1) Noninvasive ventilation (NIV) can be used to treat acute respiratory failure from COPD exacerbations, cardiogenic pulmonary edema, and severe asthma. It can reduce the need for intubation compared to standard oxygen therapy alone. 2) When using NIV, careful attention should be paid to the interface and fit to minimize leaks, patient-ventilator asynchrony, and skin breakdown. Appropriate ventilator settings are also important to provide effective ventilation while avoiding overdistention. 3) Nocturnal NIV may provide benefits for stable COPD such as improved gas exchange and sleep, but the evidence is less clear. Patient selection is important, and further research is still needed on its

1. Invasive Mechanical
Ventilation for Obstructive
Lung Disease

2. When to Intubate?
Clinical evidence of fatigue and rising.
PaC02 despite maximal therapy.
Oral intubation preferable.
Larger tube: less resistance, easier secretion.
Clearance
Lower risk of sinusitis and ventilator-associated
pneumonia.

3. Goals
Minimize air-trapping
Avoid over-distention
(Pplat < 30 cm H20)
Provide adequate oxygenation
(Sp02 88 - 92%)
Provide adequate ventilation
(pH> 7.25)

4. Initial Ventilator Settings
Pressure or volume ventilation per individual or
institutional bias.
Avoid air-trapping:
▫ Inspiratory time 0.8- 1.2 s (high flow).
▫ Respiratory rate: 12 - 15 breaths/min expiratory.
▫ Tidal volume: 6 - 8 ml/kg.
Pplat < 30 cm H20.
PEEP:
▫ Counter-balance auto-PEEP
▫ Avoid over-distention
Ft02: adequate to provide Sp02 88 - 92%
Maximum
expiratory time

5. Pressure vs. Volume
Ventilation
Volume Ventilation
Maintains minute
ventilation with air trapping
Increased risk of over-distention
with air trapping
Pressure Ventilation
Decreased risk of over-distention
with air-trapping
Loss of tidal volume and
acidosis with air trapping
If pressure control= auto-PEEP, tidal volume will be zero

8. Auto-PEEP of
5 cm H20 by
occlusion
technique
Leatherman, Grit Care Med 1996;24:54 J

9. Auto-PEEP (Air-trapping; DHI)
Minute ventilation
▫ Tidal volume
▫ Expiratory time (I:E and rate)
Lung function
▫ Resistance
▫ Compliance
↑Pplat, ↑work-of-breathing, hemodynamic
effects , pneumothorax, difficulty triggering.
Correct by reducing minute ventilation
(permissive hypercapnia) and treating lung
function.

10. Prolonged Expiratory Time
Leatherman. Crit Care Med 2004; 32:1542

12. Increase PEEP until there are no missed triggers.
Increase PEEP until Pplat and PIP increase.
PEEP to counterbalance auto·PEEP is only effective in the
context of flow limitation; e.g., COPD versus asthma.

13. Asynchrony, PSV, and COPD
▫ Decrease airways
resistance.
▫ Decrease pressure
support
▫ Set inspiratory time
(PCV).
▫ Adjust How termination
▫ Minimize leak
Parthasarathy et al Am J Respir Grit Care Mad 1998; 158:1471

14. Flow Cycle Criteria
Hess, Respiratory 2005, 50,166

15. Aerosol Delivery During
Mechanical Ventilation

16. Albuterol Delivery by MDI
Dhand et al, AJRCCM 1996;154:388

17. With Careful Attention to
Detail, Either Nebulizer or MDI
Can Be Used Effectively
Nebulizer
Placement site in circuit
Type of nebulizer
Nebulizer fill volume
Humidification device
Carrier gas (heliox)
Treatment time
 Inspiratory time
Breath-actuated versus continuous
Pressure vs. volume ventilation
Ventilator brand
Metered Dose Inhaler
Type of actuator
Timing of actuation

18. Ventilation Patterns Influence
Airway Secretion Movement
Expiratory Flow
Bias
Inspiratory Flow
Bias
Promotes airway clearance
Marcia S Volpe, RESPIRATORY CARE VOL 53 NO 10

19. Sedation and Paralysis
Sedation
▫ Benzodiazepines (anxiolytic).
▫ Narcotics (analgesic).
▫ Propofol (rapid onset and resolution of sedation;
bronchodilatation).
▫ Dexmetadomadine.
▫ Volatile anesthetics.
Paralysis -- prolonged weakness

20. Ventilator Liberation
Control of bronchospasm and infection.
Withhold sedation.
Short trial of spontaneous breathing – avoid
irritating heated or cool mist.
Extubate -avoid irritating cool mist.
Continue bronchodilator administration and
airway clearance.
Extubate selected patients to NIV.

21. Post-Extubation NIV
Failed SBT; extubate directly to NIV (COPD,
NMD).
Prevent extubation failure in patients at risk;
successful SBT; extubate directly to NIV.
Rescue failed extubation; evidence does not
support except hypercapnic respiratory failure.
No benefit for routine use; patient selection
Important.....

22. Summary
Avoid intubation if possible.
Avoid complications of mechanical ventilation:
air-trapping, over-distention, prolonged
weakness due to paralysis.
Use methods to avoid patient-ventilator
asynchrony.
Do not prolong weaning.

23. Noninvasive Ventilation

24. COPD Exacerbation
14 studies included in the review.
Decreased risk of intubation: NNT 4
Lower mortality with NIV: NNT1o
NNT = number needed to treat
Ram, Cochrane Database of Systemic reviews2008

25. Cardiogenic Pulmonary
Edema
Decreased intubation:
▫ CPAP: NNT 9
▫ NIV: NNT 14
Reduced mortality:
▫ CPAP: NNT 6
▫ NIV: NNT 8
No difference between CPAP and NIV.
No additional harm (acute MI) with NIV.
Vilal, Cochrane Database of systemic reviews 2008

26. A Prospective Randomized
Controlled Trial on the Efficacy of
Noninvasive Ventilation in Severe
Acute Asthma
Resp care 2010;55: 536

27. Patient Selection
Step 1: Patient needs mechanical ventilation
▫ Respiratory distress.
▫ Tachypnea, accessory muscle use
▫ Acute respiratory acidosis
▫ Appropriate diagnosis
Step 2: No exclusions for NIV.
▫ Airway protection
▫ Severity of illness
▫ Uncooperative patient
▫ Patient wishes

28. When to Stop
Lack of improvement within 1-2 hrs.
Patient intolerance of therapy.
Adverse effects: hypotension.
Patient wishes.

29. When to Transfer to ICU
NIV used instead of intubation.
Failure of NIV.
Mask intolerance.
High NIV settings.
Better monitoring (cannot tolerate mask off).

30. Choice of Interface
Use Oronasal Mask
for ARF

31. Why is the Interface
Important?
Comfort and compliance.
Poor fit/leak.
Facial skin breakdown.
Mouth leak.
Feeding and phonation.
Rebreathing.
Complex headgear.

32. Mouth Leak
Decreased comfort.
Less effective ventilation.
Asynchrony (Hess 2011).
NIV failure (SooHoo 1994).
Increased nasal resistance (Richards 1996).
Upper airway drying (De Araujo 2000).
Disrupted sleep (Meyer 1997; Tescheler 1999).

33. Approaches to Mouth Leak
Oronasal mask.
Coaching.
Chin strap.

34. Skin Breakdown
Assess regularly.
Correctly fitted mask.
Rotate interfaces.
Adjust headgear.
Barrier: tape.

35. The Ventilator for NIV
Leak compensation.
Trigger and cycle coupled to patient.
Rebreathing.
Oxygen delivery.
Monitoring.
Alarms (safety vs. nuisance).
Portable (battery power).
Cost.

36. The Ventilator for NIV
Bilevel.
Intermediate.
Critical care.

37. Blower &
pressure
controller
Ventilator
Ventilator

38. Rebreathing
Increase EPAP level (2 4 cmH20).
Increase leak in system.
Fixed leak in mask rather than those.
Titrate O2 into mask rather than hose.
Plateau exhalation valve.
Hess, Respiratory care principles and practice.

39. Ventilators for NIV
Ventilators for NIV are typically pressure
support devices with leak compensation:
▫ IPAP
▫ EPAP
▫ PSV= IPAP- EPAP
▫ Back up rate
Hess, Respiratory care principles and practice.

40. Humidification
Necessary for comfort and to avoid drying of
upper airway secretions.
Be certain that humidifier does not interfere
with operation of ventilator.
Use artificial nose (HME)?
Branson and Gentile, Respir Care 2010;55:209

41. Inhaled Bronchodilators
Nebulizer
Metered dose inhaler with spacer
Hess, J Aerosol Med 2007; 20.S85
Iosson N. N Engl J Med 2006;354:e8

42. Causes of Failed NIV
Poor patient selection: acuity, diagnosis.
Progression of the underlying disease process.
Wrong interface: size, leak.
Wrong ventilator: poor leak compensation.
Inappropriate ventilator settings.
Clinician inexperience.

43. Practical Application
Select appropriate patient.
Choose a ventilator capable of meeting patient
needs.
Choose interface; avoid mask that is too large.
Explain therapy to the patient.

44. Practical Application
Silence alarms; choose low settings.
Initiate NIV while holding mask in place.
Secure mask, avoid tight fit.
Titrate pressure support (IPAP) to patient
comfort.

45. Practical Application
Titrate Ff02 to Sp02 > 90%.
Avoid PIP> 20 cm H2O.
Titrate PEEP/EPAP/CPAP per trigger effort and
Sp02.
 Coach and reassure patient; make adjustments
..per patient compliance.

46. Rationale for Nocturnal NIV
Stable COPD
Respiratory muscle rest.
Improved sleep.
Improved gas exchange.

47. NIV for Stable COPD
Meta-analysis: nocturnal NIV in stable COPD.
(Wijkstra. Chest2003;124;337)
▫ 3 months of NIV did not improve lung function,
gas exchange, or sleep efficiency.
Systematic review: NIV in severe stable COPD.
(Kolodziej, Eur Resplr J 2007;30:293)
▫ May Improve gas exchange, exercise tolerance,
dyspnea, work of breathing, frequency of
hospitalization, health-related quality of life, and
functional status.
▫ Based primarily on observational studies.

48. High Intensity NIV (Windisch)
Nocturnal NIV (and up to 6 h during the day).
Admitted (about 2 weeks) for acclimation.
Inspiratory pressure increased until not to
lerated; rate increased until passive ventilation.
Further rate increases to produce normocapnia.
Pressure 28 cm H20 (range 17 - 40 cm H20),
rate 21 /min (range 14 - 24/min).
Generalizability unknown; observational
studies.

49. NIV for Stable COPD
PaC0 2 ≥ 52 mm Hg; awake and breathing usual
FI02.
Nocturnal Sp02 ≤ 88% for at least 5 continuous
min, while breathing O2 at 2 L/min or the
patient's usual FI02.
Rule out OSA; CPAP as necessary.

50. Clinician
skills
Patient
selection
Acute
stable
Equipme
nt
interface
ventilator
NIV
Success