NON INVASIVE VENTILATION

1. NON INVASIVE
VENTILATION
Archana R Yashwanth

2. What is non invasive ventilation?
• Modality that supports breathing with out the need for
intubation or surgical airway
• Greatest advancement in the management of acute type
2 respiratory failure
• Types
Negative pressure ventilation
Non invasive positive pressure
Continous positive airway pressure
Bi level positive airway pressure

3. Why NPPV?
• 1.Avoids complication of invasive ventilation
• Injury to the teeth , vocal cords, larynx, surgical
complications of tracheostomy tube placements
• .infections- VAP , sinusitis
• in ability to verbalise, eat , drink and patients comfort
• 2. may be administered outside of ICU/ Domestic use
MECHANISM- reduction in inspiratory muscle work ,
decrease in WOB , decrease in pressure time
product(index of muscle oxygen consumption), also by
recruitment of alveoli

4. Goals of NPPV
• Short term-1.relieve symptoms
2.Reduce WOB
3.Improve or stabilise gas exchange
4.Optimisepatient comfort
5.Good patient ventilator synchorny
6.Minimise risk
7.Avoid intubations
• Long term-1.improve sleep duration and quality
2.Maximise quality of life
3.Enchance functonal status
4.Prolong survival

5. Indications and Contraindications
Obstructive sleep apnea
syndrome
COPD with exacerbation
Bilateral pneumonia
Acute congestive heart failure with
pulmonary edema
Neuromuscular disorder
Acute lung injury
Method of weaning
Respiratory arrest or unstable
cardiorespiratory status
Uncooperative patients
Inability to protect airway
Trauma or burns involving the face
Facial oesophageal gastric injury
Apnea
Reduced consciousness
Air leak syndrome
Relative contraindications
• Extreme anxiety
• Morbid obesity
• Copious secretions
• Need for continous ventilatory
assistance
• Diseases with air trappng
Indications
Contraindications

6. TERMS USED IN NPPV
• CPAP- positive airway pressure duting spontanoues
breaths
• BiPAP-provides IPAP and EPAP
• IPAP-controls peak inspiratory pressure during inspiration
• EPAP-controls end expiratory pressure
• PEEP-positive airway pressure at end expiratory phase,
used with mechanical breaths
• Higher the IPAP , larger tidal volume and minute
,ventilation
• EPAP-same as PEEP, improves oxygenation , increases
FRC,relieves upper airway obstruction

7. Technique
• Anaesthesia
• Mild sedation and analgesia
Anxolysis
Equipments
• Available ventilators-NPPV/ Conventional ventilators
NPPV ventilators are cheaper, flexible, portable , good leak
compensation , inspiratory pressureup to 20cm h20.
Disadvantage- high flows, single limb rebreathing occurs.
• Ventilator modes- volume limited ventilation,Propotional assist
ventilation (senses patients efforts , by tracking inspiratory flow
.by adjusting gain on the flow and volume signals , operator is
able to select propotion of breathing work to be assisted.

8. • Positioning
• Face mask or nasal mask application (interfaces)
• 30 to 90 degrees upright position
• Nasal mask fits just above the junction of nasal bone&
cartilage
• Velcro straps

9. Interfaces
• Nasal prong application
• Fill the nasal openings with out stretching the skin or
undue pressure on the nares
• No lateral pressure on the septum

10. Nasal pillows Face Mask
• Pressure range of 3 to
20 cm H20
• Significant leak from
mouth
• Advantage- comfort and
patience compliance
• Disadvantage-gasleak ,
nasal dryness or
dicharge
• Tight seal’
• Advantage-good seal
• Disadvantages
• Potential dangers of
regurgitation and aspiration
• Patient non compliance
• Regurgitation and
aspiration
• Asphyxation
• Alarm and monitor is
necessary

11. Troubleshooting with interfaces
1.Air leaks
2.Pressure points, sore or dry eyes
3.Nasal congestion or discharge
4.Nasal airway drying
5.Skin break down irritation-
6.Sensitive front teeth
7.Head gear problem
 Adjust head gear
 Try chin strap
 Try spacers or foam pads
 Try diff. mask
 Adjust head gear
 Change spacers or foam pads
 Try different mask
 Adjust positive pressure setting
 Add filter
 Add humidity
 Increased fluid intake
 Increase room humidity
 Try nasal saline or water based lubricant
 Adjust or try another head gear
 Use spacers, foam pad
 Resize mask
 Change to diff cleaning solution
 Adjust head gear
 Try smaller or differentmask
 Try disposible head gear
 Try larger head gear

12. Machine setup
Humdifier-with 1 L bag of
water,adequarte .umidity
prevents drying of secretions
Oxygen flow-6-10/l min, washes
out carbondioxide,
compensates leak , generates
adequate pressure
Occlude the pressure line
connection port with the white
plug provided
For CPAP , default pressure is
4-6 cm H20
PRESSURE UP TO 10 CM H20
CAN BE USED
For BIPAP-IPAP-
15CMH20,EPAP 5 CM H20
Check water level and adjust for evaporation

13. BIPAP(pressure limited ventilation)
IPAP-15cm H20-Controls peak inspiratory pressure during
inspiration
EPAP-5CMH20-controls end expiratory pressure , PEEP when
IPAP>EPAP
Provides IPAP and EPAP
CPAP when IPAP=EPAP
Pre determined inspiratory pressure is delivered
This causes different tidal volumes, depending on the
resistance of the respiratory system.
Leak compensation

14. 3 modes
• Pressure support- set pressure during inspiration
• Pressure control-set number of breaths per minute at set
pressure
• Bilevel positive airway pressure –delivers different
pressures during inspiration and expiration
• Main indications – acute respiratory failure
• COPD Exacerbation
• Not improving on CPAP- provides increased airway pressue during expiration
, but it may add inspiratory assistance, there by reducing WOB

15. CPAP (1/3)
Continuous positive airway pressure during the spontaneous breath
Leads to increase FRC aboce closing capacity
Leads to opening of collapsed alveoli , decreased intrapulmonary shunting , improving
oxygenation and lung compliance, decrease WOB
Reduces left ventricular transmural pressure, there fore increasing CO, pressures
limited to 5-15cm H20
Provision of an adequate air flow rate
Its treatment of choice in OSA without significant carbon-dioxide retention
OSA- diagnosed by nocturnal polysomnography and severity determined by apnea and
desaturation index

16. CPAP (2/3)
• Avg. no. of apnea in each hour of sleep during
the test
Apnea –
hypoapnea indxex
• Avg. number of oxygen desaturation of 4% or
more from baseline
Desaturation
index-
• H/o snoring, obesity ,increased neck
circumference, hypertension and family history Risk factors
• Oral applications prosthetic mandibular
advancement Treatment
• Tonsillectomy Surgical and uvulopalaopharyngoplasy

17. CPAP (3/3)
After setting CPAP – pulse oximerty and no of apnea epsodes in
polysomnography are used to fine tune CPAP level
• Auto titration
• RAMP-gradually increases pressure
• C-FLEX-provides pressure relief during exhalation
• Provided breath to breath basis

18. Monitoring
• ABG
• RR
• Heart rate
• Continuous ECG recording during first 12 hrs
• Repeat ABGS- 1 hr after intiation of NIV/ change of settings ,
after 4 hrs hrs in clinicaly non improving patients
• In acutely ill patients
• Every 15 mins in first hour
• Every 30 mins in 1 to 4 hr period
• Hourly in 4 to 12 hour period
• Level of consciousness
• Patient comfort
• Chest wall movement, ventilator synchorny and accessory
muscle use

19. Weaning
• Based on clinical improvement and stability of patients
condition
• Studies show RR<24/MIN
• HR-<110/MIN
• Compensated Ph->7.5
• Spo2->90% on fio2 <4l/min

20. Predictors of success in NPPV
• Young age
• Low acuity of illness
• Able to cooperate
• Able to coordinate breathing with ventilator
• Less air leaking , intact dentition
• Hypercarbia >45 but <92 mmhg
• Acidemia7.1-7.35
• Improvement of HR, RR and gas exchange with in first
one hour

21. Criteria for failure of NNPV
• MAJOR
1.Respiratory arrest
2.LOC
3.Psychomotor agitation requiring sedation
4.Hemodynamic instabiltiy
HR<50/min with loss of alertness
• MINOR
1.RR>35/MIN and higher than as recorded on admission
2.Arterial Ph-<7.3
Pao2<45 despite oxygen supplementation
Presence of weak cough
Presence of one major criterion is an indication of immediate intubation
Presence of 2 minor criteia after 1 hr of treatment is considered an
indication of intubation

22. complications
• 1.monitoring
• 2.decreased clerance of secretions , when seal must be
mintained
• 3. caution when given to patients who have one side
affected lung
• 4. due to air seal- ulceration and pressure necrosis, eye
irritation
• 5.distension of stomach due to aerphagia, aspiration
• 6.preload reduction and hypotension

23. Refernces
• Clinical application of mechancal ventilation – 3rd edition –
David W.Chang
• RACE 2011- mechanical ventilation- JV Divatia AS
Arunkumar k thamaraiselvi,MK Renuka , JA Roche
• Non invasive ventilation- Dr. T. R. Chandrasekhar.
• Millers 7th edition

24. THANK YOU