NIPPV by Ali Nasser O. Aljarrash

1. Non-Invasive Positive Pressure Ventilation ( NPPV )
Objective :
- Definition of NPPV
- Kinds of pressures in NPPV
- Types of NPPV
- Factors contributing to NPPV interest
- Indication & contraindication for CPAP & BiPAP
- Indication & contraindication for acute & chronic cases care
- Modes & controllers in NPPV devices
- Interfaces for NPPV devices
- NPPV devices
- common cases that can be treated by NPPV
- Differences between BiPAP & BiPAP ( APRV )

- Definition of NPPV :
* It is any of ventilation support applied without use of an endotracheal \ Trach tube . It
provides two level of pressure ( I & E ) to the airway , which are triggered by the patient or
by the ventilator ( time ) depending on the mode utilized . ( 1 )
* It is technique of providing ventilation without the use of an artificial airway . ( 2 )
Kinds of pressures in NPPV : ( 2 )
* IPAP : Inspiratory Positive Airway pressure . This pressure control peak airway
pressure during inspiration .
* EPAP : Expiratory Positive Airway pressure . this pressure control end – expiratory
pressure .
* PEEP : Positive End Expiratory Pressure . this is pressure is positive airway pressure
at end expiratory phase . it is with mechanical breaths only .

(2 )Types of NPPV :
* CPAP : Continuous Positive Airway pressure . it is Positive Airway pressure during
spontaneous breaths . so there is not mechanical breaths . & CPAP is active when
IPAP = EPAP . for these reasons the work of breathing is entirely assumed by the Pt .

2. * Bilevel PAP : Bilevel Positive Airway pressure . it s provides IPAP & EPAP .
It different from CPAP in that Bilevel PAP has two pressure level . whereas CPAP has
only one .
It provides mechanical breaths from IPAP & EPAP . EPAP function as PEEP .

Factors contributing to NPPV interest : ( 3 )
- success in treatment of Obstructive Sleep Apnea .
- improve patient interfaces .
- Does not inhibit natural pulmonary defense .
- allow the patient to eat , drink & talk .
- allow patient to expectorate secretion .
- less costly than conventional MV .
- possibility of use in acute & chronic ventilatory failure .
- prevention of complication of intubation & tracheostomy .
- able to be use when patient resist intubation .

Indication & contraindication for CPAP & BiPAP : ( 2 )
* CPAP :
Contraindication Indication
Apnea due to neuromuscular causes
progressive hypoventilation
Obstructive Sleep Apnea
Fatigue of respiratory muscle
Facial trauma
Clasustrophobia

* BiPAP :
Indication Contraindication
Reduction on respiratory workload in obesity Apnea
Acute respiratory failure Unable to handle secretion
Acute hypercapnic exacerbations of COPD Facial trauma
Claustrophobia


Indication & contraindication for acute & chronic cases care : ( 1 )
* Acute care :
Indication for NPPV with Acute Respiratory Failure :
1 - acute hypercapnic respiratory failure ( at least 2 of the following should be present )

3. A – severe worsing dyspnea . or B – sustain RR > 25 BPM . or C – use accessory muscle \
abdominal paradoxical . or D – PH < 7.35 with PaCO2 > 45 mmHg .
2 – acute hypoxemia : SpO2 < 88 – 90 % with FiO2 > 60 % & P\F < 200 .
* use conventional therapy with O2 as needed & monitor patient closely if the above criteria
is not met .
If the above criteria is met so look for contraindication :
Absolute contraindication Relative contraindication
Apnea Anxiety
Cardiopulmonary arrest Bowel obstruction
Facial burns Claustrophobia
Facial & cranial trauma Copious secretion
Fixed upper airway obstruction Inability to clear secretion
Hemodynamic instability \ arrhythmias Inability to cooperate or tolerate interface
Inability to protect airway \ vomiting
(risk of aspiration )
Severe illness ( high APACHE score )

* if there is not contraindication institute NPPV therapy .
* if there is contraindication consider invasive ventilation .

* Chronic care :
Indication Contraindication
Restrictive thoracic disease
Chronic hypoventilation syndromes
secondary to :
- chest wall & spinal deformity
- Idiopathic hypoventilation
- neuromuscular disease
- obesity
Unable to protect airway due to swallowing
issue or excessive secretion & poor cough
Chronic obstructive pulmonary disease
( COPD )
- Unable to fit interface
- Rapidly progressive neuromuscular disease
Obstructive sleep apnea Unmotivated \ uncooperative patient


Modes & controllers in NPPV devices : ( 3 )
Modes of NPPV : NPPV A / C , NPPV SIMV , NPPV CPAP/PS , & Bilevel pressure ventilation
mode .
NPPV can control : volume ventilation , Respiratory rate , Insp. Time , PEEP , FiO2 , &
humidification .

4. ( 2 , 3 ) Interfaces for NPPV devices :
Note Disadvantages Advantages Interface
Too high = leaks in
eye
Gas leak
Nasal dryness or
drainage
Comfort
patient compliance
Nasal mask
The top of the mask
should be 1/3 of the
way down from the
bridge of the nose
Claustrophobia
Patient
noncompliance
Asphyxiation
good seal Facial mask
The top of the mask
should be 1/3 of the
way down from the
bridge of the nose
More claustrophobic
Must remove to
expectorate or speak
Better ventilation
Good seal
Full face mask
for CPAP therapy
only in range 3 – 20
cmH2O
Leak is potential
problem
more comfortable
than facial maskes
Nasal pillows



( 3 ) NPPV devices :
Home care NPPV ventilators and other support devices may have any of the
following features :
- the ability to provide full ventilatory support .
- the ability to ventilate at night only .
- BiPAP support or CPAP .
- low pressure or disconnect alarm .
* Examples of NPPV :
- Respironics BiPAP focus .
- Respironics BiPAP vision .
- Respironics BiPAP synchrony .
- Puritan Bennett GoodKnight 425 .

* also there are some MV used usually for invasive ventilation support NPPV : such
as ( Puritan Bennett 840 ) .


common cases that can be treated by NPPV : ( 1 )
- acute respiratory failure .
- acute pulmonary edema .
- cardiogenic pulmonary edema .
- Immuno-compromised patients .

5. Differences between BiPAP & BiPAP ( APRV ) : ( 1 )
- BiPAP : is NPPV mode used IPAP & EPAP to give mechanical breaths .
- BiPAP ( APRV ) : is mode of invasive ventilation that also has two pressure IPAP & EPAP and
in each pressure patient can take breaths by PS .



References :
1 - Ventilator Management ( Dana Oakes ) 2009 Edition .

2 - Clinical Application of Mechanical Ventilation . ( David W. Chang ) 2
nd
Edition .

3 - Mosby's Respiratory Care Equipment ( J. M. CAIRO , Susan P. PILBEAM )
8
th
Edition .






Ali Nasser O. Aljarrash .
RC student ( 3
rd
year )
210021948