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  • Non‐invasive Positive Pressure Ventilation The Who, the When, and the How

    John Park, MD

    Assistant Professor of Medicine

    park.john@mayo.edu

  • Disclosure

    • I have no financial conflicts of interests to disclose

    • I have given a variation of this talk before…but I try  to keep it updated…

    ©2010 MFMER  |  slide‐2

  • Outline

    • Terminology

    • Case studies

    • Indications

    • Contraindications

    • Clinical Applications

  • Terminology

    • Noninvasive ventilation • Means of providing respiratory assistance without the  use of endotracheal intubation

    • Typically provides assistance with gas exchange, but also  relieves severe dyspnea

    • Beyond providing oxygen supplementation

    ©2010 MFMER  |  slide‐4

  • Terminology

    • CPAP – Continuous positive airway pressure

    • BPAP – Bilevel positive airway pressure • BiPAP® ‐ Respironics • VPAP® ‐ ResMed • Bilevel – mechanical ventilation mode

    ©2010 MFMER  |  slide‐5

  • Pr es

    su re

    Respiratory Cycle

    Inspiration InspirationExhalation

    CPAP

    BPAP

    BiFlex

    Terminology

    Pressure support

    EPAP

    IPAP

  • Terminology • A‐PAP – Autotitrating PAP • BPAP S – Bilevel PAP, spontaneous • BPAP S/T • Adapt Servo Ventilator (ASV) • Auto SV • VPAP – Variable PAP • AVAPS – Average Volume Assured 

    Pressure support • OptiFlow • Respironics V60 ventilator • Trilogy

  • Terminology: Interface

    • Nasal mask

    • Nasal pillows

    • Full face mask

    • Face shield

    • Oral mask

    • Chin strap

  • Case 1

    • 72 year old with history of CHF (LVEF 30%), ischemic  cardiomyopathy, HTN, and CKD presents with four day  history of progressive dyspnea at rest. She denies any  fevers, chills, or rigors. She has been sleeping in a  recliner for the last two nights. 

    • BP 110/79, HR 100, RR 30, Temp 37.6°C, O2 sat 90% • She appears to be in slight respiratory distress and she  does not wish to lie down to be examined. Her JVP is 12.  You hear an S3 and crackles bilaterally. She has 2+ pitting  edema bilaterally.

    ©2010 MFMER  |  slide‐9

  • Case 1

    In addition to diuretics, what is the next best means of respiratory support for this patient?

    A. Oxygen by nasal cannula

    B. High flow humidified oxygen therapy

    C. Continuous positive airway pressure therapy

    D. Adaptive servo ventilation

    E. Endotracheal intubation

    ©2010 MFMER  |  slide‐10

  • Physiology CPAP

    • In acute CHF • Increased intrathoracic pressure results in decreased  preload

    • Improves afterload

  • CPAP vs BPAP in cardiogenic pulmonary edema

    ©2010 MFMER  |  slide‐12

    Gray, NEJM 2008;359:142

  • Clinical Applications CHF

    Gray, NEJM 2008;359:142

  • Clinical Applications CHF

    Gray, NEJM 2008;359:142

    P = 0.64

  • Clinical Applications CHF ‐Mortality

    Cochrane Database of Systematic Reviews 2008

  • Clinical Applications CHF – Endotracheal Intubations

    Cochrane Database of Systematic Reviews 2008

  • Clinical Applications CHF – Incidence of AMI

    Cochrane Database of Systematic Reviews 2008

  • Case 2

    • 67 year old with severe COPD (FEV1 30%), CAD, HTN  presents with three day history of progressive dyspnea.  He has had fevers and increased productive cough.

    • On exam, he appears to be in moderate respiratory  distress with RR of 35, starting to use accessory muscles,  and only able speak few words at a time. His oxygen  saturation is 89% on 2 L/min. His lung exam reveals  diffuse expiratory wheeze with prolonged expiratory  phase.

    ©2010 MFMER  |  slide‐18

  • Case 2

    In addition to antibiotics, bronchodilators, and steroids, what additional therapy should you provide?

    A. Increase oxygen with the use of a non-rebreather mask

    B. Optiflow

    C. CPAP

    D. BPAP

    E. Intubation and mechanical ventilation

    ©2010 MFMER  |  slide‐19

  • Clinical Applications COPD Exacerbations: Mortality

    Ram, Cochrane Database of Systemic Reviews 2004

  • Clinical Applications COPD Exacerbations: Intubation

    Ram, Cochrane Database of Systemic Reviews 2004

  • Clinical Applications COPD Exacerbations: Length of hospital stay

    Ram, Cochrane Database of Systemic Reviews 2004

  • Clinical Applications COPD Exacerbations

    • GOLD 2016 • Clearly states NIV improves outcomes, mortality, and  hospital length of stay as grade A evidence

    • Indications: • Respiratory acidosis (pH ≤ 7.35 and/or PaCO2 ≥ 45 mm Hg) • Severe dyspnea suggestive of respiratory muscle fatigue or  increased work of breathing

    www.goldcopd.org

  • Clinical Applications

    • Acute respiratory failure • Brief trial • In ARDS. . .perhaps

    • Except. . . • Delay in intubation may worsen outcomes • Concern about excessive tidal volumes

  • Case 3

    67 year old with severe COPD presented with an acute  exacerbation three days ago. He was briefly tried on NIV  but failed and is now intubated.

    He has remained afebrile for the past 24 hours, he is  awake, with strong cough and minimal tracheal secretion.

    ©2010 MFMER  |  slide‐25

  • Question 3

    You tried a weaning trial. On pressure support of 5 and PEEP of 5, his respiratory rate was 25 and tidal volume of 250 with oxygen saturation of 90% on 50% FiO2. What is the next best course of action?

    A. Re-sedate and try tomorrow

    B. Increase steroids and try tomorrow

    C. Extubate

    D. Extubate to NIV

    ©2010 MFMER  |  slide‐26

  • Clinical Applications Early use of NIV in Extubation

    Ferrer, AJRCCM 2006;173:164

  • Clinical Applications Extubation

    Ferrer, AJRCCM 2006;173:164

  • Clinical Applications Use of NIV in Weaning

    Burns, BMJ 2009;338:b1574

  • Contraindications

    ATS AJRCCM 2001;163:283

    **

  • Clinical Application How to

    • Decide if you will use CPAP or BPAP • Depends on indications

    • Typically try nasal interface unless they are clearly  mouth breathing

    • Full face mask may help in those with severe dyspnea but  may have some difficulty if they are claustrophobic

  • Clinical Application How to

    • Slowly introduce the mask and the pressure • Some patients may need more rapid up titration of  pressure

    • More flow for some who are claustrophobic • As you adjust the pressure, check for leaks and adjust

  • Clinical Application How to • CPAP

    • If suspect OSA • Use auto‐titrating CPAP

    • You may need to start the minimum pressure  higher

    • Consider nasal mask first • If claustrophobic, nasal pillows • Full face mask if mouth breather, or at least a chin  strap

  • Clinical Application How to

    • CPAP • For CHF • Don’t use auto‐CPAP if you suspect central sleep apnea,  unless you have updated equipment

    • Pick an empiric pressure, between 7 ‐ 10

  • Clinical Application How to

    • BPAP • Can be used with nasal pillows/masks • If neuromuscular weakness, keep EPAP low • Need EPAP high enough to keep airways open

    • If have coexisting OSA

  • Clinical Application How to

    • BPAP • Need EPAP high enough to overcome PEEPi

    • If have obstructive lung disease • Need to do this cautiously since they are already  hyperinflated

  • Waterfall Theory

    ©2010 MFMER | slide-37

    PEEPi Extrinsic PEEP < PEEPi

    PEEPi Extrinsic PEEP = PEEPi

    PEEPi Extrinsic PEEP > PEEPi

  • Clinical Application How to

    • BPAP • IPAP should be at least 4 above EPAP • If hypercapnic, increase pressure support

    • Increase IPAP > EPAP • May also need to increase EPAP if hypercapnia is not  improving

    • Can increase EPAP if hypoxemic • Maintain the pressure support if they are also hypercapnic

  • Clinical Application How to

    • BPAP • Need to carefully observe to make sure patient is  synchronizing well with the machine

    • May take some time to ensure adequate setting • Consider starting BPAP in a

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