The document outlines non-invasive positive pressure ventilation (NPPV), including its definition, goals, indications, patient selection criteria, contraindications, equipment, modes of ventilation, how to initiate NPPV, complications, monitoring, and troubleshooting. NPPV can be used to treat acute exacerbations of COPD, asthma, acute cardiogenic pulmonary edema, and other conditions. The goals of NPPV are to avoid intubation, relieve symptoms, enhance gas exchange, and improve patient comfort.

1. Non-Invasive Positive
Pressure Ventilation
NPPV

2. Outlines
• Definition.
• Goals of NPPV.
• Indication for NPPV.
• Patient Selection & Exclusion Criteria for NPPV.
• Contraindication of NPPV.
• Equipment.
• Modes.
• Initiation of NPPV.
• Complications of NPPV.
• Monitoring and Management of NPPV.
• Troubleshooting of NPPV.

3. NPPV is defined as “the application of
positive pressure to the upper respiratory
tract via an interface (mask) for the
purpose of augmentating alveolar
ventilation.

4. Goals of NPPV
Acute care setting
• Avoid intubation
• Relieve symptoms
• Enhance gas exchange
• Improve patient-ventilator
synchronization
• Maximize patient comfort
• Decrease length of stay
Chronic care setting
• Relieve or improve
symptoms
• Enhance quality of life
• Increase survival
• Improve mobility

5. Indication for NPPV
 Acute Care setting
• Acute Exacerbation of COPD
• Asthma
• Acute Cardiogenic Pulmonary Edema
• Community-Acquired Pneumonia in COPD Patients
• Hypoxemic Respiratory Failure
• Immunocompromised state

6. Indication for NPPV
 chronic care setting
• Restrictive Thoracic Disorders
• Chronic Stable COPD
• Cystic Fibrosis
• Nocturnal Hypoventilation

7. Indication for NPPV
 Other indications
• Do-Not-Intubate Orders
• Postoperative Status
• Facilitation of Weaning from invasive MV.

8. Patient Selection Criteria for NPPV
GOLD 2010
latest up date 2013

9. Patient Exclusion Criteria for NPPV

10. NPPV in COPD
• COPD is the most suitable condition for noninvasive ventilation.
• 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). The lowest threshold of effectiveness is unknown,
but success has been achieved with pH values as low as 7.10.
• Obtunded COPD patients can be treated, but the success rate is
lower.
• Improvement after a 1- to 2-hour trial may predict success.
Guy W Soo Hoo: Noninvasive Ventilation

11. Increased Raw and
RR
Hyperinflation
Increased intrinsic
PEEP
Increased WOB
Increased
ventilatory demand
Muscle fatigue
In Acute COPD Exacerbation

12. Acute Cardiogenic Pulmonary Edema
• Noninvasive ventilation is well suited for patients with
cardiogenic pulmonary edema.
• CPAP and BiPAP modalities both are effective, with CPAP
possibly being more effective.
• The greatest benefits are realized in relief of symptoms and
dyspnea.
• A decrease in intubation and mortality rates is not a universal
experience.
• Patients with hypercapnic respiratory acidosis may derive the
greatest benefit from noninvasive ventilation.
• Importantly, adjust to standard therapy, including diuresis.
• Benefit may be seen with as few as 2 hours of support.
Guy W Soo Hoo: Noninvasive Ventilation

13. Increased fluid leak
into the alveoli
Decreased lung
compliance
Increased WOB
Reduced SaO2
Increased WOB
Increased oxygenation
& ventilatory demand
In ACPE Exacerbation

14. NPPV After Extubation
• Noninvasive ventilation is effective as a bridge support after
early extubation.
• Noninvasive ventilation is an adjunct to weaning (substitutes
noninvasive support for invasive support).
• Patients with underlying COPD are most likely to benefit from
noninvasive ventilation after early extubation.
• Noninvasive ventilation is not as effective in patients with
postextubation respiratory distress.
• COPD patients are a subgroup who may benefit in that
situation.
Guy W Soo Hoo: Noninvasive Ventilation

15. NPPV in Asthma
• Similar pathophysiology to COPD; limited reported experience
with noninvasive ventilation
• Mostly case series with reported benefit
• Prospective, randomized studies based on emergency
department settings
• Improvement in spirometry main outcome measure
• Fewer admissions with noninvasive ventilation; intubation not
an outcome measure
• Hypercapnic asthma patients not represented in randomized
trials
• Noninvasive ventilation probably beneficial, but experience
limited
Guy W Soo Hoo: Noninvasive Ventilation

16. NPPV in Postoperative Patients
 Postoperative hypoxemia related to atelectasis or
pulmonary edema
 Occurrence following multiple types of surgery (eg, lung,
cardiac, abdominal)
 Randomized trials with postoperative continuous positive
airway pressure (CPAP) demonstrate benefit
 Applied as prophylactic support or with development of
hypoxemia
 Benefit noted with level CPAP levels in 7.5- to 10-cm water
range
 Lower intubation rates, days in ICU, and pneumonia
Guy W Soo Hoo: Noninvasive Ventilation

17. NPPV in Other Conditions
• Neuromuscular respiratory disease
– Nocturnal use may be especially effective for daytime
hypercapnia
– Avoid in bulbar dysfunction or excess secretions
– Effective in patients with muscular dystrophy,
kyphoscoliosis, and postpolio syndrome
– Some may be able to be treated with negative-pressure
ventilators
• Obesity-hypoventilation (or decompensated obstructive sleep
apnea) - Corrects hypercapnia, facilitates diuresis, and
provides opportunity for restorative sleep
Guy W Soo Hoo: Noninvasive Ventilation

18. Contraindication of NPPV
• Absolute contraindications
 Coma
 Cardiac arrest
 Respiratory arrest
 Any condition requiring immediate intubation
Guy W Soo Hoo: Noninvasive Ventilation

19. Contraindication of NPPV
• Other contraindications (rare exceptions)
Cardiac instability
– Shock and need for pressor support
– Ventricular dysrhythmias
– Complicated acute myocardial infarction
GI bleeding - Intractable emesis and/or
uncontrollable bleeding
Guy W Soo Hoo: Noninvasive Ventilation

20. Contraindication of NPPV
• Other contraindications (rare exceptions)
 Inability to protect airway
– Impaired cough or swallowing
– Poor clearance of secretions
– Depressed sensorium and lethargy
Status epilepticus
Potential for upper airway obstruction
– Extensive head and neck tumors
– Any other tumor with extrinsic airway compression
– Angioedema or anaphylaxis causing airway compromise
Guy W Soo Hoo: Noninvasive Ventilation

21. Equipment

22. Ventilators
• CPAP/BIPAP Machines
• Pressure Targeted Ventilators
• ICU Ventilators

23. CPAP/BIPAP Machines

24. Pressure Targeted Ventilators

25. ICU Ventilators
The Critical Care Ventilators Should Have NIV
software
To be capable of compensating for high levels
of air leak
LEAK COMPENATION?

26. Patient Interfaces

27. Patient Interfaces
• Nasal Mask: The nasal mask covers the nose only, as
its name indicates.

28. Patient Interfaces
• The Nasal Pillow – also called nasal prong – usually
consist of silicone rubber and is introduced directly
into the nostril. (rarely used in acute settings)

29. Patient Interfaces
• Chin Strap for nasal masks

30. Patient Interfaces
• The Full-Face mask: covers nose and mouth. For this
reason, this mask type is often called oronasal mask.

31. Patient Interfaces
• The Total-Face mask: covers the entire face.

32. Patient Interfaces
DisadvantagesAdvantagesInterface
Mouth leak, Eye irritation,
Ulceration over nose bridge, Nasal
congestion, Increase resistance
through passages
Easy to fit and secure, Less feeling
of claustrophobia, Patient can
speak, eat, and cough and clear
secretion, Low risk of aspiration
Less mechanical dead space
Nasal Mask
Increased risk of aspiration,
asphyxia, and dead space
Claustrophobia, Difficult to fit and
secure, Facial skin irritation,
Ulceration over nose bridge Patient
must move mask to eat, speak, or
expectorate secretions
Less air leak
Less airway resistance
Full-Face Mask
Patient must move mask to eat,
speak, or expectorate secretions
Claustrophobia
Increased risk of aspiration, and
asphyxia
Same as full-face mask
Less pressure sores or skin
ulceration
Total-Face Mask

33. Modes

34. Continuous Positive Airway Pressure
(CPAP)

35. CPAP Mechanisms of Action
 Increases gas exchange 2º to increased alveolar
ventilation
 Prevents alveolar collapse during exhalation by
maintaining a positive intra-alveolar pressure.
 Increases intrathoracic pressure, reducing
preload/afterload and improving cardiac output.

36. Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Spontaneous Breathing without CPAP

37. Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
CPAP Level
Continuous Positive Airway Pressure
(CPAP)

38. CPAP
• Continuous Positive Airway Pressure.
• The elevation of patient pressure base line.
• Patient breathing spontaneously on continuous
positive pressure applied via nasal or face mask.
• Decreases WOB.

39. Bi-level Positive Airway Pressure
(BiPAP)

40. BiPAP
• Bi-level Positive Airway Pressure delivers both inspiratory
positive airway pressure (IPAP) and expiratory positive airway
pressure (EPAP).
• IPAP controls ventilation, improve CO2 elimination.
• EPAP has direct effect on oxygenation.
• IPAP should be double the EPAP or more but not more than
20 cm H2O.
• BiPAP has three modes:
1. Spontaneous (S)
2. Spontaneous/Timed (S/T) most common
3. Timed (T)

41. Spontaneous (S) Mode
• In this mode you only set EPAP, IPAP, Trigger, and
alarms based on the type of ventilator used.
• Patient control his own rate and minute ventilation.
• No backup rate.
• Not suitable for patients with apnea episodes.
• Breath characteristics: patient’s trigger, flow cycled,
and pressure limited. (spontaneous only)

42. Spontaneous/Timed
(S/T) Mode
• In this mode you set IPAP, EPAP, RR, Trigger, and
alarms based on the ventilator used.
• The S/T (spontaneous/timed) mode guarantees
breath delivery at the user-set rate.
• It delivers pressure-controlled, time-cycled
mandatory and pressure supported spontaneous
breaths, all at the IPAP pressure level.
• Very comfortable and most commonly used.

43. Timed (T) Mode
• In this mode you set IPAP, EPAP, RR, and alarms
based on the ventilator used.
• The T (Timed) mode guarantees breath delivery at
the user-set rate.
• It delivers pressure-controlled, time-cycled
mandatory and no pressure supported spontaneous
breaths.
• May cause patient discomfort.

44. Advantages of BiPAP
• Aids oxygenation and ventilation.
• Aids in sleep apnea (Way) or ventilatory muscle
weakness (Way).
• More comfortable than CPAP (Way).
• Often prescribed if patient has problems tolerating
CPAP.

45. Other Modes of NPPV
(PSV, PCV)

46. Other Modes of NPPV
(PSV, PCV)
• Used in the ICU or acute settings.
• Can be provided by ICU ventilators.
• Not all ICU ventilators provide NPPV.
• Ventilators must have the appropriate software
which allow for leak compensation.
• Examples: Drager (Evita 4, or Evita XL), Maquet
(Servo i), Respironics V60 Ventilator, and others.

48. PSV Mode
• NIV Pressure Support Ventilation. Pressure Support is a
spontaneous ventilation mode.
• The patient initiates the breath and the ventilator
delivers support with the preset pressure level.
• The patient regulates the respiratory rate and the tidal
volume with ventilator support.
• If the mechanical properties of the lung/thorax and
patient effort change, delivered tidal volume will be
affected.
• The pressure support level must be regulated to obtain
the desired ventilation.
FEATURE_maq_niv_insert_050927

49. PCV Mode
• The PCV (pressure-controlled ventilation) mode
delivers pressure-controlled mandatory breaths,
either triggered by the ventilator (Timed) or the
patient (Spont).
• In this controlled mode of ventilation, the ventilator
delivers a flow to maintain the preset pressure at a
preset respiratory rate and during a preset
inspiratory time.
FEATURE_maq_niv_insert_050927

50. PCV Mode
• The pressure is constant during the inspiratory time.
If for any reason the pressure decreases during
inspiration, the flow from the ventilator will
immediately increase to maintain the set inspiratory
pressure.
• The volume may vary from breath to breath if the
patient’s compliance and resistance changes, and
depending on the leakage.
• Not commonly used during NPPV.

51. Application and Initiation

52. General Considerations
• Capabilities and Limitations.
• Identification of the Appropriate Patient.
• Elimination of Immediate Intubation Need.
• Equipment Available.
• Area of Application.
• The Experience and Expertise of Front-Line
Health Care Providers

53. Application
Patient
Assessment
pH < 7.3
↑ PCO2
RR > 25
↓ SaO2
↓ PO2
Distress
Establishing
Patient Need

54. Application
Patient Care
Plan
Mode of NPPV Initial Settings
Given the
Order
Initiat NPPV as following:
BiPAP , IPAP 15 cm H2O, EPAP 7 cm H2O, FiO2 45% , backup rate
of 10 BPM.
To maintain the following;
pH ≥ 7.3 and SaO2/SpO2 ≥ 90%

55. Application
Technical
Application
Ventilator
Patient
Interface
• Pressure-Targeted
Ventilators.
• Critical Care
Ventilators.
• Nasal Mask
• Full-Face Mask
• Total-Face Mask

56. Monitoring Patient on NPPV
First 30 min. of NPPV necessitate
Bedside presence of a
respiratory therapist or nurse
familiar with this mode is essential.
Providing reassurance and adequate
explanation in order to have optimal
outcome
Be ready to intubate and start on invasive
ventilation

57. Initiation of NPPV
 Place patient in an upright or sitting position. Carefully
explain the procedure NPPV, including the goals and
possible complication.
 Make sure a mask chosen that is the proper size and fit.
 Attach the interface and circuit to he ventilator. Turn on the
ventilator and adjust it initially to low pressure setting.
 Hold or allow the patient to hold the mask gently to the
face until the patient become comfortable with it.
Encourage the patient to use proper breathing technique.

58. Initiation of NPPV
 Monitor SpO2; adjust FiO2 or the O2 flow to maintain SpO2
above 90%.
 Secure the mask to the patient. Do not make the straps too
tight.
 Titrate the pressures (IPAP and EPAP) to achieve patient
comfort, adequate exhaled Vt, and synchrony with the
ventilator. Do not allow Ppeak to be more than 20 cm H2O.

59. Initiation of NPPV
 Check for leaks and adjust the straps if necessary or the
interface fit and size.
 Monitor RR, HR, level of dyspnea, SpO2, Minute
Ventilation, and Vte.
 Obtain blood gas values within 30 min to 1 hour.

60. Initiation of NPPV
• Initial IPAP/EPAP settings
 Start at IPAP of 10 to 12 cm H2O/ EPAP of 5 cm H2O
 Pressures less than 8 cm water/4 cm water not advised as this
may be inadequate
 Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP
and/or EPAP)
Guy W Soo Hoo: Noninvasive Ventilation

61. Initiation of NPPV
• Critical Care Ventilators: PSV
 PSV of 8 to 10 cm H2O
 PEEP of 5 cm H2O
 Trigger flow 2 to 5 L/min
• Critical Care Ventilators: PCV (A/C)
 PC adjust to maintain adequate Vte (8 to 10 cc/kg)
 RR 8 to 12 BPM
 PEEP 5 cm H2O
 Trigger flow 2 to 5 L/min

62. Complications of NPPV
• Facial and nasal pressure injury and sores
– Result of tight mask seals used to attain adequate
inspiratory volumes
– Minimize pressure by intermittent application of
noninvasive ventilation
– Schedule breaks (30-90 min) to minimize effects of mask
pressure
– Balance strap tension to minimize mask leaks without
excessive mask pressures
– Cover vulnerable areas (erythematous points of contact)
with protective dressings
Guy W Soo Hoo: Noninvasive Ventilation

63. Complications of NPPV
• Gastric distension
– Rarely a problem
– Avoid by limiting peak inspiratory pressures to less than 25
cm water
– Nasogastric tubes can be placed but can worsen leaks from
the mask
– Nasogastric tube also bypasses the lower esophageal
sphincter and permits reflux
Guy W Soo Hoo: Noninvasive Ventilation

64. Complications of NPPV
• Dry mucous membranes and thick secretions
– Seen in patients with extended use of noninvasive
ventilation
– Provide humidification for noninvasive ventilation devices
– Provide daily oral care
• Aspiration of gastric contents
– Especially if emesis during noninvasive ventilation
– Avoid noninvasive ventilation in patient with ongoing
emesis or hematemesis
Guy W Soo Hoo: Noninvasive Ventilation

65. Monitoring Patient on NPPV
 Response
• Physiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG/VBG
• Objective a) Respiratory rate
b) blood pressure
c) pulse rate
• Subjective a) dyspnea
b) comfort
c) mental alertness

66. Monitoring Patient on NPPV
• Mask
Fit, Comfort, Air leak, Secretions, Skin necrosis
• Respiratory muscle unloading
Accessory muscle activity, paradoxical abdominal
motion
 Abdomen
Gastric distension

67. Management of NPPV
Table 11 NPPV Adjustments
Setting Adjustment Anticipated Result
IPAP ↑
↓
Increased tidal volume; ↑ ventilation, ↓ PaCO2
Decreased tidal volume; ↓ ventilation, ↑ PaCO2
EPAP ↑
↓
Increased FRC; ↑ PaO2, ↓ tidal volume (if IPAP kept the
same)
Improve synchronization if intrinsic PEEP is present
Decreased FRC; ↓ PaO2, ↑ tidal volume (if IPAP kept the
same)
Possible rebreathing of CO2 if EPAP < 4 cmH2O
CPAP ↑
↓
Increased FRC; ↑ PaO2
Improve synchronization if intrinsic PEEP is present
Decreased FRC; ↓ PaO2
FiO2 ↑
↓
Increased PaO2
Decreased PaO2
Controlled Rate ↑
↓
Increased minute ventilation in timed modes, ↓ PaCO2
Decreased minute ventilation in timed modes, ↑ PaCO2

68. Management of NPPV
• PSV & PCV:
 Increase PS or PC level to achieve adequate Vte and Exhlaed
Minute ventilation increase CO2 wash out and correct
BG values.
 Increase PEEP then FiO2 to improve oxygenation.
 In PCV mode you may increase RR to achieve adequate
Exhlaed Minute ventilation increase CO2 wash out and
correct BG values.
 Check for leaks

69. Troubleshooting of NPPV
Table 12 NPPV Complication and Possible Remedies
Interface related
Discomfort
Pressure sores
Acneiform rash
Claustrophobia
Facial skin erythema
Minimize strap tension, assess pressure levels, change interface
Minimize strap tension, check mask fit, apply artificial skin
Administer topical steroids or antibiotics
Use smaller mask, administer sedation (low dose)
Minimize strap tension, check mask fit, apply artificial skin
Air pressure or flow related
Nasal/oral dryness or nasal congestion
Sinus or ear pain
Eye irritation
Gastric insufflation
Abdominal distention/Aerophagia
Air leak
Add or increase humidification, use decongestant
Reduce pressure if the pain is intolerable
Check mask fit, readjust strap
Reassure the patient, administer simethicone, reduce pressure
Assess patient, apply nasogastric tube, anti-vomiting medication
Check mask fit, encourage mouth closure, try chin strap or try
oronasal mask, if using nasal mask, reduce pressure

70. Troubleshooting of NPPV
Ventilator-patient interaction
Failure to cycle to expiration
Failure to trigger
Inadequate pressurization
CO2 rebreathing
Check leak, shorten inspiratory time, try oronasal mask
Check leak, reduce trigger sensitivity, change to flow triggering
Reduce pressure rise time, increase pressure
Lower respiratory rate, add PEEP, exhalation valve, reduce dead
space
Patient related
Hypotension
Aspiration
Pneumothorax
Reduce inflation pressure, inotropic support
Select patient carefully
Chest tube, reduce pressure, switch to intubation and invasive
mechanical ventilation

71. Termination of NPPV
• Deterioration in patient's condition
• Failure to improve or deterioration in arterial blood gas
tensions
• Development of new symptoms or complications such
as pneumothorax, sputum retention, nasal bridge
erosion
• Intolerance or failure of coordination with the
ventilator
• Failure to alleviate symptoms
• Deteriorating conscious level
• Patient and/or family wish to withdraw treatment

72. Weaning
↓pressures
↑ Time off
Patient Stable maintaining good Oxygenation &
Ventilation Status
Continue decreasing pressures and increainging time
off as long as the patient is stable
Patient is weaned successfully maintain Ventilator By
bedside for 12 hours reassess the patient and monitor
him closely.