Basic Concepts of

Noninvasive
Positive-Pressure
Ventilation
SALEH ALDAGHRIR
MsRC, RRT, RRT-NPS, RRT-ACCS, RPFT, RRT-SDS
Lecturer of Respiratory Therapy
Batterjee Medical College
Learning Objectives
1. Define noninvasive ventilation, and discuss the three basic
noninvasive techniques.
2. Discuss the clinical and physiologic benefits of noninvasive
positive-pressure ventilation (NIV).
3. Identify the selection and exclusion criteria for NIV
application in the acute- and chronic-care settings.
Learning Objectives—cont’d
4. Compare the types of ventilators used for NIV.
5. Explain the importance of humidification during NIV
application.
6. Describe the factors that will influence the FIO2 from a
portable pressure-targeted ventilator.
Learning Objectives—cont’d
7. Identify possible causes of rebreathing CO2 during NIV
administration from a portable pressure-targeted ventilator.
8. Compare the advantages and disadvantages of the various
types of interfaces for the application of NIV.
9. List the steps used in the initiation of NIV.
Learning Objectives—cont’d
10. Discuss several factors that affect the delivery of aerosols
during NIV.
11. Identify several indicators of success for patients on NIV.
12. Make recommendations for ventilator changes based on the
observation of the patient’s respiratory status, acid-base
status, or oxygenation status.
13. Recognize potential complications of NIV.
Learning Objectives—cont’d
14. Provide optional solutions to complications of NIV.
15. Describe two basic approaches to weaning the patient from
NIV.
 Noninvasive Ventilation
Noninvasive ventilation (NIV) is defined as the delivery of
mechanical ventilation to the lungs using techniques that
do not require an endotracheal airway.
 NPPV, NIPPV, or NIV

Three types or basic methods

1. Negative-pressure ventilation
2. Abdominal-displacement
ventilation
3. Positive-pressure ventilation
Negative-Pressure Ventilation
• Negative-pressure ventilators, or body ventilators, operated on
the principle of increasing lung volumes by intermittently
applying negative pressure to the entire body below the neck or
just to the upper region of the chest and cause air to enter the
lungs by increasing transpulmonary pressure.
• Chest cuirass, or shell ventilator
• Iron lung
Benefits of NIV
• Acute care setting
• Reduces the need for endotracheal intubation (most significant benefit)
• Reduces incidence of ventilator-associated pneumonia
• Shortens stay in the intensive care unit
• Shortens hospital stay
• Reduces mortality
• Improves patient comfort
• Reduces need for sedation
Benefits of NIV—cont’d
• Chronic-care setting
• Alleviates symptoms of chronic hypoventilation
• Improves duration and quality of sleep
• Improves functional residual capacity
• Avoid hospitalization
Indications for Noninvasive Ventilation
• Acute-care setting
• Acute exacerbation of COPD
• NIV is the standard of care for patients with moderate-to-severe exacerbations of
COPD who meet selection criteria
• First-line therapy
• Asthma
• Hypoxemic respiratory failure and acute (or adult) respiratory distress syndrome
(ARDS)
• Community-acquired pneumonia
• Acute cardiogenic pulmonary edema (ACPE)
• When patients with Acute CPE do not respond to conventional pharmacologic
and oxygen therapy, the use of mask CPAP with oxygen may expand fluid-filled
alveoli
• In the initial treatment of ACPE is to use CPAP (10 to 12 cm H O) first line
2

therapy
• If the patient remains hypercapnic and dyspneic with CPAP, a trial of NIV
(BIPAP) is indicated
• Chronic-care setting
• Restrictive thoracic disorders, include chest wall deformities and
neuromuscular conditions
• NIV is the ventilator mode of choice for chronic respiratory failure caused
by restrictive thoracic disorders in patients who can protect their airways
• Chronic but stable COPD
• Cystic fibrosis
• NIV increases VT, reduces diaphragmatic activity, and improves
oxygenation in some patients with cystic fibrosis who have acute
exacerbations
• Nocturnal hypoventilation
• Nocturnal use of NIV (4 to 6 hours) can have certain clinical benefits for
patients with chronic hypoventilation disorders, improvement of the
symptoms
 Patients with CSA & OSA are typically treated initially with CPAP therapy.
NIV is indicated if these patients continue to experience hypoventilation
and nocturnal desaturation

Other Indications
 Facilitation of weaning from invasive ventilation
 Patients with a “Do Not Intubate” order
Goals of NIV
• Physiological goal
• Improve gas exchange by resting the respiratory muscles and
increasing alveolar ventilation
• Resting of the respiratory muscles and improved VT lead to an
improved PaCO2, better oxygenation, and decreased respiratory rates
• Pressure support (PS) facilitates inspiration, thus increasing
the VT
Exclusion Criteria for NIV
• Respiratory arrest or the need for immediate intubation
(Apnea)
• Hemodynamic instability
• Inability to protect the airway (impaired cough or
swallowing and high risk of aspiration)
• Excessive (copious) secretions
• Agitated and confused patients
• Facial deformities or conditions that prevent mask from
fitting (Facial burns or trauma)
• Uncooperative patients
• Brain injury with unstable respiratory drive
Pressure-Targeted Ventilators
• In all modes of bilevel positive-pressure ventilation, the
patient’s delivered VT depends on:
• The gradient between the IPAP and EPAP
• The inspiratory time
• The patient’s inspiratory effort
• Lung characteristics (airway resistance and lung compliance)
Pressure-Targeted Ventilators—cont’d
• Most units have adjustable inspiratory and expiratory
sensitivity controls
• Pressure-targeted ventilators also allow adjustment of the
amount of time required to reach the IPAP (i.e., rise-time
control)
• Ramp control and delay-time controls
• Ramp allows positive pressure to increase gradually over a set
interval
• Ramp rate generally can be set in increments of 1, 2, or 3 cm H2O,
and the delay time can be set in 5-minute increments between 5 and
30 minutes
The BiPAP Vision Ventilatory Support
System
Respironics Philips V60 Ventilators
 Portable Home Care Ventilators

• Electrically powered, microprocessor-controlled ventilators

• Patient- or time-triggered, pressure-limited, and volume- or
pressure-cycled
• Compact size
• Use of three power sources:
• A/C current
• Internal D/C battery
• External D/C battery
Adult Acute-Care Ventilators
• Offer additional ventilatory support options and alarms, a
precise FIO2, and more monitoring features than portable
pressure-targeted ventilators
• Advantageous for patients in ARF who require close
monitoring and supervision during NIV
• Disadvantage is the inability to compensate for leaks
Humidification Issues During NIV
• A leading cause of patient discomfort and noncompliance with
the prescribed therapy is excessive drying of nasal mucosa
• Passover heated humidifiers should be used
• Treats or prevents nasal congestion and improves patient comfort
• Can improve patient compliance
• HMEs increase airway resistance and will increase inspiratory
WOB
Patient Interfaces
Effectiveness of NIV is greatly influenced by interface
Interfaces
Nasal mask
Full (oronasal) and total face mask and helmet
Oral mask
Nasal prongs (pillows)
 Oronasal/Full Face Masks
• Most often successful in critically ill patients

Double-foam
cushion

Adjustable
Forehead Support

Entrainment valve Pressure pick-

off port

Ball and
Socket Clip
 Fitting Oronasal/Full Face Mask
• Landmarks
a) Below lower lip with mouth open
b) Corners of mouth
c) Just below junction of nasal bone and cartilage

b b

a
Nasal Pillows or Nasal Cushions
• Suitable for patients with
• Claustrophobia
• Skin sensitivities
• Need for visibility
 NIV Setup and Preparation
• Important steps in the clinical application of NIV are:
1. Select patients for NIV who are most likely to benefit.
2. Choose a ventilator capable of meeting patient needs.
3. Choose the correct interface; avoid a mask that is too large.
4. Explain the therapy to the patient.
5. Silence alarms and choose low settings.
6. Initiate NIV while holding mask in place.
7. Secure mask, avoiding a tight fit.
8. Titrate inspiratory pressure to patient comfort.
9. Titrate FIO2 to SpO2 greater than 90%.
10. To minimize gastric insufflation, avoid inspiratory pressure above 20
cm H2O.
11. Continue to coach and reassure patient; make adjustments to improve
patient compliance.
Tips on Initiating NPPV Ventilation
• Let the patient breath through the mask
• If patient is claustrophobic, try nasal mask
• Consider chin strap
• Place patient upright position
• Explain the NPPV procedure
Setup and Preparation
 Initiating NPPV
• Determine desired FiO2
• Begin ventilation, coaching patient until comfortable
• Secure mask to patient
• Avoid excessive tightening of the straps (1-2 fingers
space)
• Progressively increase pressure until ordered pressures
achieved
 Example NPPV Settings

20

IPAP = 12
10
PS = 8

0
EPAP = 4

IPAP: is the total inspiratory pressure

• Common IPAP orders EPAP: is the expiratory pressure.
• 8 to 12 cm H2O
• Adjust to change tidal volume
• Typical EPAP setting
• 4 cm H2O
• Increase to improve oxygenation
 Initiating NPPV
• IPAP cannot be set BELOW EPAP
• EPAP cannot be set ABOVE IPAP
• To increase “pressure support”, increase IPAP while leaving
EPAP unchanged
• Should INCREASE VT
• Usually increase IPAP in increments of 2-5 cm H2O
• To maintain same amount of “pressure support”, have to
INCREASE IPAP at same amount of INCREASE EPAP
• Avoid peak pressures > 20 to 25 cm H20
Monitoring and Adjustments
• Patient’s initial response to NIV may be the most significant
indicator of success or failure
• Improvement in patient comfort is indicated by
• Decreased respiratory rate
• Decreased inspiratory muscle activity
• Synchronization with the ventilator
• Improved vital signs and ABGs
• Oxygenation and heart rate are monitored continuously with
pulse oximetry
• If patient worsens on optimal setting, think intubation.
Criteria for Terminating
Aerosol Delivery in Noninvasive
Ventilation
Factors affecting aerosol delivery during NIV
1. Type of aerosol generator (SVN vs. MDI)
2. Position of the leak port
• If the leak port is located in the mask, aerosol delivery from an MDI
is more efficient than from a nebulizer
3. Synchronization of MDI actuation with inspiration
4. IPAP and EPAP levels
5. Presence or absence of a humidifier in the circuit
Complications of NIV
Mask discomfort
Excessive leaks around mask
Pressure sores
Nasal/oral dryness or nasal congestion (cause of patient
discomfort and noncompliance with NPPV)
Mouthpiece/lip seal leakage
Aerophagia, gastric distention
Aspiration
Mucous plugging
Hypotension
Weaning and Discontinuing Noninvasive
Ventilation
• Increase the time off mask ventilation
• Ensure patient tolerance
• Provide supplemental oxygen
• Gradual weaning of ventilatory support and FiO2
• Wean FiO2, then titrate IPAP down until EPAP level is reached
• Closely monitor the patient
• Reverse the disease process causing ARF
Troubleshooting
Failure to Ventilate – Inadequate Volume
• Tidal volume is inadequate for patient

• Ventilating pressures adequate?

• If not, increase IPAP
 Hypotension
• Was hypotension present prior to therapy?
• treat the cause

• Did hypotension occur after initiating NPPV?

• assess ventilating pressures
 Risk of Aspiration
• Patient selection

• Stroke victims
• Individuals with drug overdose
 Claustrophobia
Nasal interface or a total face mask

Mild sedation, with caution

Gastric Insufflation (Aerophagia) and
Gastric Distention
• Caused by excessive pressure or air swallowing

• Use pressures less than 20 to 25 cm H2O

• Use simethicone agent

 Use of Nasogastric Tubes
• NG tubes to take air from the stomach is controversial

• Increases leak around mask

• Blocks nasal passage

• May increase risk of skin breakdown

 Eye Irritation
• Air blowing in the eye:

• Reposition the mask (first action)

• Ensure appropriate mask fit

• Use or adjust spacers

• Readjust headgear straps

Nasal or Oral Dryness, Nasal Congestion,
Mucus Plugging
• Possible solutions:
• Add or increase humidification
• Reduce leaks
• Irrigate nasal passages
• Use topical decongestants or steroids
• Perform oral and/or nasal hygiene
• If nasal mask is in use, use a chin strap to keep mouth closed
or change to full face mask
Identifying Success or Failure of NPPV
• Success
• Improved ABGs

• Clinical improvement

• Failure
• If in 1 to 2 hours the above are not noted, move to intubation

• Waiting too long can result in cardiac arrest

REVIEW
 A patient with acute cardiogenic pulmonary edema (ACPE), as
evidenced by pink, frothy secretions, arrives in the emergency
department (ED) by ambulance with a nonrebreather mask (NRM) at
15 L/min. An arterial blood gas sample is drawn in the ED while the
patient is on the NRM; the values are: pH = 7.50, PaCO2 = 28 mm
Hg; PaO2 = 43 mm Hg; SaO2 = 84%; HCO3- = 24 mEq/L. After
evaluating the situation, the respiratory therapist should suggest
which of the following therapies?

a. IPPB with supplemental oxygen

b. Mask CPAP with supplemental oxygen

c. Postural drainage to clear the secretions

d. NPPV via nasal mask with postural drainage
 A 62-year-old male patient with COPD is being seen in the
pulmonary clinic for dyspnea at rest and daytime hypersomnolence.
The patient has been hospitalized three times in the past year for
COPD exacerbations and once for pneumonia. He currently uses
2L/min oxygen from a concentrator all the time. The patient reports
that he is able to sleep only about 2 hours each night and that he has a
headache every morning.
Which of the following should be recommended to the physician?

a. Chest cuirass
b. Nocturnal NPPV

c. Nocturnal CPAP
d. Tracheostomy and ventilation
• A 75-year-old man with a long history of COPD is brought to the
emergency department with shortness of breath. He has a
persistent, productive cough with green purulent sputum, cyanosis
of the lips and extremities, and is uncooperative. His arterial blood
gas values on 2 L/min by nasal cannula are: pH = 7.25; PaCO2 =
90 mm Hg; PaO2 = 38 mm Hg; SaO2 = 59%; HCO3- = 38 mEq/L.
The most appropriate action at this time is which of the following?

a. IPPB
b. Mask CPAP

c. NPPV via full face mask

d. Invasive mechanical ventilation
 A patient in the subacute care unit is receiving NPPV with a PTV
system, with an IPAP of 10 cm H2O and an EPAP of 2 cm H2O. The
patient’s latest arterial blood gas values reveal an increase in the
PaCO2. The most appropriate action to take is which of the
following?

a. Increase the IPAP.

b. Decrease the IPAP.

c. Increase the EPAP and IPAP.

d. Intubate and mechanically ventilate.
Which of the following NPPV settings produces the greatest tidal
volume, with all other variables being equal (i.e., airway resistance
and lung compliance)?

a. IPAP = 20 cm H2O; EPAP = 8 cmH2O

b. IPAP = 15 cm H2O; EPAP = 5 cmH2O

c. IPAP = 12 cm H2O; EPAP = 6 cmH2O

d. IPAP = 18 cm H2O; EPAP = 4 cmH2O
A 75-year-old, 160 cm, female patient with an exacerbation of COPD
is placed on the following NPPV settings: IPAP = 8 cm H2O, EPAP
=4 cm H2O, rate = 12 breaths/min, FIO2 = 0.3. The resulting VT is
255 mL. An arterial blood gas sample is drawn 1 hour later, and the
results are: pH = 7.33, PaCO2 = 70 mm Hg, PaO2 = 58 mm Hg,
HCO3-= 35 mEq/L. What action should the respiratory therapist take
at this time?

a. Increase the rate to 14 breaths/min.

b. Increase the IPAP to 10 cm H2O.

c. Intubate and mechanically ventilate the patient.

d. Increase the IPAP to 10 cm H2O and the EPAP to 6 cm H2O.
A patient is receiving noninvasive positive pressure ventilation by
mask. Current settings and ABG results are as follows:
IPAP 12 cm H2O
EPAP 7 cm H2O
Spontaneous RR 14 bpm
pH 7.33
PaCO2 54 mm Hg
PaO2 68 mm Hg
HCO3- 25 mEq/L
BE +1 mEq/L
What should the therapist recommend to improve the patient’s
ventilation?
A patient with no lung history is placed on BiPAP with the
following settings: IPAP 14 cm H2O, EPAP 5 cm H2O, FIO2 0.70.
An ABG 1 hour after initiating BiPAP reveals: pH 7.40, PaCO2 44
mm Hg, PaO2 55 mm Hg. What would you recommend for this
patient?
If the EPAP setting were increased, which of the following would

you expect to also increase? ( Multi answers )

a. inspiratory pressure

b. expiratory pressure

c. VT

d. PaO2

e. PaCO2
• Any patient receiving +10 cm H2O CPAP and there is NO

improving in ABG (Intubate the patient)

• Any patient has DNI or an advanced directive supporting his wishes

(BiPAP)