6

Noninvasive Ventilation
Warren Isakow

GENERAL PRINCIPLES
• Noninvasive ventilation (NIV) or noninvasive positive pressure ventilation refers to
the use of a mask or similar device to provide ventilatory support.
• This definition is broad and could include external negative pressure devices (e.g., the “iron
lung,” historically used for ventilation of patients suffering from poliomyelitis-induced
paralysis), cuirass ventilation (external shell with applied negative pressure), and rocking
beds—an effective means to ventilate a patient with bilateral diaphragmatic paralysis.
• NIV by definition excludes any modality that bypasses the upper airway, such as laryngeal
masks, endotracheal intubation, or tracheostomy.
• For the purposes of this chapter, NIV refers to mechanical ventilatory support delivered
through a face mask, nasal mask, or similar device.

CLASSIFICATION
• Invasive mechanical ventilation and NIV have similar physiologic principles.
• The modes of ventilatory support (i.e., the way in which the ventilator triggers, delivers,
and ends the breath) are similar to invasive mechanical ventilation. However, there is no
standardization between manufacturers regarding mode terminology.
• Two of the most commonly encountered modes include continuous positive airway pressure
(CPAP) and bilevel positive airway pressure (BiPAP).

Continuous Positive Airway Pressure

• CPAP maintains a set positive pressure throughout the respiratory cycle (inhalation and
exhalation) and is not ventilatory support in a strict physiologic sense.
• CPAP “stents open” the upper airway with continuous pressure. This concept helps explain
the utility of CPAP in disorders such as obstructive sleep apnea but does not explain why a
treatment that does not provide ventilatory support can be of use in the patient who is
suffering from hypoxemic or hypercapnic respiratory failure.
• Clinical applications include:
Hypoxemic respiratory failure
Increases partial pressure of oxygen in the alveoli. In the alveolar gas equation,
PAO2 = FiO2 (PB – 47) – 1.2 (PaCO2), if PB is barometric pressure (or in our case, the
pressure delivered from the ventilator through the mask), an increase in the mean
 airway pressure throughout the respiratory cycle for a given fraction of inspired
oxygen (FiO2) will increase the partial pressure of inspiratory oxygen and therefore
oxygen tension in the alveoli (PAO2).
Provides extrinsic positive end-expiratory pressure (PEEP). It recruits the
underventilated or collapsed lung, probably by preventing alveolar collapse during
exhalation.
Hypercapnic respiratory failure can decrease the work of breathing, by overcoming
intrinsic PEEP in patients with chronic obstructive airway disease.
In advanced chronic obstructive pulmonary disease (COPD) with hyperinflation,
airflow obstruction and decreased elastic recoil lead to a prolonged expiratory phase.
In respiratory distress, inspiration may occur before expiration is completed, leading
to dynamic hyperinflation.
Ineffective ventilation and increasing work of breathing cause the buildup of carbon
dioxide and worsening respiratory acidosis. The positive elastic recoil pressure left
behind in this hyperinflated patient at the end of expiration is termed intrinsic PEEP.
Delivering PEEP via CPAP lessens the work of breathing by overcoming intrinsic
PEEP. In intubated patients with acute respiratory failure, extrinsic PEEP (PEEPe) has
been demonstrated to reduce the work of breathing by 50%. The same principle
applies to the noninvasively ventilated patient.

Bilevel Positive Airway Pressure

• BiPAP is CPAP with a second level of pressure support during inspiration, akin to pressure
support ventilation for mechanically ventilated patients.
• In practical terms, BiPAP requires the operator to set two variables, inspiratory positive
airway pressure (IPAP) and expiratory positive airway pressure (EPAP), that are measured
in cm H2O.
IPAP is the ventilatory pressure support the patient receives when either the machine or
the patient initiates a breath.
EPAP is the pressure against which the patient exhales at the termination of inhalation.
“Initial settings” are often referred to by the IPAP followed by the EPAP (e.g., 12 cm
H2O and 5 cm H2O).
The greater the difference between the IPAP and the EPAP, the greater the theoretical
ventilatory support the patient receives.
However, progressively higher levels of EPAP and IPAP are not usually well tolerated
by the patient, and as with any initiation of NIV, the patient should be observed
closely to see if effective patient–ventilator synchrony occurs.

SPECIFIC DISEASE INDICATIONS FOR NONINVASIVE VENTILATION

• NIV may improve outcomes by avoiding intubation and the attendant risks of secondary
infections in this patient population.
• In general, NIV is most effective in patients with cardiogenic pulmonary edema, patients
with hypercapnic respiratory failure, and in weaning patients from invasive mechanical
ventilation.
Cardiogenic Pulmonary Edema
• NIV helps to unload the respiratory muscles in respiratory failure caused by heart failure
and pulmonary edema and improves cardiac performance by reducing right and left
ventricular preload and mean transmural filling pressures.
• CPAP is recommended for hypoxemic patients with cardiogenic pulmonary edema who
remain hypoxemic despite maximal medical therapy.
• A recent meta-analysis pooled the results of 34 trials in patients with acute cardiogenic
pulmonary edema confirmed an overall mortality benefit utilizing NIV (both CPAP or
bilevel modes), as well as a reduction in the risk of intubation.1
• Noninvasive methods of respiratory support should not be used in hemodynamically
unstable patients or in those with ongoing cardiac ischemia.

Chronic Obstructive Pulmonary Disease

• NIV can be an effective initial respiratory support modality in the setting of acute COPD
exacerbation. Studies have shown improvements in pH, PCO2, and respiratory rate, and
lower intubation rates and lower mortality when compared to standard therapy.2,3
NIV should be considered in patients with acute exacerbations of COPD in whom a
respiratory acidosis persists (pH <7.35) despite maximum medical therapy. In a
multicenter randomized controlled trial of BiPAP via nasal or face mask with standard
therapy (n = 236 patients), NIV reduced the need for intubation and rate of in-hospital
mortality was significantly reduced compared to the standard therapy group.
NIV helps to decrease the need for invasive mechanical ventilation. Between 1998 and
2008 in the United States, NIV use increased from about 1% to 4.5% of all patients
admitted with COPD exacerbations, and invasive ventilation dropped from 6% to 3.5%
accordingly. Similarly, patients who fail NIV and require intubation have a much higher
mortality.4
• NIV can also facilitate weaning and extubation of COPD patients from invasive mechanical
ventilation. Randomized trials in this population of patients have shown shorter durations
of intubation, lower rates of nosocomial pneumonia, shorter hospital stays, and improved
survival.5

Postextubation Respiratory Failure

• Most of the benefit of NIV in postextubation respiratory failure applies to hypercapnic
patients who may benefit from a trial of NIV and close monitoring.
• In most cases, reintubation is more prudent and helps to prevent situations of emergent
reintubation from a failure of trial of NIV.

Chest Wall Deformity and Neuromuscular Disease

• NIV can be an appropriate first-line choice in patients with acute and acute-on-chronic
respiratory failure.
• In our experience at Washington University, these patients often do better in the long term
with NIV that delivers a fixed tidal volume using laptop ventilators in assist control (AC),
synchronized intermittent mandatory ventilation (SIMV), or even newer modes of average
volume assured pressure support (AVAPS).
 With bilevel pressure ventilation, tidal volume and minute ventilation may decrease with
disease progression.
Similarly, acute changes in lung compliance due to alveolar consolidation due to
pneumonia may render pressure-based NIV inadequate.

Trauma Patients
• CPAP can be considered in patients with chest wall trauma who remain hypoxemic despite
regional anesthesia.
• Several small randomized, controlled trials support using CPAP for patients with isolated
chest trauma, rib fractures, and hypoxemia.6,7
• Standard mechanical ventilation should still be used in patients with greater than moderate
lung injury (defined by a PaO2 of <60 mm Hg on an FiO2 of ≥40%), as these patients
were excluded from the study. Furthermore, the injury severity score was higher in the
intubated group.6

Acute Hypoxemic Respiratory Failure and Pneumonia

• The use of NIV in hypoxemic respiratory failure is less clear than in the above disorders and
depends on the severity of disease.
• The current recommendation is that NIV can be used as an alternative to endotracheal
intubation in carefully selected patients with acute hypoxemic respiratory failure with
recognition that many of these patients may require intubation and if NIV is chosen, the
patient should be intubated if not improving within 1–2 hours of initiation.

Asthma
• Routine use of NIV is not recommended.
• Severe respiratory acidosis in the setting of an acute asthma exacerbation should be treated
with intubation and invasive ventilation.

Palliative Noninvasive Ventilation

• NIV has the potential to alleviate dyspnea in end-of-life circumstances.8
• Use of NIV should be weighed with issues of discomfort and claustrophobia from face–mask
ventilation. Effective communication and clarification of the goals of care need to occur
and managed on a case-by-case basis.

INITIATION OF NONINVASIVE VENTILATION

• NIV is best used for patients with:
High PaCO2 (pH range of 7.25–7.35)
Low alveolar–arterial oxygen gradient
A good level of consciousness and cooperation
• NIV should only be initiated in locations with experienced staff, including respiratory
therapists who are immediately available. In practice, this tends to restrict NIV to intensive
care units (ICUs) or a designated respiratory ward.
• For initial settings see Table 6-1.9
 IPAP
EPAP
FiO2: this may be from a flow rate of O2 L/min or from direct FiO2 setting.
In some models, high flow rates may become uncomfortable and can lead to ventilator
dyssynchrony.
Newer ventilators use an oxygen mixer that allows for titration of FiO2 before its entry
into the circuit without adjusting the flow rate. This setup is subsequently more
comfortable for the patient and more beneficial for ventilation.

TABLE 6-1 TYPICAL INITIAL VENTILATOR SETTINGS FOR BILEVEL POSITIVE AIRWAY
PRESSURE IN A PATIENT WITH ACUTE HYPERCAPNIC RESPIRATORY
FAILURE DUE TO COPD

TABLE 6-2 CONTRAINDICATIONS TO NONINVASIVE VENTILATION

CONTRAINDICATIONS FOR NONINVASIVE VENTILATION

• Absolute and relative contraindications are listed in Table 6-2.10,11
• Certain situations such as severe acidosis (pH <7.30) or a lack of improvement in clinical
state and blood gas values make the immediate availability of intubation and critical care a
necessity.

SPECIAL CONSIDERATIONS AND MONITORING

• Check arterial blood gas (ABG) within the first hour after initiation. ABG values usually
improve within the first 1–2 hours if NIV is going to succeed.
• Clinical stabilization and improvement should occur within the first 4–6 hours.
• Optimize patient–ventilator synchrony and minute ventilation by fine-tuning flow rate,
IPAP, EPAP, and FiO2.
• Do not hesitate to intubate the patient if NIV is failing. Delay in intubation is a significant
cause of rapid clinical deterioration and significant morbidity and mortality.

REFERENCES
1. Mariani J, Macchia A, Belziti C, et al. Noninvasive ventilation in acute cardiogenic
pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail.
2011;17(10):850–9.
2. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations
of chronic obstructive pulmonary disease. N Engl J Med. 1995;333:817–22.
3. Celikel T, Sungur M, Ceyhan B, et al. Comparison of non-invasive positive pressure
ventilation with standard medical therapy in hypercapnic acute respiratory failure. Chest.
1998;114:1636–42.
4. Chandra D, Stamm JA, Taylor B, et al. Outcomes of noninvasive ventilation for acute
exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008.
Am J Respir Crit Care Med. 2012;185(2):152–9.
5. Nava S, Amrosini N, Clini E, et al. Non-invasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease: a
randomized study. Ann Intern Med. 1998;128:721–8.
6. Bollinger CT, Van Eeden SF. Treatment of multiple rib fractures. Randomized controlled
trial comparing ventilatory with nonventilatory management. Chest. 1990;97(4):943–8.
7. Hernandez G, Fernandez R, Lopez-Reina P, et al. Noninvasive ventilation reduces
intubation in chest trauma-related hypoxemia: a randomized clinical trial. Chest.
2010;137(1):74–80.
8. Azoulay E, Demoule A, Jaber S, et al. Palliative noninvasive ventilation in patients with
acute respiratory failure. Intensive Care Med. 2011;37(8):1250–7.
9. British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute
respiratory failure. Thorax. 2002;57(3):192–211.
10. Vianello A, Bevilacqua M, Arcaro G, et al. Non-invasive ventilatory approach to treatment
of acute respiratory failure in neuromuscular disorders. A comparison with endotracheal
intubation. Intensive Care Med. 2000;26(4):384–90.
11. Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540–
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