Noninvasive ventilation is a ventilatory technique in which a
patient receives ventilatory assistance without the need for endotracheal
intubation or a tracheostomy. While both negative and positive pressure
ventilation are possible, the latter will be the focus of this chapter.
Definitions and Terms
- ▪ Noninvasive positive pressure ventilation (NPPV):
Positive pressure ventilation delivered via nasal or full face mask
using volume, pressure, bilevel positive airway pressure (BIPAP),
or continuous positive pressure (CPAP) modes.
- ▪ CPAP: Positive pressure is applied through the mask
at one pressure—CPAP is typically used for patient with
upper airway obstruction to open collapsed airways.
- ▪ BIPAP: A ventilatory mode in which CPAP is supplied
cycling between a higher and lower pressure at a regular rate—BIPAP
is typically used to reduce the work of breathing and augment alveolar
- —Timed mode: Ventilator cycles regularly between
high and low pressures and patient can breathe at each.
- —Spontaneous mode (ie, pressure support): Patient
inspiration triggers application of the higher pressure.
- ▪ Nasal mask: A mask applied over the nose, leaving
the mouth uncovered—may be adequate for CPAP administration
in diseases such as sleep apnea.
- ▪ Face mask: A mask applied over the nose and mouth—often
preferred in acute respiratory failure, because most patients in
this situation breathe primarily through the mouth.
- ▪ ARF: Acute respiratory failure.
- ▪ CHF: Congestive heart failure.
- ▪ There are a variety of potential indications for the
application of NPPV.
- —Respiratory insufficiency in patients with
- —Respiratory insufficiency in patients with ARF
- —Respiratory insufficiency following extubation
- —Respiratory insufficiency with asthma
- —Respiratory insufficiency in patient with CHF and
- —Respiratory insufficiency in patients with restrictive
lung diseases and neuromuscular disorders
- ▪ There are a variety of contraindications to NPPV.
- —Status post respiratory arrest
- —Facial trauma
- —Agitation, claustrophobia, lack of patient cooperation
- —Excessive secretions
- —High risk of regurgitation and aspiration
- —Hemodynamic lability
- —Decreased/impaired mental status
- —Severe hypoxemia
- ▪ Patient preparation.
- —Select appropriate mask (nasal vs. face) and
size to patient.
- —Secure mask to patient using circumferential straps
around the head.
- —Adjust for maximal patient comfort (Figure 25-1).
- —Elevate head of bed to 45°.
- —Selected ventilatory mode.
- —Titrate ventilatory and oxygen support to achieve
desired goals (Figure 25-2).
- —Monitor respiratory rate, tidal volume, and pulse
Clinical Pearls and Pitfalls
- ▪ Skillful
mask selection and fitting will maximize ventilatory support.
- ▪ Certain patients ...