A 62-year-old female with a history of hypertension, diabetes, and COPD presented with worsening cough, expectoration, and breathlessness over the past 3 days. On examination, she was drowsy with tachycardia, tachypnea, and low oxygen saturation. Tests showed respiratory acidosis and congestive cardiac failure. She was started on non-invasive ventilation (NIV) with initial settings of IPAP 10 cm H2O and EPAP 4 cm H2O, which were gradually increased. NIV was given for decreasing durations over 4 days as her condition improved before being discontinued.

2. CASE PROFILE
62 year Female k/c/o
HTN/T2DM/COPD on domiciliary 02
C/O: cough with expectoration
worsening of breathlessness 3days
Associated History of :
Orthopnea/PND
No history of:
 Fever
 chest pain
 Haemoptysis
 palpitations.

3. Drowsy
Vitals:
PR-108/min.
BP-140/80mmhg
RR-28/m
SP02-80%on Room
air
Afebrile to touch
 General Physical
Examination:
 P-
 I- NIL
 C-
 O- B/L LOWER LIMBS
 JVP-RAISED

4. Chest: B/L Symmetrical
Diffuse Wheeze
Fine Crepts ISA(Bilateral)
CVS: S1,S2 +
P/A: Mild Distention, Mild tenderness RHC
CNS: Drowsy
Moving all limbs Equally.

5. HTN/T2DM/COPD a/w
 COPD acute exacerbation.
 Congestive cardiac failure .
 PTE.
 ? ? Pneumonia.

6. HB TLC DLC PLT MCV/MCH HCT
14 12.7 83/12 220 87/25 48
14.5 8.9 77/13 238 88/24 48.2
BIL ALT ALP TP ALB AMY
0.38 58 79 7.7 4.06 88
UREA CREA CPK CA PO4 LDH
38 0.89 70 9.5 2.8 290
CPK GLU PT 1NR D-DIMER
87 132 12.5 1.07 307

7. PH PC02 P02 HC03 SP02 Na K Lac
7.26 114 57 51.2 83 133 3.8 4.4
7.24 95 63 37.2 85 136 4.4 2.1
7.25 76 70 28.9 88 `127 4.0 1.1
7.30 80 75 34.0 89 140 3.9 1.9
7.41 62 81 41.2 92 139 3.7 1.7
7.39 55 81 37 90 133 3.5 2.0
7.40 49 82 35 92 135 3.9 1.9

8.  ECG: Sinus tachy. LAD, P-Pulmonale
 CHEST X-RAY : Hyper inflated lung fields
with prominent upper zone bronchiovascular
markings
 BLOOD CULTURE: Sterile
 RUE: 3-4 pus cells
 ECHO: RVSP=30+RAP,EF=68%, conc.LVH.

9. HTN/T2DM/COPD A/W COPD acute
exacerbation with CCF precipitated by:
? dietary indiscretions and
?non-compliance to medicine

10. PHARMACOTHERAPY
 O2 INHALATION @4L/min
 Inj ceftriaxone salbactum 1.25g I/V BID
 Tab. Azithromycin
 Inj Methylprednisolone 125mg TID
 Salbutamol nebulisation
 Inj UFH 5000U S/C BD
 Inj Insulin R 4,4,4. Inj Insulin N 6u BT
 Inj Lasix 20mg BD

11. VENTILATION
 NIV: initially started on IPAP of 10 cm of H2O
& EPAP of 4 cm of H2O
 Subsequently increased to IPAP of 18 & EPAP
of 8 cm of H2O
 NIV given for around 14-16 hrs on D1, 10-12
hrs D2, 8-10hrs D3, 4-6 hrs on D4

12. DISSCUSSION
Non invasive
ventillation

13. Is the delivery of ventillatory support
without the need for an invasive airway.
It is provided through a machine
consisting of monitor, flexible tubing, and
mask .

14. Types of NIV
•Negative pressure NIV
•Positive pressure NIV –
Positive pressure delivered through mask case –
CPAP & BiPAP
Negative Pressure Ventilation (NPV)
•Negative pressure ventilators apply a negative
pressure intermittently around the patient’s body or ch
est wall
•Negative pressure is applied intermittently to the th
oracic area resulting in a pressure drop around the thor
ax •This negative pressure is transmitted to the pleural
space and alveoli creating a pressure gradient be
tween the inside of the lungs and the mouth

15. CPAP
 In this mode the device delivers a continuous
pressure to the patient at all times. All breaths in
this mode are spontaneous breaths
 CPAP improves pulmonary function by reducing
work of breathing, maintaining inflation of
atelectatic alveoli,improves pulmonary
compliance,improves hemodynamics by
reducing preload & afterload.

16.  While initiating CPAP pressures 5-15cm of H2o
are most commonly used ,however pressures
greater than 15 cm should be cautiosly used as
they may produce fall in BP
 Used in COPD,asthma ,ARDS,pnemonia.

17. . Spontaneous mode
. Spontaneous timed mode
. Timed mode
.pressure control mode
. Ventillation control-synchronised intermittent
mandatory ventillation mode

18. Spontaneous ventillation
 Delivers Bi –level pressure support and
provides spontaneous breaths.
 in this mode ,IPAP is delivered during
inhalation & a lower EPAP is delivered during
exhalation.

19. Spontaneous /Timed mode
 Delivers Bi- level pressure support .& provides
spontaneous & mandatory breaths. Mandatory
breaths are delivered when the patient does not
breathe spontaneously within a prescribed
breath rate.

20. Timed Mode
Delivers Bi-level pressure support but it delivers
only mandatory breaths. Means ventilator will not
respond to patient effort .
Pressure Control Mode
The device delivers bi-level pressure support. This
mode delivers assist and mandatory breath. This
mode is identical to S/T mode, except that all
breaths have a fixed inspiratory time.

21. Pressure controll- synchronised intermittent
mandatory ventillation (PC-SIMV) mode
 The PC-SIMV mode provides
spontaneous,Assist & mandatory breaths.This
mode uses a time window to decide what type
of breaths should be delivered.

22.  An initial IPAP of 10 cm H2O & EPAP of 4to5 cm H2O
should be used .
 IPAP should be increased by 2to5 cm increments at a
rate of approximately 5 cm H2O every 10 mins, with a usual
IPAP target of 20 cm H2O with EPAP/IPAP=1:2.5
or until a therapeutic response is achieved or patient
tolerability has been reached.
 O2should be entrained into the circuit and the flow
adjusted to SpO2>88–92% .
BTS: NIV in COPD: management of acute type 2 respiratory failure

23. Indications:
1.Airway obstruction
 –COPD.
 –Facilitation of weaning in COPD.
 –Asthma.
 –Extubation failure in COPD.
 –Cystic Fibrosis .
 –OSA/obesity hypoventilation .

24. NIV & stable COPD
•NIV increasingly used in stable very severe
COPD
•NIV+O2 therapy–
in selected patients with pronounced daytime
hypercapnia
•Clear benefits in both survival & risk of hospital a
dmission in patients with both COPD & OSA

25.  At least one of the following
 Respiratory acidosis (pH<7.35 &/or PaCO2>45)
 Severe dyspnea with clinical signs s/o respiratory
muscle fatigue, increased WOB or both
 Use of respiratory accessory muscles
 Paradoxical motion of abdomen
 Intercostal retraction
GOLD update 2013

26. 2)Hypoxemic respiratory failure
–Acute pulmonary edema‐CPAP
–Immunocompromised patients
–Postoperative patients
–ARDS
–Pneumonia
–Trauma or burns
–Restrictive thoracic disorders

27.  Cardiac/Respiratory arrest.
 Encephalopathy.
 Severe UGI bleed.
 Upper airway obstruction .
 Hemodynamic instability.
 Untreated pneumothorax.
 High risk of aspiration .
 Uncooperative/irritable patient.
 Facial or neurological surgery , trauma or
deformity.

28.  Less sedation, Non invasive , patient able to
maintain verbalisation,
 Early improvement in hypoxia, acidosis and
hypercapnia
 Shorter hospital stay, decreased rate of
intubation without risks of ET.
 Decreased mortality.

29. Interface related
.C02 rebreathing
.Discomfort
.Facial skin erythema
.Nasal bridge ulceration
Air pressure/ flow related
.Air leaks
.Nasal or oral dryness or congestion
.Gastric distrension
Patient related
.Aspiration pneumonia
.Barotrauma
.Haemodynamic effects

30. 1. Appropriately monitored location, oximetry, respiratory impedance, vital signs as clinically
indicated
2. Patient in bed or chair at >30 angle
3. Select and fit interface
4. Select ventilator
5. Apply headgear; avoid excessive strap tension (one or two fingers under strap)
6. Connect interface to ventilator tubing and turn on ventilator
7. Start with low pressure in spontaneously triggered mode with backup rate; pressure limited:
8 to 12 cm H2O inspiratory pressure; 3 to 5 cm H2O expiratory pressure
8. Gradually increase inspiratory pressure (10 to 20 cm H2O) as tolerated to achieve alleviation
of dyspnea, decreased respiratory rate, increased tidal volume (if being monitored), and good
patient-ventilator synchrony
9. Provide O2 supplementation as need to keep O2 sat >90 percent
10. Check for air leaks, readjust straps as needed
11. Add humidifier as indicated
12. Consider mild sedation (eg, intravenously administered lorazepam 0.5 mg) in agitated
patients
13. Encouragement, reassurance, and frequent checks and adjustments as needed
14. Monitor occasional blood gases (within 1 to 2 hours) and then as needed
Protocol for initiation of noninvasive positive pressure ventilation

31. Steps For Initiating NPPV
1. Place patient in an upright or sitting position.Carefully explain the procedure for
noninvasive positive pressure ventilation, including the goals and possible
complications.
2. Using a sizing gauge , make sure a mask is chosen that is the proper size and fit.
3. Attach the interface and circuit to the ventilator . Turn on the ventilator and
adjust it initially to low pressure setting.
4. Hold or allow the patient to hold the mask gently to the face until the patient
becomes comfortable with it. Encourage the patient to use proper breathing
technique.
5. Monitor oxygen ( O2 ) saturation; adjust the fractional inspired oxygen ( F1 O2 )
to maintain O2 saturation; above 90%.
6. Secure the mask to the patient . Do not make the straps too tight.
7. Titrate the inspiratory and end-expiratory positive airway pressures (IPAP and
EPAP) to achieve patient comfort ,adequate exhaled tidal volume, and
synchrony with the ventilator. Do not allow peak pressures to exceed 20 cm H2O.
8. Check for leaks and adjust the Straps if necessary
9. Monitor the respiratory rate, heart rate,level of dyspnea, O2 saturation , minute
ventilation,and exhaled tidal volume.
10. Obtain blood gas values within 1 hour.

32. ACUTE CARE
•Reduces need for intubation
•Reduces incidence of nosocomial pneumonia
•Shortens stay in intensive care unit
•Shortens hospital stay
•Reduces mortality
•Preserves airway defenses
•Improves patient comfort
•Reduces need for sedation
CHRONIC CARE
•Alleviates symptoms of chronic hypoventilation
•Improves duration and quality of sleep
•Improves functional capacity
•Prolongs survival
clinical Benefits of Noninvasive Positive Pressure Ventilation

33. Guidelines for providing NIV
•Duration of treatment –
Patients who benefit from NIV during the first 4 hour
s of treatment should receive NIV for as long as possi
ble (a minimum of 6 hours)during the first 24 hou
rs
•Treatment should last until the acute cause has res
olved, commonly after about 3 days
•When NIV is successful (pH>7.35, resolution of
cause, normalisation of RR) after 24 hrs or more –
plan weaning.
BTS: NIV in COPD: management of acute type 2 respiratory failure

34. Response
Physiological
a) Continuous oximetry.
b) Exhaled tidal volume.
c) ABG at 1 hour or as necessary, at 2 to 6 hour intervals.
Objective
a) Respiratory rate.
b) blood pressure.
c) pulse rate.
Subjective
a) dyspnea.
b) comfort.
c) mental alertness.

35. Mask
Fit, Comfort, Air leak, Secretions, Skin necrosis.
Respiratory muscle unloading
Accessory muscle activity, paradoxical
abdominal motion.
Abdomen
Gastric distension.

36. • Most often successful in the critically ill patient
Respironics PerformaTrak® Full Face Mask
Entrainment
valve
Adjustable
Forehead Support
Ball and
Socket Clip
Double-foam
cushion
Pressure
pick-off
port

37. 360
swivel
standard
elbow
Respironics Contour Deluxe™ Mask
Dual flap
cushion
Thin flexible &
bridge
material
Dual density
foam bridge
forehead
support

38. Nasal Pillows or Nasal Cushions (continued)
• Suitable for patients with
–Claustrophobia
–Skin sensitivities
–Need for visibility
Respironics Comfort Lite Nasal Mask

39. Advantages of Nasal Masks
Disadvantages of Nasal Masks
• Less risk of aspiration
• Enhanced secretion clearance
• Less claustrophobia
• Easier speech
• Less dead space
• Mouth leak
• Less effectiveness with nasal obstruction
• Nasal irritation and rhinorrhea
• Mouth dryness

40. Younger age
Lower acuity of illness (APACHE score)
Able to cooperate, better neurologic score
Less air leaking
Moderate hypercarbia (PaCO2 >45 mmHG, <92 mmHG)
Moderate acidemia (pH <7.35, >7.10)
Improvements in gas exchange and heart respiratory rates within first 2 hours
Potential indicators of success in NPPV use

41. Weaning strategy
•Continue NIV for 16 hours on day 2.
•Continue NIV for 12 hours on day 3 including
6-8 hours overnight use.
•Discontinue NIV day 4, unless continuation
is clinically indicated.
BTS: NIV in COPD: management of acute type 2 respiratory failure

42.  Inability to tolerate the mask because of
discomfort or pain
 Inability to improve gas exchange or dyspnea
 Need for endotracheal intubation to manage
secretions or protect airway
 Hemodynamic instability
 ECG – ischemia/arrhythmia
 Failure to improve mental status in those with
CO2 narcosis.

43.  Life threatning Refractory hypoxemia(Pa02<60
mmHg on 100% of inspired oxygen).
 Bronchiectasis with copious secretions.
 Severe Pneumonia.
 Hemodynamic Instability.

44. THANK YOU