Non Invasive Ventilation

(NIV)
Dr. Kavita Khandelwal
Consultant, Critical Care Unit
Kailash Hospital, Noida
 Definition
It is defined as a ventilatory mode that delivers a mechanical ventilatory
support breath without use of an endotracheal tube or surgical airway, but
using face or nasal mask.
 History
Until the early 1960s, negative-pressure ventilation in the form of tank
ventilators was the most common type of mechanical ventilation outside the
anesthesia suite

With the introduction of nasal CPAP to treat obstructive sleep apnea in the
early 1980s, NIPPV rapidly displaced negative-pressure ventilation as the
treatment of choice for chronic respiratory failure in patients with
neuromuscular and chest wall deformities.

The past 12 years, noninvasive ventilation has moved from the outpatient to
the inpatient setting, where it is used to treat acute respiratory failure.
• Several factors are vital to the success of NIV:
-careful patient selection
- properly timed initiation
- comfortable & well-fitting interface
- coaching and encouragement; and careful
monitoring.
• Noninvasive ventilation should be used to avert
endotracheal intubation rather than as an alternative
to it.
 Advantages (NIV)
• Decreased direct upper airway trauma & bypass of the upper airway defense
mechanisms

• Allows patients to eat orally, vocalize normally, and expectorate secretions.

• Noninvasive ventilation reduces hospital acquired infections including VAP,

sinusitis, and sepsis.

• Lowers morbidity and mortality

• Shorten hospital length of stay, thus reducing costs.

 Goals of NIV
• Relieve symptoms

• Reduce work of breathing

• Offset the effect of i PEEP

• Improve gas exchange

• Minimize risk of barotrauma

• Avoid intubation
NIV: CLASS 1 INDICATION
1. COPD with Acute Exacerbation: Respiratory acidosis and high PaCO2 plus 2 of the
following:
− RR >30
− pH <7.35 on room air for at least 10 min.
− PaO2 <60 mmHg.
2. Cardiogenic Pulmonary Edema: Early improvement in physiological variables. No
improvement in outcome.
3. Early extubation of ventilated patients with COPD and Type 2 Respiratory Failure.
4. Immunocompromised patients with Respiratory Failure: Preserved airway reflexes
and lesser risk of infection.
NIV: OTHER INDICATIONS
• Pre-oxygenation before intubation.
• Early and mild ARDS
• Pneumonia
• Obstructive Sleep Apnea.
• Prevention of Post-extubation Respiratory Failure in High-risk patients.
• Post-extubation Hypercapnic Respiratory Failure.
• Post-operative Respiratory Failure following Abdominal Surgery.
 EXCLUSION CRITERIA
1. Cardiac or Respiratory arrest
2. Hemodynamic instability-uncontrolled arrythmias ,very high dose of inotropes
3. Unconscious, unable to protect airways
4. Life threatening hyoxemia
5. Excessive secretions
6. Persistent vomiting or hemoptysis , upper GI bleed
7. Agitated or uncooperative
8. Facial trauma, burns, surgery or anatomic
abnormalities interfering mask application
PREDICTORS OF SUCCESS DURING ACUTE
APPLICATIONS OF NPPV
• Younger age
• Lower acuity of illness (APACHE score)
• Able to cooperate; better neurologic score
• Able to coordinate breathing with ventilator
• Less air leaking, intact dentition
• Hypercarbia, but not too severe (Paco2 > 45 mm Hg, <92 mm Hg)
• Acidemia, but not too severe (pH < 7.35, > 7.10)
• Improvements in gas exchange and pulse and respiratory rates within first 1-2 h
Modes of Non Invasive
Mechanical Ventilation
1-Pressure modes

2-Volume modes

Volume ventilation, initial tidal volumes range from 10 to 15 [Link].

Pressure-cycled vents are better tolerated than volume-cycled vents.
 Pressure modes
Continuous Positive Airway Pressure(CPAP)
• It provides positive airway pressure throughout the respiratory cycle.
• Predominately augments oxygenation with the goal of recruiting alveoli,
increasing functional residual capacity, and decreasing shunting.
• Most beneficial in hypoxemic respiratory failure
• It is equivalent to positive end-expiratory pressure (PEEP) and facilitates
inhalation by reducing pressure thresholds to initiate airflow.
• This mode should never be used in patients who may have apneic episodes
because of the lack of a backup rate.
 Pressure Modes
Spontaneous Modes
• In spontaneous mode, the airway pressure cycles between an inspiratory positive airway pressure
(IPAP) and an expiratory positive airway pressure (EPAP).
• This is commonly referred to as bilevel or biphasic positive airway pressure (BL-PAP or BiPAP).
• The patient's inspiratory effort triggers the switch from EPAP to IPAP. The limit during inspiration
is the set level of ІРАР.
• The inspiratory phase cycles off, and the machine switches back to EPAP when it detects a
cessation of patient effort, indicated by a decrease in inspiratory flow rate, or a maximum
inspiratory time is reached, typically 2-3 seconds.
• Tidal volume (Vt) varies breath to breath and is determined by degree of IPAP, patient effort, and
lung compliance.
• Spontaneous mode depends on patient effort to trigger inhalation. A patient breathing at a low
rate can develop a respiratory acidosis.
Pressure modes
Spontaneous/timed (ST) mode
• The trigger in the ST mode can be the patient's effort or an elapsed time
interval, predetermined by a set respiratory backup rate.
• If the patient does not initiate a breath in the prescribed interval, then IPAP
is triggered. For machine-generated breaths, the ventilator cycles back to
EPAP based on a set inspiratory time.
• For patient-initiated breaths, the ventilator cycles as it would in the
spontaneous mode.
Conceptually:
One can consider BiPAP as PEEP with pressure support (PS). The pressure
during the inspiratory phase is termed IPAP and is analogous to PS.
• The pressure during the expiratory phase is termed EPAP and is analogous
to PEEP.
• The IPAP is necessarily set higher than EPAP by a minimum of 5cm H2O,
and the difference between the two settings is equivalent to the amount of
PS provided
Average volume-assured pressure support
(AVAPS)
• Similar to BiPAP as it pro vides an IPAP on continuous EPAP
• the inherent difference is the clinician-defined parameters. An EPAP is
identically chosen as in BiPAP
• however, an IPAP range is selected to target a goal tidal volume. Therefore, as
patient effort varies, the NIV will either uptitrate IPAP to increase, or
downtitrate to decrease to the targeted inhaled tidal volume
• By setting a minimal respiratory rate and target inhaled tidal volume, a provider
can more closely target a goal minute ventilation.
• AVAPS also has utility in both hypoxemic and hypercarbic respiratory failure.
APPLICATION OF NIV
INITIATION OF NONINVASIVE
VENTILATION
1-Appropriate candidate selected,
2-Ventilator and interface must be chosen,
3-Ventilator settings must be selected,
4-Location (Icu or step-down unit that offers
adequate continuous monitoring until stabilized)
NIV - Apparatus
• Bilevel Pressure Support Ventilator (portable)/ ICU
Ventilator
• Interface - Interface is crucial to success of NIV
Silicon Bubble cushion Nasal mask, Nasal Pillow, Silicon
Full Face mask (better in acute RF)
 Head gear
 Oxygen supplementation
Interface
Definition:
The device that makes physical contact between the patient and the ventilator
is termed the interface.
Interfaces for NPPV come in a variety of shapes and sizes
Include:
Nasal mask, Nasal pillow, Oronasal mask (face mask) or the helmet.
Ideally, interfaces should be comfortable, offer a good seal, minimize leak, and
limit dead space.
• Nasal masks are widely used for the administration of CPAP or noninvasive
ventilation, particularly for chronic applications.

• Nasal masks are usually better tolerated than full face masks for long-term
applications, because they cause less claustrophobia and discomfort and
allow eating, conversation, and expectoration.

• The standard nasal mask is a triangular or cone-shaped clear plastic device

that fits over the nose and uses a soft cuff that forms an air seal over the
skin.

• Full facemasks cover both the nose and the mouth and are preferable to
nasal masks in the acute setting.
• The efficacy of both nasal and oronasal masks in lowering PaCO2 and avoiding
intubation is similar in the acute setting,

• but in a recent randomized trial, patients tolerated the full facemask better
because of reduced air leakage through the mouth.

• Selection of a comfortable mask that fits properly is key to the success of

noninvasive ventilation.

• The full facemask should be tried first in the acute setting, and if possible,

• The mask straps are then tightened with the least tension necessary to avoid
excessive air leakage.
NIPPV MASKS
Nasal Pillow
Nasal Mask
NIPPV MASKS
• Full Face Masks

Most of our patients !!

NIPPV MACHINES
• BiPAP
NIPPV MACHINES
• CPAP
 Head straps
• Head straps hold the mask in place and are important for
patient comfort.

• Straps attach at two to five points, depending on the type

of mask. More points of attachment add to stability.
OXYGENATION AND HUMIDIFICATION
• Oxygen is titrated to achieve a desired oxygen saturation, usually greater
than 90% to 92% either by using oxygen blenders on critical care and
some bilevel ventilators or by adjusting liter flow (up to 15 L/min)
delivered via oxygen tubing connected directly to the mask or ventilator
circuit.
• Bilevel ventilators have limited oxygenation capabilities (maximal
inspired oxygen fraction( %45 to 50)
• Ventilators with oxygen blenders should be used for patients with
hypoxemic respiratory failure.
• A heated humidifier should be used to prevent drying of the nasal
passage and oropharynx when the duration of application is anticipated
to be more than a few hours.
Initiating Noninvasive Mechanical
Ventilation
• Appropriately monitored location(spo2,vitals)
• Patient >30 angle
• Select interface to ensure a good fit and seal, select ventilator/machine
• Apply headgear ,connect interface to ventilatory tubing &turn on ventilator
• Initially supply to 5 cm H2O of CPAP with supplemental oxygen.
• Sequentially increase the CPAP pressure by 2-3 cm H2O increments every 5 to 10 minutes (ABG-Pulse
oximetry)
• Recommended initial settings for BiPAP machines in the noninvasive support of patients in respiratory
distress or failure are IPAP of 8-12 cm H2O and EPAP of 3 -5cm H2O, for a pressure support (IPAP minus
EPAP) of 5 cm H2O.
• The level of supplemental oxygen should be governed by goal pulse oximetry and corroborated by ABG
results as necessary;
• It is appropriate to initiate therapy with 2 to 5 L/minute, but this amount should be adjusted with each
titration of IPAP or EPAP.
Conceptually:
The intrinsic positive end-expiratory pressure (IPEEP), or
auto-PEEP, cannot be measured by a noninvasive
ventilator; therefore, EPAP should generally be
maintained below 8-10 cm H2O to be certain that it does
not exceed PEEP, in patients with obstructive lung disease.
The IPAP must always be set higher than EPAP
Continuation of NIV
• ABG at initiation & after 1-2hrs
• If PCO2 decreases, pH increases & Spo2 is maintained continue treatment
• Consider reduction in duration of NPPV Light diet to avoid nausea &
vomiting
• Continue other medication
• The first few hours are Labour intensive
• Motivation, training, & dedication leads to success
 Criteria for failure of NIV
Major Criteria
• Respiratory arrest
• Loss of consciousness
• Psychomotor agitation requiring sedation
• Haemodynamic instability
• Heart rate < 50 beats /min with loss of alertness
 Criteria for failure of NIV
Minor Criteria
• Respiratory rate > 35 breaths /min
• pH < 7.3
• pO2 < 45 mmHg
• Presence of weak cough reflex

One major or two minor criteria  Intubation

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+EPAP;
may need to go higher depending on ventilation requirements
>> ie BiPAP 14/10 or 8/5
From a Cochrane Review
• 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
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)
Typical starting point: BiPAP 10-12/6
Management Strategies
• Obesity-Hypoventilation Syndrome:-
Goal of therapy is to decrease work of breathing and increase ventilation
Combined disease as >90% will also have concurrent obstraction sleep Apnea
(OSA)
• EPAP:- usually on the higher side; enough to overcome OSA and
cardiopulmonary disease: ~10cmH2O, more for bigger individuals
IPAP+EPAP: at least a 4cm H2O differential
Need to adjust according to ventilation requirements; may benefit from back
up rate
Management Strategies
• Sleep Disordered Breathing:-

Most often post-op with known OSA or as a complication associated with

admit (CHF or Obesity-Hypoventilation)
For elective admit with known OSA: usual CPAP/BiPAP unless physiologic
changes with acute illness, surgery or narcotics.
Management Strategies
• Neuromuscular Disease:-
Goal to decrease work of breathing, decrease fatigue, assist ventilation
EPAP: usually low; 4-5cm H2O
IPAP+EPAP: at least 4cmH2O differential
May benefit from backup rate
Management Strategies
• ARDS:-
NIV may be used with great caution in cases of Acute Lung Injury & that too
only in ICU.
Reserved for hemodynamically stable patient who can be closely monitored
in an ICU where facilities for invasive ventilation are present
Management Strategies
• ARDS:-
 Independent risk factors for NIV failure include severe hypoxemia, shock, and
metabolic acidosis.
Those with > 2 organ failures, hemodynamic instability, or encephalopathy were
excluded
Predictors of NIV failure were Simplified Acute
Physiology Score II > 34 and Pao2/Fio2 < 175 after the first hour of therapy.
NIV cannot be recommended as routine therapy for ALI/ARDS, a cautious trial in highly
selected patients with a Simplified Acute Physiology Score II ≤ 34 and readiness to
promptly intubate if oxygenation fails to improve sufficiently within the first hour.
Rana S. Crit Care 2006, Antonelli M. Crit Care Med 2007
Management Strategies
• Hypoxemic Respiratory Failure Practice Points:-
Preferably Full-face mask during acute phase
Preferably ICU Ventilator as a high FiO2 can be administered
Pressure support with PEEP with fast rise time high inspiratory flow to
compensate for air leaks
NIV should be discontinued if no improvement in gas exchange & dyspnea,
significant mouth leak, severe mask intolerance, no improvement in mental
status in 30 min in a agitated hypoxemic patient
Management Strategies
• Other causes of respiratory failure:-
Pneumonia
Cancer and respiratory failure
Post-op management:
o Settings depend on disease and other cardiopulmonary disease
o Most often used as a bridge to mechanical ventilation or for pts DNR/DNI
o Usually moderate settings: 12/8 or 14/8
MONITORING
Once noninvasive ventilation is initiated, patients should be closely monitored in
a critical care unit or a step-down unit until they are sufficiently stable to be
moved to a regular medical floor.
The Aim of Monitoring is:-
Relief of symptoms, reduced work of breathing, improved or stable gas
exchange, good patient-ventilator synchrony, and patient comfort
A drop in the respiratory rate with improved oxygen saturation or improving pH
with a lower PaCO2, reduce heart rate, within the first 1 to 2 hours portends a
successful outcome.
The absence of these propitious signs indicates a poor response to noninvasive
ventilation
MONITORING OF NIV
• Subjective - Mask comfort
- Tolerance of ventilator settings
- Respiratory distress
• Physical findings - Respiratory rate
- Other vital signs
- Accessory muscle use - Abdominal paradox
• Ventilator parameters - Air leaking
- Adequacy of Pressure support
- Adequacy of PEEP
- Tidal volume 5-7 ml/kg
- Patient-ventilator synchrony
MONITORING OF NIV
• Gas Exchange
- Continuous oximetry until stable
- ABGS baseline & 1-2 hrs, then as indicated
• Location
- Usually ICU to start
- General Ward if stable
- Depends on monitoring needs of patient & monitoring capabilities
ADVERSE EFFECTS AND COMPLICATIONS IN
NIV
• Air-leak
• Discomfort and erythema or skin ulcers.
• Conjunctival irritation.
• Ear pain
• Nasal or oral dryness.
• Nasal congestion and discharge
• Gastric insufflation
• Patient-ventilator asynchrony
• Failure to ventilate
High-Flow Nasal Oxygenation (HFNO)
• HFNO is a respiratory support technique delivering heated, humidified
oxygen at high flow rates (upto60l/minute)through a nasal cannula.
• It improves oxygenation by reservoir effect and reduced dilution of inspired
oxygen.
• High-Flow washes out CO2 in anatomical dead space which improves CO2
clearance and respiratory efficiency by pharyngeal dead space washout.
• High-Flow overcomes resistance against the expiratory flow and creates
positive naso-pharyngeal pressure.
• HFNC can generate FIO21.0 and PEEP of upto 7.4 cm with mouth closed.
 HFNC Clinical Indications, Contrindications &
Complications

Clinical Indications:
• The prevention of, or relief from, hypoxemia with respiratory distress due to bronchiolitis or
pneumonia.
• Respiratory support to infants and children with chronic lung disease.
• HFNC therapy can be used if there is continuing hypoxemia (SpO2<90%) and signs of
moderate to severe respiratory distress despite oxygen therapy (like in COVID-19 patients).
• There is provision for use of HFNC therapy on patients in mild respiratory distress or who
exhibit signs of increasing oxygen requirements in order to prevent further deterioration.
• Weaning therapy from mask CPAP or BiPAP.
• Respiratory support post extubation and mechanical ventilation.
Contraindications:

• Critically ill infants and children requiring immediate higher level of

respiratory support i.e. NIV or invasive ventilation (especially in patients
with COVID-19)
• Upper airway obstruction
• Central apnea
• Asthma
• Blocked nasal passages/choanal atresia
• Trauma/surgery to nasopharynx
• Pneumothorax
• Decreased level of consciousness.
Complications:

• Abdominal distension.
• Pressure areas.
• Blocked HFNC due to secretions.
• Pneumothorax.
 HFNC VS NIV
• The FLORALI study (2015) found no difference in the intubation rate but
improvement in 90 days mortality and ventilator free days with the use of
HFNC
• In Thrive trial (2015), a case series including 25 patients with difficult
airways, apnic oxygenation time were extended to 14 minutes with HFNC.
• In systematic review and meta-analysis, Huang et al. (2018) explored HFNO
in immuno-compromised patients with acute respiratory failure.
Results suggest that compared to NIV, HNFO therapy might significantly
reduce mortality and intubation rate in the immuno-compromised patient
THANK YOU