1. “Bi-Level and Non-invasive Intermittent Postive Pressure Ventilation”.
M.A . King
Respiratory Support & Sleep Centre,
Papworth Hospital, Cambridge,
CB3 8RE, UK

2. Bi-level and NIPPV
Volumetric mechanical ventilation is usually reserved for the unconscious patient and is delivered by an endotracheal tube.
Non-invasive Intermittent Positive Pressure Ventilation is delivered by a mask.
Bi-level and NIPPV

3. Plan Avoid mentioning CPAP and Bi-Level in OSA !
Focus in non-invasive ventilatory support.
What is ventilatory failure?
Who needs this treatment?
What do the machines do?
What are the outcomes?
Discusion
: Do Sleep Technologists need to be involved in these treatments?

4. Technological developments since the invention of CPAP
Ventilatory insufficiency
Ventilatory Failure
OSA with lung problems
OSA
Bi-Level
Bi-Level
Bi-Level
CPAP
Pressure support ventilators
Pressure support ventilators
1987
1990
1995
<1987
2000
<1987

5. Ventilatory Failure. Lung Function = Ventilation and gas exchange
Minute Ventilation is a function of respiratory rate and tidal volume
Ventilatory Failure causes a rise in CO2 and drop in O2
Gas Exchange (respiratory) failure causes hypoxia alone

6. “Pump” Failure. Respiratory control centres.
Neurological system ( Nerves and synapses)
Muscle
Mechanics ( Thoracic cage).
RESTRICTIVE VENTILATORY DEFECT

7. Restrictive defect. Small lungs in a rigid chest cage.
Normal lungs which can not be expanded.
Lung mechanics are altered and efficiencey lost.

8. Ventilatory Pump. Cerebral cortex Brainstem Respiratory muscles
WAKE
Sleep-wake
Respiratory muscles
Airflow resistance
Chemoreceptors
Restrictive lung defect.
Mechanoreceptors
Ventilation
Minute ventilation = MV

10. Respiratory Muscle Weakness
Begin AJRCCM

11. Progressive and insidious
pump TV
Control
MV reduced
work RR
Prolonged hypoventilation + or – events (AHI), Desats, Arousals, WASO, poor sleep architecture.
Muscle fatigue
Hypoxia
(hypersomnia)
Hypercapnoea
Progressive and insidious
Acidosis
Ventilatory Failure

12. Acute Hypoxia Hypercapnoea TV Control MV reduced RR
work RR
Prolonged hypoventilation + or – events (AHI), Desats, Arousals, WASO, poor sleep architecture.
Neuro-Muscle insult
CVA
Trauma
Neuro’ disease
Hypoxia
Hypercapnoea
Infection
Acidosis
Ventilatory Failure
Acute

13. Obesity epidemic hits Europe (not France).

14. Nocturnal ventilatory insufficiency
Reduced tidal volume and reduced frequency.
Reduced minute volume = hypercapnoea and hypoxia.

15. Indications for NIPPV. Ventilatory pump failure. Chronic or acute.
Reduced MV, hypoxia with hypercapnoea.
( potential for normal gas exchange – single system failure).

16. Assessment. Arterial blood gases (ABGs). Overnight oximetry and CO2
Lung Function.( volumes and muscle strength)
Medical exam ( cardio-vascular)
AHI and sleep stages have little diagnostic or prognostic value.

17. Simple overnight oximetry.

18. What do the machines do?

19. Non-invasive ventilation- objectives
Improve alveolar ventilation & oxygenation.
Reduction of work of breathing.
Airway support.

20. Objective:Improve alveolar ventilation & oxygenation.
The physiological mechanism is complex & dependent upon the pathology/disease mechanism.
paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQ
Increased Tidal volume and rate = minute Ventilation.

21. Work of breathing
Work increases when FRC reduced or when TV = VC

22. Work of breathing
When FRC and lung compliance are reduced more work is required to inflate the lung. By applying PEEP, the lung volume at the end of exhalation is increased. The already partially inflated lung requires less pressure and energy than before for full inflation TV

23. FiO2 & improved MV ( TV & RR)Te
FiO2 Ti TV
rco RR

24. Mechanical Ventilatory Support
Invasive – endo-tracheal tube.
Non- invasive ventilation (NIV).
Negative Pressure NIV
Positive Pressure NIV *

25. Negative Pressure NIV precedes positive pressure ventilation by 100 years.
- Patient lays inside a rigid cylinder with neck and head outside cylinder.
A vacuum pump creates a negative pressure within the chamber (outside of chest)
- this causes expansion of the patient's chest. This change in chest geometry reduces intrapulmonary pressure and ambient air flows into the lungs.
When the vacuum ends, the negative pressure applied to the chest drops to zero, and the elastic recoil of the chest and lungs results in passive exhalation.
Pump – Adjustable rate and adjustable negative pressure.

26. Iron lung.

28. Limitations of Negative Pressure NIV
Unsupported upper airway- obstruction induced with high transluminal pressure gradients.
Can reduce cardiac OP and peripheral oedema.
CONTROLLED ventilation.
Limited technologies.

30. Positive Pressure NIV NIPPV 1. Delivery of positive pressure to lungs
without intubation.
2. Delivery of air is patient controlled (with machine back up delivery).
3. Air is delivered via a nasal mask or oro-naso mask ( full face mask).
NIPPV

31. Nomenclature of Positive pressure systems
CPAP
Bi-level
NIPPV
IPAP
EPAP
PEEP
Ventilating – peak pressure (pressure support)
Triggers - Cycling
Ti. Te, I/E ratio
Mode S, ST, T
Rise Time
Ramps

32. FiO2, tidal volume & rate.
FiO2 – room air 20.8%, facility to add oxygen. O2 % not measured.
TV – Patient controlled breath enhanced by delivery of air to a target pressure level. Missed breaths recognised.
RR- apnoea recognised. Back up rate. delivered. Tachypnea reduced by control of inspiratory time and expiratory time.

33. Improved alveolar ventilation & oxygenation.
The physiological mechanism is dependent upon the pathology/disease mechanism.
paO2=[(Pb-SWVP)xFiO2]-PaCO2/RQ
Increased Tidal volume and rate = minute Ventilation.

34. Status/progress measured with CO2 & O2 measurements
Basic summary
Trigger level= spontaneous patient effort to trigger a machine “breath”.
IPAP = expands the lungs more.
EPAP = supports small airways and allows for PEEP.
PEEP= increases the volume held in the lungs after passive recoil. Holds open alveoli & improves gas exchange.Reduces work.
T or back up rate- ensures machine breaths if the patient does not trigger.
Status/progress measured with CO2 & O2 measurements

35. FiO2 & improved MV ( TV & RR)Te
FiO2 Ti TV
rco RR

36. Bi-level Technology has developed from CPAP over several years.
Splints upper airway.
Supplements Spontaneous breathing, synchronisation, improves comfort.
Reduces work of breathing.
Time. Missed breaths delivered.
Range of features and settings added in recent times. Alarms – essentially a ventilator.NIPPV

38. Unrecognised ventilatory insufficiency leads to big problems

39. Problems with Home nocturnal NIV
Cost of ventilator.
Choice of ventilator- locked settings.
Mask problems.
Compliance ( nights and hrs used)
Need to monitor efficacy and share medical care with local doctor.
Rare diseases, physical disability, mental disability, agitation, poor sleep.

40. Clinical Outcomes & observational studies.
Physiology – ABGs, TcCO2, SpO2.
Lung Function.
Psg – AHI little value. WASO and better sleep.
Quality of Life – Activities of Living.
Health care utility (cost)
Survival

41. Post NIV

42. Mean overnight oximetry before and after NIV
elective
Post exacerbation
Mode of Referral
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Sleep Study
Baseline
Mean O2
Discharge

43. NIV : Wake ABGs in Myotonic Dystrophy
Nugent Chest

44. No prospective randomised controlled trials
Numerous publications: NIV in Restrictive lung and neuromuscular disease
No prospective randomised controlled trials
Multiple case series and 2 withdrawal trials all showing similar treatment effects

45. Should NIV be used in COPD?

46. UK: 30,000 COPD deaths each year
600,000 patients diagnosed with COPD in the UK
UK: 30,000 COPD deaths each year
· By 2020 COPD is predicted to be the third biggest killer in the world and will be responsible for the deaths of over six million people
· COPD is a major cause of medical admissions, particular in winter. 308,355 emergency hospital admissions per year.
· Of those that are admitted to hospital for COPD, 1 in 10 will die in hospital, one in three will die within six months, and 43% will die within twelve months of their admission to hospital

47. Cochrane Systematic Review
Nocturnal NIPPV for at least 3 months in hypercapnic patients with stable COPD had no consistent clinically or statistically significant effect on lung function, gas exchange, respiratory muscle strength, sleep efficiency or exercise tolerance.
The small sample sizes of these studies precludes a definite conclusion regarding the effects of NIPPV in COPD.
More evidence is required.

48. Summary Bi Level is needed for some OSA patients.
Bi-Level machines have some features of pressure support ventilators but may not be appropriate for all patients.
Ventilatory Failure is common in some diseases.
Long term NIV is more effective for some patient groups than others.
Potential for dramatic increase of Obesity Hypopnoea Syndrome across Europe.

49. Should Psg technologists be involved in NIV services?
Nocturnal (sleep related) Ventilatory insufficiency.
Diagnostics. (type of abnormality)
Ventilatory Failure is not determined by events (AHI)
Treatment – medical speciality.
Outcomes. (efficacy of NIV)

50. Is our speciality led by technologies ?
Bi-level machines
CPAP
(OSA is one of 87 sleep disorders)
Ventilatory Failure ?

51. Equipment by disorder ( few patients with OSA develop Ventilatory failure) Papworth,Cambridge,Sept 2006
Bi-level machines used for OSA and in 78 COPD
CPAP=3503
(OSA is one of 87 sleep disorders)
Ventilatory Failure = 385