2. Definition..
Noninvasive ventilation is the delivery of ventilatory support without the need for an invasive artificial airway
The use of NIV in acute hospital settings and at home has been steadily increasing

3. INTRODUCTION
Negative pressure ventilators (Tank and Cuirass ventilators) were the only non-invasive methods of assisting ventilation for many years mainly for ventilating large number of victims of Polio during their acute illness. In 1980s it was recognized that delivery of continuous positive airway pressure by close fitting nasal masks for treatment of obstructive sleep apnea could also be used to deliver an intermittent positive pressure. This was followed by improvements in the interface and establishment of role of NIMV in patients of COPD. The use of NIMV has increased in last decade in various conditions to avoid complications of intubation.

4. Negative-Pressure Ventilation
Late 1880s – iron lungs first used
Early 1900s – iron lungs used for polio epidemics
This continued throughout the 20th century until 1960s when invasive ventilation became available

6. Types of NIV
Negative pressure ventilation (iron or tank-chest cuirass)
Abdominal Displacement(Pneumobelt-Rocking bed)
Positive pressure ventilation(pressure BIPAP- CPAP)

7. 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

8. Noninvasive positive pressure ventilation (NPPV)
Noninvasive positive pressure ventilation (NPPV) is the delivery of mechanically assisted or generated breaths without placement of artificial airway
Both CPAP and BiPAP are considered NPPV

9. Location of NIV
NIV can be administered in the emergency department, intermediate care unit, or general respiratory ward

10. Mechanism of benefit Improved alveolar ventilation
Reduced work of breathing
Rest of the respiratory musculature
Increased intrathoracic pressure, decreases preload and afterload
Why does it decrease mortality?
Decreased hospital-acquired infections
Decreased trauma from intubation
Less complications of sedation

11. Permits normal eating, drinking and communication with your patient
Benefits of Using NPPV
NPPV provides greater flexibility in initiating and removing mechanical ventilation
Permits normal eating, drinking and communication with your patient
Preserves airway defense, speech, and swallowing mechanisms

12. Disadvantages of NIV 1.System 2.Mask
Slower correction of gas exchange abnormalities
Increased initial time commitment
Gastric distension (occurs in <2% patients)
2.Mask
Air leakage
Transient hypoxemia from accidental removal
Eye irritation
Facial skin necrosis –most common complication.

13. Potential indicators of success in NPPV use
Younger age
Lower acuity of illness (APACHE score)
Able to cooperate, better neurologic score
Less air leaking
Moderate hypercarbia (PaCO2 >45 mmHG, <92 mmHG)
Moderate acidemia (pH <7.35, >7.10)
Improvements in gas exchange and heart respiratory rates within first 2 hours

27. Nasal Masks Dual density foam bridge forehead support
360 swivel standard elbow
Dual density foam bridge forehead support
Thin flexible & bridge material
Dual flap cushion
Respironics Contour Deluxe™ Mask

28. Full Face Masks Most often successful in the critically ill patient
Entrainment valve
Adjustable
Forehead Support
Ball and Socket Clip
Double-foam cushion
Pressure pick-off port
Respironics PerformaTrak® Full Face Mask

29. Less effectiveness with nasal obstruction
Advantages of Nasal Masks
Disadvantages of Nasal Masks
Less risk of aspiration
Enhanced secretion clearance
Less claustrophobia
Easier speech
Less dead space
Mouth leak
Less effectiveness with nasal obstruction
Nasal irritation and rhinorrhea
Mouth dryness

30. Suitable for patients with Claustrophobia Skin sensitivities
Nasal Pillows or Nasal Cushions (continued)
Suitable for patients with
Claustrophobia
Skin sensitivities
Need for visibility
Respironics Comfort Lite Nasal Mask

32. Indications for CPAP Cardiogenic Pulmonary Oedema
Obstructive Sleep Apnoea
Chest Wall Trauma if hypoxic on adequate analgesia
Pneumonia

34. Indications for BiPAP Exacerbation of COPD with Respiratory acidosis
Type II respiratory failure with chest wall deformity or neuromuscular disease
Failure of CPAP
Pneumonia with respiratory acidosis
Therapeutic trial with a view to intubation if it fails
Others (ARDS, post-op respiratory failure, to buy time prior to intubation)

47. CPAP
Nasal or face mask
Continuous positive pressure applied to the airways
Usually well-tolerated
Similar to use of PEEP
Reduces work of breathing
Improve ventilation to collapsed areas of lung

48. BiPAP Bi-Level pressure support
Inspiratory Positive Airway Pressure (IPAP) & Expiratory PAP (EPAP)
IPAP is the pressure support machine gives to help patients own inspiration
Helps to reduce WOB and increase alveolar ventilation
EPAP is essentially PEEP and help to prevent alveolar collapse

49. Indications for CPAP Cardiogenic Pulmonary Oedema
Obstructive Sleep Apnoea
Chest Wall Trauma if hypoxic on adequate analgesia
Pneumonia

50. Indications for BiPAP Exacerbation of COPD with Respiratory acidosis
Type II respiratory failure with chest wall deformity or neuromuscular disease
Failure of CPAP
Pneumonia with respiratory acidosis
Therapeutic trial with a view to intubation if it fails
Others (ARDS, post-op respiratory failure, to buy time prior to intubation)

51. Contraindications Uncooperative patient Altered mental status
Risk of aspiration
Hemodynamic instability/Severe sepsis
Acute myocardial infarction or ischemia
Facial/neck trauma or surgery
Excess secretions or upper GI bleed

52. Patient Selection Sick but not moribund Able to protect airway
Conscious and co-operative
Haemodynamically stable
No excessive secretions
Few co-morbidities
Improvement on ABG with NIV

53. Patient Rejection Respiratory arrest Haemodynamically unstable
Uncooperative
Unable to protect airway (swallowing and cough impaired or vomiting)
Facial, oesophageal, or gastric surgery
Craniofacial trauma or burns
Airway obstruction
Undrained Pneumothorax

54. Position of exhalation port and mask design affect CO2 rebreathing during NIV
Crit Care Med Aug;31
facial mask with exhalation port within the mask compared with port in the ventilator circuit
smallest mask volume
less rebreathed CO2
inspiratory load

55. Humidification during NIV
No humidification: drying of nasal mucosa; increased airway resistance; decreased compliance.
HME lessens the efficacy of NIV
Only pass-over humidifiers should be used
Intensive Care Med. 2002;28

56. Aerosol bronchodilator delivery during NIV
optimum nebulizer position: between the leak port and patient connection
Optimum ventilator settings: high inspiratory pressure and low expiratory pressure.
Optimum RR 20/mt. Rather than 10/mt.
25% of salbutamol dose may be delivered
Crit Care Med Nov;30

57. Monitoring Response Physiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG should be obtained with 1 hour and, as necessary, at 2 to 6 hour intervals.
Objective a) Respiratory rate
b) blood pressure
c) pulse rate
Subjective
a) dyspnea
b) comfort
c) mental alertness

58. Monitoring…..
Mask Fit, Comfort, Air leak, Secretions, Skin necrosis Respiratory muscle unloading Accessory muscle activity, paradoxical abdominal motion Abdomen Gastric distension

59. Criteria to discontinue NIV
Inability to tolerate the mask because of discomfort or pain
Inability to improve gas exchange or dyspnea
Need for endotracheal intubation to manage secretions or protect airway
Hemodynamic instability
ECG – ischemia/arrhythmia
Failure to improve mental status in those with CO2 narcosis.

60. THANK YOU
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