Positive airway pressure (PAP) therapy is a sleep apnea treatment that uses compressed air to support the airway. It involves wearing a mask and a portable machine blowing pressurized air into the upper airway through a tube connected to the mask. This positive airflow prevents apnea collapse and allows normal breathing. In this presentation "PAP Therapy" has been described including its use, indications, complications, etc. For more information, please contact us: 9779030507.

1. S. K. Jindal
Department of Pulmonary Medicine
P.G.I.M.E.R., Chandigarh
PAP Therapy & to track its use

2. NON INVASIVE RESPIRATORY
SUPPORT
The provision of mechanical ventilatory assistance without
“invasion of airways” (i.e. intubation).
Based on the results of clinical trials showing improved outcomes
in certain types of acute respiratory failure its use has increased in
recent years
Am J Respir Crit Care Med 2001

3. N.I.R.S.: Resuscitative measure
“First used by prophet Elisha” Mouth to Mouth breathing
• I.P.P.B. – “Ambu Bag…ging”

4. Noninvasive Ventilation (NIV): Types
• Negative Pressure Ventilation (NPV)
• Continuous Positive Airway Pressure (CPAP)
• Noninvasive Positive Pressure Ventilation (NPPV)

5. Negative Pressure Ventilation
• Negative pressure ventilators apply a negative pressure intermittently around the
patient’s body or chest wall  iron lung or tank ventilator
• Pressure is applied intermittently to the thoracic area resulting in a pressure drop
around the thorax
• Negative pressure is transmitted to the pleural space and alveoli creating a pressure
gradient between the inside of the lungs and the mouth
• As a result gas flows into the lungs

6. Non Invasive Positive Pressure
Ventilation: Settings of use
1. Emergency Room/I.C.U.
Intermediate Care Units
2. Transfer to different units
3. Home – Long term use

7. NIPPV: Essentials
• Selection of appropriate patient
• Availability of suitable equipment
• Familiarity with the technique
• Adequate staffing
• Team approach

8. NIPPV: Criteria for trial
• Acute Respiratory Failure
• Normal (or near normal) bulbar function
• Ability to clear bronchial secretions
• Haemodynamic stability
• Functioning G.I.T.
• Able to cooperate

9. Clinical Indications
A. COPD: Acute exacerbation
B. Non-COPD disorders (ARF)
• Pneumonias
• Immunosuppressed patient
• Cardiogenic pulmonary edema
• Acute Severe asthma
• Acute exacerbation – cystic fibrosis,
bronchiectasis
• Neuromuscular Disease
• Chest trauma
• Post extubation COPD

10. Indications of NIV
Evidence &Recommendation
Crit Care Med 2007

11. Contraindications to NIPPV
Absolute
• Urgent need for
intubation e.g. arrest
• Coma
• Need for vasopressor
• MODS (> 2 organs)
• Severe bulbar weakness
• Extensive facial trauma
or upper airway obst.
Relative
• Confusion/noncoop.
• Evolving M.I.
• Unstable angina
• Poor cough reflex
• Moderate bulbar weakness
• Recent oesophageal or
gastric surgery
• Facial deformity

12. Acute Respiratory Failure
(Any two of the following)
• Dyspnoea at rest & RR > 25/min
• PaCO2 > 6KPa (45 mmHg)
• pH < 7.35
• PaO2 < 8kPa (60 mm Hg) on room air, or PaO2:FiO2 ratio <
250 (on FiO2 > 0.5)

13. Hypercapnic Respiratory Failure
NIV should be considered first-line therapy in the management of ARF
due to COPD exacerbations based on evidence derived from multiple
randomized trials
N Engl J Med 1990
Lancet 1993
Am J Respir Crit Care Med 1995

14. Contraindications
to NIPPV
PaCO2 >6 kPa
pH >7.35
Is assisted ventilation
appropriate?
Immediate endotracheal intubation
(ETI) and IPPV required?
ETI and ICU
admission appropriate?
Trial of NIPPV
Improvement in ABG
after one hour
Adjust settings
Review therapy
Improvement
Continue NIPPV
ETI and NIPPV
Consider NIPPV
for weaning
Medical
therapy
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES

15. NIPPV in COPD: Unfavourable Factors
• No improvement in pH and RR
after 30 to 120 minute
• High APACHE II scores
• Inability to minimize leak
• Excessive secretions
• Pneumonia
• Underweight
• Inability to coordinate
• Neurological compromise
• Low pH

16. Hypoxemic Respiratory Failure
Hypoxemic ARF is defined by a PaO2/ FIO2 ratio < 300
while breathing oxygen through venturi mask and a variety
of different non-COPD etiologies

17. Cardiogenic Pulmonary Oedema
• Use of NIV or CPAP in patients with CPE is supported by multiple RCT
• Physiologic benefit from NIV or CPAP in these patients is likely due to
– increase in FRC that reopens collapsed alveoli and improves oxygenation 
increases lung compliance and reduces work of breathing
– increased intrathoracic pressure leading to improve cardiac performance by
decreasing ventricular preload and afterload
• Meta-analyses have shown equivalent reductions in intubation and mortality rates with
CPAP and NIV
JAMA 2005, Crit Care 2006

18. NIV-CPE : Cochrane review
• Data from RCTs have demonstrated that NPPV(CPAP and bilevel NPPV) is
effective in reducing hospital mortality, intubation rate and ICU length of stay
• NPPV resulted in faster improvement and was better tolerated than standard
medical care
• Meta-analysis did not demonstrate an increase in the incidence of adverse
events or AMI during & after NPPV
Vital FMR et al. Cochrane Database of Systematic Reviews 2008

19. NIV for Asthma
• CPAP
– has bronchodilatory effect
– Unloads fatigued inspiratory muscles
– Improves gas exchange
– prevents methacholine and histamine-induced asthma
• Noninvasive ventilatory support
– increases tidal volume
– Adds external PEEP to offset the intrinsic PEEP that builds up during
an asthmatic attack  decreasing the work of the inspiratory muscles

20. NIPPV - Asthma
• Cochrane systemic review - application of NPPV in patients suffering from
status asthmaticus, despite some interesting and very promising preliminary
results, still remains controversial
• Large, prospective, randomised controlled trials are needed to determine the
role of NPPV in status asthmaticus
Rowe BH et al. Cochrane Database Syst Rev 2005

21. NIV- For Weaning
Facilitating Extubation in COPD
• Supported by strong evidence
• RCT in patients with COPD and hypercapnic respiratory failure who failed a
single / repeated T-piece trials  extubated to NIV or continued on invasive
ventilation and weaned according to a standard pressure support protocol
– an increased weaning rate at 28 days
– decreased durations of MV and ICU stay
– reduced nosocomial pneumonia and 60-day mortality
Ferrer M et al. Am J Respir Crit Care Med 2003

22. NIV For Weaning
• Patients intubated for hypercapnic respiratory failure due to COPD who fail
SBT should be considered for a trial of extubation to NIV
• Approach should be reserved for patients who are
– Good candidates for NIV
– Able to tolerate levels of pressure support
easily administered via mask (i.e., 15 cm H2O)
• Should not have been a difficult intubation

23. NIV for Pneumonias (with respir failure)
• Challenge to treat noninvasively and has been identified as a risk factor for NIV
failure
Intensive Care Med 2001
• Cohort study
– 2/3rd of patients with severe CAP required intubation
– Successful NIV had very good outcomes
Intensive Care Med 2001
• An RCT on severe CAP showed that NIV reduced intubation rates, ICU length of
stay, and 2-month mortality rate, but only in the subgroup with underlying COPD
Am J Respir Crit Care Med 1999

24. Immuno-compromised Patients
• RCTs in recipients of solid-organ or bone-marrow transplants who developed
hypoxemic respiratory failure
– decreased intubation and ICU mortality rates
– shorter ICU stay
• Similar findings in a nonrandomized study for AIDS patients
JAMA 2000
N Engl J Med 2001
Intensive Care Med 2002

25. NIV- Immuno-compromised Patients
• The reduced mortality is likely related to reduced infectious complications
associated with NIV use compared with endotracheal intubation
– VAP
– Other nosocomial infections
– Septic shock
Intensive Care Med 1999; 25:567–573
• Data support NIV as the preferred initial ventilatory modality to avoid
intubation and its associated risks

26. Postoperative Respiratory Failure
• Benefit in the postoperative period when used prophylactically after major
abdominal surgery or thoracoabdominal aneurysm repair
• CPAP (10 cm H2O) reduces the incidence of hypoxemia, pneumonia,
atelectasis, and intubations
• Patients with hypoxemic respiratory failure after lung resection had reduced
intubation and mortality rates compared to standard management
Respir Crit Care Med 2001

27. Agarwal R et al. Respir Care 2007

28. Palliative Care and Do-Not-Intubate Status
• Prospective cohort series of 114 patients with acute respiratory failure and
a status of do not intubate
• 43% of the patients survived the hospitalization
• CPE & COPD had hospital survival rates 50%
• Presence of a cough and an awake mental status had favorable prognosis
Levy MM et al. Crit Care Med 2004

29. NIV for Flail chest
• Prospective, randomised study of CPAP via a face mask to compared with IPPV with
ETI in 52 patients with flail chest
• Nosocomial infection diagnosed in 10 of 21 patients in the ET group, but only in 4 of 22
in he CPAP group (p <0.001)
• Mean PO2 was significantly higher in the ET group in the first 2 days but no significant
differences in length of ICU stay
• 20 CPAP patients survived, but only 14 of 21 intubated patients who received IPPV (p
<0.01)
• study supports the application of CPAP as a first line of treatment for flail chest caused
by blunt thoracic trauma
Gunduz M et al. Emerg Med J 2005

30. Other ICU Applications
Preoxygenation Before Intubation
• Critically ill patients with AHRF are at high risk of O2 desaturations during intubation
• RCT of such patients showed that pre-oxygenation with NIV before intubation resulted
in
– improved oxygen saturation during and after intubation
– decreased the incidence of oxygen desaturations below 80% during intubation
Am J Respir Crit Care Med 2006
• Approach is promising & needs further studied before routine use can be recommended

31. Fiberoptic Bronchoscopy
• CPAP alone (up to 7.5 cm H2O) improves oxygenation and reduces postprocedure
respiratory failure in patients with severe hypoxemia
• RCT of 26 patients with hypoxemia (PaO2/FIO2 ratio < 200 NIV
– increased PaO2/FIO2 by 82%
– 10% worsening in the conventional O2 therapy
• NPPV is superior to conventional O2 supplementation in preventing gas-exchange
deterioration during FOB with better hemodynamic tolerance
Chest 2002
Am J Respir Crit Care Med 2000

32. Equipment for NIPPV
A. Ventilator: Volume or Pressure preset
B. Interfaces: Nasal masks, plugs
Full face mask; Customized
C. Accessories: Humidifiers, oxygen source, Pumps, oscillator, etc.

33. Ventilator characteristics
Characteristic
1. Delivery
2. Leak compensation
3. Addition of
PEEP/EPAP
4. Ppeak
5. Size
Volume preset
Constant TV with
changing Raw & CL
Poor
Can add PEEP
Difficult to limit
Bulkier
Pressure preset
TV falls with increasing
Raw or falling CL
Good
EPAP on bilevel
machines
Can preset
Smaller

34. Which Ventilator?
Pressure Preset
• Pneumothorax
• Bullous lung disease
• Persisting air leak (post-
surgery)
• Gastric distension
• PEP required (atelectasis)
Volume Preset
• Labile airflow resistance or
CL
• Very high thoracic
impedence e.g. chest wall
disease

37. Disadvantages of NIPPV
• Less effective
• Mask uncomfortable/claustrophobic
• Time consuming for staff
• Facial pressure sores
• Airway not protected
• Tracheobronchial secretions

38. When to extubate/decannulate
and use NIPPV?
• Able to breathe spontaneously for 5 minute
• Alert and able to tolerate mask
• No bulbar weakness
• Intact upper airway
• Minimal bronchial secretion
• Low FiO2 (< 0.4)
• Normal G.I. function

39. NIPPV Problems
A. ARF or procedure related
1. Hypercapnia: Low Pinsp, TV, RR; rebreathing; asynchrony; leaks;
insufficient duration, oxygenation
2. Persistent hypoxaemia
3. Hypocapnia/respir. alkalosis - too high MV, RR
4. Leaks
5. Asynchrony
6. Unexpected high inflation pressure
7. Ventilator over dependence

40. B. Other complications
1. Confusion/aggression
2. Nasal problems (soreness of nose, bridge, congestion)
3. Gastric distension
4. REM sleep rebound (catch up on missed sleep)
5. Troublesome cough (airway cooling & drying)
6. Claustrophobia

41. Other care on NIPPV
A. Pharmacotherapy
B. Physiotherapy: To
• Reduce fear, anxiety, pain
• Improve ventilation, work of breathing
• Mobilize secretions; expectoration
• Improve knowledge, understanding, exercise tolerance and
function
C. Nursing
D. Rehabilitation (Multidisciplinary)

42. Home Ventilation: Indications
I. Well supported by evidence
• COPD
• Motor Neurone Disease/ALS
II. Consensus evidence
• Chest wall
• Neuromuscular
• Neurological disorders
• Others (Bronchiectasis, CF)

43. Goals of Home Ventilation
• To extend life
• To enhance Q.O.L.
• To reduce morbidity
• To improve physical and physiological function
• To deliver treatment safely and cost-effectively

44. How does long term ventilation help?
1. Relief of chronic respir. muscle fatigue
2. Improved central respiratory drive
3. Improved chest wall/lung mechanics
4. Improved sleep efficiency and quality
5. Altered cardiopulmonary and renal haemodynamics

45. When to use LT-NIPPV in COPD?
1. Deterioration despite LTO2 & Rehabilitation
2. Hypercapnia during spontaneous breathing
3. Not end stage emphysema
4. Well motivated patient
5. Inpatient acclimatization and education
6. Documented control of nocturnal hypoventilation by NIPPV

46. 100
80
60
40
20
0
0 1 2 3
Years
4 5 6
Poliomyelitis
Tuberculosis
Neuromuscular disease
Kyphoscoliosis
COPD
Bronchiectasis
%
continuing
NIPPV

47. Ideal Domiciliary Ventilator
• User friendly
• Portable & quiet
• Operates in assist/assist control & control mode
• Apply CPAP/BiPAP
• Sensitive trigger
• Battery option
• Versatile
• Low pressure, high pr, power failure alarms
• Reliable
• Low cost & maintenance
• Compliance data for down loading

48. NIPPV in Sleep Apnoea Syndrome
1. Obstructive SAS:
- CPAP
- BiPAP: Better compliance, hypercapnic patient, severe end stage
SAS
2. Central SAS:
- Alveolar hypoventilation (Impaired chemo sensitivity)
- Increased respiratory drive (e.g. Cheyne – Stokes breathing – LVF)

49. Levels of Assisted Ventilation
Type
I. Short periods e.g. acute illnesses,
postoperative; ac.exacerbation
II. Regularly during sleep
III. During sleep and part of the day
IV. Continuously, 24 hrs a day Either
Noninvasive
Invasive

50. CONCLUSIONS
NIPPV is useful to provide respiratory support in
- Early respiratory failure,
- Intermittent support for Hypercapnia,
- Domicilliary and outside ICU,
- Allows normal eating, drinking, communication and physiotherapy.
NIPPV is not alternative to invasive ventilation
- Patients should be monitored closely for NIV failure.
- Should be intubated promptly at failure before a crisis develops.
- Application of NIV by a trained and experienced ICU team, with careful
patient selection, should optimize patient outcomes.

51. THANK YOU