NON INVASIVE NON INVASIVE VENTILATIONVENTILATION

NON INVASIVE NON INVASIVE VENTILATIONVENTILATION

Definition: Definition: NIV is the delivery of mechanical NIV is the delivery of mechanical

ventilation to the lungs ventilation to the lungs

using techniques that do not require an using techniques that do not require an endotracheal airwayendotracheal airway

Definition: Definition: NIV is the delivery of mechanical NIV is the delivery of mechanical

ventilation to the lungs ventilation to the lungs

using techniques that do not require an using techniques that do not require an endotracheal airwayendotracheal airway

Types: Types: o negative pressure NIVnegative pressure NIV

Main means of NIV Main means of NIV during the 1during the 1stst half of the half of the 2020thth century century

o positive pressure NIVpositive pressure NIV

resurgence in the resurgence in the early 1980s due to the early 1980s due to the development of nasal CPAPdevelopment of nasal CPAP

Why the interest in NIVWhy the interest in NIV Why the interest in NIVWhy the interest in NIV The desire to avoid complications The desire to avoid complications

of invasive ventilation of invasive ventilation Complications related to the Complications related to the

process of intubation and process of intubation and mechanical ventilationmechanical ventilation

• Aspiration Aspiration • TraumaTrauma• Arrythmias and hypotensionArrythmias and hypotension• barotraumabarotrauma Complications caused by loss of Complications caused by loss of

airway defense mechanismsairway defense mechanisms• Direct conduit to lower airway Direct conduit to lower airway chronic chronic

bacterial colonizationbacterial colonization

The desire to avoid complications The desire to avoid complications of invasive ventilation of invasive ventilation Complications related to the Complications related to the

process of intubation and process of intubation and mechanical ventilationmechanical ventilation

• Aspiration Aspiration • TraumaTrauma• Arrythmias and hypotensionArrythmias and hypotension• barotraumabarotrauma Complications caused by loss of Complications caused by loss of

airway defense mechanismsairway defense mechanisms• Direct conduit to lower airway Direct conduit to lower airway chronic chronic

bacterial colonizationbacterial colonization

Complication that occur Complication that occur after removal of ETTafter removal of ETT

• Hoarseness, sore throat, coughHoarseness, sore throat, cough• Sputum productionSputum production• Upper airway obstructionUpper airway obstruction• hemoptysishemoptysis

From the patient’s point of From the patient’s point of viewview

• Discomfort Discomfort • Decreased ability to eat and communicateDecreased ability to eat and communicate

Complication that occur Complication that occur after removal of ETTafter removal of ETT

• Hoarseness, sore throat, coughHoarseness, sore throat, cough• Sputum productionSputum production• Upper airway obstructionUpper airway obstruction• hemoptysishemoptysis

From the patient’s point of From the patient’s point of viewview

• Discomfort Discomfort • Decreased ability to eat and communicateDecreased ability to eat and communicate

Advantages of NIV Advantages of NIV Advantages of NIV Advantages of NIV

Leaves upper airway intactLeaves upper airway intact Preserve airway defense Preserve airway defense

mechanismsmechanisms Allows patient to eat, drink, Allows patient to eat, drink,

verbalize and expectorateverbalize and expectorate Enhance comfort, convenience Enhance comfort, convenience

and portabilityand portability Less costLess cost

Leaves upper airway intactLeaves upper airway intact Preserve airway defense Preserve airway defense

mechanismsmechanisms Allows patient to eat, drink, Allows patient to eat, drink,

verbalize and expectorateverbalize and expectorate Enhance comfort, convenience Enhance comfort, convenience

and portabilityand portability Less costLess cost

InterfacesInterfacesInterfacesInterfacesDevices that connect the Devices that connect the

ventilator‘s tubing to the face ventilator‘s tubing to the face allowing pressurized gas to enter allowing pressurized gas to enter

into upper airwayinto upper airway

Devices that connect the Devices that connect the ventilator‘s tubing to the face ventilator‘s tubing to the face

allowing pressurized gas to enter allowing pressurized gas to enter into upper airwayinto upper airway

Nasal Nasal Cone shaped clear plastic device Cone shaped clear plastic device with soft cuffwith soft cuff

Multiple sizes and shapesMultiple sizes and shapesChronic applicationChronic applicationBetter tolerated by patients Better tolerated by patients with claustrophobiawith claustrophobia

Exert pressure over the bridge Exert pressure over the bridge of the noseof the nose

Avoided byAvoided byo Fore head spacerFore head spacero Nasal mask with gel sealNasal mask with gel sealo Mini-masksMini-maskso Custom-molded individualized Custom-molded individualized masksmasks

o Thin plastic flapThin plastic flapo Nasal pillows (pledgets directed Nasal pillows (pledgets directed to the nostrils)to the nostrils)

Avoided byAvoided byo Fore head spacerFore head spacero Nasal mask with gel sealNasal mask with gel sealo Mini-masksMini-maskso Custom-molded individualized Custom-molded individualized masksmasks

o Thin plastic flapThin plastic flapo Nasal pillows (pledgets directed Nasal pillows (pledgets directed to the nostrils)to the nostrils)

Oronasal ( full face mask)Oronasal ( full face mask) PreferredPreferred

o in acute settingsin acute settingso for patients with copious air leaking for patients with copious air leaking through the mouththrough the mouth

o For edentulous patientsFor edentulous patients Interferes with speech, eating and Interferes with speech, eating and

expectorationexpectoration Increase risk of aspiration, rebreathingIncrease risk of aspiration, rebreathing Increase likelihood of claustrophobic Increase likelihood of claustrophobic

reactionreaction Total face mask (hockey goalie‘s mask)Total face mask (hockey goalie‘s mask)

Oronasal ( full face mask)Oronasal ( full face mask) PreferredPreferred

o in acute settingsin acute settingso for patients with copious air leaking for patients with copious air leaking through the mouththrough the mouth

o For edentulous patientsFor edentulous patients Interferes with speech, eating and Interferes with speech, eating and

expectorationexpectoration Increase risk of aspiration, rebreathingIncrease risk of aspiration, rebreathing Increase likelihood of claustrophobic Increase likelihood of claustrophobic

reactionreaction Total face mask (hockey goalie‘s mask)Total face mask (hockey goalie‘s mask)

Mouth piecesMouth pieces Provides NIPPV to patients with Provides NIPPV to patients with

chronic respiratory failurechronic respiratory failure Simple inexpensiveSimple inexpensive Nasal air leaking decrease its efficacyNasal air leaking decrease its efficacy

o Managed by increasing ventilator‘s Managed by increasing ventilator‘s tidal volumetidal volume

o Occluding nostrils with cotton Occluding nostrils with cotton pledgets or nose clips pledgets or nose clips

Ventilators for NIPPVVentilators for NIPPVVentilators for NIPPVVentilators for NIPPV

CPAPCPAP Delivers constant pressure during both Delivers constant pressure during both

inspiration and expirationinspiration and expiration Increase functional residual capacityIncrease functional residual capacity

• Improve lung complianceImprove lung compliance• Open collapsed alveoliOpen collapsed alveoli• Improve oxygenationImprove oxygenation• Decrease work of breathingDecrease work of breathing

Decrease left ventricular transmural Decrease left ventricular transmural pressure, ↓ afterload and ↑COPpressure, ↓ afterload and ↑COP

Simple, small and cheap portable units are Simple, small and cheap portable units are availableavailable

CPAPCPAP Delivers constant pressure during both Delivers constant pressure during both

inspiration and expirationinspiration and expiration Increase functional residual capacityIncrease functional residual capacity

• Improve lung complianceImprove lung compliance• Open collapsed alveoliOpen collapsed alveoli• Improve oxygenationImprove oxygenation• Decrease work of breathingDecrease work of breathing

Decrease left ventricular transmural Decrease left ventricular transmural pressure, ↓ afterload and ↑COPpressure, ↓ afterload and ↑COP

Simple, small and cheap portable units are Simple, small and cheap portable units are availableavailable

Pressure limited ventilatorsPressure limited ventilators PCVPCV

Delivers time- cycled preset inspiratory and Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E expiratory pressures with adjustable I/E ratioratio

Permits patient triggering with a back up Permits patient triggering with a back up raterate

PSVPSV Assist spontaneous breathingAssist spontaneous breathing Peak inspiratory and expiratory pressures Peak inspiratory and expiratory pressures

are selectedare selected Close matching with patient‘s spontaneous Close matching with patient‘s spontaneous

breathingbreathing Allow patient to control rate and Allow patient to control rate and

inspiratory durationinspiratory duration Portable devices (bilevel devices) Portable devices (bilevel devices)

Pressure limited ventilatorsPressure limited ventilators PCVPCV

Delivers time- cycled preset inspiratory and Delivers time- cycled preset inspiratory and expiratory pressures with adjustable I/E expiratory pressures with adjustable I/E ratioratio

Permits patient triggering with a back up Permits patient triggering with a back up raterate

PSVPSV Assist spontaneous breathingAssist spontaneous breathing Peak inspiratory and expiratory pressures Peak inspiratory and expiratory pressures

are selectedare selected Close matching with patient‘s spontaneous Close matching with patient‘s spontaneous

breathingbreathing Allow patient to control rate and Allow patient to control rate and

inspiratory durationinspiratory duration Portable devices (bilevel devices) Portable devices (bilevel devices)

Volume limited ventilatorsVolume limited ventilators

VVtt is usually set higher (10→ is usually set higher (10→ 15ml/kg ) 15ml/kg )

Usually set in the A/C mode, RR Usually set in the A/C mode, RR set slightly below the patient’s set slightly below the patient’s raterate

Portable devices are more Portable devices are more convenient, cheap, have more convenient, cheap, have more sophisticated alarm system, sophisticated alarm system, generate high pressure generate high pressure

Volume limited ventilatorsVolume limited ventilators

VVtt is usually set higher (10→ is usually set higher (10→ 15ml/kg ) 15ml/kg )

Usually set in the A/C mode, RR Usually set in the A/C mode, RR set slightly below the patient’s set slightly below the patient’s raterate

Portable devices are more Portable devices are more convenient, cheap, have more convenient, cheap, have more sophisticated alarm system, sophisticated alarm system, generate high pressure generate high pressure

Proportional assisted Proportional assisted ventilation (PAV)ventilation (PAV)

Targets and respond rapidly Targets and respond rapidly patient‘s effort ( inspiratory patient‘s effort ( inspiratory flow and volume)flow and volume)

Able to select the proportion of Able to select the proportion of breathing work that is to be breathing work that is to be assistedassisted

Negative pressure Negative pressure ventilationventilation

Negative pressure Negative pressure ventilationventilation

Intermittently apply a sub Intermittently apply a sub atmospheric pressure to the atmospheric pressure to the chest wall and upper chest wall and upper abdomenabdomen

Efficiency depends on chest Efficiency depends on chest wall and abdomen wall and abdomen compliance and surface area compliance and surface area over which negative pressure over which negative pressure is appliedis applied

E.g.E.g.• Tank ventilatorTank ventilator• CuirassCuirass• WrapWrap• ShellShell• Iron lungIron lung• Rocking belt and pneumobelt (work by Rocking belt and pneumobelt (work by

displacing abdominal viscera)displacing abdominal viscera)

Goals of NIVGoals of NIVGoals of NIVGoals of NIVShort term (acute)Short term (acute)

Relieve symptoms Relieve symptoms Reduce work of Reduce work of

breathing breathing Improve or Improve or

stabilize gas stabilize gas exchange exchange

Good patient-Good patient-ventilator ventilator synchrony synchrony

Optimize patient Optimize patient comfort comfort

Avoid intubation Avoid intubation Minimize riskMinimize risk

Short term (acute)Short term (acute) Relieve symptoms Relieve symptoms Reduce work of Reduce work of

breathing breathing Improve or Improve or

stabilize gas stabilize gas exchange exchange

Good patient-Good patient-ventilator ventilator synchrony synchrony

Optimize patient Optimize patient comfort comfort

Avoid intubation Avoid intubation Minimize riskMinimize risk

Long term (chronic)Long term (chronic) Improve sleep Improve sleep

duration and duration and quality quality

Enhance Enhance functional status functional status

Prolong survivalProlong survival Maximize quality Maximize quality

of life of life

Long term (chronic)Long term (chronic) Improve sleep Improve sleep

duration and duration and quality quality

Enhance Enhance functional status functional status

Prolong survivalProlong survival Maximize quality Maximize quality

of life of life

PROTOCOL FOR INITIATION OF PROTOCOL FOR INITIATION OF NIVNIV

PROTOCOL FOR INITIATION OF PROTOCOL FOR INITIATION OF NIVNIV

1.1. Appropriately monitored locationAppropriately monitored location2.2. Patient in bed or chair sitting at > Patient in bed or chair sitting at >

30-degree angle30-degree angle3.3. Select and fit interfaceSelect and fit interface4.4. Select ventilatorSelect ventilator5.5. Apply headgear; avoid excessive Apply headgear; avoid excessive

strap tensionstrap tension6.6. encourage patient to hold maskencourage patient to hold mask7.7. Connect interface to ventilator Connect interface to ventilator

tubing and turn on ventilatortubing and turn on ventilator

1.1. Appropriately monitored locationAppropriately monitored location2.2. Patient in bed or chair sitting at > Patient in bed or chair sitting at >

30-degree angle30-degree angle3.3. Select and fit interfaceSelect and fit interface4.4. Select ventilatorSelect ventilator5.5. Apply headgear; avoid excessive Apply headgear; avoid excessive

strap tensionstrap tension6.6. encourage patient to hold maskencourage patient to hold mask7.7. Connect interface to ventilator Connect interface to ventilator

tubing and turn on ventilatortubing and turn on ventilator

8.8. Start with low pressures/volumes in Start with low pressures/volumes in spontaneously triggered mode with spontaneously triggered mode with backup rate; pressure-limited: 8 to 12 backup rate; pressure-limited: 8 to 12 cm H2O inspiratory; 3 to 5 cm H2O cm H2O inspiratory; 3 to 5 cm H2O expiratory, volume-limited: 10 ml/kgexpiratory, volume-limited: 10 ml/kg

9.9. Gradually increase inspiratory Gradually increase inspiratory pressure (10 to 20 cm H2O) or tidal pressure (10 to 20 cm H2O) or tidal volume (10 to 15 ml/kg) as tolerated volume (10 to 15 ml/kg) as tolerated to achieve alleviation of dyspnea, to achieve alleviation of dyspnea, decreased respiratory rate, increased decreased respiratory rate, increased tidal volume , and good patient-tidal volume , and good patient-ventilator synchronyventilator synchrony

10.10. Provide O2 supplementation as Provide O2 supplementation as needed to keep O2 sat > 90%needed to keep O2 sat > 90%

PROTOCOL FOR INITIATION OF PROTOCOL FOR INITIATION OF NIVNIV

PROTOCOL FOR INITIATION OF PROTOCOL FOR INITIATION OF NIVNIV

11.11. Check for air leaks, readjust straps Check for air leaks, readjust straps as neededas needed

12.12. Add humidifier as indicatedAdd humidifier as indicated13.13. Consider mild sedation (i.e., Consider mild sedation (i.e.,

intravenously administered intravenously administered lorazepam 0.5 lorazepam 0.5 g) in agitated g) in agitated patientspatients

14.14. Encouragement, reassurance, and Encouragement, reassurance, and frequent checks and adjustments as frequent checks and adjustments as neededneeded

15.15. Monitor occasional blood gases Monitor occasional blood gases (within 1 to 2 h and then as needed)(within 1 to 2 h and then as needed)

11.11. Check for air leaks, readjust straps Check for air leaks, readjust straps as neededas needed

12.12. Add humidifier as indicatedAdd humidifier as indicated13.13. Consider mild sedation (i.e., Consider mild sedation (i.e.,

intravenously administered intravenously administered lorazepam 0.5 lorazepam 0.5 g) in agitated g) in agitated patientspatients

14.14. Encouragement, reassurance, and Encouragement, reassurance, and frequent checks and adjustments as frequent checks and adjustments as neededneeded

15.15. Monitor occasional blood gases Monitor occasional blood gases (within 1 to 2 h and then as needed)(within 1 to 2 h and then as needed)

MonitoringMonitoringMonitoringMonitoringSubjective responsesSubjective responseso Bed side observationBed side observationo Ask about discomfort related to the mask or Ask about discomfort related to the mask or

airflowairflow

Physiologic responsePhysiologic responseo ↓ ↓ RR, ↓ HRRR, ↓ HRo Patient breath in synchrony with the ventilatorPatient breath in synchrony with the ventilatoro ↓ ↓ accessory muscle activity and abdominal accessory muscle activity and abdominal

paradoxparadoxo Monitor air leaks and VMonitor air leaks and Vtt

Gas exchangeGas exchangeo Continuous oximetryContinuous oximetryo Occasional ABGOccasional ABG

Subjective responsesSubjective responseso Bed side observationBed side observationo Ask about discomfort related to the mask or Ask about discomfort related to the mask or

airflowairflow

Physiologic responsePhysiologic responseo ↓ ↓ RR, ↓ HRRR, ↓ HRo Patient breath in synchrony with the ventilatorPatient breath in synchrony with the ventilatoro ↓ ↓ accessory muscle activity and abdominal accessory muscle activity and abdominal

paradoxparadoxo Monitor air leaks and VMonitor air leaks and Vtt

Gas exchangeGas exchangeo Continuous oximetryContinuous oximetryo Occasional ABGOccasional ABG

Uses of NIVUses of NIVUses of NIVUses of NIV

Respiratory failureRespiratory failureHypercapnic respiratory failureHypercapnic respiratory failure Obstructive diseasesObstructive diseases Restrictive diseasesRestrictive diseases

Hypoxic respiratory failureHypoxic respiratory failure Acute pulmonary edemaAcute pulmonary edema Acute pneumoniaAcute pneumonia ARDSARDS TraumaTrauma

Respiratory failureRespiratory failureHypercapnic respiratory failureHypercapnic respiratory failure Obstructive diseasesObstructive diseases Restrictive diseasesRestrictive diseases

Hypoxic respiratory failureHypoxic respiratory failure Acute pulmonary edemaAcute pulmonary edema Acute pneumoniaAcute pneumonia ARDSARDS TraumaTrauma

Imunocomprimized patientsImunocomprimized patients Avoid ETT→ ↓infectious and hemorrhagic Avoid ETT→ ↓infectious and hemorrhagic

complicationscomplications Morbidly obese patientsMorbidly obese patients

used in obstructive sleep apneaused in obstructive sleep apnea Do not intubate patientsDo not intubate patients

ETT is contraindicated or postpondETT is contraindicated or postpond Refuse intubationRefuse intubation

Post operative patientsPost operative patients Avoid reintubation if RF developsAvoid reintubation if RF develops Improve gas exchange and pulmonary Improve gas exchange and pulmonary

functionfunction Weaning and extubationWeaning and extubation

Before meeting extubation criteriaBefore meeting extubation criteria

Imunocomprimized patientsImunocomprimized patients Avoid ETT→ ↓infectious and hemorrhagic Avoid ETT→ ↓infectious and hemorrhagic

complicationscomplications Morbidly obese patientsMorbidly obese patients

used in obstructive sleep apneaused in obstructive sleep apnea Do not intubate patientsDo not intubate patients

ETT is contraindicated or postpondETT is contraindicated or postpond Refuse intubationRefuse intubation

Post operative patientsPost operative patients Avoid reintubation if RF developsAvoid reintubation if RF develops Improve gas exchange and pulmonary Improve gas exchange and pulmonary

functionfunction Weaning and extubationWeaning and extubation

Before meeting extubation criteriaBefore meeting extubation criteria

Adverse effects and Adverse effects and complications of NIV complications of NIV Adverse effects and Adverse effects and

complications of NIV complications of NIV Mask relatedMask related Nasal painNasal pain Nasal bridge erythema and Nasal bridge erythema and

ulcerationulceration

Ventilator air flow or pressure Ventilator air flow or pressure complicationscomplications Conjunctival irritationConjunctival irritation Sinus or ear painSinus or ear pain Nasal or oral drynessNasal or oral dryness Nasal congestion or dischargeNasal congestion or discharge Gastric insufflationGastric insufflation

Mask relatedMask related Nasal painNasal pain Nasal bridge erythema and Nasal bridge erythema and

ulcerationulceration

Ventilator air flow or pressure Ventilator air flow or pressure complicationscomplications Conjunctival irritationConjunctival irritation Sinus or ear painSinus or ear pain Nasal or oral drynessNasal or oral dryness Nasal congestion or dischargeNasal congestion or discharge Gastric insufflationGastric insufflation

Failure of NIVFailure of NIV Mask intoleranceMask intolerance Failure to improve ventilationFailure to improve ventilation ClaustrophobiaClaustrophobia Sensation of excessive air pressureSensation of excessive air pressure Patient-ventilator asynchronyPatient-ventilator asynchrony

MIMI Specially with BIPAPSpecially with BIPAP

Failure of NIVFailure of NIV Mask intoleranceMask intolerance Failure to improve ventilationFailure to improve ventilation ClaustrophobiaClaustrophobia Sensation of excessive air pressureSensation of excessive air pressure Patient-ventilator asynchronyPatient-ventilator asynchrony

MIMI Specially with BIPAPSpecially with BIPAP

ANY ANY QUESTIONS?QUESTIONS?

THANKTHANK YOUYOU