Overview of

Noninvasive
Positive-Pressure
Ventilation (01)

Dr Mazen Qusaibaty
MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital
Ministry of Syrian health
Email: qusaibaty@gmail.com
 2

Noninvasive
Positive-pressure
Ventilation (NPPV)
‫اﻟﺘﮭﻮﯾﺔ اﻟﻐﯿﺮ‬
‫راﺿﺔ ﺑﺎﻟﻀﻐﻂ اﻹﯾﺠﺎﺑﻲ‬

Was first studied in the 1930s

Barach AL, Martin J, Eckman M. Positive pressure respiration and its

application to the treatment of acute pulmonary edema. Ann Intern Med
1938;12:754-95
3

Indication

• Management of
• Improved gas
the Respiratory
exchange
Failure
• Decreased work of
• Acute
breathing
• Chronic

Barach AL, Martin J, Eckman M. Positive pressure respiration and its application to the treatment of acute pulmonary edema. Ann Intern
Med 1938;12:754-95
4
 Complications of endotracheal intubation

• Diminished cardiac
output and hypotension
• Pulmonary barotrauma
(eg, pneumothorax)
• Ventilator-associated
lung injury
• Auto-PEEP (ie, intrinsic
PEEP)
• Elevated intracranial
pressure

https://www.uptodate.com/contents/mechanical-ventilation-of-adults-in-the-emergency-
department?search=complications%20of%20invasive%20mechanical%20ventilation&sectionRank=1&usage_type=default&anchor=H5&source=machi
neLearning&selectedTitle=1~150&display_rank=1#H5
 6

In certain patient populations…

• NPPV offers the benefits of Mechanical

Ventilation
• without the risks associated with
intubation
 9

All Health Care Providers

Patient-selection criteria
 10

All Health Care Providers

• Familiar with
• The available equipment
 11

All Health Care Providers

The appropriate ventilator settings
NIV Absolute Contraindications

Should be Avoided

Relative contraindications

Should be closely managed by

Experienced Staff
Criteria for NIV discontinuation and
endotracheal intubation
NIV Absolute Contraindications
14

The only absolute Contraindications to

BPAP and CPAP

Cardiac arrest
Respiratory arrest

N Engl J Med 2015;372:e30

NIV Absolute Contraindications

Should be Avoided
16

NIV should be avoided

• Severe Hypotension
• Life-threatening Arrhythmia

N Engl J Med 2015;372:e30

17

NIV should be avoided

• Recent surgery
•Upper-airway
•Upper
Gastrointestinal
•Facial or
trauma

Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation.Respir

Care2004; 49: 295–303.
 18

• NIV should be avoided

• Discomfort from the mask that cannot be
resolved with adjustments

N Engl J Med 2015;372:e30

NIV Absolute Contraindications

Should be Avoided

Relative contraindications
20

Relative contraindications

High risk of
Aspiration

Impaired

Mental Status

Swallowing
N Engl J Med 2015;372:e30
21

Relative contraindications

• Alarge volume of secretions

• Recurrent vomiting

N Engl J Med 2015;372:e30

NIV Absolute Contraindications

Should be Avoided

Relative contraindications

Should be closely managed by

Experienced Staff
23

Should be closely managed by Experienced

Staff

• Severe Hypoxaemia:
• PaO2/ FIO2 ≤ 100
• Morbid obesity
• > 200% of ideal body weight
• Unstable Angina
• Acute Myocardial Infarction
Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation.Respir
Care2004; 49: 295–303.
NIV Absolute Contraindications

Should be Avoided

Relative contraindications

Should be closely managed by

Experienced Staff
Criteria for NIV discontinuation and
endotracheal intubation
 25

Criteria
for NIV discontinuation and endotracheal
intubation
Criteria for NIV discontinuation and endotracheal
intubation

• Respiratory arrest
• Respiratory pauses with loss of
consciousness or gasping
Criteria for NIV discontinuation and endotracheal
intubation

• Inability to correct
dyspnoea
• Tachypnoea and
activation of
accessory
respiratory
muscles
Criteria for NIV discontinuation and endotracheal
intubation

• Failure to improve oxygenation (i.e. PaO2 ≤

65 mmHg with anFIO2 ≤ 0.6)
• Inability to decrease PaCO2 and improve
academia (i.e. pH:7.25 and below the value
at baseline)
 29

Criteria for NIV discontinuation and

endotracheal intubation

• Development of conditions requiring

protection of the airways (coma or seizure
disorders)
30

Criteria for NIV discontinuation and

endotracheal intubation

Inability to manage Copious Tracheal

Secretions
31

Criteria for NIV discontinuation and

endotracheal intubation

• Haemodynamic instability
• Systolic arterial tension<70 mmHg despite
fluid resuscitation
32

Criteria for NIV discontinuation and

endotracheal intubation

• Heart rate or electrocardiographic

instability
33

Criteria for NIV discontinuation and endotracheal

intubation

• Inability to tolerate
the mask or helmet
Criteria for NIV discontinuation and endotracheal
intubation

• Psychomotor
agitation
• Making nursing
care impossible
• Requiring
sedation
35

NPPV

Continuous
Bilevel Positive
Positive-airway
Airway Pressure
Pressure
(BPAP)
(CPAP)
N Engl J Med 2015;372:e30
 Benefits of
Bilevel Positive Airway Pressure
(BPAP)
 Indications : BPAP

Respiratory
Distress

N Engl J Med 2015;372:e30

 Respiratory Distress

• Dyspnea
• Tachypnea
• The use of accessory
muscles of
respiration

N Engl J Med 2015;372:e30

 39

The measurement of Arterial Blood Gas may reveal

Acidemia

• Arterial pH: <7.35

• Hypercapnia [Paco2]: >45 mm Hg

N Engl J Med 2015;372:e30

 The measurement of Arterial Blood Gas may
reveal Hypoxemia

PaO2 / FiO2 <200

N Engl J Med 2015;372:e30

 41

• Multiple randomized,
controlled trials have
proven the benefits of
BPAP
• Hypercapnic respiratory
failure resulting from
• An acute exacerbation of
COPD

Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute

exacerbations of chronic obstructive pulmonary disease. N Engl J Med
1995;333:817-22
 42

• BPAP has been shown to

benefit patients with:
• Immune compromise
• Fever
• and pulmonary infiltrates
who have acute
hypoxemic respiratory
failure

Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed

patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J
Med 2001;344:481-7
43

BPAP

Facilitates the
transition from
invasive ventilation
→
Spontaneous
breathing in patients
with COPD

Ferrer M, Sellarés J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled
trial. Lancet 2009;374:1082-8./Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N
Engl J Med 2004;350:2452-60
 Insufficient Evidence to
recommend BPAP

Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of
asthma. Cochrane Database Syst Rev 2012;12:CD004360./ Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid
tumours: a randomised feasibility trial. Lancet Oncol 2013;14:219-27
 Severe exacerbations of
asthma
Pneumonia
ARDS

BPAP
???

Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of
asthma. Cochrane Database Syst Rev 2012;12:CD004360./ Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid
tumours: a randomised feasibility trial. Lancet Oncol 2013;14:219-27
 • Postoperative respiratory
failure
• Palliation of respiratory
distress in terminally ill
patients

BPAP
???
Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. Crit Care Med 2005;33:1976-82. Zarbock A, Mueller E, Netzer S, Gabriel A, Feindt P,
Kindgen-Milles D. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 2009;135:1252-9.
 Benefits of
Continuous Positive Airway Pressure
(CPAP)
 48

• Multiple randomized,
controlled trials have
proven the benefits of
both BPAP and CPAP
• Cardiogenic pulmonary
edema
• In the absence of shock or
ischemia

Gray A, Goodacre S, Newby DE, Masson

M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary
edema. N Engl J Med 2008;359:142-51.
• Continuous Positive Airway Pressure
(CPAP)
• The treatment of sleep-disordered breathing
associated with:
1. COPD
2. Congestive heart failure
3. Obesity hypoventilation syndrome

Bradley TD, Logan AG, Kimoff RJ, et al; CANPAP Investigators. Continuous positive airway pressure for
central sleep apnea and heart failure. N Engl J Med 2005; 353:2025–2033.
 Continuous Positive Airway Pressure
(CPAP)

Treatment of choice

Obstructive Sleep
Apnea
Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults.
Cochrane Database Syst Rev 2006; 3:CD001106.
The Ventilation ?
 Airways

Alveoli

Blood-Gas barrier

Capillaries
 The Ventilation ?

is the Movement of Gas to the Alveoli

Action of Diaphragm
57
58
 59

Boyle’s Law

↑ Pressure / ↓ Volume
 64

Tidal volume is the Lung Volume representing…

• The normal volume of air displaced between

normal inhalation and exhalation when extra
effort is not applied
Beardsell, I et al: MCEM Part A:MCQs, page 33, Royal Society of Medicine Press, 2009
 65

Tidal volume (VT) In a healthy, young human

adult

approximately 7 mL/kg of body mass

500 mL per inspiration
Beardsell, I et al: MCEM Part A:MCQs, page 33, Royal Society of Medicine Press, 2009
The difference between the Inspiratory and
Expiratory Pressures
The Inspiratory Time
The patient’s inspiratory effort
The mechanical characteristics of the patient’s
airways and lungs