Part I: Noninvasive Positive Pressure Ventilation in the Acute Care Facility By: Susan P. Pilbeam, MS, RRT, FAARC John D. Hiser, MEd, RRT, FAARC Ray Ritz, BS, RRT, FAARC American Association for Respiratory Care December, 2006

Objectives 1.Define noninvasive positive pressure ventilation (NPPV) 2.Explain the benefits and complications of NPPV 3.Identify patients who are selected for or excluded from the use of NPPV 4.Describe the operating characteristics of NPPV devices that may be used for CPAP, bi-level non-emergent NIV and emergent NIV 5.Describe the selection, fitting and application of the patient interface

Objectives (continued) 6.Compare advantages and disadvantages of the different interfaces used with NPPV 7.Explain the need for and application of humidification during NPPV 8.List the key components of patient assessment used to monitor NIV effectiveness 9.Discuss the steps in the initiation and management of NPPV 10.Recognize complications of NPPV and recommend ways to correct these problems 11.Describe weaning from NPPV

Types of Noninvasive Ventilation (NIV) Negative Pressure Ventilation (NPV) Continuous Positive Airway Pressure (CPAP) Noninvasive Positive Pressure Ventilation (NPPV)

Negative Pressure Ventilation (NPV) Negative pressure ventilators apply a negative pressure intermittently around the patient’s body or chest wall The patient’s head (upper airway) is exposed to room air An example of an NPV is the iron lung or tank ventilator

Function of Negative Pressure Ventilators Negative pressure is applied intermittently to the thoracic area resulting in a pressure drop around the thorax This negative pressure is transmitted to the pleural space and alveoli creating a pressure gradient between the inside of the lungs and the mouth As a result gas flows into the lungs

Continuous Positive Airway Pressure - CPAP Another form of noninvasive support is CPAP that is usually applied through a mask-type device CPAP does not actually provide volume change nor does it support a patient’s minute ventilation However, it is often grouped together in discussions about noninvasive ventilation

CPAP CPAP is most often used for two different clinical situations First, CPAP is a common therapeutic technique for treating patients with obstructive sleep apnea Second, CPAP is used in the acute care facility to help improve oxygenation, for example in patients with acute congestive heart failure (more on this later)

Infant Nasal CPAP Nasal CPAP in infants appears to help reduce several types of respiratory distress that occur in infants –Example, apneic episodes –Another example, delivery by Caesarean section (no vaginal “squeeze”) –Relief of severe hypoxemia in premature infants … along with surfactant replacement

Noninvasive Positive Pressure Ventilation NPPV provides positive pressure through the upper airway by some type of mask or other noninvasive interface (See Part II - Section on Interface Devices) With NPPV, pressure is applied intermittently with inspiration having a higher pressure than expiration

Noninvasive Positive Pressure Ventilation NPPV is used to treat both acute and chronic respiratory failure In the acute care setting NPPV can be used to treat patients with acute respiratory failure (ARF), such as acute exacerbation of COPD In the patient with chronic respiratory failure, NPPV can be used to provide 24-hour ventilatory support

NPPV in the Chronic Care Setting Neuromuscular Diseases Restrictive Thoracic Disorders Chronic Stable COPD Cystic Fibrosis Nocturnal Hypoventilation All patients requiring long term support are candidates for NPPV

Noninvasive Ventilation in the Acute Care Setting This module will focus on NPPV and CPAP in the acute care setting, beginning with NPPV It will include noninvasive positive pressure ventilation (NPPV) in patients with acute respiratory failure (ARF). Other indications for NPPV: –Do Not Intubate Patients –Facilitation of Weaning from Invasive ventilation And CPAP in specific types of patients with ARF, i.e. those with acute congestive heart failure (WITHOUT myocardial infarction)