Basic Principles of Critical Care

1. INVASIVE AND NONINVASIVE
VENTILATION
Gradian Health Systems
Basic Principles of Critical Care
RESPIRATORY SYSTEM

2. Disclaimer
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 2
Gradian Health Systems
Basics Principles of Critical Care
Respiratory System

4. Module 2: Respiratory System
MODULE OVERVIEW
Lesson 1 I Respiratory System Anatomy and Physiology
Lesson 2 I Oxygen Therapy
Lesson 3 I Evaluation of the Respiratory System
Lesson 4 I Airway Equipment and Management
Lesson 5 I Invasive and Non-invasive Ventilation
Lesson 6 I Basics of Mechanical Ventilation
Lesson 7 I Ventilator Modes and Settings
Lesson 8 I Ventilation Complications
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

5. Components of the Gradian CCV SystemLesson 5: Invasive and Non-invasive Ventilation
Lesson Objectives
• Differentiate between invasive and non-invasive ventilation
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

6. Components of the Gradian CCV SystemLesson 5: Invasive and Non-invasive Ventilation
Key Concepts
• Invasive ventilation
• Non-invasive ventilation (NIV)
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

7. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Definitions of Key Terms
• Positive pressure ventilation I refers to the movement of air into the airway
using positive pressure
• Noninvasive ventilation I refers to ventilatory support provided without the
use of an invasive airway (e.g. supraglottic device, ETT, tracheostomy), i.e.
with the use of a nasal or face mask
• Invasive ventilation I refers to ventilatory support provided with the use of
an invasive airway (e.g. supraglottic device, ETT, tracheostomy)
• Hypoxemic respiratory failure I AKA respiratory failure type I; characterized
by low oxygen levels (PaO2 <60mmHg) and normal or low PaCO2
• Hypercapnic respiratory failure I AKA respiratory failure type II;
characterized by high PaO2 levels (PaCO2 > 50mmHg)
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

8. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Noninvasive Ventilation (NIV) Indications
• Acute hypercapnic ventilatory failure (e.g. acute exacerbations of COPD,
asthma)
• Post-extubation period
• Cardiogenic pulmonary edema – used in addition to other measures
• Hypoxemic respiratory failure
• Obstructive sleep apnea
• Patients who may not need intubation but admitted to the HDU to support
respiratory system
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

9. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Noninvasive Ventilation (NIV) Contraindications
• Cardiac or respiratory arrest
• Coma or altered mental status (confusion, agitation)
• Inability to protect the airway
• Airway obstruction
• Staff inexperience
• Vomiting
• Trauma to the face and neck
• Hypotension
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

10. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Noninvasive Ventilation (NIV) Complications
• Claustrophobia
• Aspiration – this is increased with air swallowing
• Inability to talk or eat
• Trauma – pressure sores, abrasions
• Hypotension –occurs if the pressure settings are so high such that venous
return is impaired
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

11. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Types of NIV
• Continuous positive airway pressure ventilation (CPAP)
• Bilevel positive airway pressure ventilation (BiPAP)
CPAP
Provides positive pressure throughout the respiratory cycle (inspiration and
expiration). Airways remain open, reducing the work of breathing and improving
oxygenation.
BiPAP
Provides different pressures in inspiration and expiration. Inspiratory pressure
(iPAP) is usually higher than expiratory pressure (ePAP).
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

12. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
NIV Preparation
• Be familiar with equipment and ventilator
• Ensure mask fits appropriately on patients face
• Seek patient consent
• Explain how to breathe through the mask and allow them to practice and
become comfortable with the use
• Set the machine to allow for comfort and escalate gradually to the desired
setting while evaluating patient’s synchronization with the machine
• Ensure constant monitoring of the patient (ECG, SpO2, RR, ABG)
• Consider antiemetic, if patient is nauseous
• Have a plan in case of NIV failure or if patient deteriorates
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

13. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Invasive Ventilation
This is what most people refer to as mechanical ventilation (MV). The
components of MV include the ventilator, oxygen source, and the artificial airway
tubes – standard ETTs and tracheostomy tubes
This section is intended to be introductory. Ventilators and ventilation will be
covered in more detail during the next lesson.
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

14. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Indications for Mechanical Ventilation (MV)
• Cardiorespiratory arrest
• Tachypnea
• Respiratory failure
Goals of MV
Based on the indications for mechanical ventilation and broadly classified as:
• Support of the respiratory system – relief of respiratory distress, decrease
work of breathing and muscle fatigue
• Improve gaseous exchange
• Protect the airway from complications of mechanical ventilation
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

15. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
MV Complications
• Hypotension due to reduction in cardiac output
• Ventilator associated lung injury (VALI)
• Barotrauma: injury due to high pressures
• Volutrauma: injury due to high volume
• Oxygen toxicity
• Aspiration
• GI bleeding due to stress ulcers
• Ventilator associated pneumonia (VAP)
• Deep venous thrombosis
• Trauma associated with endotracheal intubation – laryngeal injury
and stenosis, tracheal stenosis
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

16. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Weaning From Mechanical Ventilation
Ventilation, when not required, can be life threatening so should be discontinued
as early as possible. It takes up considerable ICU staff time. There are two
components of weaning: discontinuation of ventilation and removal of the airway.
Weaning should be attempted when the following conditions are met:
Every day in the morning we should assess patient for weaning by daily
screening and spontaneous breathing tests (SBTs):
• Alert, cooperative patient
• Acute phase of disease process has resolved
• Acceptable pattern and depth of spontaneous breathing
• Patient coughs when suction catheter is passed, entacting gag reflex
• Patient not receiving any vasopressor or sedative infusion drip
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

17. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Weaning from Mechanical Ventilation
Successful weaning takes place in three stages:
• Patient is gradually removed from the ventilator
• Patient is removed from the tube
• Patient is removed from oxygen
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

18. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Weaning from Mechanical Ventilation
Weaning should be done within the shortest time possible but with consideration
for patient safety. The decision should be based on physiological, rather than
mechanical, point of view. The patient’s clinical status is the key determinant
factor and weaning should be started when the patient is recovering from the
acute stage and when the primary need for ventilator support has been
addressed. To achieve greater success there should be collaboration between
the physician, respiratory therapist, and the nurse to aid in conservation of the
patient’s strength, efficient use of resources, and to maximize outcomes.
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation

19. Components of the Gradian CCV SystemInvasive and Non-invasive Ventilation
Care Related to Weaning
• Prepare for weaning from the beginning of mechanical ventilation.
• Patient should be reassured that the use of a ventilator is temporary
• Remain with the patient during weaning as they are not attached to the
ventilator alarms and may be unable to summon for help
• Patient deterioration may go unnoticed.
• Weaning should not be attempted at night until prolonged day time periods of
spontaneous breathing are well established – staff patient ratio is important
Assess status of blood gasses
• Reduce oxygen concentration gradually
• Provide psychological support for the patient
• Maintain IPC at all times
Basic Principles of Critical Care Training I Invasive and Non-invasive Ventilation