2. Overview
History
Types of ventilators and modes of NIV
Interfaces
Indications & Contraindications
How to start and Monitor
Advantage, disadvantages and complications
NIV in different clinical conditions
Conclusion
3. History
Initially negative pressure ventilators (Tank & cuirass
ventilators) were used for ventilating large number of
victims of polio during acute illness
Drinker-Shaw’s Iron Lung 1928
5. History
In 1981 Sullivan and colleague -continuous positive
airway pressure(CPAP) for obstructive sleep apnea (OSA)
BiPAP was developed in mid 1990's
This was followed by improvements in the interface and
establishment of role of NIV in patients of COPD
American Journal of Respiratory and Critical Care Medicine Volume 191
Number 10 | May 15 2015
6. Definition
Non-invasive ventilation is a technique of providing
ventilation without the use of an artificial airway
(endotracheal intubation or tracheostomy)
ARFC Consensus Conference: non-invasive
positive pressure ventilation: consensus
statement, Respir Care 42:362,
7. Types ventilators for NIV
Conventional ICU ventilators Portable NIV ventilators
• Separate inspiratory and
expiratory tubing
• Non vented mask is used
• Precise and high FiO2
• Better monitoring and
alarm system
• Has single limb tube
• Requires vented mask
• Less precision
8. Basic settings and graphics
EPAP
IPAP
Trigger
Cycle
Inspiratory time
Back up ventilation
Types of breath
9. What causes the
breath to begin ?
TRIGGER:
Initiation of a
new breath
(start
inspiration)
MACHINE:
Time
PATIENT:
Flow
Pressure
Trigger
21. Mechanism of action
NIV
Positive end
expiratory
pressure
Unloads
respiratory
muscles
Decrease
work of
breathing
Increase FRC
by recruitment
of lungs
Decreases
preload and
afterload
Offsets
auto-PEEP
Improves
compliance
Improves
oxygenation
Unloading of
respiratory
muscles
Improves
cardiac
output
Inspiratory
pressure
support
22. AUTO PEEP
+8
EPAP - 0
Patient effort required
-10 cm H2O
AUTO PEEP
+8
SET TRIGGER
-2 cm H2O
EPAP - 6
Patient effort required
-4cm H2O
SET TRIGGER
-2 cm H2O
AUTO PEEP and EPAP
23. Interfaces
Devices that connect ventilator and tubing to the face
Types
– Nasal mask
– Nasal pillow
– Oro-nasal mask
– Full face mask
– Helmet
Interfaces should be comfortable, offer a good seal,
minimize leak, and limit dead space
24. Nasal Masks
Covers only nose
Less claustrophobia and discomfort
– allow eating, conversation and
expectoration
Better tolerated than full face masks
Problem –air leakage through mouth
30. Full Face Masks
Advantages Disadvantages
1.Better control of mouth leaks 1. Difficulty in speaking and
coughing
2.Little cooperation required 2. High risk of aspiration
3.Better for mouth breather 3. Claustrophobia
31. NIV helmet
Covers the whole head and all or part of neck
No immediate contact with face
32. NIV helmet
Advantages Disadvantages
1. Minimum air leak 1. Rebreathing
2. Little cooperation 2. Axillary skin
required damage
3. Absence of nasal
or facial skin damage
33. Indications
Acute setting
AECOPD with type2 respiratory failure
Obesity hypoventilation syndrome with acute on chronic
type2 respiratory failure
Acute cardiogenic pulmonary edema
Immunocompromised with pneumonia
Rochwerg et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation
for acute respiratory failure. Eur Respir J 2017
34. Indications
Acute setting
Mild ARDS under close monitoring
Post operative respiratory failure
Weaning
As palliative therapy
Rochwerg et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation
for acute respiratory failure. Eur Respir J 2017
35. Indications
Chronic setting
Home NIV for COPD
OSA
Obesity hypoventilation syndrome
Neuromuscular disorder, chest wall deformity
Rochwerg et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation
for acute respiratory failure. Eur Respir J 2017
36. Contraindications
Need for an emergent intubation
Hemodynamic instability, cardiorespiratory arrest
Inability to co-operate/protect airway/clear secretions
Severely impaired consciousness (GCS <10)
Non respiratory organ failure that is acutely life
threatening
Facial surgery /trauma
Prolonged MV anticipated
Rochwerg et al. Official ERS/ATS clinical practice guidelines: noninvasive
ventilation for acute respiratory failure. Eur Respir J 2017
37. Application of NIV in portable ventilators
Choose correct interface
Explain therapy and its benefit and outcome
Set spontaneous (S) or S/T mode
Start with IPAP of 6-8cmH20, EPAP2-4 cmH2o
IPAP-EPAP should be 4 cmH2o
Administer O2 at 2 lit/min
NIV guidines ISCCM 2006
38.
39. Hold interface with hand over his face, do not fix it
Increase EPAP by 1-2 cm increments till all his inspiratory
efforts are able to trigger the ventilators
EPAP usually titrated to 4 to 6cm
Adjust Ti max to approx 1 sec, set up backup rate
Increase IPAP- 1-2 cm H2O up to maximum
pressure which patient can tolerate
Now Secure interface
Increase O2 to target spo2 of 88 to 92%
40. Application of NIV in standard ICU ventilator
Choose correct interface
Explain therapy and its benefit and outcome
choose mode- pressure support or pressure control
silent ventilator alarms, keep FiO2 minimum
Inspiratory PS 5-6 cm H20 , PEEP 2 cmH20
NIV guidines ISCCM 2006
41. Hold interface with hand over his face, do not fix it
Increase PEEP by 1-2 cm increments till all his inspiratory
efforts are able to trigger the ventilators
PEEP usually titrated to 5-10
Adjust Ti max to approx 1 sec, set up backup rate
Increase Insp. pressure - 1-2 cm H2O up to maximum
pressure which patient can tolerate
Now Secure interface
Increase Fio2 to target spo2 of 88 to 92%
42. Monitoring
Subjective responses
Bed side observation
Ask about discomfort related to the mask or airflow
Physiologic response
↓ RR, ↓ HR, BP, continuous ECG
Level of consciousness
↓ accessory muscle activity and abdominal paradox
Monitor air leaks and Vt
43. Monitoring
Patient machine synchrony
Chest wall movement, air leak
Gas exchange
Continuous spo2 monitoring
ABG after ½ to 1 hr of initiation and 1 hr after every
subsequent change in setting
Every 4 hr till patient is stable
44. Criteria for switching to invasive
mechanical ventilation
Worsening pH and PaCO2
Tachypnea (over 30 bpm)
Hemodynamic instability
SpO2 < 90%
Decreased level of consciousness
Inability to clear secretions
Inability to tolerate interface
45. Complications Corrective actions
• Mask discomfort
• Excessive leak around mask
• Pressure sores
Nasal or oral dryness
Aerophagia/gastric distention
Aspiration
Mucus plugging
Hypotension
• Check mask for correct size & fit
• Minimize headgear tension
• Change to different mask
• Use wound care dressing
• Add or increase humidification
• Irrigate nasal passage with saline
• Use lowest effective pressure for
adequate Vt
• Use simethicone agents
• Make sure patient able to protect
airway
• Ensure adequate hydration
• Ensure adequate humidification
• Avoid excessive O2 flow(>20 l/min)
• Avoid excessive high PEEP
46. Sedation with NIV
Sedation should only be used with close monitoring
Infused sedative /anxiolytic only in ICU
Agitated /distressed on NIV
(iv morphine 2.5-5 mg (+/- benzodiazepine) may improve
tolerance of NIV)
A Craig Davidson AC et al.thorax 2016;ii1-ii35
48. NIV in COPD exacerbation
Multiple RCTs support a success rate of 80‐ 85%
Mortality & intubation rates are reduced
(Evidence A)
GOLD update2017
49.
50. NIV in COPD exacerbation
Respiratory acidosis (pH<7.35 &/or PaCO2 >45mmHg)
Severe dyspnea with clinical signs s/o respiratory muscle
fatigue
Use of respiratory accessory muscles
Paradoxical motion of abdomen
Intercostal retraction
Persistent hypoxemia despite supplemental oxygen therapy
GOLD update2017
51. NIV in acute cardiogenic
pulmonary edema
CPAP/BIPAP recommended in addition to standard
medical treatment in cases of cardiogenic pulmonary
edema. (Level 1)
CPAP & BIPAP equally effective in cardiogenic
pulmonary edema (Level I).
BIPAP is preferable in patients associated with
hypercapnic respiratory failure. (Level II)
NIV guidlines for acute respiratory failure,Indian Society Of Critical
care Medicine(ISCCM) 2006
52.
53. Chronic respiratory failure (Obstructive
lung disease)
As chronic home NIV
Stable very severe COPD
Excessive daytime hypercapnia
Recent hospitalization
Concurrent OSA
GOLD update 2017
54. NIV in ARDS
NIV may be used with great caution in cases of Acute Lung
Injury and that too only in ICU (Level III)
Reserved for hemodynamically stable patient who can be
closely monitored in an ICU
NIV in CAP
NIV may be used in the ICU with caution in selected patients
with community acquired pneumonia particularly in those with
associated COPD (Level II)
NIV guidelines for acute respiratory failure, Indian
Society Of Critical care Medicine(ISCCM) 2006
55. Cystic fibrosis
• NIV may be helpful as rescue therapy to support acute
respiratory failure in cystic fibrosis, providing
a bridge to lung transplantation (Level II)
• Improvement in hypoxemia but not in hypercapnia
ILD
• NIV is not recommended for interstitial lung disease with acute
on chronic respiratory failure. (Level III)
NIV guidlines for acute respiratory failure,Indian
Society Of Critical care Medicine(ISCCM) 2006
56. NIV for weaning
Weaning in uncomplicated COPD who fail a trial of spontaneous
breathing. (Level II)
Not recommended postextubation respiratory failure in non-
COPD cases . It may, however, be used in COPD patients. (Level
III)
Routinely after extubation for reducing incidence of respiratory
failure and reintubation rate is not recommended. (Level II)
Can be recommended in after extubation who have a high risk of
developing respiratory failure and reintubation (age>65 yrs,
APACHE II>12 at the time of extubation, cardiac failure at time of
intubation). (Level I)
NIV guidlines for acute respiratory failure,Indian
Society Of Critical care Medicine(ISCCM) 2006
57. NIV in Asthma
GINA 2018 update
Evidence regarding the role of NIV in asthma is weak
If NIV is tried, the patient should be monitored
closely (Evidence D)
It should not be attempted in agitated patients, and
patients should not be sedated in order to receive NIV
(Evidence D)
58. Immunocompromised patients
Multiple RCTs support whenever possible, NIV should be
tried first in immunocompromised patients with hypoxemic
RF (Level 1)
Trauma
Can be recommended for hemodynamically stable
patients of chest trauma with flail chest (Level II)
Post- op RF
After lung resection or abdominal surgery (levelII)
NIV guidlines for acute respiratory failure,Indian
Society Of Critical care Medicine(ISCCM) 2006
59.
60. 1) Which of the following statements
concerning mask is/are true?
a) Masks covering mouth and nose are more effective in improving
blood gases than nasal masks in acute respiratory failure
b) Oro nasal masks are better tolerated than nasal masks in acute
respiratory failure
c) Nasal masks are the first choice for NIV in acute respiratory
failure
d) Mask switching is not recommended in the first 24 hr of NIV in
acute respiratory failure
61.
62. Fitting Orofacial Mask
Landmarks
a) Below the lower lip with
mouth open
b) Corners of the mouth
c) Just below the junction of
nasal bone and cartilage
Sizes
S- Small (8-9cm)
M- Medium (9-10cm)
L- Large (10-11cm)
1
a
b
c
b
63. Nasal Mask Fit
Anatomic Landmarks
a) Sides of nose
b) Bridge of nose (caution)
c) Above the lip
64. Interfaces of choice
Oro nasal Total
face
Helmet Nasal
Mask
Nasal
prongs
Mouth
piece
Acute setting
Claustrophobic
Home NIV
Frequent
Expectoration
High level of
noise
Abnormal facial
anatomy
66. 2) Which of the following statements concerning
interface-related pressure ulcers in NIV is/
are true?
a. Pressure ulcers occur more often with oro nasal than nasal
masks
b. A helmet cannot create pressure ulcers
c. The use of skin protective dressings can reduce the incidence of
pressure ulcers
d. The most important strategy to prevent mask- related pressure
ulcers is rotation of different masks
67. 3) A 55 yr old male k/c/o COPD presents in emergency
with acute onset shortness of breath for last 2 days and
decrease in sensorium since last 4 hrs
O/E GCS- 8/15, tachypneic, tachycardic, BP- 110/80
mmHg
ABG : pH- 7.27, Pco2- 72, Po2 – 64 mmHg, Hco3- 30
How will you manage?
a. Intubate and ventilate with PPV
b. Start on BIPAP therapy using portable ventilator
c. Start on NIV using ICU ventilator using orofacial mask
d. Start on high flow Oxygen therapy
68. 4) A 58 yr old smoker presents with an exacerbation of his COPD to the
emergency department.
O/E- Tachypnoeic (respiratory rate 32 per min)
Initial ABG on room air
pH - 7.28, PaO2- 50 mmHg , PaCO2- 58 mmHg.
He is started on nebulized bronchodilators, steroids, antibiotics, and
NIV with a facial mask and a ventilator in the emergency department.
He synchronises well with the ventilator, his respiratory rate decreases
to 23 per min after 1 h,
ABG: pH 7.32, PaO2 64 mmHg and PaCO2 50 mmHg, and the patient
feels better.
69. He is transferred to a HDU and NIV is restarted with a smaller
ventilator. The patient is doing well on the ventilator. There is
no significant air leak, no signs of auto-positive end-expiratory
pressure, patient ventilator asynchrony or pneumothorax, but
the next arterial blood gas shows a pH of 7.29, PaO2 60 mmHg
and PaCO2 of 65 mmHg. What is the most appropriate next step?
a. Continue the patient on oxygen only
b. Repeat the arterial blood gas analysis
c. Check the equipment used (ventilator, circuit and mask)
d. Intubate the patient immediately
e. Change to a nasal mask
71. Carbon dioxide rebreathing
Circuit- open single limb circuit or a closed double-limb
circuit.
Single limb circuit- requires a vented mask or a non vented
mask with exhalation valve
A closed double limb circuit is used with a non vented mask
Exhalation port should never be obstructed intentionally to
reduce leakage
Colours on the mask or the mask elbow
Blue colour represents non vented masks
Clear entrainment elbow for vented masks
72. 5) A 45 year old female k/c/o severe obstructive
sleep apnea , on CPAP therapy for last 3 months
presents to sleep clinic with complaints dryness of
mouth and throat. What will you advise?
a) Reassurance and continue the same
b) Increase daily intake of fluids
c) Use mouth lubricants
d) Use a humidifier
73. Dryness of mucosa and humidification
Oral and nasal dryness or a blocked nose are frequent complaints
-occurrence rate of 10–50%
Air leaking through the mouth or around the mask, but even
without an air leak
Treatment
Topical nasal application of saline, hyaluronic acid, steroids,
decongestants or antihistamines, and regular mouth care
Addition of heat/moisture exchangers and an external heated
humidifier to the circuit.
Decrease dryness and enhance comfort and tolerance
of mask ventilation
It is also recommended to avoid thickened and tenacious
secretions.
Humidifier is not routinely recommeded
74. NIV has an important role in the management of acute respiratory
failure
Careful Patient selection, explanation, Close observation & monitoring
are critical for success of NIV
Selection of a comfortable interface is the key to success
Low GCS is not a contraindication for NIV in Acute exacerbration
of COPD
NIV shoudn’t be attempted in patient who has indication for
endotracheal intubation
Take home messages
