invasive ventilation

1. NON INVASIVE
VENTILATION
Presented By-
Dr. Dilip Jain
MBBS, DNB, Fellowship in Pediatric Intensive Care
Consultant Pediatrician

2.  Non-Invasive Ventilation is a technique of providing ventilation without the use of an artificial
airway.
 NIV can be negative pressure or positive pressure ventilation.
 Non-Invasive negative pressure ventilation includes the old negative pressure tank ventilator &
the iron lung used during polio epidemics & the newer devices like chest cuirass or the body suit.
 Non-Invasive positive pressure uses some form of interface to provide positive ventilation.

3.  Acute Asthma
 Hypoxemic Respiratory failure
 Community acquired pneumonia
 Cardiogenic Pulmonary edema
 Immunocompromised patients
 Post-operative patients
 Postextubation (weaning)
 “Do not Intubate”

4.  Patients with respiratory symptoms including tachypnea / dyspnea with moderate to severe
respiratory distress (chest retractions / accessory muscle use) can be commenced on NIV in the
presence of normal airway reflexes.
 Blood gas can be used as an additional factor initiate NIV (PaCO2 > 45 mm Hg, pH < 7.35 or
PaO2 / FIO2 < 200).

5.  Respiratory arrest or the need for immediate intubation.
 Hemodynamic instability.
 Inability to protect the airway (impaired cough or swallowing).
 Excessive secretions.
 Facial deformities or conditions that prevent mask form fitting.
 Uncooperative or unmotivated patients.
 Brain injury with unstable respiratory drive.

6.  Niv can be given as Continuous positive airway pressure (CPAP) or Bilevel positive airway
pressure (BiPAP).
 In CPAP, airway pressure is continuously maintained above the atmospheric pressure at a set
level.
 In BiPAP, two different pressure levels are set – Inspiratory Positive Airway Pressure (IPAP) &
– Expiratory Positive Airway Pressure (EPAP).

7. CPAP BiPAP
Mechanism Splinting of airways & improves FRC Increases tidal volume
Oxygenation &
Ventilation
Improves oxygenation by maintain FRC.
Minimal improvement in ventilation
Improvement in both Oxygenation &
Ventilation
Tolerance Better Lesser compared to CPAP
Indications Obstructive sleep apnoea,
Laryngo/tracheomalacia, Bronchiolitis
Parenchymal disease, Cardiogenic
Pulmonary Edema

8.  It is the most important component of any NIV. It acts like an endotracheal tube in invasive ventilation.
Interface connects the ventilator tubing to the face, facilitating ventilation.
 Types: 1. Non-Vented (vent for CO2 escape.)
2. Vented.
 Non-vented mask should be connected to the ventilator through a double limb (separate inspiratory &
expiratory limbs) circuit to prevent CO2 rebreathing.
 Vented mask should be connected to the ventilator through a single limb circuit.
 The other types of interface includes: oro-nasal mask, nasal mask, full face mask, nasal pillows, nasal
prongs, face helmet etc.

10. ACUTE CARE SETTING
 Reduce the need for endotracheal intubation.
 Reduces incidence of ventilator-associated pneumonia.
 Shortens stay in ICU.
 Shortens hospital stay.
 Reduces mortality
 Preserves physiological airway defenses.
 Reduces need for sedation.

11. CHRONIC CARE SETTING
 Alleviates symptoms of chronic hypoventilation.
 Improves duration and quality of sleep.
 Improves functional capacity.
 Prolongs survival.

12.  Delayed intubation.
 Reduced clearance of secretions.
 Gastric distentions.
 Skin breakdown, eye irritation, nasal bridge ulceration.

13.  Improvement in respiratory distress / oxygenation within 2 hours.
 Improvement in CO2 clearance.
 Minimal leak around mask & good patient coordination.

14. 1. Best evidence is for COPD exacerbation from multiple large RCTs – avoids intubation and
avoids mortality.
2. Cardiogenic pulmonary edema – NIV reduces intubation rates & improves mortality from
multiple small RCTs. the last largest RCT from “3CPO trialists” showed only a improvement in
distress & metabolic problems without any effect on intubation rates & mortality.
3. Immuno-compromised patients - NIV should be tried early in immunocompromised patients
with mild to moderate respiratory failure based upon multiple small prospective & retrospective
studies, Latest RCT shows no benefits of NIV over oxygen therapy alone in immune-
compromised patients.
4. Palliative care – Patients under palliative care with respiratory distress can be offered NIV
subjected to patient comfort.
5. Pneumonia & Asthma – NIV is not beneficial to oxygen therapy alone.

15. 6. Post-operative respiratory failure – NIV will decrease intubation and secondary pneumonia
based upon pooled analysis of data from multiple small studies.
7. Post-extubation – Elective NIV after extubation in high risk patients will help in prevention of
respiratory failure & decrease re-intubation rate & improves mortality based upon 2 RCTs
(moderate evidence). NIV should not be used in the treatment of patients with established
post-extubation respiratory failure.

16. 1. The smallest size mask that just encompasses the nose is usually the best nasal mask.
2. Forehead spacers should be used and replaced regularly to redistribute pressure away from
nasal bridge.
3. Strap tension should be adjusted so that one-two fingers should be accommodated under
them. Preferably use elasticated straps.
4. Barrier dressing (comfeel or duoderm) should be applied on the pressure points to prevent skin
breakdown.
5. Before starting NIV, explain the patient about the exact process. After setting up the NIV, start
with minimum pressure, hold the mask to the face & once the patient is feeling comfortable
fasten the strap. Pressure should be gradually raised.

17. 6. Some leak is inevitable, accept the leak if the patient can trigger the ventilator appropriately.
Minimal leak can be compensated by NIV machines.
7. Full face mask or helmet can be helpful in patients not tolerating the nasal mask.

18.  NIV is very useful mode of providing positive pressure ventilation in select group of patients.
 Understanding the limitations clear insights into the modes, settings and trouble shooting are
necessary to avail the benefits of NIV.
 Once NIV is initiated, frequent monitoring is required to prevent delayed intubation.
 Good nursing care is important to prevent skin breakdown.
 Having an appropriate NIV team & frequent training of the team members is essential to provide
NIV support.

19. Whether to intubate or not ?
NIV
ADVANTAGES
Maintain normal function –
speech swallowing and cough
Easy to implement or remove
Improves patient comfort
Reduced need of sedation
Intermittent ventilation
Patient can cooperate with
physioterapy
Avoidance of complecation of
intubation
INVASIVE
DISADVANTAGES
Tracheal injury
Nosocomial infection
Requirment of Sedation
Barotrauma & volutauma
Resistive work of ETT
Cost and length of stay
DISADVANTAGES
Delayed intubation.
Lack of potection – aspiration
Gastric distentions.
Skin breakdown.
Eye irritation.
Nasal bridge ulceration
Claustrophobia
ADVANTAGES
Faster correction of gas exchange
abnormalities
Airway access for suction

21. THANK YOU