Non-Invasive Positive Pressure Ventilation ( NPPV )

Objective :

- Definition of NPPV

- Kinds of pressures in NPPV

- Types of NPPV

- Factors contributing to NPPV interest

- Indication & contraindication for CPAP & BiPAP

- Indication & contraindication for acute & chronic cases care

- Modes & controllers in NPPV devices

- Interfaces for NPPV devices

- NPPV devices

- common cases that can be treated by NPPV

- Differences between BiPAP & BiPAP ( APRV )

- Definition of NPPV :

* It is any of ventilation support applied without use of an endotracheal \ Trach tube . It

provides two level of pressure ( I & E ) to the airway , which are triggered by the patient or

by the ventilator ( time ) depending on the mode utilized . ( 1 )

* It is technique of providing ventilation without the use of an artificial airway . ( 2 )

Kinds of pressures in NPPV : ( 2 )

* IPAP : Inspiratory Positive Airway pressure . This pressure control peak airway

pressure during inspiration .

* EPAP : Expiratory Positive Airway pressure . this pressure control end – expiratory

pressure .

* PEEP : Positive End Expiratory Pressure . this is pressure is positive airway pressure

at end expiratory phase . it is with mechanical breaths only .

(2 )Types of NPPV :

* CPAP : Continuous Positive Airway pressure . it is Positive Airway pressure during

spontaneous breaths . so there is not mechanical breaths . & CPAP is active when

IPAP = EPAP . for these reasons the work of breathing is entirely assumed by the Pt .

* Bilevel PAP : Bilevel Positive Airway pressure . it s provides IPAP & EPAP .

It different from CPAP in that Bilevel PAP has two pressure level . whereas CPAP has

only one .

It provides mechanical breaths from IPAP & EPAP . EPAP function as PEEP .

Factors contributing to NPPV interest : ( 3 )

- success in treatment of Obstructive Sleep Apnea .

- improve patient interfaces .

- Does not inhibit natural pulmonary defense .

- allow the patient to eat , drink & talk .

- allow patient to expectorate secretion .

- less costly than conventional MV .

- possibility of use in acute & chronic ventilatory failure .

- prevention of complication of intubation & tracheostomy .

- able to be use when patient resist intubation .

Indication & contraindication for CPAP & BiPAP : ( 2 )

* CPAP :

Contraindication Indication

Apnea due to neuromuscular causes progressive hypoventilation

Obstructive Sleep Apnea

Fatigue of respiratory muscle

Facial trauma

Clasustrophobia

* BiPAP :

Indication Contraindication

Reduction on respiratory workload in obesity Apnea

Acute respiratory failure Unable to handle secretion

Acute hypercapnic exacerbations of COPD Facial trauma

Claustrophobia

Indication & contraindication for acute & chronic cases care : ( 1 )

* Acute care :

Indication for NPPV with Acute Respiratory Failure :

1 - acute hypercapnic respiratory failure ( at least 2 of the following should be present )

A – severe worsing dyspnea . or B – sustain RR > 25 BPM . or C – use accessory muscle \

abdominal paradoxical . or D – PH < 7.35 with PaCO2 > 45 mmHg .

2 – acute hypoxemia : SpO2 < 88 – 90 % with FiO2 > 60 % & P\F < 200 .

* use conventional therapy with O2 as needed & monitor patient closely if the above criteria

is not met .

If the above criteria is met so look for contraindication :

Absolute contraindication Relative contraindication

Apnea Anxiety

Cardiopulmonary arrest Bowel obstruction

Facial burns Claustrophobia

Facial & cranial trauma Copious secretion

Fixed upper airway obstruction Inability to clear secretion

Hemodynamic instability \ arrhythmias Inability to cooperate or tolerate interface

Inability to protect airway \ vomiting (risk of aspiration )

Severe illness ( high APACHE score )

* if there is not contraindication institute NPPV therapy .

* if there is contraindication consider invasive ventilation .

* Chronic care :

Indication Contraindication

Restrictive thoracic disease Chronic hypoventilation syndromes

secondary to : - chest wall & spinal deformity

- Idiopathic hypoventilation - neuromuscular disease

- obesity

Unable to protect airway due to swallowing issue or excessive secretion & poor cough

Chronic obstructive pulmonary disease ( COPD )

- Unable to fit interface - Rapidly progressive neuromuscular disease

Obstructive sleep apnea Unmotivated \ uncooperative patient

Modes & controllers in NPPV devices : ( 3 )

Modes of NPPV : NPPV A / C , NPPV SIMV , NPPV CPAP/PS , & Bilevel pressure ventilation

mode .

NPPV can control : volume ventilation , Respiratory rate , Insp. Time , PEEP , FiO2 , &

humidification .

( 2 , 3 ) Interfaces for NPPV devices :

Note Disadvantages Advantages Interface

Too high = leaks in eye

Gas leak Nasal dryness or

drainage

Comfort patient compliance

Nasal mask

The top of the mask should be 1/3 of the way down from the bridge of the nose

Claustrophobia Patient

noncompliance Asphyxiation

good seal Facial mask

The top of the mask should be 1/3 of the way down from the bridge of the nose

More claustrophobic Must remove to

expectorate or speak

Better ventilation Good seal

Full face mask

for CPAP therapy only in range 3 – 20

cmH2O

Leak is potential problem

more comfortable than facial maskes

Nasal pillows

( 3 ) NPPV devices :

Home care NPPV ventilators and other support devices may have any of the

following features :

- the ability to provide full ventilatory support .

- the ability to ventilate at night only .

- BiPAP support or CPAP .

- low pressure or disconnect alarm .

* Examples of NPPV :

- Respironics BiPAP focus .

- Respironics BiPAP vision .

- Respironics BiPAP synchrony .

- Puritan Bennett GoodKnight 425 .

* also there are some MV used usually for invasive ventilation support NPPV : such

as ( Puritan Bennett 840 ) .

common cases that can be treated by NPPV : ( 1 )

- acute respiratory failure .

- acute pulmonary edema .

- cardiogenic pulmonary edema .

- Immuno-compromised patients .

Differences between BiPAP & BiPAP ( APRV ) : ( 1 )

- BiPAP : is NPPV mode used IPAP & EPAP to give mechanical breaths .

- BiPAP ( APRV ) : is mode of invasive ventilation that also has two pressure IPAP & EPAP and

in each pressure patient can take breaths by PS .

References :

1 - Ventilator Management ( Dana Oakes ) 2009 Edition .

2 - Clinical Application of Mechanical Ventilation . ( David W. Chang ) 2nd Edition .

3 - Mosby's Respiratory Care Equipment ( J. M. CAIRO , Susan P. PILBEAM )

8th Edition .

Ali Nasser O. Aljarrash .

RC student ( 3rd year )

210021948