Use of NoninvasiveUse of Noninvasive

Positive Pressure Ventilation Positive Pressure Ventilation

in Acute Respiratory Failurein Acute Respiratory Failure

Mehrdad Ghaffari M.D

Pulmonary/critical care/Sleep medicineThe University of Tennessee Health Science Center

Memphis

Use of NoninvasiveUse of Noninvasive

Positive Pressure Ventilation Positive Pressure Ventilation

in Acute Respiratory Failurein Acute Respiratory Failure

Mehrdad Ghaffari M.D

Pulmonary/critical care/Sleep medicineThe University of Tennessee Health Science Center

Memphis

2222

European Respiratory Monograph 2001; pages106-124.

3333

Aims of Positive Pressure VentilationAims of Positive Pressure Ventilation

To improve the pathophysiology of ARFTo improve the pathophysiology of ARF

To reduce the work of breathing To reduce the work of breathing

To correct gas exchange abnormalityTo correct gas exchange abnormality

To ameliorate dyspneaTo ameliorate dyspnea

To improve the pathophysiology of ARFTo improve the pathophysiology of ARF

To reduce the work of breathing To reduce the work of breathing

To correct gas exchange abnormalityTo correct gas exchange abnormality

To ameliorate dyspneaTo ameliorate dyspnea

4444

Endotracheal IntubationEndotracheal Intubation

Invasive procedureInvasive procedure

Potential complicationsPotential complications

DiscomfortDiscomfort

Confines the use of Confines the use of

PPV to severe ARFPPV to severe ARF

Invasive procedureInvasive procedure

Potential complicationsPotential complications

DiscomfortDiscomfort

Confines the use of Confines the use of

PPV to severe ARFPPV to severe ARF

5555

Endotracheal Tube

Complications

Endotracheal Tube

Complications

6666

7777

Endotracheal Tube vs MaskEndotracheal Tube vs Mask Since 1989 there has been a rapid increase in both published and clinical Since 1989 there has been a rapid increase in both published and clinical

use of an use of an alternativealternative interface interface Since 1989 there has been a rapid increase in both published and clinical Since 1989 there has been a rapid increase in both published and clinical

use of an use of an alternativealternative interface interface

Chest 1996;109: 179-93

1997-2007: > 1,500 papers and 14 meta-analyses 1997-2007: > 1,500 papers and 14 meta-analyses 1997-2007: > 1,500 papers and 14 meta-analyses 1997-2007: > 1,500 papers and 14 meta-analyses

8888

ET ET

Endotracheal Tube vs MaskComplimentary role

Endotracheal Tube vs MaskComplimentary role

Mask

Resolving ARFResolving ARF

Mask

Early ARFEarly ARF

Respiratory failureRespiratory failureEvolving ARFEvolving ARF Resolving ARFResolving ARF

9999

Strong evidenceStrong evidenceCOPD exacerbationCOPD exacerbationAcute cardiogenic pulmonary edemaAcute cardiogenic pulmonary edemaImmunocompromised patientsImmunocompromised patientsFacilitate weaning in COPD patientsFacilitate weaning in COPD patients

Less strong evidenceLess strong evidenceAsthmaAsthmaCystic fibrosisCystic fibrosisPostoperative respiratory failurePostoperative respiratory failureAvoidance of extubation failureAvoidance of extubation failureDo-not-intubate patientsDo-not-intubate patients

Weak evidenceWeak evidenceUpper airway obstructionUpper airway obstructionARDSARDSTraumaTraumaOSA, obesity, hypoventilationOSA, obesity, hypoventilation

Evidence for NPPV in ARFEvidence for NPPV in ARFEvidence for NPPV in ARFEvidence for NPPV in ARF

10101010

Flexibility in initiating and removing MVFlexibility in initiating and removing MV Avoids ETI-associated complicationsAvoids ETI-associated complications Decreases the need for invasive monitoringDecreases the need for invasive monitoring Preserves airway defense mechanismsPreserves airway defense mechanisms Preserves speech and swallowingPreserves speech and swallowing Improves patient comfortImproves patient comfort Decreases sedation requirementsDecreases sedation requirements

Flexibility in initiating and removing MVFlexibility in initiating and removing MV Avoids ETI-associated complicationsAvoids ETI-associated complications Decreases the need for invasive monitoringDecreases the need for invasive monitoring Preserves airway defense mechanismsPreserves airway defense mechanisms Preserves speech and swallowingPreserves speech and swallowing Improves patient comfortImproves patient comfort Decreases sedation requirementsDecreases sedation requirements

Advantages of NPPV in ARFAdvantages of NPPV in ARF

11111111 Respiratory Care 2004; 49: 810-829.

Reduction in VAPReduction in VAP

12121212

OutlineOutline

Patient SelectionPatient Selection Ventilator SettingsVentilator Settings

InterfaceInterface Adjustments for air leakAdjustments for air leak

Modes of ventilationModes of ventilation CommunicationCommunication

Initial setupInitial setup MonitoringMonitoring

ComfortComfort Criteria to discontinue NPPVCriteria to discontinue NPPV

Patient SelectionPatient Selection Ventilator SettingsVentilator Settings

InterfaceInterface Adjustments for air leakAdjustments for air leak

Modes of ventilationModes of ventilation CommunicationCommunication

Initial setupInitial setup MonitoringMonitoring

ComfortComfort Criteria to discontinue NPPVCriteria to discontinue NPPV

13131313

Alert and cooperativeAlert and cooperative

COPD and CO2 narcosisCOPD and CO2 narcosis

Anxious patients may improve with NPPVAnxious patients may improve with NPPV

Absence of contraindications (next slide)Absence of contraindications (next slide)

Managed only by experienced personnelManaged only by experienced personnel Morbidly obeseMorbidly obese

Acute myocardial infarctionAcute myocardial infarction

Alert and cooperativeAlert and cooperative

COPD and CO2 narcosisCOPD and CO2 narcosis

Anxious patients may improve with NPPVAnxious patients may improve with NPPV

Absence of contraindications (next slide)Absence of contraindications (next slide)

Managed only by experienced personnelManaged only by experienced personnel Morbidly obeseMorbidly obese

Acute myocardial infarctionAcute myocardial infarction

Patient SelectionPatient Selection

14141414

ContraindicationsContraindicationsContraindicationsContraindications

Facial surgery, trauma, or deformityFacial surgery, trauma, or deformity Upper airway obstruction, excluding vocal cords edemaUpper airway obstruction, excluding vocal cords edema Inability to cooperate/protect the airwayInability to cooperate/protect the airway Inability to clear copious amount of secretionsInability to clear copious amount of secretions High risk for aspirationHigh risk for aspiration

Facial surgery, trauma, or deformityFacial surgery, trauma, or deformity Upper airway obstruction, excluding vocal cords edemaUpper airway obstruction, excluding vocal cords edema Inability to cooperate/protect the airwayInability to cooperate/protect the airway Inability to clear copious amount of secretionsInability to clear copious amount of secretions High risk for aspirationHigh risk for aspiration

Am J Respir Crit Care Med 2001; 163:283-291.Am J Respir Crit Care Med 2001; 163:283-291.

Cardiac or respiratory arrestCardiac or respiratory arrest Hypoxemia refractory to 100% FiOHypoxemia refractory to 100% FiO22 by NRM by NRM Nonrespiratory organ failureNonrespiratory organ failure

• Severe encephalopathy (e.g, GS < 10)Severe encephalopathy (e.g, GS < 10)• Severe upper gastrointestinal bleedingSevere upper gastrointestinal bleeding• Hemodynamic instability or unstable cardiac arrhythmiaHemodynamic instability or unstable cardiac arrhythmia

Cardiac or respiratory arrestCardiac or respiratory arrest Hypoxemia refractory to 100% FiOHypoxemia refractory to 100% FiO22 by NRM by NRM Nonrespiratory organ failureNonrespiratory organ failure

• Severe encephalopathy (e.g, GS < 10)Severe encephalopathy (e.g, GS < 10)• Severe upper gastrointestinal bleedingSevere upper gastrointestinal bleeding• Hemodynamic instability or unstable cardiac arrhythmiaHemodynamic instability or unstable cardiac arrhythmia

15151515

Interface: Nasal vs. Facial MaskInterface: Nasal vs. Facial Mask

Hess D. Respiratory Care 2004; 49: 810

16161616

Interface: Facial MasksInterface: Facial Masks

Type of sealsType of seals• contoured cushioncontoured cushion

• bladder cushionbladder cushion

• foam cushionfoam cushion

• double springdouble spring

Positions of prongsPositions of prongs• centralcentral

• peripheralperipheral

Type of sealsType of seals• contoured cushioncontoured cushion

• bladder cushionbladder cushion

• foam cushionfoam cushion

• double springdouble spring

Positions of prongsPositions of prongs• centralcentral

• peripheralperipheral

17171717

Newer masksNewer masksNewer masksNewer masks

18181818

Italian perspectives: HelmetItalian perspectives: HelmetItalian perspectives: HelmetItalian perspectives: Helmet

Courtesy of Dr Massimo Antonelli (Rome)Courtesy of Dr Massimo Antonelli (Rome)

Latex-free transparent PVCLatex-free transparent PVC

Secured by 2 arm = pit Secured by 2 arm = pit

braces (A) at two hooks (B) braces (A) at two hooks (B)

of the metallic ring (C) joining of the metallic ring (C) joining

helmet with a soft collar (D) helmet with a soft collar (D)

A seal connection (E) allowsA seal connection (E) allows

the passage of NGTthe passage of NGT

Latex-free transparent PVCLatex-free transparent PVC

Secured by 2 arm = pit Secured by 2 arm = pit

braces (A) at two hooks (B) braces (A) at two hooks (B)

of the metallic ring (C) joining of the metallic ring (C) joining

helmet with a soft collar (D) helmet with a soft collar (D)

A seal connection (E) allowsA seal connection (E) allows

the passage of NGTthe passage of NGT

A

BC

D

E