Non-invasive Ventilation

Noninvasive ventilation (NIV)

• NIV is the administration of ventilatory support without using an invasive artificial

airway (endotracheal tube or tracheostomy tube)

• Use of NIV has markedly increased over the past few years

• An integral tool in the management of acute and chronic respiratory failure, in

home setting and in the critical care unit

• NIV has been used as a replacement for invasive ventilation

• Its flexibility also allows it to be a valuable complement in patient management

Clin Chest Med. 2016;37(4):711-721.

 Advantages of NIV

• The main theoretic advantages of NIV include:

• Avoiding side effects and complications associated with endotracheal intubation

• Improving patient comfort

• Preserving airway defense mechanisms

Clin Chest Med. 2016;37(4):711-721.

 General Considerations

• Key to the successful application is in recognizing its capabilities and limitations

• Also requires identification of the appropriate patient for the application of NIV

• Patient selection is crucial for the successful application of NIV

• Once patients who require immediate intubation are eliminated, a careful

assessment of the patient and his or her condition determines if the patient is a
candidate for NIV

• Requires evaluation on several levels, and it may involve a trial of NIV

Clin Chest Med. 2016;37(4):711-721.

 Factors that affect the success of NIV

• Factors that affect the success of NIV in patients with ARF are

• Clinicians' expertise

• Selection of patient

• Choice of interface

• Selection of ventilator setting

• Proper monitoring

• Patient motivation

Clin Chest Med. 2016;37(4):711-721.

 Patient Inclusion Criteria
• Patient cooperation: Essential component that excludes agitated,

belligerent, or comatose patients

• Dyspnea: moderate to severe, but short of respiratory failure

• Tachypnea: >24 breaths/min

• Increased work of breathing: accessory muscle use, pursed-lips

breathing

• Hypercapnic respiratory acidosis: pH range 7.10-7.35)

• Hypoxemia: PaO2/FIO2 < 200 mm Hg, best in rapidly reversible

causes of hypoxemia
Complications Of Invasive Mechanical
Ventilation

Ambrosino N et al. Eur Respir J. 2011;38(2):440-9

Complications of invasive mechanical ventilation
Related to tube insertion

• Aspiration of gastric contents

• Trauma of teeth, pharynx, oesophagus, larynx, trachea

• Sinusitis (nasotracheal intubation)

• Need for sedation

Related to mechanical ventilation

• Arrhythmias, hypotension

• Barotrauma
Ambrosino N et al. Eur Respir J. 2011;38(2):440-9
 Complications Related to Tracheostomy
• Haemorrhage

• Trauma of trachea, oesophagus

• False lumen intubation

• Stomal infections, mediastinitis

• Tracheomalacia, tracheal stenoses, granulation tissue formation

• Tracheo-oesophageal or tracheoarterial fistulas

Ambrosino N et al. Eur Respir J. 2011;38(2):440-9

 Complications of invasive mechanical ventilation
Caused by loss of airway defence mechanisms

• Airway colonisation with Gram-negative bacteria

• Pneumonia

Occurring after removal of the endotracheal tube

• Hoarseness, sore throat, cough, sputum

• Haemoptysis

• Vocal cord dysfunction, laryngeal swelling

Ambrosino N et al. Eur Respir J. 2011;38(2):440-9

Characteristics of invasive and non-invasive
ventilation
 Complications and Invasive ventilation Non-invasive
clinical aspects ventilation
Ventilator Increased risk after 3 Rare
(endotracheal tube) or 4 days of ventilation
associated pneumonia
Additional work of Yes No
breathing due to the (during spontaneous
endotracheal tube breathing and in case
of inadequate
compensation for the
endotracheal tube)
Early and late tracheal Yes No
damage
Sedation Often necessary Rarely necessary
Schönhofer B et al. Dtsch Arztebl Int. 2008;105(24):424-33.
 Complications and Invasive ventilation Non-invasive
clinical aspects ventilation
Intermittent Rarely possible Often possible
application
Effective coughing No Yes
possible
Eating and drinking Difficult with Yes
possible tracheostomy, not
possible with
intubation
Communication Difficult Yes
possible
Upright body posture Limited feasibility Often possible
Difficult weaning from 10% to 20% Rare
ventilator
 Complications and Invasive ventilation Non-invasive
clinical aspects ventilation
Airway access Direct Difficult
Pressure sites on the No Sometimes
face
Back-breathing of CO2 No Rare
Leakage Very little Usually present to a
greater or lesser
extent
Aerophagy Very little Sometimes

Schönhofer B et al. Dtsch Arztebl Int. 2008;105(24):424-33.

Different Types of Ventilation Interface
Nose Mask
Full Face Mask
Total Face Mask
Patient with an exacerbation of COPD undergoing treatment with noninvasive ventilation
using an orofacial mask
Ventilation Helmet
Advantages and Disadvantages of Common
Types of Ventilation Interface
 Aspect Nose mask Nose-mouth mask Helmet
Oral leakage – + +
Volume monitoring – + –
Initial response of blood gases 0 + 0

Speaking + – 0
Expectoration + – –
Risk of aspiration + 0 +
Aerophagy + 0 0
Claustrophobia + 0 0
Dead space + 0 –
(compressible volume)

Noise and limitation of hearing + + –

Schönhofer B et al. Dtsch Arztebl Int. 2008;105(24):424-33.

Criteria for the success of non-invasive ventilation

Criterion Success
Dyspnea Decrease
Alertness Gradual improvement
Respiratory rate Decrease
Ventilation Decrease in PaCO2
pH Increase
Oxygenation Rise of SaO2 to 85% or above
Heart rate Decrease

Schönhofer B et al. Dtsch Arztebl Int. 2008;105(24):424-33.

Types of Noninvasive Ventilation with
Proposed Settings

Aboussouan LS et al. Cleve Clin J Med. 2010;77(5):307-16

 Abbreviations

• CPAP: Continuous Positive Airway Pressure

• EPAP: Expiratory Positive Airway Pressure

• IPAP: Inspiratory Positive Airway Pressure

• PEEP: Positive End-Expiratory Pressure

• Paco2 = partial pressure of arterial carbon dioxide

 CPAP Mode

• Provides a constant pressure

• Provides no ventilatory support

• More effective in hypoxemic than in hypercapnic states

• Improves alveolar edema

• Increases Functional Residual Capacity (FRC)

• Setting: Slowly increase up to 5–12 cm H2O to improve hypoxemia

 “Pressure-limited” Mode

• Cycles between higher inspiratory and lower expiratory pressures

• Breath trigger includes spontaneous patient effort (with pressure support) or a time

instruction such as backup rate (for pressure control)

 Pressure-limited: Setting

• IPAP 8–20 cm H2O for respiratory rate < 25 breaths per minute

• EPAP/PEEP of 0–10 cm H2O to improve oxygenation

• Adjust settings to goals

• Example:

• Pressure support of 15 cm H2O with PEEP of 5 cm H2O can decrease dyspnea,

respiratory rate, and Paco2 more than a pressure support of 10 cm H2O with PEEP
of 10 cm H2O

• However, the latter setting can be associated with better oxygenation.

 “Volume-limited” Mode

• Provides a constant volume

• Triggers to the breaths include patient effort (with assisted breaths) or a time

instruction such as backup rate (for controlled breaths)

 Volume Limited: Settings

• 250–500 mL (4–8 mL/kg) volumes to obtain a respiratory rate < 25 breaths per

minute

• Adjust settings to goals:

• Increase volumes for ventilatory support and hypercapnia

• Adjust PEEP upwards to improve oxygenation

Contraindications
 Absolute Contraindications

• Lack of spontaneous breathing; gasping

• Anatomical or functional airway obstruction

• Gastrointestinal bleeding or ileus

Schönhofer B et al. Dtsch Arztebl Int. 2008;105(24):424-33.

 Relative Contraindications

• Coma

• Massive agitation

• Massive retention of secretions despite bronchoscopy

• Severe hypoxemia or acidosis (pH < 7.1)

• Hemodynamic instability (cardiogenic shock, myocardial infarction)

• Anatomical and/or subjective difficulty gaining access to the airway

• Status post upper gastrointestinal surgery

Current Evidence to Support Use of NIV

Khilnani GC et al. Natl Med J India. 2002;15(5):269-74.

 Level A
(Multiple controlled trials)

• Chronic obstructive pulmonary disease

• Cardiogenic pulmonary edema

• Immunocompromised patients
 Potential benefits of NIV in severe stable COPD
• Can improve respiratory muscle strength

• Increases in maximum inspiratory pressure

• Improvement (or at least prevention of deterioration) in nocturnal

and daytime gas exchange, and better quality-of-life (QOL) scores

• May increase walking distance, particularly if combined with

rehabilitation

• Prolongation of total sleep time in severely hypercapnic patients with

some sleep-disordered breathing

• Reduces the need for hospitalization

Díaz-Lobato S et al. Int J Chron Obstruct Pulmon Dis. 2006;1(2):129-35

 Guidelines for use of noninvasive ventilation in severe stable COPD

• Symptomatic patient after optimal therapy

• Sleep apnea excluded

• PaCO2 >55 mmHg or

• PaCO2 50–54 mmHg and evidence of nocturnal hypoventilation based on nocturnal

oximetry showing sustained desaturation to < 89% for > 5 min while patient is on
his or her usual FIO2

• Repeated hospitalizations
 Monitoring noninvasive ventilation in COPD: basic aspects in a chronic
setting
• Patient comfort

• Mask fit and leak

• Hours of use

• Problems with adaptation (eg, nasal congestion, dryness, gastric insufflation, conjunctival irritation,

inability to sleep)

• Symptoms (eg, dyspnea, fatigue, morning headache, hypersomnolence)

• Gas exchange: daytime, nocturnal oximetry, blood gases measured periodically to assess PaCO2

• Polysomnography if symptoms of sleep disturbance persist or nocturnal desaturation persists

without clear explanation

Relative contraindications to long-term noninvasive ventilation for
COPD patients
• Severe comorbidity that is likely to shorten survival more than lung

disease (end-stage malignancy, liver disease)

• CHF may respond favorably

• Unmotivated patient

• Nonadherence to oxygen or medical therapy

• Cognitive impairment that interferes with patient’s ability to understand

therapy

• Insufficient financial resources

• Insufficient caregiver resources

• Unable to tolerate or fit mask, claustrophobic patient

 Cardiogenic pulmonary edema
• NIV is well suited for patients with cardiogenic pulmonary edema.

• CPAP and BiPAP modalities both are effective, with CPAP possibly being more effective

• Greatest benefits are realized in relief of symptoms and dyspnea

• Decrease in intubation and mortality rates is not a universal experience

• Patients with hypercapnic respiratory acidosis may derive the greatest benefit from noninvasive

ventilation.

• Importantly, adjust to standard therapy, including diuresis

• Benefit may be seen with as few as 2 hours of support

 Level B
(Single controlled trial or multiple case series)
• Weaning from mechanical ventilation in COPD patient

• Community-acquired pneumonia in COPD Patients

• Asthma

• Postoperative respiratory distress and respiratory failure

• Avoidance of extubation failure

• “Do-not-Intubate” patients

• Neuromuscular respiratory failure

• Decompensated obstructive sleep apnea/cor pulmonale

 Community-acquired pneumonia

• NIV not established to be beneficial

• Secretions may be limiting factor

• Improvement with noninvasive ventilation best achieved in patients also with COPD

• Hypercapnic respiratory acidosis may define group likely to respond

• Decrease in intubation rate and mortality may be limited to those also with COPD
 Asthma

• Similar pathophysiology to COPD

• Limited reported experience with NIV

• Mostly case series with reported benefit

• Noninvasive ventilation probably beneficial, but experience limited

Soroksky A et al. Chest. 2003;123(4):1018-25

 Postoperative patients
• Postoperative hypoxemia related to atelectasis or pulmonary edema

• Occurrence following multiple types of surgery (eg, lung, cardiac,

abdominal)

• Randomized trials with postoperative continuous positive airway

pressure (CPAP) demonstrate benefit

• Applied as prophylactic support or with development of hypoxemia

• Benefit noted with level CPAP levels in 7.5- to 10-cm water range

• Lower intubation rates, days in ICU, and pneumonia

Squadrone V et al. JAMA. 2005;293(5):589-95

 Do-not-intubate status (advanced disease or terminal malignancy)

• Numerous case series

• COPD patients comprise most patients

• Most with hypercapnic respiratory failure

• Report of 60% success rate, but discharge home rate of 40-50%

• Median survival following treatment 179 days in one series

• One-year survival rate of 30%

Levy M et al. Crit Care Med. Oct 2004;32(10):2002-7.

• Some with more distress from the mask and noninvasive ventilation than benefit

• Issues with resource utilization and prolonging the inevitable

• Better outcomes in CHF, awake patients, and those with strong cough (mobilized

secretions)

• Benefit in patients with malignancy if treating reversible condition

• Benefit in dyspnea relief for patients with terminal malignancy

Cuomo A et al. Palliat Med. 2004;18(7):602-10

 Level C
(Few case series or case reports or failure to
demonstrate benefit in controlled trials )
• Cystic fibrosis

• Acute respiratory distress syndrome

• Community-acquired pneumonia in non-COPD patients

• Upper airway obstruction

• Mild Pneumocysis Carnii pneumonia

• Trauma
 Rib fractures (traumatic, with nonpenetrating chest injuries)

• Older single report using low-level CPAP (5 cm water)

• Fewer episodes of pneumonia, duration of hospitalization

• No mortality benefit

• Hernandez et al found that in patients with hypoxemia related to severe thoracic

trauma, noninvasive mechanical ventilation reduced intubation rates

Hernandez G et al. Chest. 2010;137(1):74-80

• In a randomized clinical trial, patients with PaO2/FiO2 ratio of less than 200

for more than 8 hours while receiving oxygen by high-flow mask within
the first 48 hours after thoracic trauma were randomized to remain on
high-flow oxygen mask or to receive NIV

• The trial was halted after 25 patients were enrolled in each group because

the intubation rate was much higher in controls than in noninvasive

mechanical ventilation patients (40% vs 12%, P = .02)

• In addition, length of hospital stay was shorter in noninvasive mechanical

ventilation patients (14 vs 21 d, P = .001)

• However, no difference in survival was observed

Hernandez G et al. Chest. 2010;137(1):74-80

 Acute respiratory distress syndrome

• Not recommended as first-line therapy in management

• Limited experience, but may benefit those who do not require immediate

intubation

• NIV provided via mask or helmet; able to avoid intubation in approximately half

• Ventilator settings in successful NIV - Pressure support ventilation of 14 cm water;

positive end-expiratory (PEEP) of 7 cm water

• Successfully treated patients found to have lower severity of illness (Simplified

Acute Physiology Score II < 34 or improvement of PaO2/FIO2 ratio >175 after 1 h)

Antonelli M et al. Crit Care Med. 2007;35(1):18-25.
Noninvasive ventilation in acute respiratory failure: which recipe
for success?
 Time frames for the application of noninvasive positivepressure ventilation in acute
respiratory failure (ARF) according to the severity and end-of-life choices of patients.

ETI: endotracheal intubation; IMV: invasive mechanical ventilation; NIV: noninvasive ventilation; EXT-F: extubation failure.
Evidence-based indications for NPPV according to the severity and time of
ARF
Integrated strategies to reduce noninvasive positive-pressure ventilation
failure in different clinical– physiological scenarios.
ECCO2R: extra-corporeal
carbon dioxide removal;
HFNC: high-flow nasal
cannula; FBO: fibre-optic
bronchoscopy; HFCWO:
high-frequency chest
wall oscillation; IPV:
intrapulmonary
percussive ventilation;
VILI: ventilator-induced
lung injury
 Overview of Noninvasive Ventilation
• Noninvasive ventilation has now become an integral tool in the management of both

acute and chronic respiratory failure, in both the home setting and in the critical care
unit.

• Noninvasive ventilation has been used as a replacement for invasive ventilation, and

its flexibility also allows it to be a valuable complement in patient management.

• Its use in acute respiratory failure is well accepted and widespread.

• The role of noninvasive ventilation in those with chronic respiratory failure is remains

to be defined.

https://emedicine.medscape.com/article/304235-overview, Oct 22, 2018 Guy W Soo Hoo, MD, MPH

 Summary

• There is a growing interest in the use of NIV in patients with acute and chronic

respiratory failure

• Offers several advantages over conventional ventilation

• When applied in the setting of acute respiratory failure it may obviate the need for

endotracheal intubation and thus preserve speech and swallowing, and reduce the
trauma associated with the insertion of an endotracheal tube

• NIV can significantly reduce infectious complications, duration of ICU stay and

mortality in patients with acute respiratory failure due to various causes

 Summary

• Reverses nocturnal hypoventilation and improves daytime gas exchange in chronic

respiratory failure

• Can also be of some benefit to patients with postoperative hypoxaemia, acute lung

injury and left heart failure

• Not appropriate for all patients

• NIV represents an advance in the management of patients with respiratory failure

• Sound understanding of this promising technique is essential for all physicians

involved in the care of critically ill patients

Thank You!