1. NON-INVASIVE MV Good news It works !!!!!!! Warnings Not always Not for all Know the technique Be skilled

2. (from Vitacca M. et al. AJRCCM 2001; 164: 638-641) i-PSV and n-PSV delivered before and after extubation in patients not weaned Arterial Blood Gases i-PSV 7.38 59.1 206 n-PSV 7.38 61 210 pH PaCO 2 PaO 2 /FIO 2 T-tube 7.33 69 183

3. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

4. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

5. The Use of Noninvasive Ventilation in Acute Respiratory Failure at a Tertiary Care Center* Elizabeth S. Paus-Jenssen, MD; John K. Reid, MD; Donald W. Cockcroft, MD, FCCP; Karen Laframboise, MD; and Heather A. Ward, MD, FCCP Chest 2004; 126: 165-72

7. 60% Hypercapnic 55% Hypoxic

8. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

10. Appropiate setting for long-term NPSV (n=23 hypercapnic COPD patients) (from Vitacca M. et al. Chest 2000) Change (% of SB)

11. Assessment of Physiologic Variables and Subjective Comfort Under Different Levels of Pressure Support Ventilation* Michele Vitacca, MD; Luca Bianchi, MD; Ercole Zanotti, MD; Andrea Vianello, MD; Luca Barbano, MD; Roberto Porta, MD; and Enrico Clini, MD, FCCP† Chest 2004; 126: 851-59

12. Study protocol Time (min) SB (baseline) 10 V’ E, PTP 0 setting V’ E, PTP Pao, IE RANDOM of ventilators comfort

15. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

16. (from BTS Guideline Thorax 2002;57:192-211)

19. Major problems with mask during NIV support Air leaks Side-effects Size

20. Side effects due to NPPV N=26 (compliant patients) (from Criner GJ. et al. Chest 1999;116:667-675) Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 %

22. MOUTH LEAKS IN NASAL NPPV (n=9, hypercapnic=7, COPD=6, age 64 years) (from Teschler H. et al. ERJ 1999; 14: 1251-1257) PtcCO 2 (mmHg)Arousal Index (events h -1 ) p<0.001p<0.0002

25. Side effects due to NPPV N=26 (compliant patients) (from Criner GJ. et al. Chest 1999;116:667-675) Mask leaks Skin irritation Rhinitis / aerophagia Discomfort 43 23 13 8 %

26. Tissue Necrosis Caused by an Improperly Fitting Mask

29. (CCM 2002; 30: 602-608)

30. CRITERI PER LA SCELTA DELLA MASCHERA Esperienza dell’équipe Considerazioni anatomiche Modalità di ventilazione Compliance e sensorio del paziente

31. (from BTS Guideline Thorax 2002;57:192-211)

32. NON-INVASIVE MV NIV in the “real-world” Setting the ventilator Choice of interfaces Humidification and drug delivery

34. In the present pilot study, the use heated humidification and heat and moisture exchanger showed similar tolerance and side-effects, but a higher number of patients decided to continue long-term noninvasive mechanical ventilation with heated humidification.

36. Crit Care Med 2002; 30:2515–2519

37. To conclude, when using noninvasive positive pressure ventilation with two-level respirators, oxygen should be added close to the exhaust port (ventilator side) of the circuit. If inspiratory airway pressure levels are >12 cmH2O, oxygen flows should be at least 4 L*min -1

38. Respir Care 2004;49(3):270–275. CONCLUSIONS Delivered oxygen concentration during BiPAP is a complex interaction between the leak port type, the site of oxygen injection, the ventilator settings, and the oxygen flow. Because of this, it is important to continuously measure arterial oxygen saturation via pulse oximetry with patients in acute respiratory failure who are receiving noninvasive ventilation from a bi-level ventilator.