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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 ventilation.
    • —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 COPD
    • —Respiratory insufficiency in patients with ARF
    • —Respiratory insufficiency following extubation
    • —Respiratory insufficiency with asthma
    • —Respiratory insufficiency in patient with CHF and pulmonary edema
    • —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 oximetry.
    Figure 25-2.

    BIPAP ventilator with inspiratory and expiratory settings.

Figure 25-2.

BIPAP ventilator with inspiratory and expiratory settings.

Clinical Pearls and Pitfalls

  • ▪  Skillful mask selection and fitting will maximize ventilatory support.
  • ▪  Certain patients ...

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