Non-invasive ventilation (NIV) delivers ventilatory support without an invasive artificial airway. It has benefits over invasive ventilation like preserving airway function and reducing risks. NIV is indicated for exacerbations of COPD, respiratory failure, cardiac pulmonary edema, and other conditions. Contraindications include coma, inability to protect airway. NIV includes CPAP, bilevel PAP and negative pressure devices. Settings are tailored to the condition but aim to reduce work of breathing and improve ventilation and oxygenation without overdistending the lungs. Response is monitored closely and NIV may be switched to invasive support if the patient deteriorates.

1. Non-Invasive
Ventilation
KHALID ARAB
RESPIRATORY THERAPIST

2. What we are going to cover…
 What is NIV?
 Benefits of NIV
 Indications for NIV
 Contra-indications
 Types of NIV
 Case examples

3. What is Non-Invasive
Ventilation (NIV)
‘Delivery of ventilatory support without
the need for an invasive artificial airway’

4. BENEFITS OF NIV
• provides greater flexibility in
initiating and removing
mechanical ventilation
• Permits normal eating, drinking
and communication with your
patient
• Preserves airway defense,
speech, and swallowing
mechanisms
• Avoids the trauma associated
with intubation and the
complications associated with
artificial airways
• Reduces the risk of ventilator
associated pneumonia (VAP)
• Reduces the risk of ventilator
induced lung injury associated
with high ventilating pressures

5. Other Benefits of Using NIV
• Reduces inspiratory muscle work and helps to avoid
respiratory muscle fatigue that may lead to acute
respiratory failure
• Provides ventilatory assistance with greater comfort,
convenience and less cost than invasive ventilation
• Reduces requirements for heavy sedation
• Reduces need for invasive monitoring

6. Indications
 Exacerbation of COPD with
Respiratory acidosis
 Type II respiratory failure
 neuromuscular disease
 Pneumonia with respiratory acidosis

7. Indications
 Cardiogenic Pulmonary Oedema
 Obstructive Sleep Apnoea
 Others (ARDS, post-op respiratory
failure)

8. Contraindications for NIV
Absolute contraindications:
 Coma
 Respiratory arrest
 Any condition requiring immediate intubation
 Cardiac instability (shock+need for vasopressors,
ventricular dysrhythmias, complicated AMI)
 GI bleeding – intractable emesis, uncontrolled
bleeding

9. Contraindications for NIV
 Inability to protect airway
 impaired cough or swallowing
 poor clearance of secretions
 Status epilepticus
 Potential for upper airway obstruction
 Extensive head / neck tumors
 Any other tumor with extrinsic airway
compromise

10. Candidates for NIV
 Patient cooperative (excludes agitated, comatose
patients)
 Dyspnea (moderate to severe, shortness of breath/
agonal breathing)
 Tachypnea (rr> 24 /min)
 Increased work of breathing (accessory muscle use,
pursed lip breathing)
 Hypercapnic respiratory acidosis (pH range 7.10 –
7.35)
 Hypoxemia (PaO2/FiO2 < 200 mm Hg,

11. Types of NIV
 Negative-Pressure Ventilation (Iron
Lung)
 Continuous Positive Airway Pressure
(CPAP)
 Bi-level Positive Airway Pressure
(BiPAP)

12. Negative-Pressure Ventilation
•Negative pressure ventilators apply
a negative pressure intermittently
around the patient’s body or chest wall
• The patient’s head (upper airway) is
exposed to room air
• An example of an NIV is the iron lung or
tank ventilator

13. CPAP
 Continuous positive pressure
applied to the airways
 Similar to use of PEEP
 Reduces work of breathing
 Improve ventilation to collapsed
areas of lung
 Nasal or face mask

14. NIV machines
 CPAP machine

15. CPAP
 CPAP is most often used for two different clinical
situations
 First, CPAP is a common therapeutic technique for
treating patients with obstructive sleep apnea
 Second, CPAP is used in the acute care facility to
help improve oxygenation, for example in patients
with acute congestive heart failure .

16. CPAP
Recruits lung units
• improved V/Q matching > rapid correction of PaO2
• increased functional residual capacity
• decreased respiratory rate and WOB
Reduces airway resistance
Improves hemodynamic in pulmonary edema
• decreases venous return
• decreases after load and increases cardiac index (in
50%)
• decreases heart rate
Average requirement: 10cmH2O

17. BIPAP
 Bi-Level pressure support
 Inspiratory Positive Airway Pressure (IPAP) &
Expiratory PAP (EPAP)
 IPAP is the pressure support machine gives to
help patients own inspiration
 Helps to reduce WOB and increase alveolar
ventilation
 EPAP is essentially PEEP and help to prevent
alveolar collapse

18. BIPAP
 IPAP=5-40 cm/H2O EPAP=4-20
 Mode( S , S/T )
 Improve ventilation depends to
difference of IPAP & EPAP
 Nasal or face mask

19. NIV machines
 BiPAP

20. NIV masks
 Nasal mask

21. NIV masks
 Full face mask

22. Methodology
 Initial ventilator settings: CPAP (EPAP) 4 cm H2O &
PSV (IPAP) 5 cm H20.
 Mask is held gently on patient’s face.
 Increase the pressures until adequate Vt (7ml/kg),
RR<25/mt, and patient comfortable.
 Titrate FiO2 to achieve SpO2>92%.((88-90% target
for COPD pt.))
 Keep peak pressure <25-30 cmH2O
 Head of the bed elevated (( 45 – 90º ))

23. Monitoring
Response
Physiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG should be obtained within12 hour
and, 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

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

25. Criteria for Terminating NIV and Switching to
Invasive Mechanical Ventilation
•Worsening pH and arterial partial pressure of
carbon dioxide (PaCO2 )
•Tachypnea (over 30 breaths/min)
•Hemodynamic instability
•Oxygen saturation by pulse oximeter (SpO2 ) less
than 90%
•Decreased level of consciousnees
•Inability to clear secretions
•Inability to tolerate interface

26. Management Strategies
 COPD
 Main goal to decrease work of breathing
(decreasing V/Q mismatch) and provide adequate
ventilation
 Relatively low EPAP: 5-8cm H2O (assuming no
obesity or sleep disordered breathing)
 Relatively moderate IPAP+EPAP: 10-14cm H2O
 Goal to have at least a 5cm H2O differential
between EPAP and IPAP.

27. Management Strategies
 A meta-analysis of 14 studies of NIV in
COPD exacerb showed:
  mortality
  need for intubation
 pCO2, and resp. rate faster
  length of stay by 3.24 days
  complications of treatments

28. Management Strategies
 CHF
 Goal is to decrease work of breathing,
decrease afterload and decrease overall
static pressure
 Relatively moderate EPAP: 6-12 cm H2O
 Relatively low IPAP+EPAP: 12-18cm H2O
 Patient will benefit mostly with EPAP unless
other concurrent disease ( COPD, Obesity-
Hypoventilation)

29. Management Strategies
 Obesity-Hypoventilation Syndrome
 Goal of therapy is to decrease work of breathing
and increase ventilation
 EPAP: usually on the higher side; enough to
overcome OSA and cardiopulmonary disease:
~10cmH2O.

30. Management Strategies
 Other causes of respiratory failure
 Pneumonia/ARDS
 Cancer and respiratory failure
 Post-op management
 Settings depend on disease and other
cardiopulmonary disease
 Most often used as a bridge to mechanical
ventilation or for pts DNR/DNI
 Usually moderate settings: 8/4 or 12/7

31. Any Questions?
?