NIV in COVID-19 Pandemic

2. COVID-19 disease:
NonInvasive
Ventilation

20. Main finding was that the vast majority of Covid-19 patients
treated by CPAP recovered from moderate-to-severe AHRF

21. Italian Experience

24. When and for which patients?

33. HFNC vs NC

51. COVID-19 & NIV
Early series suggested high mortality for
patients with COVID-19–associated
respiratory failure who received invasive
mechanical ventilatory support

52.  Current thinking suggests that NIV may be an
appropriate bridging adjunct in the early part
of the disease progress and may prevent the
need for intubation or invasive ventilation

53.  Published cohorts suggest that noninvasive
ventilation is a commonly used intervention in
COVID-19-related AHRF
 It is uncertain whether noninvasive ventilation is
beneficial or harmful for patients with COVID-19

54.  A total of 586 confirmed COVID-19-positive patients were
hospitalised during the study period, of whom 103 (17.6%)
required noninvasive ventilation or invasive mechanical
ventilation
 Among those patients who had an initial trial of noninvasive
ventilation, 27/ 58 progressed to invasive mechanical
ventilation whereas 31/58 did not require subsequent invasive
mechanical ventilation

55. Of note, 29/31 (94%) patients in Group
NIV alone were discharged from hospital
alive with the remaining 2/31 (6%) being
alive in the ICU at the time of data
collection

56. Network Metaanalysis: Ferreyro BL et.al.JAMA. Published
online June 4, 2020
Association of helmet NIV with reduced
rate of intubation and reduced mortality

65. Continuous Positive Airway Pressure
(CPAP), a form of NIV, appeared to have
a more significant and positive role than
initially thought

66.  For some patients, while NIV may temporarily
improve oxygenation and work of breathing, it
does not change natural disease progression
and is not a replacement for intubation and
invasive ventilation

67. General Considerations
 The key to the successful application of noninvasive
ventilation is in recognizing its capabilities and
limitations
 Identification of the appropriate patient for the
application of noninvasive ventilation (NIV).
 It may involve a trial of noninvasive ventilation.

69. Patient Selection

70. Patient inclusion criteria
 Patient cooperation (an essential component that excludes agitated,
belligerent, or comatose patients)
 Dyspnea (moderate to severe, but short of respiratory failure)
 Tachypnea (>24 breaths/min)
 Increased work of breathing (accessory muscle use, pursed-lips
breathing)
 Hypercapnic respiratory acidosis (pH range 7.10-7.35)
 Hypoxemia (PaO2/FIO2< 200 mm Hg, best in rapidly reversible
causes of hypoxemia)

71. Absolute contraindications
Coma
Cardiac arrest
Respiratory arrest
Any condition requiring immediate
intubation

72. Other Contraindications
Cardiac instability
GI bleeding - Intractable emesis and/or
uncontrollable bleeding
Inability to protect airway
Potential for upper airway obstruction

74. Interface
Vented Mask Non-Vented Mask

76. Full Face Nasal Mask

82. Oronasal Mask Helmet

86. NIV Ventilators
Critical care Ventilators Specialty NIV Ventilators

88. Mode of Ventilation
Past experience
In part on the capability of ventilators
available to provide support
In part on the condition being treated.

90. Mode of Ventilation
 The primary NIV mode is the continuous positive airway
pressure (CPAP), the pressure is initially set at 10 cm H2O and
then adjusted according to SpO2 and clinical tolerance
 Pressure support ventilation (PSV) should be considered over
CPAP in patients who showed respiratory acidosis (pH < 7.35),
tachypnea >30/min or a vigorous activity of respiratory
accessory muscles

94. Boussignac positive pressure valve

95. UCL Ventuar CPAP device

105. UCL Ventura CPAP Device

107.  In severe COVID-19, initial CPAP settings have
been suggested 10 cmH2O and 60% oxygen

109. Initial IPAP/EPAP settings
 Start at 10 cm water/5 cm water
 Pressures less than 8 cm water/4 cm water not
advised as this may be inadequate
 Initial adjustments to achieve tidal volume of
5-7 mL/kg (IPAP and/or EPAP)

111. Subsequent adjustments
 Increase IPAP by 2 cm water if persistent hypercapnia
 Increase IPAP and EPAP by 2 cm water if persistent
hypoxemia
 Maximal IPAP limited to 20-25 cm water (avoids
gastric distension, improves patient comfort)
 Maximal EPAP limited to 10-15 cm water

114. NIV Failure
A mean VTE higher than
9.5mL/kg over the first four
cumulative hours of NIV
accurately predicted NIV
failure

116. Be careful that NIV may unduly delay
intubation in non-expert hands
We insist on the notion that
intubation should not be delayed

119. The expiratory limb of the circuit was
equipped with an antimicrobial filter

121. Surgical Mask on HFNC

122. Periods off NIV should be of short
duration, to prevent desaturation

123.  Regular assessment of the patient’s pressure
areas on the face must be taken, and
protective dressings applied if necessary