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Chapter 45 Noninvasive Ventilation. Learning Objectives. Discuss the concept of noninvasive ventilation (NIV). List the goals of and indications for NIV. Select patients who should be managed with NIV. List those factors that are predictive of success during NIV. Learning Objectives (cont.).

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learning objectives
Learning Objectives

Discuss the concept of noninvasive ventilation (NIV).

List the goals of and indications for NIV.

Select patients who should be managed with NIV.

List those factors that are predictive of success during NIV.

learning objectives cont
Learning Objectives (cont.)

Discuss patient interfaces, types of ventilators, and modes of ventilation used during NIV.

Discuss the initiation and management of NIV in the acute care setting.

List and discuss complications associated with NIV and their possible solutions.

Discuss the appropriate approach to the initial application of NIV.

introduction to noninvasive ventilation
Introduction to Noninvasive Ventilation

Abbreviated NPPV, NIPPV, or NIV

Supports ventilation without artificial airway

bag-mask provides the earliest example

Encompasses both ventilation and CPAP

Typically provided by nasal or oral mask

introduction to noninvasive ventilation cont
Introduction to Noninvasive Ventilation (cont.)

Use has increased due to:

Improved patient interfaces

Improved quality of NIV ventilators

NIV software available for critical care ventilators

Reports of success in literature

types of noninvasive ventilation
Types of Noninvasive Ventilation

Can be provided by a number of mechanisms


Rubber bladder strapped to abdomen

Bladder filling compresses abdominal contents pushing up diaphragm causing exhalation

Bladder deflation causes diaphragm to fall and inhalation occurs

Some patients prefer this while in wheelchair

types of noninvasive ventilation1
Negative-pressure ventilators (NPV)

Negative pressure around thorax causes pressure gradient across chest wall – inspiration occurs

Iron lung: widely for polio epidemic (1920-1960s)

Surrounds entire body

Porta lung is a simplified, cheaper version

Chest cuirass: seals around the chest

NPV fell from use with development of positive-pressure ventilation

Types of Noninvasive Ventilation

All of the following are goals for noninvasive ventilation, except?

  • Avoid Intubation
  • Improve mortality
  • Maximize patient comfort
  • Airway protection
acute care copd
Acute Care: COPD

Hypercapnic respiratory failure due to COPD is primary indication for NIV

Strong evidence of efficacy in reducing

Need for intubation

Hospital mortality and length of stay


Standard of care for managing an acute exacerbation of COPD

First-line therapy

acute care asthma cardiogenic pulmonary edema
Acute Care: Asthma & Cardiogenic Pulmonary Edema

Asthma and NIV

Some evidence of positive results

Improved P/F ratio, PaCO2, and pH

Reduction intubation rates

Use remains controversial

Acute cardiogenic pulmonary edema:

Numerous studies show power of CPAP

CPAP first-line therapy

NIV reserved for those with ventilatory failure

acute care cap hypoxemic respiratory failure
Acute Care: CAP & Hypoxemic Respiratory Failure


Only improves outcomes with COPD patients who develop pneumonia

Hypoxemic respiratory failure (P/F < 300)

First-line therapy for immunocompromised, awaiting transplant, and post lung resection

NIV very controversial for all other groups

If used, note marked improvement in 1 to 2 hours or accept failure and intubate.

60% mortality noted if intubation is further delayed

acute care other indications for niv
Acute Care: Other Indications for NIV

DNI patients (do not intubate)

Only use if it makes patient more comfortable or to manage a reversible disorder

Postoperative use shows promise

Some evidence CPAP post abdominal surgery improves outcomes

NIV to facilitate weaning

Reserve for COPD and CHF patients

For other patient groups, NIV instead of reintubation worsened outcomes


Noninvasive ventilation may be used for a patient with a DNI (do not intubate) order, in all of the following situations, except:

  • Make patient more comfortable
  • Patient refuses artificial ventilation
  • Managing a reversible disorder
  • Manage obstructive sleep apnea
chronic care restrictive thoracic diseases
Chronic Care:Restrictive Thoracic Diseases

Indicated for patients: post polio, NMD, chest wall deformities, spinal injuries, and severe kyphoscoliosis

If evidence of nocturnal hypoventilation

Hypersomnolence, morning headache, fatigue, dyspnea, cognitive dysfunction

If present, use NIV to prevent chronic hypercapnia and associated hypoxemia

Helps by resting muscles, lowering CO2, and improved compliance, FRC, and deadspace

chronic care of copd patients
Chronic Care of COPD Patients

Use is controversial

Consensus conference recommendation

Use for severe COPD with symptoms of nocturnal hypoventilation and one of the following

PaCO2 > 55 mm Hg

PaCO2 50 to 54 mm Hg with nocturnal desaturation

Two hospital admissions for ventilatory failure


Associated with a number of diseases including central and obstructive sleep apnea and lung parenchymal diseases

Nasal CPAP is first-line therapy

NIV is recommended when other first-line therapies failed to alleviate hypoventilation

patient selection exclusion predictors of success niv
Patient Selection & Exclusion & Predictors of Success: NIV

Selection is generally established by signs and symptoms of respiratory distress (see Box 45-3).

Exclusion occurs once the need for ventilatory assistance has been established (see Box 45-4).

Predictors of success

Summarized in Box 45-5 but generally patients are not as sick and/or respond rapidly to NIV


All of the following are selection criteria for NIV patients in respiratory failure, except:

  • Excessive use of accessory muscles
  • Respiratory rate <25 breaths/min
  • Paradoxical breathing
  • Dyspnea
niv equipment patient interfaces
NIV Equipment: Patient Interfaces

Most common types

Nasal mask

Full-face mask (nasal-oral)


Less common

Total face mask (covers whole face)

Nasal pillows


patient interfaces nasal masks
Patient Interfaces: Nasal Masks

Triangular in shape, only covers the nose

Made of hard, clear plastic with a cushion below for contact with face

A strap assembly holds mask on face.

Do not overtighten as may cause tissue necrosis

patient interfaces nasal masks cont
Patient Interfaces: Nasal Masks (cont.)

Proper sizing

Reduces incidence of pressure sores and tissue necrosis

Reduces leaks

Increases patient comfort

Improves likelihood of long-term patient tolerance

patient interfaces full face masks
Patient Interfaces: Full-Face Masks

Interface of choice for patients with acute respiratory failure

>90% of this group should start with full-face mask

Designed for either

Noninvasive ventilators: entrainment valve that prevents asphyxia if ventilator fails

ICU ventilators: entrainment valve absent

patient interfaces full face masks cont
Patient Interfaces: Full-Face Masks (cont.)

Disadvantages compared to nasal mask:

Increased deadspace, claustrophobia, risk of aspiration

Harder to talk and expectorate

noninvasive ventilators1
Noninvasive Ventilators

Most are electrically powered, blower driven, microprocessor controlled

Designed to work with small leak and compensate for that leak

Advantage: Patient ability to trigger and cycle properly in face of small to moderate leaks

Internal oxygen blender is desirable but often absent

hard to obtain >0.5 FIO2

noninvasive ventilators cont
Noninvasive Ventilators (cont.)

Typical modes


Pressure support (PSV)

Pressure assist/control (P-A/C)

With PSV and P-A/C, machine is patient or time triggered, pressure limited, and flow or time cycled

Generate lower rates, pressures, and flows than ICU ventilators

critical care ventilators
Critical Care Ventilators

Much more sophisticated, allow for precise oxygen control, high flows, pressures, etc

Inability to compensate for leaks is common

Often results in triggering and cycling issues

PSV breaths end at set percent peak flow; if flow does not fall to set percent, may lock in inspiration

Modern vents can adjust cycle off percent

Time-cycling solves problem and improves patient comfort

Often causes lots of nuisance alarms

Use full-face mask to minimize leaks

critical care ventilators1
Critical Care Ventilators

CPAP, PSV, and P-A/C have all have been used.

VC modes used but not recommended

Leaks can lead to hypoventilation

Various NIV packages now available on ICU ventilators; some will

Compensate for leaks

Allow audio alarm deactivation

Set maximum inspiratory time (great option)

No proven advantage of any mode


Patients with symptoms of sneezing, nasal draining, nasal and oral dryness, and/or nasal obstruction benefit from humidity therapy

Heated humidity relieves many of above symptoms, thus improving patient compliance

Heat to about 30º C (patient comfort level).

As length of use is unpredictable, recommend use of humidification for all patients receiving NIV

identifying success or failure of niv
Identifying Success or Failure of NIV

Success easy to identify

Improved ABGs: PaCO2 decreases, pH increases, PaO2 increases

Clinical improvement: decreased RR, VT increased, diminished accessory muscle use


If in 1 to 2 hours the above are not noted; move to intubation

Waiting too long can result in cardiac arrest

adjusting niv
Adjusting NIV

Adjustments determined by patient presentation and ABGs

High PaCO2: Increase pressure (VT) or rate

Low PaCO2: Decrease pressure (VT) or rate

Often rate is for backup only; if set in A/C may have above effects, but patient inspiratory efforts override ventilator setting

High PaO2: Decrease oxygen or PEEP

Low PaO2: Increase oxygen or PEEP

When PEEP is adjusted, may alter pressure gradient and thus VT

monitoring niv
Monitoring NIV

Must assess for


Accessory muscle use

Ventilator synchrony and patient comfort

Improved vital signs and ABGs

If patient worsens on optimal setting, think immediate intubation

Particular attention must be paid to those with respiratory failure

adverse effects complications of niv
Adverse Effects & Complications of NIV

Causes of NPPV failure include:

Mask-related problems

Flow-related problems

Large air leaks

Patientventilator asynchrony

Lack of improvement in gas exchange

See Table 45-2.

Major complications: aspiration, hypotension, and pneumothorax


All of the following are types problems which may occur with NIV, except:

  • Mask-related problems
  • Flow-related problems
  • Large air leaks
  • Improvement in gas exchange
time and costs of niv
Time and Costs of NIV

Success of NPPV is closely tied to time-intensive involvement of RT staff for

Mask fitting


Adjustment of NIV settings

Patient education

Following initiation, time required (costs, also) should fall to reflect those required for invasive ventilation