Recent Advances in NIV 1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases. 2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options. 3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema. 4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher

2. Recent Advances in NIV
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
ERS National Delegate of Egypt

6. NPPV: definition
Any form of ventilatory support applied without
the use of an endotracheal tube considered to
include:
*CPAP with or without pressure support
*Volume- and pressure- cycled systems
*Proportional assist ventilation (PAV).
AJRCCM 2001; 163:283-91

7. Ventilators for NIV: Not all are
useful in each indication

8. Standard interfaces
Facial masks
advantages:
– sufficient ventilation also
during mouth breathing
– sufficient ventilation in patients
with limited co-operation
disadvantages:
– coughing is difficult
– skin lesions (bridge of the nose)

9. Nasal masks
advantages:
– better comfort
– good seal
– coughing is possible
– communication is possible
disadvantages:
– effective in nose breathing only
– good co-operation is necessary
Standard interfaces

10. Nasal prong/nasal pillow systems
for patients with
claustrophobia
for patients with allergies
against straps
for low to moderate
pressures only
(< 20 cmH2O)
Standard interfaces

11. total-face masks
• Safe interface for acute respiratory
insufficiency with high pressures
• well tolerated by the patients
Standard interfaces

12. helmet
• well tolerated by the patient
• no direct contact to the skin of
the face
• large dead space
• may influence the triggering of
the patient; use with CPAP
• very noisy
Standard interfaces

13. mouthpieces
• simple and cheap
• short-interval alternative
interface for long-term
ventilated patients
Custom-made masks
• for long-term ventilation
• if standard masks are not
tolerated
Standard interfaces

14. Physiologic evaluation of three
different interfaces
cohort: 26 stable patients with hypercapnic COPD or interstitial lung disease.
intervention: three 30 minute tests in two ventilatory modes with
facial mask / nasal mask / nasal prongs
Conclusions: NIPPV was effective with all interfaces.
patients‘ tolerance: nasal mask > facial mask or nasal prongs
pCO2 reduction: facial mask or nasal prongs > nasal mask
Navalesi P et al. Crit Care Med 2000;28:2139-2140

16. *COPD
*Obesity
*Neuromuscular disease & chest
wall deformity

17. Rationale for ventilatory assistance
 Respiratoryload
 Respiratorymuscles
capacity
Alveolar hypoventilation
 PaO2 and  PaCO2
Abnormal
ventilatorydrive

18. Mechanical ventilation unloads the
respiratory muscles
Respiratory load Respiratory muscles
Mechanical
ventilation

19. NIV - Meta-analysis (n=8)
NPPV resulted in
– decreased mortality ,
– decreased need for ETI .
Greater improvements within 1 hour in
– pH .
– PaCO2 .
– RR .
Complications associated with treatment and length of
hospital stay were also reduced with NPPV
Lightowler, Elliott, Wedzicha& Ram BMJ 2003;326:185

21. NIV v invasive ventilation
In the NPPV group, 48% patients avoided
intubation, survived, and had a shorter
duration of ICU stay than intubated patients
(p=0.02). One year following hospital
discharge, the NPPV group had fewer
patients readmitted to the hospital (65% vs.
100%; p = 0.016) or requiring de novo
permanent oxygen supplementation (0% vs.
36%; p < 0.01).
Conti et al Intensive Care Med 2002; 28:1701

22. YONIV Study - outcome by enrolment
pH
0
10
20
30
40
50
pH < 7.3 pH >= 7.3
Con fail
NIV fail
Con died
NIV died
Plant et al Lancet 2000; 355:1931-5

23. Change in practice over time
1992-1996 (mean pH = 7.25+/-0.07) 1997-1999
(7.20+/-0.08; P<0.001).
> 1997 - risk of failure pH <7.25 three fold
lower than in 1992-1996.
> 1997 ARF with a pH >7.28 were treated in
Medical Ward (20% vs 60%).
Daily cost per patient treated with NIV (€558+/-
8 vs €470+/-14,P<0.01)
Carlucci et al Intens Care Med 2003; 3:419-25

24. Late failure
n=137 Acute exacerbations of COPD
23% deteriorated after 48 hours
Late failure predicted by low ADL scores,
pH and co-morbidity at admission
Moretti et al Thorax 2000; 55:819-25

25. Neuromuscular disease / scoliosis
Hypercapnia
Normocapnia with reduced vital capacity and
tachypnoea
Don’t forget
– Upper airway
– Aspiration
– Occult cardiac disease
– Secretion management (cough assist)

26. NIV – when and where?
COPD – designated NIV service
– pH < 7.35
– pH < 7.30
Neuromuscular disease / chest wall deformity
– hypercapnia
– reduced VC with normal CO2
– Will usually require long term domiciliary NIV
Obesity
– Hypercapnia with acidosis (probably as for
COPD)
– NIV success - consider switch back to CPAP
(or no ventilatory support)

28. THE RATIONALE

29. LV failure
Pulmonary
edema

Pulmonary
compliance
 Airway
resistance
 Negative
Intrathoracic
Pressure
Swing

Work of
breathing
 CO
 PaO2
Respiratory
muscle
fatigue
 DaO2
+
 PaCO2

30. LV failure
Pulmonary
edema
 Pulmonary
compliance
 Airway
resistance
 Negative
Intrathoracic
Pressure
Swing
 LV
transmural
pressure
 O2
Cost of
breathing
 LV afterload
+

31. Rasen et al: Chest 1985; 87: 158-162
Negative intrathoracic pressure swings during CPE
Pes
(cmH20)
0
-20

32. IntraThoracicPressure
and
LV function
AO
LV
ITP  effort =  ITP = Ptm

 LV afterload
100
-20
Ptm = 100-(-20) = 120

33. CPAP IN CPE
Rasen et al: Chest 1985; 87: 158-162
Pes
(cmH20)
0
-20
Spontaneous breathing CPAP 15 cmH20

34. IntraThoracicPressure
and
LV function
AO
LV
ITP  effort =  ITP =  Ptm

 LV afterload
100
-5
Ptm = 100-(-5) = 105

35. Rationale of positive pressure
ventilation in CPE
Positive Pressure
 ITP  FRC
Pre-load
 Venous return
 LVafterload
 PTM
 PaO2  WOB
 Cardiac performance
 pulmonary congestion

38. Intervention
*Standard nitrate, diuretic and opioid therapy
*Consent + Randomised for 2 hours to:
-Standard oxygen therapy (by facial mask)
-CPAP (5 cmH2O  to a max 15 cmH2O)
-NIPPV (8/4 cmH2O  to a max 20/10
cmH2O)
*Fi02 0.6

39. Randomised n = 1156
Treated
n = 367
7 day
n = 367
Treated
n = 346
7 day
n = 343
Treated
n = 356
30 day
n = 352
30 day
n = 348
30 day
n = 325
30 day
n = 344
Patient
Withdrawal
n = 0
Patient
Withdrawal
n = 3
Patient
Withdrawal
n = 4
Patient
Withdrawal
n = 1
Refused
Retrospective
consent
n = 18
Patient
Withdrawal
n = 4
Refused
Retrospective
consent
n = 14
Patient
Withdrawal
n = 1
Refused
Retrospective
consent
n = 17
Potentially eligible n = 1874
Refused initial consent n=68
Too sick to consent n=125
Unable to consent n=18
Clinician choice n=23
Known previous randomisation n=32
No equipment n=15
Randomisation service problem n=33
Other n=41
Screened n = 1511
Recruited n = 1069
Protocol Violations n=44
Duplicates n=43

40. Mortality (Oxygen alone vs NIV)
1.0
0.9
0.8
0 10 20 30
Days
Cumulative
Survival
Standard
Oxygen Therapy
Non-invasive
Ventilation
P=0.685

41. Primary Outcome: Mortality
Standard
Therapy
Non-
Invasive
Ventilation
OR 95% CI P Value
7-Day 9.8% 9.5% 0.97 0.63 -
1.48
0.869
30-
Day
16.7% 15.4% 0.93 0.65 -
1.32
0.685
7-day mortality, non-recruited 9.9%
No interaction with disease severity

44. Standard NIV
Patients, n= 13 13
PaO2/FiO2 ratio
Baseline 155 143
Bronchoscopy 139 261
1 hour after 140 176
Antonelli et al, Chest 2002; 121: 1149
Indication: Pneumonia

45. Intensive Care Med 2003; 29:126-129

46. Chest 1997; 112:1466-1473

48. ACUTE AND CHRONIC NPPV
IN CHILDREN
Brigitte Fauroux
Pediatric Pulmonology & Research unit INSERM U 719
Armand Trousseau Hospital
Paris - France
Noninvasive Positive Pressure Ventilation
ERS School Courses
Pisa - Italy - 2005
Inserm
Institut national
de la santé et de la recherche médicale

49. Interface adapted
for the child

50. Conclusion
 NPPV represents a logical therapeutic option in
disorders characterised by alveolar hypoventilation
– Neuromuscular disorders
– Dynamic upper airway obstruction
– Cystic fibrosis
– Hypoxic RF, cardiogenic pulmonary edema ?
 Future research
– Define the criteria for starting NPPV and the benefit
of NPPV in children
• in the acute and chronic setting
• according to the underlying disease
– Improve the ventilators and interfaces
– Evaluate the long term benefit of NPPV in childen

51. ERS School Course
“Noninvasive Positive Pressure Ventilation”
Hanover, Germany
13. Feb. 2009
NIV in weaning: based on and beyond studie
Prof. Dr. B. Schönhofer

54. Non-invasive ventilation in
acute hypoxic respiratory
failure: Pro
Hanover, 13th February, 2009
Miquel Ferrer, MD
RIICU, Dept. Pneumology, Hospital
Clínic, IDIBAPS, CibeRes,
Barcelona, Spain.
miferrer@clinic.ub.esmail:-E

55. Severe Community-Acquired Pneumonia
Clin Infect Dis. 2007;44 Suppl2:S27-S72
1 Major or 3 Minor Criteria
Pneumonia is associated with
poor outcome in patients
receiving NIV
*Mechanical ventilation
*Septic shock
Respiratory rate >30 min-1
PaO2/FiO2 <250
Bilateral or multilobar
SBP <90 mmHg *
BUN >25
Platelets <100,000
Leukocytes <4,000
Confusion
Hypothermia
Minor CriteriaMajor Criteria

56. NIV in acute COPD: correlates for
success
AmbrosinoN. Thorax1995;50:755-7
NIV failure
Other Pneumonia
%
0
20
40
60
n=8
p=0.019
n=5
Retrospective analysis
59 episodes of ARF in 47
COPD patients
NIV success: 46
NIV failure: 13
Predictors for NIV failure:
Higher PaCO2 at
admission
Worse functional
condition
Reduced treatment
compliance
Pneumonia

57. NIV failure in acute hypoxemic respiratory
failure
AntonelliM. Intensive Care Med 2001; 27:
• Eight ICUs
• n=354:
• Success: 246
• Failure: 108

58. Non-invasive ventilation and
pneumonia
but, …..
is NIV effective in patients with pneumonia?
???
Conclusion:
Patients with pneumonia causing ARF and
needing NIV are among those with worst
outcome

59. NIV in severe community-acquired
pneumonia
 Prospective, randomised, controlled
 Severe CAP (ATS criteria).
 Standard treatment vs ST + NPPV. n: 28 + 28 = 56
ConfalonieriM. Am J Respir Crit Care Med 1999;160:1585-91
Overall population
NIV Control
%
0
20
40
60
p=0.03
n=6
n=14
COPD +
Hypercapnia
NIV Control
%
0
20
40
60
Non-COPD +
Non-hypercapnia
NIV Control
0
20
40
60
n=0
n=6
n=6
n=8
p=0.005
p=0.73
Intubation rate

60. Improving
End-Of-Life Care
Decision-making
In the ICU
Palliation
of symptoms
Dyspnea
Management
NIV in Palliation and Oncology

62. Don’t forget contraindications for
NIV
Am J Respir Crit Care Med 2001;163:283-91
Need for immediate intubation:
Cardiac or respiratory arrest
Respiratory pauses +  alertness + gasping
Psychomotor agitation  sedation
Massive aspiration
Inability to manage secretions
Other limitations for NIV:
Severe non-respiratory organ failure
Face surgery, trauma or deformity
Upper airway obstruction
Inability to cooperate/protect the airways