This document discusses non-invasive positive pressure ventilation (NIPPV). It defines NIPPV and describes its increasing importance and advantages over invasive ventilation. These advantages include avoiding intubation, reducing complications, decreasing ICU stay and costs. The document discusses the types of NIPPV, including negative pressure ventilation, continuous positive airway pressure, and noninvasive positive pressure ventilation. It covers interfaces, modes, humidification, and evidence-based guidelines for indications of NIPPV, including for acute exacerbations of COPD and acute cardiogenic pulmonary edema.

1. NIPPV
BY Dr Irappa Madabhavi

2. NON INVASIVE VENTILATION
DR IRAPPA MADABHAVI

3. DIFFERENT INDICATIONS
Carlucci et al, AJRCCM, 2001

4. INCREASING IMPORTANCE OF NIV

5. WHY THE INTEREST IN NIV?
• It avoids the need for endotracheal
intubation/sedation/NMB
• It reduces the occurrence of complications such
as Nosocomial infection and tracheal stenosis
• It decreases intensive care unit (ICU) stay and
overall cost of hospitalization in selected patients
• Achieves alveolar ventilation and gas exchange
parameters similar to IMV
• Permits removal of secretions, eating and speech
Brochard L, Mancebo J, Elliott MW.
Noninvasive ventilation for acute respiratory
failure. Eur Respir J 2002;19(4):712-721.

6. DEFINITION OF NIV
• Noninvasive ventilation is the delivery of
ventilatory support without the need for an
invasive artificial airway (an endotracheal or
tracheostomy tube)
• NPPV typically is administered through a nasal or an
oral mask
ARFC Consensus Conference: non-invasive positive pressure
ventilation: consensus statement, Respir Care 42:362, 1997

7. Types of Noninvasive Ventilation (NIV)
• Negative Pressure Ventilation (NPV)
• Noninvasive Positive Pressure Ventilation
(NPPV)

8. Negative Pressure Ventilation (NPV)
• Iron lung/tank ventilator
• Cuirass
• Pneumojacket /pneumosuit

9. Iron lung constructed 1950

10. Continuous Positive Airway Pressure
(CPAP)
• Provides a constant pressure, but no ventilatory support.
So CPAP is not considered as a form of ventilation
• More effective in hypoxemic than in hypercapnic states.
• It requires a spontaneously breathing patient and is
unable to support in the case of apnea.
• Improves alveolar edema and increases functional
residual capacity
• Main uses are:
OSA pt
Congestive heart failure
Am J Respir Crit Care Med 2001;163: 283–291

11. Noninvasive Positive Pressure
Ventilation
• Both pressure-cycled and volume-cycled
modes are available.
• Pressure-cycled ventilation is the preferred
mode. In this mode, a preset pressure is
applied with inspiration and expiration known
as IPAP and EPAP

12. IPAP – Inspiratory positive airway
pressure
• Reduces the work of breathing
– Alleviates respiratory distress
– Unloads respiratory muscles
– Improves respiratory muscle function
Augments alveolar ventilation
Reduces dead space ventilation
Reduces rate related auto PEEP dynamic
hyperinflation
• Improves gas exchange: hypoxemia and
hypercapnia
Antonelli M et al, Crit Care 2000

13. EPAP – Expiratory positive airway
pressure
• Improves gas exchange: by alveolar recruitment and
corrects hypoxemia
• Increases FRC by preventing end exp collapse
• Improves respiratory muscle fn : reduces dynamic
hyperinflation advantage to the diaphragm and
intercostals
• Auto PEEP (Inspiratory threshold load) : Offsets
intrinsic PEEP, aids triggering
• Reduces re-breathing
• Enhances the delivery of bronchodilators to distal
bronchial tree

14. DIFFERENT MODES
• Continuous positive airway pressure
• Pressure support ventilation( IPAP alone)
• Bilevel positive airway pressure: BiPAP (IPAP+
EPAP)
• Proportional assist ventilation(PAV)
• Assist-controlled ventilation (mask IPPV)
Craig TH, Emerg Med 2002
Mehta Set al, AJRCCM 2001

15. CHOICE OF INTERFACES
• Currently available interfaces include nasal,
oronasal and facial masks, mouthpieces and
helmets.
• For treatment of acute respiratory failure,
facial masks are most commonly used (70% of
cases), followed by nasal masks (25%) and
nasal pillows (5%)

16. NASAL MASKS
• More air leakage through the mouth so fail to
deliver air pressures to the lungs reliably
• Better tolerance, less claustrophobia
• Small dead space (104 ml vs. 250 ml facial mask)
• Better ability to vocalize, expectorate, eat and
drink
• Resistance of the nasal passages. Limited
effectiveness when the nasal resistance exceeds 5
cm H2O/L per second

17. ORO NASAL MASKS OR FULL FACE
MASKS
• It permits mouth breathing and reduce air leaks
through the mouth
• They may be preferred by acutely dyspneic
patients who are “mouth breathers.”
• They interfere more with speech, eating, and
expectoration and may contribute more to
claustrophobic reactions and dead space than
nasal masks.
Crit Care Med 2003 Vol. 31, No. 2,468-473

19. VARIOUS INTERFACES

21. Crit Care Med 2009; 37:124 –131

22. face mask group
nasal mask group
A face mask should be the first-line strategy in the initial
management of hypercapnic acute respiratory failure with
NIPPV. However, if NIPPV has to be prolonged, switching to
a nasal mask may improve comfort by reducing face mask
complications.

23. HUMIDIFICATIONS
MOUTH LEAK
Unidirectional inspiratory nasal airflow
DRYING OF NASAL MUCOSA
RELEASE OF INFLAMM. MEDIATOR
INCREASE NASAL RESISTANCE
Different types include heated or unheated Passover devices, pass
through devices, and HME, however with pressure-targeted
ventilators only pass-over humidifiers should be applied, since
pass through devices, and HME may compromise pressure and
flow delivery and triggering.

24. EVIDENCE BASED
GUIDELINES:
INDICATION OF NIV

25. INDICATIONS FOR ACUTE NON-
INVASIVE VENTILATION
Recommended: first choice for ventilatory support in selected patients. Guideline: can
be used in appropriate patients, but careful monitoring is advised.
Option: suitable for a very carefully selected and monitored minority of patients.
b Best evidence for severe COPD with pH < 7.35.
c In most recent review, no evidence of survival benefit

26. INDICATIONS FOR ACUTE NON-
INVASIVE VENTILATION

27. INDICATIONS FOR ACUTE NON-
INVASIVE VENTILATION
Ambrosino N, Vagheggini G. Noninvasive positive pressure ventilation in the acute care
setting : where are we? Eur Respir J 2008;31:874–886; and Hill NS, Brennan J,
Garpestad E, Nava S. Noninvasive ventilation in acute respiratory failure . Cri t Care
Med 2007; 35:2402–2407

28. NIPPV AND AE-COPD
• NPPV has been proposed as the first-line
ventilatory strategy for treatment of acute-
on-chronic respiratory failure due to AECOPD.

29. Non-invasive positive pressure ventilation to treat respiratory failure
resulting from AE-COPD Cochrane systematic review and meta-analysis

30. What studies showed?
• A lower mortality rate (RR 0.41;95% CI 0.26–0.64)
• Less need for endotracheal intubation(RR 0.42;
95% CI 0.31–0.59)
• A lower rate of treatment failure (RR0.51; 95% CI
0.38–0.67)
• Greater improvements in the 1-hour post
treatment pH and PaCO2 levels
• A lower respiratory rate
• A shorter length of stay in the hospital
Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Cochrane systematic
review and meta-analysis. BMJ 2003; 326:185.

31. USE OF NIPPV AND DIFFERENT
SEVERITY OF ARF
Eur Respir J 2008; 31: 874–886

32. WHEN TO START NIPPV?

33. NIV in COPD. ERS School in Pisa

34. IDENTIFICATION OF PATIENT SUB GROUP
IN AE-COPD
Ann Intern Med. 2003;138:861-870
This meta-analysis of 15 trials found that adding
NPPV to standard care reduced rates of
endotracheal intubation, length of hospital stay, and
in-hospital mortality rates in patients with AE-COPD

35. SUB-GROUP ANALYSIS

36. Selection Guidelines for NIV in the
Acute Setting
• Appropriate diagnosis with potential reversibility
• Establish need for ventilatory assistance
Moderate-to-severe respiratory distress
Tachypnea (respiratory rate > 24/min for
COPD, 30/min for CHF)
Accessory muscle use or abdominal paradox
Blood gas derangement (pH <7.35,
Paco2 > 45 mm Hg, or Pao2/Fio2 <200)

37. Do not use this therapy if the patient
Has
• Respiratory arrest
• Is medically unstable (hypotensive shock, uncontrolled
cardiac ischemia or arrhythmias)
• Cannot protect the airway (impaired cough or
swallowing mechanism)
• Has excessive secretions
• Is agitated or uncooperative
• Has facial trauma, burns, or surgery, or anatomic
abnormalities interfering with mask fit
• Has an Acute Physiology and Chronic Health Evaluation
(APACHE) score > 29
RESPIR CARE 1997; 42:364–369
EUR RESPIR J 2005; 25:348–355;
THORAX 2002; 57:192–211.

38. Predicting NIV Failure in COPD: Chart
of Failure (baseline and 2 hrs)

39. MODE OF ACTIONS

40. EFFECT OF NIPPV ON WOB

42. CONSEQUENCES OF AUTO-PEEP
• Increases the work of breathing
• Worsens gas exchange
• Can cause hemodynamic compromise .
Reduces the preload of the right and left ventricles, decreases LV
compliance and can increase RV after load by increasing PVR.
Can lead to inappropriate treatment
Misinterpretation of CVP AND PCWP measurements
Erroneous calculations of static respiratory compliance:
The true value of static compliance will be
underestimated
Inappropriate fluid administration or unnecessary
vasopressor therapy

43. Auto-positive end-expiratory pressure:
Mechanisms and treatment
CLEVELAND CLINIC JOURNAL OF MEDICINE

44. ACUTE CARDIOGENIC PULMONARY
ACPE
EDEMA

46. CARDIOGENIC PULMONARY EDEMA
The 3CPO Trial
N Engl J Med 2008;359:142-51.

47. Primary Outcome: Mortality
Standard Oxygen Therapy versus Non-invasive
Ventilation
Cumulative
Survival
1.0
0.9 Non-invasive
Ventilation
Standard
Oxygen Therapy
P=0.685
0.8
0 10 20 30
Days

48. OUTCOME OF 3CPO Trial
• CPAP or NIPPV was significantly better than standard
oxygen therapy in the first hour of treatment in terms
of the
Dyspnea score
Heart rate
Acidosis
Hypercapnia.
However, there were no significant differences
between groups in the 7- or 30-day mortality rates, the
rates of intubation, rates of admission to the critical
care unit, or in the mean length of hospital stay.

49. CARDIOGENIC PULMONARY EDEMA
• NIV and CPAP equally and safely improve vital
signs and gas exchange
• To date, no trial has been sufficiently powered
to confirm a mortality benefit from either
technique.
• At this time we cannot conclude that NIV
offers any advantages over CPAP.

50. Potential Mechanisms of Action of CPAP and
NIV in Patients With Acute CPE
• CPAP
Increased functional residual capacity
Reduced atelectasis
Reduced right-to-left intrapulmonary shunt
Reduced work of breathing from improved pulmonary compliance
Increased cardiac output from reduced pre-load and after-load
Reduced mitral regurgitation
• NIV
Same benefits as CPAP
Unloads the respiratory muscles
Respir Care 2009;54(2):186 –195

51. Causes significant decrease in the heart rate
due to parasympathetic tone (by CPAP induced
lung inflation)
Anesthesiology 2005; 103:419–28

52. DIASTOLIC HEART FAILURE
• CPAP improves oxygenation and ventilatory
parameters in all kinds of CPE.
• In patients with preserved LV contractility, the
hemodynamic benefit of CPAP results from a
decrease in LV end-diastolic volume (preload)
• CPAP, by decreasing respiratory work in patients
with cardiopulmonary edema, unloads the heart
from the large amount of cardiac output that
supplies the respiratory muscles and improves
oxygen delivery for other tissues.
Chest 2005; 127:1053–1058

53. WHEN TO USE NIV IN ACPE?
• GRAY ET AL noninvasive ventilation (CPAP or
NIPPV) be considered as “adjunctive
therapy” in patients with acute cardiogenic
pulmonary edema who have severe
respiratory distress or whose condition does
not improve with pharmacologic therapy
Start with CPAP•If persisting dyspnea or
hypercapnia with CPAP alone, add pressure
support

54. Respiratory Failure in Immunocompromised
Patients
RCTs have found
decreased intubation
shorter ICU lengths of stay and
Decreased ICU mortality rates
The reduced mortality is likely related to reduced
infectious complications associated with NIV use
VAP, other nosocomial infections, and septic shock
Antonelli et al JAMA 2000; 283:235
Hilbert G, et al: N Engl J Med 2001; 344: 481

55. NIV is recommended as first choice treatment

56. Am J Respir Crit Care Med Vol
168. pp 70–76, 2003
Intubated patients who met criteria to proceed in the weaning
attempt but had failed a spontaneous breathing trial for 3
consecutive days were considered eligible for the study

58. Noninvasive Ventilation during Persistent Weaning Failure
A Randomized Controlled Trial
Miquel Ferrer at al Am J Respir Crit Care Med Vol 168. pp 1438–1444,
2003
NIV
NIV

59. Am J Respir Crit Care Med Vol 168. pp 70–76, 2003

60. SERIOUS COMPLICATIONS

61. MECHANISMS OF IMPROVEMENT
• Because patients with unsuccessful weaning
are likely to develop a rapid and shallow
breathing pattern, the ability of NIV to
improve hypoxemia and hypercapnia by
correcting such an abnormal breathing
pattern might explain the benefits of NIV in
these patients
• Decrease period on MV will reduce the
complications associated with it

62. OUTCOME
Earlier extubation with NIV results in
shorter
• Mechanical ventilation
• length of stay
• less need for tracheotomy
• lower incidence of complications, and
improved survival

63. HYPOXAEMIC RESPIRATORY FAILURE
• Several diseases may lead to hypoxaemic ARF
which is defined by a PaO2/FIO2 ratio ≤300
mmHg
• Result is conflicting due to heterogeneous
group of clinical conditions, ARDS, pneumonia
and thoracic trauma.

64. NIV in Acute Hypoxemic Respiratory
Failure
Respir Care 2009;54(12):1679 –1687

66. RECOMMENDATIONS IN DIFFERENT
SUBGROUPS
Crit Care Med 2007;
35:2402–2407

67. RECOMMENDATIONS IN DIFFERENT
SUBGROUPS
• NIV cannot be recommended as routine
therapy for ALI/ARDS
• A cautious trial in highly selected patients with
a Simplified Acute Physiology Score II ≤34 and
readiness to promptly intubate if oxygenation
fails to improve sufficiently within the first
hour.
• Trial should always be done in ICU

68. Predictors for failure in hypoxaemic
respiratory failure
• No or minimum rise in the ratio of PaO2/FIO2
after 1–2 h
• Patients older than 40 years (one study)
• Simplified acute physiology score >34 at
admission
• Presence of ARDS
• CAP with or without sepsis, and multiorgan
system failure

69. Intensive Care Med 2001; 27:1718–1728.

70. NIV IN ASTHMA
• According to the British Thoracic Society
Standards of Care Committee Statements:
• ‘‘NPPV should not be used routinely in acute
asthma, but a trial might be considered in
patients not promptly responding to standard
treatments’

71. POST OPERATIVE RESPIRATORY
FAILURE
• Respiratory insufficiency in patients undergoing
major surgery, especially of the chest or upper
abdomen, is relatively common.
• After abdominal surgery, respiratory
complications occur in approximately 10% of
patients, and reintubation represents 30% of
those complications.
• Pain, splinting, and respiratory muscle
dysfunction, atelectasis are likely contributors to
hypoxemia and respiratory insufficiency.

72. POST OPERATIVE RESPIRATORY
FAILURE: prevention and treatment
Anesthesiology 2010; 112:453– 61

73. MECHANISMS OF IMPROVEMENT
Although multiple studies support this application, further studies
need to focus on the use of NIV following specific surgical procedures
before firmer recommendations can be made

75. Portable vs critical care ventilators
Liesching T et al , Chest 2003

76. Critical care versus portable
ventilators
• The elaborate alarms may be counter-productive
since they frequently indicate very minor air leaks
that are common during NIV and not of clinical
significance
• Use of single limb circuits in the portable devices,
which may have an effect upon CO2 elimination
• While home ventilators can adequately
compensate large gas leaks, ICU ventilators are
not able to cope with large leaks
Eur Respir J 2002; 20: 1029–1036

77. COMPLICATIONS
• Masks- pressure ulceration on the bridge of
the nose or above the ears (due to mask
straps/headgear).
• Conjunctival irritation may be associated with
air leak around the mask.
• Nasal congestion, oral or nasal dryness and
insufflation of air into the stomach.
• Claustrophobia

78. COMPLICATIONS
• More serious complications include aspiration
pneumonia, haemodynamic compromise
associated with increased intrathoracic
pressures and pneumothorax.
• The occurrence of each of these more serious
complications, however, has been identified as
less than 5% (Hill 2006).

79. COMPLICATIONS
• Significant air leak for most bi level devices is
0.4L/sec above intentional leak
• Decreased effectiveness of ventilation (NIPSV)
– Inability to maintain optimal pressures (CPAP)
– Sleep fragmentation
– Inability to trigger ventilator
– Prolonged inspiratory time
– Greater oxygen requirement
Leak Monitoring in Noninvasive Ventilation
Arch Bronconeumol 2004;40(11):508-17

80. EXTUBATION FAILURE
• USE OF NIV routinely after extubation for
reducing extubation failure not recommended
• Can be recommended in high risk patients
after extubation
Age>65
APACHEII>12 at the time of ext.
Cardiac failure at the time of intub.
KHILNANI ET AL, IJCCM,2006
GUIDELINES FOR NIV IN ARF

81. PREDICTORS OF FAILURE
b likelihood of failure
50% if any 3 and 82% if all 4 present
at baseline;
75% if any three and 99% if all four
present after 2 hrs of NIV.
Ambrosino Thorax ’94
Confalonieri, Rana, Antonelli ICM 2001,
Antonelli ,CCM 2006

82. WEANING METHODS
• SBT after 48hrs stabilization on MV
• FAIL SBT>STABILIZE WITH FULL MV SUPPORT
FOR 1 HR> EXTUBATE AND PUT ON NIV
GUIDELINES FOR NIV IN ARF
IJCCM,2006