1) Noninvasive ventilation (NIV) refers to respiratory support provided without an endotracheal tube and allows spontaneously breathing patients. 2) NIV modalities like CPAP and BiPAP raise functional residual capacity and splint alveoli open, reducing work of breathing and increasing oxygen levels. 3) Studies show NIV effectively treats respiratory failure types 1 and 2, pulmonary edema, and as an adjunct in COPD exacerbations by decreasing intubation need, mortality, and length of stay. However, effectiveness in milder COPD, pneumonia, and asthma requires further research.

1. NIV in emergency department
Dr.Venugopalan.P.P
DA,DNB,MNAMS,MEM[GWU]
Director ,Emergency Medicine, Aster –DM health care
Site Director ,MEM program –GWU
Deputy Director –MIMS Academy
Founder and Executive Director -ANGELS
Emcon2014 Mumbai November 6 to 9

2. What is it?
• Respiratory support given
without an ETT
• Spontaneously breathing
patients
Emcon2014 Mumbai November 6 to 9

3. Normal
breathing
• Negative pressure
• Air drawn when the
Diaphragm descends

4. Lung capacities

5. Types • IPPB –intermittent Positive
pressure breathing
• CPAP- Continues positive
airway pressure
• BiPAP- Bi-level positive
airway pressure

6. CPAP
• High flow oxygen plus PEEP
• Raises FRC away from Residual volume
• Splints alveoli open
-Reduce work of breathing
-Increase PaO2
Re-expands atlectasis
• Resolution of pulmonary edema

7. BiPAP
• IPAP +EPAP
• EPAP =PEEP
• Inspirtory pressure increases Tidal volume
Decreases PaCO2
Increases PaO2
Decreases WOB

8. Terminology
16
12
8
4
0
IPAP
EPAP
Pressure Support

9. - IPAP: assists in
improving tidal volume,
thus decreasing CO2
- EPAP : improve FRC,
helps recruit more
alveoli, thus
increasing O2. may
reduce work of
breathing associated
with autopeep
20
10
0
IPAP = 12
EPAP = 4
PS = 8
BiPAP

10. NIV - Changes in EPAP Pressure
15 cm
5 cm
Delta P 10 cm
10 cm
Delta pressure 5 cm
EPAP increased to 10 cm
IPAP increased to 20 cm
Delta P returned to 10 cm
P
R
E
S
S
U
R
E
Decreasing delta pressure will usually result in lower Vt

11. • Differential in pressure between inspiration
and expiration allows for better patient-ventilator
synchrony and thus more
comfort
• EPAP  CPAP  PEEP
• IPAP  PS
–Augments TV
– Reduces Atelectasis
– Reduces WOB

12. PAV
• New Assist Mode of Ventilation
– Fundamentally different concept
• Ventilator Generates Pressure in
Proportion to Patient Effort
– Follows and adjusts to patient changes

13. From Pressure Support to PAV
Pressure
Patient
Effort
PSV PAV

14. Non-invasive PAV for Acute Respiratory
Insufficiency
• Peter Gay and coll, Am J Respir Crit Care
• General ICU
• COPD patients with acute exacerbation
• 44 patients were randomized to receive NPPV with PAV or Pressure Support (PS)
Mortality and intubation rate were similar but refusal rate was
lower with PAV
Reduction in respiratory rate was more rapid with PAV and there
were fewer complications in the PAV group

15. Respiratory Failure
• Type 1 –Low PaO2,
All else Normal
• Type 2 –Low PaO2,High
PaCO2
CPAP or BiPAP

16. ABG Normal Value

17. • Type 1 respiratory
failure
• Type 2 Respiratory
failure
Hypoxia
CPAP
Hypoxia Hypercapnea
BiPAP

18. Clinical Benefits
• Type 1 respiratory failure
• Type 2 respiratory failure
• Pulmonary Edema

19. Clinical Benefits
• Weaning
• Post intubation
Sub acute

20. Clinical Benefits
• Sleep apnea
• Type 2 respiratory failure
COPD
CF
Neuromuscular Disease

21. Precautions • Impaired conscious level
• Agitation ,Confusion
• Consolidation
• Copious secretions
• Inability to protect airway
• Hemodynamic instability
• Bowel obstruction
• Recent GI surgery

22. Contra Indications
• Need for immediate
intubation
• Facial Trauma and Burns
• Frequent vomiting
• Recent facial /Upper airway
surgery
• Undrained pneumothorax

23. Avoid intubation • No paralysis or sedation
• Ability to move –pressure
relief
• Able to communicate
• Able to eat and drink
• Self care
• Less need of invasive
monitoring
• Less risk of infection
Advantages

24. No intubation
• Less infection risk
• No tracheal Damage
• Able to communicate

25. Decreased need
of ICU admin
• Cost
• Patient and Care givers
experience
• Less debilitating

26. Implications of
Physiotherapy
• Mask fitting
• Deoxygenation
• Expectoration
• Familiarity with Machine
and Alarms

27. Skills needed
• Patient handling
&communication
• Knowledge of respiratory
physiology
• Familiarity with interfaces
• Knowledge of pressure
area care
• Time to spend with patient
• Patience

30. NIPPV in COPD
Meta-analysis of fourteen RCT
• Decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76)
• Decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53)
• Reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63)
• Less complications associated with treatment (RR 0.38; 95%CI 0.24
to 0.60)
• Shorter hospital stay ( -3.24 days; 95%CI -4.42 to -2.06)
• “Data from good quality randomised controlled trials
show benefit of NPPV as first line intervention as an
adjunct therapy to usual medical care in all suitable
patients for the management of respiratory failure
secondary to an acute exacerbation of COPD.”
Cochrane Database Syst Rev. 2004

31. NIPPV &COPD

33. • Noninvasive ventilation is most effective in patients with
moderate-to-severe disease
• Hypercapnic respiratory acidosis may define the best
responders (pH 7.20-7.30).
– Noninvasive ventilation is also effective in patients with a
pH of 7.35-7.30, but no added benefit is appreciated if the
pH is greater than 7.35.
– The lowest threshold of effectiveness is unknown, but
success has been achieved with pH values as low as 7.10.

34. Respir Care. 2005 May
• NIV in pts with milder COPD exacerbations: RCT.
• Patients with mild COPD + pH of >7.30 were eligible .
• MEASUREMENTS: Borg dyspnea index at baseline, 1 hour, and
daily, Length of hospital stay, endotracheal intubation, hospital
survival
• RESULTS : NPPV was poorly tolerated, sig. decrease in dyspnea
at 1 hour and 2 days, No differences were seen for any
measured variable.
• CONCLUSIONS: The effectiveness and cost-effectiveness of the
addition of NPPV to standard therapy in milder COPD
exacerbations remains unclear.

35. NIPPV & Cardiogenic pulmonary edema
• There are clear benefits in meta-analysis of
randomized trials for CPAP
– risk of mortality 0.59
• 95%CI 0.38-0.90
– risk of intubation 0.44
• 95%CI 0.29-0.66
Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive
positive pressure ventilation (NIPPV) on mortality in patients with
acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367:
1155–1163.

36. Rasanen
1985
Finland
40 patients
CPAP (20)
V
Control (20)
Intubation
Mortality
6/20 v 12/20
17/20 v 14/20
NS
NS
Bersten
1991
Australia
39 patients
CPAP (19)
V
Control (20)
Intubation
Mortality
0/19 v 7/20
2/19 v 4/20
<0.005
NS
Lin
1991
Taiwan
55 patients
CPAP (25)
V
Control (30)
Intubation
Mortality
7/25 v 17/30
2/25 v 4/30
<0.05
NS
Lin
1995
Taiwan
100 patients
CPAP (50)
V
Control (50)
Intubation
Mortality
8/50 v 18/50
4/50 v 6/50
<0.01
NS
Takeda
1998
Japan
22 patients
CPAP (11)
V
Control (11)
Intubation
Mortality
2/11 v 8/11
1/11 v 7/11
<0.03
0.02

37. • In CPAP group all studies showed a significant
improvement in :
Respiratory status
Cardiovascular parameters
Blood gas analysis
• No reported complications in any study

38. Asthma &NIPPV
• Number of studies investigating the use of NPPV in
acute asthma exacerbations is limited
• Available data suggests that it is safe .
• There are some studies to support the use of BiPAP
for acute asthma exacerbations in the pediatric
population .

41. • Lot of papers that address the question there are
• Only 3 completed RCTs and all these have relatively
small numbers.
 Addition of NIV in treating status asthmaticus is safe
and well tolerated.
 NIV shows promise as a beneficial adjunct to
conventional medical treatment.
 further prospective investigation is warranted

42. NIPPV & Pneumonia
– Noninvasive ventilation not established to be
beneficial
– Secretions may be limiting factor
– Improvement with noninvasive ventilation best
achieved in patients also with COPD
– Hypercapnic respiratory acidosis may define group
likely to respond
– Decrease in intubation rate and mortality may be
limited to those also with COPD

44. Conclusion
• Judicious use of NIV is a useful tool to manage
respiratory emergencies
• Close observation and timely interference is
absolutely essentials.
• EP and EMS should familiar with equipment ,
usages and guidelines

45. www.drvenu.net
www.emergencymedicinemims.com