Essentials of MV

(Basic level)

Abdelrhman Ali Aboshady

Assistant Lecturer of Critical Care Medicine
Menoufia University
Contents:
 Definition & Types
 Goals
 Advantages & Disadvantages/Complications
 Patient selection ( Indications & Contraindications)
 Equipment Required for NIV
 How to initiate NIV
 Predictors for Success
 When to switch to Invasive MV
 Weaning
 Definition:

the delivery of mechanical ventilation to the lungs using

techniques that do not require an endotracheal airway.1

1. Mehta S, Hill NS: Noninvasive ventilation. Am J Respir Crit Care Med 2001,577-163:540.
Types of Noninvasive ventilation

1- Noninvasive positive-pressure ventilation

( NPPV )
a) Pressure limited
b) Volume Targeted

2- Negative-pressure ventilation (body ventilators).

Goals of Non-Invasive Ventilation

Avoid Minimize the risk of

Invasive Lung Injury
Ventilation

Adequate pulmonary
Gas Exchange
Maintain
Spontaneous
Reduce patient
Breathing
WOB

Optimize patient
Faster
Comfort
Weaning
Advantages
• Avoids artificial airways with its complications (airway trauma, VAP, ….)

• Reduces requirements for heavy sedation

• Preserves airway defense, speech, and swallowing mechanisms >>> decreased risk
of aspiration
• Reduces need for invasive monitoring

• Provides flexibility in initiating and removing mechanical ventilation

>>>>>>>>>>
- Shorter hospital stay,
- Lower mortality rate
- Lower health care costs.
Disadvantages/ Complications:

- Gastric Distension & Areophagia

- Facial Pain & Skin Pressure ulcers,

- Dry Nose,

- Mask Leaks & Eye Irritation (Conjunctivitis),

- Discomfort, Claustrophobia,

- Poor Sleep
SELECTION CRITERIA ***
 PATIENT SELECTION CRITERIA ***
Appropriate Selection of patients = Success of NIV
• Two-step process:
1- Establishing the need for ventilatory assistance (according to clinical and
blood gas criteria). …….. Indications

2- Exclude patients at increased risk of failure and complications ……. Exclusion

criteria/Contraindications

• The REVERSIBILITY of the disease process must be considered before NIV is

initiated.
Choice of Interface
 Disorders May be Managed with NIV

Acute (Acute on Chronic) Hypercapnic Respiratory Failure:

• Acute exacerbations of COPD

• Post-extubation in difficult to wean patients
• Obesity Hypoventilation & Obstructive sleep apnea
• Postoperative complications
• Neuromuscular disorders
 Disorders May be Managed with NIV
Acute Hypoxemic Respiratory Failure:

• Cardiogenic pulmonary edema …… CPAP >> NIV

• “Do Not Intubate” Patients ??? ……… relieve severe dyspnea and preserve patient comfort.

• Pneumonia In immunocompromised Patients

• Blunt Chest Trauma
• Post operative Atelectasis

• Pneumonia
• Acute Asthma … Cautious & controversial
• Acute respiratory distress syndrome (ARDS) ???
Evidence based medicine recommendation of NIV
Evidence based medicine recommendation of NIV
Evidence based medicine recommendation of NIV
Evidence based medicine recommendation of NIV
Step 1: Indications (Clinical & ABG)

The following items are evaluated:

• Respiratory rate >25 breaths/min

• Moderate to severe acidosis: pH, 7.25 to 7.30; PaCO2, 45 to 60 mm Hg

• Moderate to severe dyspnea

• Use of accessory muscles

• Paradoxical breathing pattern

Step 2: Contraindications
Absolute Contraindications

• Respiratory arrest
• Cardiac arrest
• Cardiovascular instability (hypotension, severe dysrhythmias, )

• Inability to protect the airway &/or high risk of aspiration

• Uncooperative patient (Agitation, impaired mental status, hypersomnolence & severe encephalopathy)

• Facial or head surgery or trauma

• Patent tracheoesophageal fistula
• Severe gastrointestinal bleeding, trauma or surgery,
Step 2: Contraindications
Relative Contraindications

• Copious or viscous secretions

• Fixed nasopharyngeal abnormalities

• Extreme obesity
 Equipment
Required for NIV
 Equipment Required for NIV
• Ventilators:
- Adult acute care ventilators
- Portable homecare ventilators
- Portable pressure-targeted ventilators (CPAP & BiPAP units)

• Interfaces or masks (with fixator)

• Humidifiers
 Pressure-Targeted Ventilators (CPAP & BiPAP units)

• Microprocessor controlled,

• Electrically powered

• Blower to regulate gas flow

• Single-circuit gas delivery system

• Intentional leak port Vs true exhalation valve.

• Flow- and time-triggered

• Pressure-limited

• Flow- and time-cycled

Patient Interfaces
• Oro-nasal masks (Full face mask)

• Total face masks

• Helmets

• Nasal masks

• Nasal pillows

• Mouthpieces with lip seals.

 Patient Interfaces

Full-face mask
Total
or
Face Mask
Oro-nasal mask.
Patient Interfaces

Helmet
Patient Interfaces

Nasal
Mask

Nasal
Mini-mask

Nasal Pillows
Patient Interfaces

Oral
Mouth-seal
Steps for Initiating NIV
 Steps for Initiating NIV
1. Upright Or Sitting Position. Carefully Explain the NIV procedure including
goals and possible complications.

2. Using a sizing gauge, make sure a mask is chosen that is the Proper
Size And Fit.

3. Attach the interface and circuit to ventilator. Turn on the ventilator and
adjust it INITIALLY to Low-pressure Settings.
 Steps for Initiating NIV
4. Hold or allow the patient to hold the mask gently to the face until the
patient becomes comfortable with it. Encourage the patient in proper
breathing technique.

5. Monitor oxygen (O2) saturation; adjust the fractional inspired oxygen (FIO2)
to maintain O2 saturation above 90%.

6. Secure the mask to the patient. Do Not make the straps Too Tight.
 Steps for Initiating NIV
7. Titrate (IPAP) and (EPAP) to achieve patient comfort, adequate Exhaled
Tidal Volume, and synchrony with the ventilator. Monitor the peak airway
pressure delivered.

8. Check for leaks and adjust the straps if necessary.

9. Monitor Respiratory Rate, heart rate, level of dyspnea, O2 saturation,

minute ventilation, and exhaled tidal volume.

10. Obtain blood gas values within 1 hour.

 NIV for
Acute Hypercapnic
Respiratory Failure
NIV for Acute Exacerbation of COPD
Indications:

At least two of the following factors should be present:

1) Respiratory rate >25 breaths/min

2) Moderate to severe acidosis: pH, 7.25 to 7.30; PaCO2, 45 to 60 mm Hg

3) Moderate to severe dyspnea with use of accessory muscles and paradoxical

breathing pattern
NIV for Acute Exacerbation of COPD
1. NIV is Effective in the treatment of AECOPD (Evidence A).

2. NIV can be started effectively in the Prehospital setting.

3. Bi-level NPPV is used, apply a PS of 10–15 cmH2O on top of PEEP 5 cmH2O, closely

monitoring patient-ventilator interaction, respiratory rate (RR), and tidal volume (Vt).

4. Titrate PS to obtain a Vt 6-8 ml/kg IBW and a RR <25 bpm.

5. An initial PEEP level of 5 cmH2O & Increase PEEP up to 10 cmH2O if AutoPEEP is

suspected.
NIV for Acute Exacerbation of COPD

6. Titrate FiO2 to a SpO2 >94 %.

7. Set the minimal inspiratory trigger to avoid auto-triggering.

8. Set a short rise time according to RR.

9. Set a Early expiratory trigger (e.g., 30–50 %).

 NIV for
Acute Hypoxemic
Respiratory Failure
 NIV for Cardiogenic Pulmonary Edema
1. NIV is Effective in the treatment of ACPE
(Evidence A; NNT = 8 for ETI, NNT = 13 for mortality).

2. NIV can be started effectively in the Prehospital setting.

3. Patients with Acute Respiratory Acidosis can be treated with either CPAP
or NPPV, provided that the patient does not have any preexisting
respiratory muscle overload.

4. Reversible Causes (e.g., ischemia, arrhythmias, valvular disease) should be

identified.

5. Patients Without Hypertensive response have a worse prognosis.

Noninvasive Mechanical Ventilation: Theory, Equipment, and Clinical Applications,2nd edition: 2016
 NIV for Cardiogenic Pulmonary Edema

• If CPAP is used, high-flow stand-alone devices are preferred.

• An initial PEEP level of 10 cmH2O is probably the best choice.

• Increase PEEP up to 12–15 cmH2O if necessary.

• Titrate FiO2 to a SpO2 >94 %.

Noninvasive Mechanical Ventilation: Theory, Equipment, and Clinical Applications,2nd edition: 2016
 NIV for Cardiogenic Pulmonary Edema

• If bi-level NPPV is used, apply a PS of 10–15 cmH2O on top of PEEP 8–10

cmH2O, closely monitoring patient-ventilator interaction, respiratory rate
(RR), and tidal volume (Vt).

• Titrate PS to obtain a Vt ≤6 ml/kg IBW and a RR <25 bpm.

• After 30-60 min of NIV, reassess Arterial Blood Gases to evaluate both
oxygenation and ventilation.

Noninvasive Mechanical Ventilation: Theory, Equipment, and Clinical Applications,2nd edition: 2016
Predictors of
Success
with NIV
 Predictors of Success with NIV
• Higher level of consciousness

• Younger age

• Intact dentition, Minimal air leakage around the interface

• Less severe illness; no comorbidities, Less severe gas exchange abnormalities

• Lower quantity of secretions

• Absence of pneumonia

• Positive Initial Response to NIV within 1 to 2 hours

- Decreased RR - Reduced PaCO2 with Correction of pH

 Predictors of Success with NIV
Good Patient SELECTION
+
Good TOOLS
+
Good APPLICATION
=
NIV SUCCESS
 When to switch
from NIV to Invasive Ventilation ??
 When to switch
from NIV to Invasive Ventilation ??

1) “ Failure of NIV “

• Respiratory rate >30-35 breaths/min

• Severe dyspnea with use of accessory muscles and possibly paradoxical breathing

• Life-threatening hypoxemia: (SpO2) less than 90%, PaO2 <40 mm Hg or PaO2/FIO2 < 200

• Persistent/Worsening Severe acidosis (pH <7.25) and hypercapnia (PaCO2 >60 mm Hg)
 When to switch
from NIV to Invasive Ventilation ??

2) Appearance of“ Contraindications of NIV “

• Respiratory arrest

• Cardiovascular complications (hypotension, shock, heart failure)

• Hypersomnolence, impaired mental status

• Inability to clear secretions

• Inability to tolerate interface

Weaning of NIV
Weaning of NIV

STANDARD weaning techniques have NOT been established,

But
• The most common approach:
- Increasing periods of time off mask ventilation.

• Another approach (same as weaning from PSV during invasive ventilation):

- IPAP is gradually reduced to a minimum level. Once the minimum level has
been reached, NIV can be discontinued.
Thank You