Introduction
• Non-invasive ventilation (NIV) is the delivery
of oxygen (ventilation support) via a face mask
and therefore eliminating the need of an
endotracheal airway.
• It has two modes CPAP and Bi-PAP
Mechanical Ventilation
• The purpose of mechanical ventilation is
to support the respiratory system until
the underlying cause of respiratory
failure can be corrected. Most
ventilatory support require an artificial
airway; however it may be applied
without an artificial airway and is called
non-invasive ventilation.
Classification of Mechanical Ventilation
Invasive Mechanical Ventilation
Non-Invasive Mechanical Ventilation
Non-Invasive Mechanical Ventilation
Non-invasive mechanical ventilation (NIV) is the delivery of oxygen via face mask
therefore eliminating the need for intubation.
NIV can be of two types:
• Non-invasive negative pressure ventilation
• Non-invasive positive pressure ventilation
Non-Invasive Negative Pressure Ventilation
• Traditionally, non-invasive ventilation has been given with the use of devices that apply
intermittent negative extra-thoracic pressure (non-invasive negative pressure ventilation).
• Tank-type negative-pressure ventilators, such as the Emerson iron lung or Drinker
respirator, were the mainstay of ventilatory support during the polio epidemics in the
1950's.
• Although the tank ventilator is reliable, it is bulky (3 meters long) and heavy (300 kg),
virtually precluding portability.
• A more portable fiberglass tank ventilator is available (Portalung, Nellcor Puritan
Bennett, St. Louis, MO), but it weighs approximately 50 kg and requires 2 persons to
move.
• Subsequently, less bulky, more portable negative-pressure ventilators were developed.
• Today, the most commonly used negative-pressure ventilator is the poncho wrap (or
jacket) ventilator (Numowrap, Respironics, Inc., Pittsburgh, PA), which consists of an
impermeable nylon jacket suspended by a rigid chest piece that fits over the chest and
abdomen
• Negative-pressure ventilators work by intermittently applying a sub-atmospheric
pressure to the chest wall and abdomen; this increases transpulmonary pressure and
causes atmospheric pressure at the mouth to inflate the lungs.
• Expiration occurs passively by elastic recoil of the lung and chest wall as pressure within
the device rises to atmospheric levels.
Non-Invasive Positive Pressure Ventilation
(NIPPV)
• NIPPV works by creating a positive airway pressure that is the pressure outside the lungs
being greater than the pressure inside of the lungs. This causes air to be forced into the
lungs (down the pressure gradient), lessening the respiratory effort and reducing the
work of breathing.
• NIPPV is the delivery of mechanical ventilation without an ET tube or TT tube.
NIPPV provides ventilation via:
A face mask that covers the mouth, nose or both
A nasal mask or pillow
A full face mask
Advantages of NIPPV
• NIPPV eliminates the need for endotracheal tube or tracheostomy and decreases the risk
of nosocomial infections such as pneumonia.
• Complications associated with artificial airway are reduced such as vocal cord injury and
ventilator associated pneumonia (VAP).
• Sedation needs are less.
• It can prevent reintubation in the patients who are having respiratory distress.
• It can be used to provides ventilatory support to the patients in whom intubation is not
desirable such as those with “do no intubate” orders.
Indications of NIPPV
• Acute or chronic respiratory failure
• Acute pulmonary edema
• COPD
• Chronic heart failure
• Sleep related breathing disorder such as OSA
• Respiratory conditions without complications such as upper airway trauma, sinusitis,
respiratory muscle weakness and ventilator-associated pneumonia.
Contraindications
• Patients who have experienced respiratory arrest.
• Apnea
• Cardiovascular instability (hypotension, uncontrolled dysrhythmias and myocardial
ischemia)
• Claustrophobia
• Somnolence
• High aspiration risk, viscous or copious secretions
• Recent facial or gastroesophageal surgery
• Craniofacial trauma
• Burns
NIPPV
• The most common modes of ventilation delivered via NIPPV are pressure support or
pressure control with PEEP and CPAP.
• During NIPPV, it is important for the nurse to ensure the right size and type of mask is
chosen, and that it fits snugly enough to prevent air leaks.
• If mouth-breathing is a problem with nasal mask a chin strap can be applied, or the mask
should be changed to an oronasal or full-face mask.
• The nurse also monitors the total RR, the EVT to ensure it is adequate, and the PIP.
Delivery of Non-invasive Mechanical Ventilation
• NIPPV can be delivered via:
Continuous Positive Airway Pressure (CPAP)
Bi-level Positive Airway Pressure (Bi-PAP)
Continuous Positive Airway Pressure (CPAP)
• Continuous positive airway pressure (CPAP) is a type of positive airway pressure, where
the air flow is introduced into the airways to maintain a continuous pressure to constantly
stent the airways open, in people who are breathing spontaneously.
• It is used with a leak-proof mask to keep alveoli open, thereby preventing respiratory
failure.
• Positive end-expiratory pressure (PEEP) is the pressure in the alveoli above atmospheric
pressure at the end of expiration. It is measure in cm H2O.
• CPAP is a way of delivering PEEP but also maintains the set pressure throughout the
respiratory cycle, during both inspiration and expiration
Cont.
• In CPAP no additional pressure above the set level is provided, and patients are required
to initiate all of their breaths.
• CPAP is the most effective treatment for OSA because the positive pressure acts as a
splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient
must be breathing independently.
Indications for CPAP
• When a patient remains hypoxic despite medical intervention.
• Atelectasis
• Type 1 respiratory failure
• Rib fractures
• Congestive heart failure
• Cardio-pulmonary edema
• Obstructive sleep apnea
• Pneumonia
CPAP : A method of weaning
• CPAP can also be effectively used as a method of weaning from ventilator, allows the
patient to breathe spontaneously while applying positive pressure throughout the
respiratory cycle to keep the alveoli open and promote oxygenation.
• Providing CPAP during spontaneous breathing also offers the advantage of an alarm
system and may reduce patient anxiety if the patient has been taught that the machine has
been keeping track of breathing.
Cont.
• It also maintains lung volumes and improves patient’s oxygenation status.
• CPAP is often used in conjunction with PSV.
• Nurses should carefully assess for tachypnea, tachycardia, reduced tidal volumes,
decreasing oxygen saturation and increasing carbon dioxide levels.
Bi-level Positive Airway Pressure (Bi-PAP)
• Bi-PAP ventilation offers independent control of inspiratory and expiratory pressures that
is inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure
(EPAP) while providing pressure support ventilation.
• It delivers two levels of positive airway pressure provided via a nasal or oral mask, nasal
pillow, or mouthpiece with a tight seal and a portable ventilator.
• Each inspiration can be initiated either by the patient or by the machine if it is
programmed with a backup rate.
Cont.
• The backup rate ensures that the patient
receives a set number of breaths per minute.
• Bi-PAP is most often used for patients who
require ventilatory assistance at night, such
as those with severe COPD or sleep -apnea.
• The inspiratory positive airway pressure (IPAP) is higher and supports a breath as it is
taken in. Conversely, the expiratory positive airway pressure (EPAP) is a lower
pressure that allows to comfortably breathe out.
• Bilevel ST includes the timed delivery of a breath if breathing pauses occur. These
pauses are often present in central sleep apnea.
• Set inspiratory positive airway pressure level (IPAP) (10-15 up to 30 cms of H2O)
• Set expiratory positive airway pressure level (EPAP) (3-5 cm H2O up to 15cms of H2O)
Indications of Bi-PAP
• Type 2 respiratory failure
• Acidotic exacerbation of COPD, pH<7.35
• Increased work of breath causing ventilatory failure, for eg: hypercapnia, fatigue,
neuromuscular disorder.
Complications of NIV
• Facial pressure ulcers: The nurse should monitor the skin under the mask edges for
signs of breakdown.
Cont.
• Eye irritation: It is important to ensure mask is fitted correctly, if it is not it causes
oxygen to leak upwards to the eyes causing eye irritation and conjunctivitis.
• Excessive drying of air passages: The mouth and air passages should be monitored for
excessive drying, and a humidification system should be applied as indicated.
• Retention of secretions: The use of a face mask may interfere the ability to cough and
the effective clearance of secretions. As well as, this positive pressure created may
compromise the patient’s ability to generate sufficient expiratory flow rates affecting the
mobilization of secretions and also resistance to cough leading to retention of secretions.
