Non-invasive positive pressure ventilation (NPPV) provides ventilatory support without an endotracheal or tracheostomy tube. It uses inspiratory positive airway pressure and expiratory positive airway pressure to assist breathing. NPPV includes continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). NPPV is used to treat acute and chronic respiratory failure, obstructive sleep apnea, and exacerbations of chronic obstructive pulmonary disease. It has advantages over invasive ventilation such as allowing speaking and swallowing. Common interfaces include nasal and full face masks. NPPV is delivered via home ventilators that can provide various modes and controls.

1. Non-Invasive Positive Pressure Ventilation ( NPPV )
Objective :
- Definition of NPPV
- Kinds of pressures in NPPV
- Types of NPPV
- Factors contributing to NPPV interest
- Indication & contraindication for CPAP & BiPAP
- Indication & contraindication for acute & chronic cases care
- Modes & controllers in NPPV devices
- Interfaces for NPPV devices
- NPPV devices
- common cases that can be treated by NPPV
- Differences between BiPAP & BiPAP ( APRV )
- Definition of NPPV :
* It is any of ventilation support applied without use of an endotracheal Trach tube . It
provides two level of pressure ( I & E ) to the airway , which are triggered by the patient or
by the ventilator ( time ) depending on the mode utilized . ( 1 )
* It is technique of providing ventilation without the use of an artificial airway . ( 2 )
Kinds of pressures in NPPV : ( 2 )
* IPAP : Inspiratory Positive Airway pressure . This pressure control peak airway
pressure during inspiration .
* EPAP : Expiratory Positive Airway pressure . this pressure control end – expiratory
pressure .
* PEEP : Positive End Expiratory Pressure . this is pressure is positive airway pressure
at end expiratory phase . it is with mechanical breaths only .
Types of NPPV : (2 )
* CPAP : Continuous Positive Airway pressure . it is Positive Airway pressure during
spontaneous breaths . so there is not mechanical breaths . & CPAP is active when
IPAP = EPAP . for these reasons the work of breathing is entirely assumed by the Pt .

2. * Bilevel PAP : Bilevel Positive Airway pressure . it s provides IPAP & EPAP .
It different from CPAP in that Bilevel PAP has two pressure level . whereas CPAP has
only one .
It provides mechanical breaths from IPAP & EPAP . EPAP function as PEEP .
Factors contributing to NPPV interest : ( 3 )
- success in treatment of Obstructive Sleep Apnea .
- improve patient interfaces .
- Does not inhibit natural pulmonary defense .
- allow the patient to eat , drink & talk .
- allow patient to expectorate secretion .
- less costly than conventional MV .
- possibility of use in acute & chronic ventilatory failure .
- prevention of complication of intubation & tracheostomy .
- able to be use when patient resist intubation .
Indication & contraindication for CPAP & BiPAP : ( 2 )
* CPAP :
Indication
Obstructive Sleep Apnea
Contraindication
Apnea due to neuromuscular causes
progressive hypoventilation
Fatigue of respiratory muscle
Facial trauma
Clasustrophobia
Indication
Reduction on respiratory workload in obesity
Acute respiratory failure
Acute hypercapnic exacerbations of COPD
Contraindication
Apnea
Unable to handle secretion
Facial trauma
Claustrophobia
* BiPAP :
Indication & contraindication for acute & chronic cases care : ( 1 )
* Acute care :
Indication for NPPV with Acute Respiratory Failure :
1 - acute hypercapnic respiratory failure ( at least 2 of the following should be present )

3. A – severe worsing dyspnea . or B – sustain RR > 25 BPM . or C – use accessory muscle
abdominal paradoxical . or D – PH < 7.35 with PaCO2 > 45 mmHg .
2 – acute hypoxemia : SpO2 < 88 – 90 % with FiO2 > 60 % & PF < 200 .
* use conventional therapy with O2 as needed & monitor patient closely if the above criteria
is not met .
If the above criteria is met so look for contraindication :
Absolute contraindication
Apnea
Cardiopulmonary arrest
Facial burns
Facial & cranial trauma
Fixed upper airway obstruction
Hemodynamic instability arrhythmias
Inability to protect airway vomiting
(risk of aspiration )
Relative contraindication
Anxiety
Bowel obstruction
Claustrophobia
Copious secretion
Inability to clear secretion
Inability to cooperate or tolerate interface
Severe illness ( high APACHE score )
* if there is not contraindication institute NPPV therapy .
* if there is contraindication consider invasive ventilation .
* Chronic care :
Indication
Restrictive thoracic disease
Chronic hypoventilation syndromes
secondary to :
- chest wall & spinal deformity
- Idiopathic hypoventilation
- neuromuscular disease
- obesity
Chronic obstructive pulmonary disease
( COPD )
Obstructive sleep apnea
Contraindication
Unable to protect airway due to swallowing
issue or excessive secretion & poor cough
- Unable to fit interface
- Rapidly progressive neuromuscular disease
Unmotivated uncooperative patient
Modes & controllers in NPPV devices : ( 3 )
Modes of NPPV : NPPV A / C , NPPV SIMV , NPPV CPAP/PS , & Bilevel pressure ventilation
mode .
NPPV can control : volume ventilation , Respiratory rate , Insp. Time , PEEP , FiO2 , &
humidification .

4. Interfaces for NPPV devices :
Interface
Nasal mask
Advantages
Comfort
patient compliance
Facial mask
good seal
Full face mask
Better ventilation
Good seal
Nasal pillows
more comfortable
than facial maskes
(2,3)
Disadvantages
Gas leak
Nasal dryness or
drainage
Claustrophobia
Patient
noncompliance
Asphyxiation
More claustrophobic
Must remove to
expectorate or speak
Leak is potential
problem
Note
Too high = leaks in
eye
The top of the mask
should be 1/3 of the
way down from the
bridge of the nose
The top of the mask
should be 1/3 of the
way down from the
bridge of the nose
for CPAP therapy
only in range 3 – 20
cmH2O
NPPV devices : ( 3 )
Home care NPPV ventilators and other support devices may have any of the
following features :
- the ability to provide full ventilatory support .
- the ability to ventilate at night only .
- BiPAP support or CPAP .
- low pressure or disconnect alarm .
* Examples of NPPV :
- Respironics BiPAP focus .
- Respironics BiPAP vision .
- Respironics BiPAP synchrony .
- Puritan Bennett GoodKnight 425 .
* also there are some MV used usually for invasive ventilation support NPPV : such
as ( Puritan Bennett 840 ) .
common cases that can be treated by NPPV : ( 1 )
- acute respiratory failure .
- acute pulmonary edema .
- cardiogenic pulmonary edema .
- Immuno-compromised patients .

5. Differences between BiPAP & BiPAP ( APRV ) : ( 1 )
- BiPAP : is NPPV mode used IPAP & EPAP to give mechanical breaths .
- BiPAP ( APRV ) : is mode of invasive ventilation that also has two pressure IPAP & EPAP and
in each pressure patient can take breaths by PS .
References :
1
- Ventilator Management ( Dana Oakes ) 2009 Edition .
2
- Clinical Application of Mechanical Ventilation . ( David W. Chang ) 2nd Edition .
3
- Mosby's Respiratory Care Equipment ( J. M. CAIRO , Susan P. PILBEAM )
8th Edition .
Ali Nasser O. Aljarrash .
RC student ( 3rd year )
210021948