatory cycle in
spontaneous breaths
 It is not a ventilatory mode
 CPAP is active when IPAP= EPAP

17. Titration of CPAP
Auto titration
INDICATIONS
 Uncomplicated OSA
CONTRAINDICATIONS
 Central sleep apnea
 CVA
 Prolonged hypoventilation
 Hypovolemic Cardiac failure
POTENTIAL CONRAINDICATION
 Uncontrolled asthma
 Epilepsy
 Angina
 Dyselectrolytemia
 Nocturnal myoclonus
 Available for long-term home treatment to improve effectiveness
 Detects snoring or inspiratory flow pattern or airway vibration
 Ensures the optimal pressure as per patient’s need
Severe air leak around the mask should be corrected before CPAP auto titration

18. Titration of CPAP
Ramp
 Starting pressure gradually increases over time (upto 45 min ) until the desired pressure is reached
 Ideal for patients who have trouble tolerating a sudden onset of high pressure
C-FLEX
 provides pressure relief during exhalation.
 In CPAP there is trouble to exhale against the continuous positive pressure
 CFLEX reduces the continuous pressure which the patient must overcome during exhalation
 The machine measures the airflow during exhalation & reduces expiratory pressure proportional to
expiratory flow.
 This relief pressure is provided on a breath-to breath basis, depending on the actual expiratory
airflow.
 Prior to the end of expiration & start of inspiration, the preset CPAP level is restored.
 3 levels of C-FLEX are available(1,2,3) and each provides progressively increased pressure relief

19. Supplemental Oxygen
ADMINISTRATION
Supplemental oxygen can be given by connecting oxygen directly
to be a port on the mask
The best way to monitor oxygen administration by pulse- oxymetry.

20. Application of NIPPV
Ventilator settings & adjustments

21. Application of NIPPV
Ventilator settings & adjustments
 Choose the correct interface
 Explain therapy & its benefit to the patient in detail. Also
discuss the possibility of intubation.
 Set the NIV in the spontaneous or spontaneous/timed mode

22. Application of NIPPV
Ventilator settings & adjustments
 Administer oxygen at 2L/ min
 Hold the mask with the hand over patient’s face. Do not fix it
 Start with very low settings. Start with low IPAP- 8 & EPAP- 4
 The difference between IPAP & EPAP should be at least 4 cm of H2O
 Increase EPAP by 1-2 cm increments till all his inspiratory efforts are
able to triggers the ventilator

23. Application of NIPPV
 Ventilator Settings & Adjustments
 If the patient is making inspiratory effort & the ventilator does not
respond to that inspiratory effort, increase EPAP further till this
happens
 Most of the patients require EPAP of about 4 to 6 cm of H2O
 Obese or have OSA patient require higher EPAP

24. Application of NIPPV
Ventilator settings & adjustments
 When all patients efforts are triggering the ventilator, leave EPAP at
that level.
 Now start increasing IPAP in increments of 1-2 cm upto a maximum
pressure, which the patient can tolerate without discomfort &there is
no major air leaks
 Now secure interface with head straps.
 Avoid excessive tightness

25. Monitoring of NIV

26. Monitoring
 PARAMETERS
 Monitoring is important not only for optimizing ventilator setting, but
also to warn against impending catastrophe if NIV falls
 Monitoring includes
1)Subjective Response
2)Physiological Response
3)Gas exchange Response

27. Monitoring
 SUBJECTIVE RESPONSE
Smooth adaptation of the patient to the ventilator
Alleviation of symptoms like dyspnea
Improved tolerance

28. Monitoring
 Physiological Response
 Simple vital signs should show an improvement.
 Assess - chest wall movement,
- heart rate,
- respiratory rate,
- mental status &
- patient coordination with ventilator

29. Monitoring
Gas exchange response
 Pulse oxymetry oxygen saturation should be maintained >92%.
 ABG should be cheeked at baseline & at 1-4 hours
 Improvement in ABG particularly in PH ,after a short period of NIV
predicts successful outcomes

30. Thank You..