This document discusses non-invasive positive pressure ventilation (NIPPV) delivered via a nasal or oronasal mask for respiratory failure. NIPPV has been shown to be effective for acute pulmonary edema, respiratory failure in immunocompromised patients, and facilitating extubation in COPD patients. Factors vital for success include careful patient selection, timely initiation, a comfortable fitting interface, coaching, and monitoring. NIPPV should be used to avoid intubation rather than as an alternative. Conditions with strong evidence for NIPPV use include cardiogenic pulmonary edema, COPD exacerbations, and respiratory failure in immunocompromised patients. Contraindications include pulmonary fibrosis, ARDS with multi-organ failure, and

1. NIV FOR EM
Emergency Practice Update

2. Introduction
* Non Invasive Positive Pressure Ventilation(NIPPV) is
recent phenomenon, mainly because of advances
in noninvasive interfaces and ventilator modes
* NIPPV delivered o2 by nasal or oronasal mask
* The efficacy of noninvasive positive-pressure
Ventilation has been demonstrated for acute
pulmonary edema, for respiratory failure in
immunocompromised patients, and to facilitate
extubation in COPD patients.

4. * Patients who develop respiratory failure or who
refuse intubation are potentially good candidates for
noninvasive positive-pressure ventilation
*Several factors are vital to the success of noninvasive
positive-pressure ventilation: careful patient
selection; properly timed initiation; comfortable,
well-fitting interface; coaching and encouragement;
and careful monitoring.
*Noninvasive ventilation should be used to avert
endotracheal intubation rather than as an
alternative to it.

5. Indication
• Strong evidence:
i. Cardiogenic pulmonary
edema.
ii. Acute or chronic respiratory
failure (COPD).
iii. Respiratory failure in
immunocompromised
patients.
• Intermediate evidence:
i. Asthma.
ii. Community---acquired
pneumonia.
iii. DNR/DNI patients.
• Weak evidence:
i. Trauma.
ii. Neuromuscular diseases
(e.g., myasthenia gravis).
iii. Cystic fibrosis.

6. • Contraindicated
i. Pulmonary fibrosis.
ii. ARDS (when complicated with
multi---organ failure.
• Relative Contraindications
i. Hemodynamic instability
ii. Severe hypoxia and/or
hypercapnia,
iii. PaO2/FiO2 ratio of < 200 mm
Hg,
iv. PaCO2 > 60 mm Hg
v. Poor patient cooperation
vi. Lack of trained or experienced
staff
• Absolute Contraindications
i. Need for immediate
endotracheal intubation
ii. Decreased level of
consciousness
iii. Excess respiratory secretions
and risk of vomiting and
aspiration
iv. Past facial surgery precluding
mask fitting

9. Pressure setting:
•For CPAP start at 10 cm H2O.
•For bi---level NIV start at IPAP 15 cm H2O, EPAP 5 cm
H2O.
•Pressure should not exceed 25 cm H2O
•If tolerated and needed, then increasing the inspiratory
pressure by 2 cm of H2O every 20---30 minutes.
•May increase the pressure support to a maximum
inspiratory pressure of 20---25 cm of H2O and a
maximum expiratory pressure of 15 cm of H2O.

10. Parameters of failure in a patient on NIV
include
• Vomiting
• Persistent coughing
• Aspiration
• Progressive respiratory
distress
• Respiratory arrest
• Loss of consciousness
• Respiratory rate rising
greater than 35---40
• Persistent hypoxia
despite supplemental
oxygenation.
• Hemodynamic
instability or shock
• Worsening arterial pH,
PCO2, PO2, or venous
pH
• Worsening PaO2/FiO2
ratio

11. HACOR SCORE
1.HACOR is a potentially
useful bedside tool for the
prediction of NIV failure.
2. A HACOR score >5 at
1hour of NIV highlights
patients with a >80% risk
of NIV failure regardless of
diagnosis, age, and
disease severity.

13. REMEMBER
• The Enemy of NIV is LEAK !!!!!!!