Noninvasive Positive Pressure Ventilation

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Noninvasive Positive Pressure Ventilation

• Department of Critical Care Support Services
• C. S. Mott Childrens Hospital
• University of Michigan Medical Center

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Noninvasive Positive Pressure Ventilation

• Noninvasive Positive Pressure Ventilation (NPPV)
  is a method of providing ventilatory support
  without the use of an artificial airway. When
  positive pressure is applied to the nose via a
  mask or prongs, the soft palate pushes against
  the tongue and provides a variable but adequate
  seal for conducting air flow to the trachea.
  NPPV avoids the hazards of endotracheal
  intubation, especially nosicomial pneumonia, and
  retains the patients abilities to talk, swallow,
  and cough effectively.
• NPPV has been used for over a decade to treat
  patients with Obstructive Sleep Apnea. Recent
  advances in this technology make it possible to
  treat patients with acute or chronic respiratory
  failure caused by atelectasis, airway collapse
  (malacia), or pulmonary edema. NPPV is
  increasingly being used to avoid intubation or as
  a bridge to extubation for patients with
  neuromuscular disorders, post liver transplant,
  and post BMT.

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NPPV Pressure Waveforms
P r e s s u r e
IPAP
EPAP
Time
The patient can be supported with one or two
levels of positive pressure. Expiratory Positive
Airway Pressure (EPAP), also known as Continuous
Positive Airway Pressure (CPAP), supplies an
elevated baseline pressure, usually 5 - 8 cmH2O,
for a spontaneously breathing patient. This
pressure stents open alveoli or airways which
would otherwise collapse during exhalation.
Inspiratory Positive Airway Pressure (IPAP)
provides a pressure boost, usually 10 - 16 cmH2O,
during inspiration. IPAP is used to recruit
atelectatic lung tissue and to provide support
for patients whose work of breathing is high. To
use IPAP, the patient must be able to trigger a
breath on and off. When EPAP and IPAP are used
together, it is called Bi-level Positive Airway
Pressure (BiPAP).
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NPPV The Mask
The support bridge helps to stabilize the mask
and prevent overtightening.
The lower strap fits under the ear.

• Fitting and maintaining the mask is one of the
  most critical aspects of successful NPPV. The
  patient is fitted with the smallest mask possible
  in order to minimize dead space around the nose.
  This allows the patient to trigger a breath
  easily and prevents build up of CO2 in the mask.
  During use, the BiPAP unit can compensate for
  small leaks around the mask. The mask should fit
  firmly but comfortably on the face.
  Overtightening the straps on the mask will
  interfere with the function of the BiPAP unit and
  will quickly cause pressure erosion sores on the
  face.

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Delivery Systems Respironics BiPAP Unit
Low Pressure/Patient Disconnect Alarm

• The Respironics BiPAP unit can provide IPAP
  and/or EPAP for patients approximately 18 months
  of age to adult. A back up rate for breaths can
  be set from 0 to 30 breaths per minute. The FiO2
  is provided by a flow meter which can add oxygen
  to the system up to 15 LPM (which delivers
  approximately 60 O2).

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Respironics BiPAP Unit Circuit Mask
Exhalation ports or oxygen tubing attachment
ports

• The Respironics BiPAP circuit is designed to
  accommodate leaks in the circuit, in fact, some
  leaks are built in. The patient exhales through
  an open valve in the system and there are two
  ports on the mask which can be left open if CO2
  retention is a problem. Oxygen tubing might be
  attached to one of the mask ports, if necessary,
  to boost oxygenation.

Exhalation valve DO NOT OCCLUDE.
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LTV The mask circuit
The exhalation ports on the mask are plugged.

• The LTV 1000 is an ICU ventilator which can be
  set up to deliver NPPV. The LTV offers more
  variety in the choice of modes so synchronized
  support to the patient can be optimized. A back
  up respiratory rate from 0 - 60 can be set. The
  FiO2 can be set from 21 - 100 via a blender.
• The LTV BiPAP system is not designed to work with
  fixed leaks in the system so the ports on the
  mask are sealed and the exhalation valve is open
  only during exhalation. The ventilator can
  accommodate small leaks around the mask.

LTV 1000
Exhalation/PEEP valve
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Delivery Systems Aladdin

• The Aladdin system provides Nasal CPAP (NCPAP)
  for infants. Pressure is delivered via nasal
  prongs which are held in place by a special cap.
  The patient must have a reliable spontaneous
  respiratory rate because only continuous baseline
  pressure is delivered. An FiO2 of 21 - 100 can
  be dialed in via a blender.

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NPPV Contraindications Side Effects

• Contraindications
• Intrapulmonary air leaks
• Bullous pulmonary disease
• High risk of aspiration
• Recent gastric surgery/trauma
• Impaired mental status
• Life threatening hypoxemia
• Hemodynamic instability
• Mask intolerance
• Patient-ventilator dissynchrony
• Sinusitis/Otitis Media

• Side Effects/Hazards
• Gastric distention/vomiting
• Facial pressure erosions
• Eye irritation/drying

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NPPV Nursing Care

• 1. Observe the patient and listen to breath
  sounds to assure patient-ventilator synchrony.
  If dyssynchrony is present, assess for leak or
  obstruction.
• Reposition the mask to eliminate large leaks. Do
  not overtighten!
• Assess the patients need for suctioning.
• Ask RT to check circuit/troubleshoot system.
• 2. Check under the BiPAP mask Q 3-4 hours for
  skin breakdown or irritation. If irritation
  occurs,
• cushion the area with microfoam tape.
• rotate 2-3 different masks to relieve pressure
  points.
• 3. Encourage cough and monitor secretions for
  amount, color, and consistency. If secretions
  become thick and tenacious.
• Contact RT to increase humidification.

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Bibliography

• Hillberg RE, Johnson DC. Noninvasive Ventilation.
  NEJM, 19971746-1752
• Strumpf DA, Carlisle CC, Millman RP, Smith KW,
  Hill NS.
• An Evaluation of the Respironics BiPAP
  Bi-Level CPAP Device for Delivery of Assisted
  Ventilation. Resp Care, 199035415-422