MECHANICAL VENTILATOR

Project Report

SUBMITTED BY
MUHAMMAD NAVEED
What is Mechanical Ventilation?
Mechanical ventilation, or assisted ventilation, is the medical term for artificial
ventilation where mechanical means are used to assist or replace spontaneous breathing. This
may involve a machine called a ventilator, or the breathing may be assisted manually by a
suitably qualified professional by compressing a bag valve mask device.

Bag Valve Mask

A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically
as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to
provide positive pressure ventilation to patients who are not breathing or not breathing
adequately. The device is a required part of resuscitation kits for trained professionals in out-
of-hospital settings (such as ambulance crews)

Two principal types of manual resuscitators exist;

 One version is self-filling with air, although additional oxygen (O2) can be added but
is not necessary for the device to function.
 The other principal type of manual resuscitator (flow-inflation) is heavily used in non-
emergency applications in the operating room to ventilate patients during anesthesia
induction and recovery.
Use of manual resuscitators to ventilate a patient is frequently called "bagging" the
patient[2] and is regularly necessary in medical emergencies when the patient's breathing is
insufficient (respiratory failure) or has ceased completely (respiratory arrest). Use of the
manual resuscitator force-feeds air or oxygen into the lungs in order to inflate them under
pressure, thus constituting a means to manually provide positive-pressure ventilation. It is used
by professional rescuers in preference to mouth-to-mouth ventilation, either directly or through
an adjunct such as a pocket mask.

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Standard Components of Bag Valve Mask

Bag valve mask.

Part 1 is the flexible mask to seal over the patients face,

Part 2 has a filter and valve to prevent backflow into the bag (prevents
patient deprivation and bag contamination)

Part 3 is the soft bag element which is squeezed to expel air to the
patient

Method of operation
Manual resuscitator cause the gas inside the inflatable bag portion to be force-fed to the patient
via a one-way valve when compressed by the rescuer; the gas is then ideally delivered through
a mask and into the patient's trachea, bronchus and into the lungs. In order to be effective, a
bag valve mask must deliver between 500 and 800 millilitres of air to a normal male adult
patient's lungs, but if supplemental oxygen is provided 400 ml may still be adequate. Squeezing
the bag once every 5 to 6 seconds for an adult or once every 3 seconds for an infant or child
provides an adequate respiratory rate (10–12 respirations per minute in an adult and 20 per
minute in a child or infant).
Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed
around the patient's face (that is, to ensure proper "mask seal"); otherwise, pressure needed to
force-inflate the lungs is released to the environment. This is difficult when a single rescuer
attempts to maintain a face mask seal with one hand while squeezing the bag with other.
Therefore, common protocol uses two rescuers: one rescuer to hold the mask to the patient's
face with both hands and focus entirely on maintaining a leak-proof mask seal, while the other
rescuer squeezes the bag and focuses on breath (or tidal volume) and timing.
An endotracheal tube (ET) can be inserted by an advanced practitioner and can substitute for
the mask portion of the manual resuscitator. This provides more secure air passage between
the resuscitator and the patient, since the ET tube is sealed with an inflatable cuff within the
trachea (or windpipe), so any regurgitation is less likely to enter the lungs, and so that forced
inflation pressure can only go into the lungs and not inadvertently go to the stomach (see
"complications", below). The ET tube also maintains an open and secure airway at all times,
even during CPR compressions; as opposed to when a manual resuscitator is used with a mask
when a face mask seal can be difficult to maintain during compressions.

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Additional components and features
Filters
A filter is sometimes placed between the mask and the bag (before or after the valve) to prevent
contamination of the bag.
Positive end-expiratory pressure
Some devices have PEEP valve connectors, for better positive airway pressure maintenance.
Medication delivery
A covered port may be incorporated into the valve assembly to allow inhalator medicines to be
injected into the airflow, which may be particularly effective in treating patients in respiratory
arrest from severe asthma.
Airway pressure port
A separate covered port may be included into the valve assembly to enable a pressure-
monitoring device to be attached, enabling rescuers to continuously monitor the amount of
positive-pressure being generated during forced lung inflation.
Pressure relief valves
A pressure relief valve (often known as a "pop-up valve") is typically included in paediatric
versions and some adult versions, the purpose of which is to prevent accidental over-
pressurization of the lungs. A bypass clip is usually incorporated into this valve assembly in
case medical needs call for inflation at a pressure beyond the normal cutoff of the pop-up valve.
Device storage features
Some bags are designed to collapse for storage. A bag not designed to store collapsed may lose
elasticity when stored compressed for long periods, reducing its effectiveness. The collapsible
design has longitudinal scoring so that the bag collapses on the scoring "pivot point," opposite
to the direction of normal bag compression.

TYPES OF MANUAL RESUSCITATORS

 Self-inflating bags

This type of manual resuscitator is the standard design most often used in both in-hospital
and out-of-hospital settings. The material used for the bag-portion of a self-inflating
manual resuscitator has a "memory", meaning after it is manually compressed it will
automatically re-expand on its own in between breaths (drawing in air for the next breath).
These devices can be used alone (thus delivering room-air) or can be used in connection
with an oxygen source to deliver nearly 100% oxygen. As a result of these features, this
type of manual resuscitator is appropriate for in-hospital use and in out-of-hospital
settings e.g., ambulances.

 Flow-inflating bags

Also termed "anaesthesia bags", these are a specialized form of manual resuscitator with a
bag-portion that is flaccid and does not re-inflate on its own. This necessitates an external
flow source of pressurized inflation gas for the bag to inflate; once inflated the provider
can manually squeeze the bag or, if the patient is breathing on his/her own, the patient can

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 inhale directly through the bag. These types of manual resuscitators are used extensively
during anaesthesia induction and recovery, and are often attached to anaesthesia consoles
so anaesthesia gases can be used to ventilate the patient. They are primarily utilized by
anaesthesiologists administering general anaesthesia, but also during some in-hospital
emergencies which may involve anaesthesiologists or respiratory therapists. They are not
typically used outside hospital settings. As per a recent Indian study, these flow inflation
bags can also be used to provide CPAP in spontaneously breathing children. The study
quotes that this mode of CPAP is cost effective in limited resource settings

Non-invasive Ventilation
Non-invasive ventilation (NIV) refers to the administration of ventilatory support without
using an invasive artificial airway (endotracheal tube or tracheostomy tube). The use of non-
invasive ventilation (see the video below) has markedly increased over the past two decades,
and non-invasive ventilation has now become an integral tool in the management of both acute
and chronic respiratory failure, in both the home setting and in the critical care unit. Non-
invasive ventilation has been used as a replacement for invasive ventilation, and its flexibility
also allows it to be a valuable complement in patient management. Its use in acute respiratory
failure is well accepted and widespread. It is the focus of this review. The role of non-invasive
ventilation in those with chronic respiratory failure is not as clear and remains to be defined.
Historical background
An interest in the methods of artificial respiration has long persisted, stimulated by attempts at
resuscitation of drowning victims. Reports dating from the mid 1700s document a bellows-
type device being the most commonly used form of respiratory assistance. Negative-pressure
tank-type ventilators came into use in the next century, with a prototype developed by Dalziel
in 1832. This spawned a variety of cuirass and tank negative-pressure ventilators, with the
general principle of enclosing the thorax, creating negative pressure to passively expand the
chest wall and lungs. This led to the Drinker-Shaw iron lung in 1928, which was the first widely
used negative-pressure ventilator. In 1931, Emerson modified these large devices, and the
Emerson tank ventilator became the standard for ventilatory support. The Emerson tank
ventilator was especially crucial in the treatment of poliomyelitis victims.
Rudimentary devices that provided continuous positive airway pressure were described in the
1930s, but the negative-pressure ventilators were the predominant method of ventilatory
support until the polio epidemics overwhelmed their capacity in the 1950s. Development of
positive-pressure valves delivered through tracheostomy tubes permitted the delivery of
intermittent positive pressure during inspiration. This quickly replaced the negative-pressure
ventilators, further supported by the development of the cuffed endotracheal tube and bedside
ventilators. However, positive-pressure ventilation delivered through either a translaryngeal
endotracheal tube or a tracheostomy tube was also associated with a host of complications,
specifically injury to the larynx and trachea, as well as other issues involving the timing of
extubation, preservation of speech, and the ability to continue swallowing.
In the 1980s, increasing experience with positive-pressure ventilation delivered through a mask
in patients with obstructive sleep apnea led to this type of ventilatory support, initially in
patients with neuromuscular respiratory failure. Success led to its adoption in other conditions,
and noninvasive ventilation became especially promising in the treatment of patients with
decompensated chronic obstructive pulmonary disease. In the ensuing 20 years, noninvasive
positive-pressure ventilation delivered via a mask has been widely adopted, to the point where
it is a first-line therapy in some medical centers. The conditions and patients best suited for
noninvasive ventilation are discussed.
Note the images below.

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 Patient with decompensated congestive heart failure
undergoing non-invasive ventilatory support with BiPAP
ventilation and an orofacial mask.

Patient with an exacerbation of chronic obstructive

pulmonary disease (COPD) undergoing treatment with
non-invasive ventilation using an orofacial mask.

Methods of Delivery
Noninvasive positive-pressure ventilation
Positive-pressure ventilation delivered through a mask has become the predominant method of
providing noninvasive ventilatory support and is the focus of this and subsequent sections.
Early bedside physiologic studies in healthy patients and in patients with respiratory conditions
document successful ventilatory support (ie, reduction in respiratory rate, increase in tidal
volume, decrease in dyspnea) with reduction in diaphragmatic electromyography (EMG),
transdiaphragmatic pressures, work of breathing and improvement in oxygenation with a
reduction in hypercapnia.

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Ventilatory support can be achieved through a variety of interfaces (mouth piece or nasal, face,
or helmet mask), using a variety of ventilatory modes (eg, volume ventilation, pressure support,
bilevel positive airway pressure [BiPAP; see the image below], proportional-assist ventilation
[PAV], continuous positive airway pressure [CPAP]) with either ventilators dedicated to
noninvasive ventilation (NIV) or those capable of providing support through an endotracheal
tube or mask. Older models of noninvasive ventilators required oxygen to be bled into the
system, but current models incorporate oxygen blenders for precise delivery of the fraction of
inspired oxygen (FIO2).

Screen shot of ventilator graphics and information panel

of a patient undergoing BiPAP ventilation.

NONINVASIVE NEGATIVE-PRESSURE VENTILATION

Negative-pressure ventilators provide ventilatory support using a device that encases the
thoracic cage starting from the neck, and devices range from a whole-body tank to a cuirass
shell. The general principal is the same with a vacuum device, which lowers the pressure
surrounding the thorax, creating subatmospheric pressure and thereby passively expanding the
chest wall with diaphragmatic descent, all leading to lung inflation. Exhalation occurs with
passive recoil of the chest wall.
This was the predominant technology during the polio epidemics, but these devices were bulky
and cumbersome to use. Upper airway obstruction was also a problem. These ventilators have
been largely supplanted by the more widespread positive-pressure noninvasive ventilators;
however, some patients continue to be treated with this modality. While the bulk of the
experience lies in patients with chronic respiratory failure, specifically neuromuscular

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respiratory failure, reports described successful application in patients with acute respiratory
failure.
With respect to the two modes, positive-pressure ventilation has supplanted negative-pressure
ventilation as the dominant mode of delivery of noninvasive ventilation. Positive-pressure
ventilation is more effective than negative-pressure ventilation in unloading the respiratory
muscles, at least under investigational conditions. The primary focus of this article is positive-
pressure noninvasive ventilation, and the mention of "noninvasive ventilation" will refer to
positive-pressure delivery. That being stated, the reader should be aware that in certain patients
and under certain circumstances, negative-pressure ventilatory support may also be
acceptable. [1]
High-flow nasal oxygen
As a result of prospective, randomized clinical trials, another option has emerged for the patient
with hypoxemic respiratory failure. Heated, humidified, high-flow nasal cannula oxygen has
been available for over a decade, but refinements and increasing clinical experience have made
it a solid alternative for management that exists in the spectrum of options before noninvasive
and invasive mechanical ventilation. This modality was initially developed for neonatal
patients, and refinements have permitted its use in adults. Conventional oxygen therapy is not
well tolerated at high flow rates because of problems with unheated and nonhumidified oxygen.
The high-flow nasal cannula oxygen systems are able to heat and humidify, improving patient
tolerance and comfort. The high flow rates have other advantages in that high flow rates
minimize room air entrainment, thereby increasing the FIO2 that can be provided to patients;
are able to wash out dead space carbon dioxide, improving the efficiency of oxygen delivery;
and the increased flow rate translates into positive end-expiratory pressure (PEEP). The amount
of PEEP provided is a function of the flow rate but falls somewhere in the range of 0.35-0.69
cm water for each 10 L/min of increased flow rate. [2] Therefore, while high-flow nasal
cannula devices technically do not provide assisted support or augment inspired tidal volume
as provided by the other forms of mechanical ventilation, the small amount of positive pressure
provided does help reduce the work of breathing and improve breathing patterns similarly to
that achieved with CPAP. An intact respiratory drive is required with this modality, which
means that it is not suited for patients with hypoventilation or a blunted respiratory drive. It is
reasonable to consider this modality as another method of providing low-level CPAP, which at
its most rudimentary level, is a form of noninvasive ventilation.
The focus of this review is on noninvasive ventilation provided through a mask-ventilator
interface, but it is important to recognize that the option of high-flow nasal cannula oxygen
exists and may be a viable option for some patients. It seems especially suited to the recently
extubated, postoperative patient and those with mild-to-moderate hypoxemic respiratory
failure as may occur in patients with decompensated heart failure. [3] There may be efficacy
in other conditions, but experience is limited. Additional comments have been included to
highlight additional clinical features unique to high-flow nasal cannula oxygen.

General Considerations

The key to the successful application of noninvasive ventilation is in recognizing its capabilities
and limitations. This also requires identification of the appropriate patient for the application
of noninvasive ventilation (NIV). Patient selection is crucial for the successful application of
noninvasive ventilation. Once patients who require immediate intubation are eliminated, a
careful assessment of the patient and his or her condition determines if the patient is a candidate
for noninvasive ventilation. This requires evaluation on several levels, and it may involve a
trial of noninvasive ventilation. The following variables and factors help identify patients who
may be candidates for noninvasive positive-pressure ventilation.

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Absolute contraindications are as follows:
 Coma
 Cardiac arrest
 Respiratory arrest
 Any condition requiring immediate intubation
Other contraindications (rare exceptions) are as follows:
 Cardiac instability - Shock and need for pressor support, ventricular dysrhythmias,
complicated acute myocardial infarction
 GI bleeding - Intractable emesis and/or uncontrollable bleeding
 Inability to protect airway - Impaired cough or swallowing, poor clearance of secretions,
depressed sensorium and lethargy
 Status epilepticus
 Potential for upper airway obstruction - Extensive head and neck tumors, any other tumor
with extrinsic airway compression, angioedema or anaphylaxis causing airway
compromise
Other considerations that may limit application are as follows:
 Implementation - Staff learning curve and time requirements (nursing and respiratory
therapy), potential for delay in definitive therapy (limit trials of therapy)
After eliminating unsuitable candidates for noninvasive ventilation, successful application of
noninvasive ventilation mandates close assessment and selection of patients and identification
of conditions best suited for treatment. Not all patients with diagnoses capable of management
with noninvasive ventilation (eg, chronic obstructive pulmonary disease [COPD]) are suitable
candidates for treatment with noninvasive ventilation. Patients with mild disease or very severe
distress may not benefit from noninvasive ventilation, which is best suited for patients with a
moderate severity of illness.
Patient inclusion criteria are as follows:
 Patient cooperation (an essential component that excludes agitated, belligerent, or
comatose patients)
 Dyspnea (moderate to severe, but short of respiratory failure)
 Tachypnea (>24 breaths/min)
 Increased work of breathing (accessory muscle use, pursed-lips breathing)
 Hypercapnic respiratory acidosis (pH range 7.10-7.35)
 Hypoxemia (PaO2/FIO2< 200 mm Hg, best in rapidly reversible causes of hypoxemia)
Not all respiratory conditions are suitable for treatment with noninvasive ventilation.
Conditions that have garnered the most experience and success are generally conditions that
also respond relatively quickly to treatment, for which noninvasive ventilation provides an
important adjunctive support to other simultaneously administered therapeutics. These are
listed below and are discussed in subsequent sections. Be aware that the list and indications
continues to change as more experience is accumulated in these and newer conditions.
Suitable clinical conditions for noninvasive ventilation (most patients) are as follows:
 Chronic obstructive pulmonary disease
 Cardiogenic pulmonary edema
Suitable clinical conditions for noninvasive ventilation (selected patients) are as follows:
 After discontinuation of mechanical ventilation (COPD)
 Community-acquired pneumonia (and COPD)
 Asthma
 Immunocompromised state (known cause of infiltrates)
 Postoperative respiratory distress and respiratory failure
 Do-not-intubate status
 Neuromuscular respiratory failure (better in chronic than acute; avoid if upper airway
issues)
 Decompensated obstructive sleep apnea/cor pulmonale
 Cystic fibrosis

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  Mild Pneumocystic carinii pneumonia
 Rib fractures
Use with caution in the following clinical conditions:
 Idiopathic pulmonary fibrosis (exacerbation)
 Acute respiratory distress syndrome (consider helmet ventilation)

Application of Noninvasive Ventilation

Several considerations can enhance the likelihood of successful noninvasive

ventilation (NIV). In addition to these factors, the experience and expertise of front-
line health care providers, specifically nursing and respiratory therapy staff, cannot
be underestimated. This is not a concern in hospitals where noninvasive ventilation
is well established, but it is an important factor in facilities where noninvasive
ventilation has been infrequently administered or not used at all.
Location of application
It can be used in the ICU, especially if there is the possibility of intubation.
It can be used in a step-down unit (lower severity of illness), as follows:
 Moderately severe COPD (pH >7.30)
 Do-not-intubate status
 Intermittent or nocturnal ventilatory support
It can be used in the ward setting (not recommended if intubation is a consideration),
as follows:
 Suitable in specialized units
 Same considerations as step-down unit
 Emergency department - Local considerations, expertise may mirror ICU or
step-down unit
Patient interfaces
In its simplest terms, noninvasive ventilation differs from invasive ventilation by the
interface between the patient and the ventilator. Invasive ventilatory support is
provided via either an endotracheal tube or tracheostomy tube. Noninvasive
ventilatory support uses a variety of interfaces, and these have continued to evolve
with modifications based on patient comfort and efficacy. Many of the interfaces or
masks were initially used in patients with obstructive sleep apnea before they were
adapted for use in patients to provide noninvasive ventilatory support.
Nasal masks and orofacial masks were the earliest interfaces, with subsequent
development and use of full face masks, mouthpieces, nasal pillows, and helmets.
Nasal masks and orofacial masks are still the most commonly used interfaces.
Orofacial masks are used almost twice as frequently as nasal masks. Both have
advantages and disadvantages in the application of noninvasive ventilation. Note the
images below

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Nasal mask. Courtesy of Philips Healthcare (previously
Respironics).

Full face mask. Courtesy of Philips

Healthcare (previously Respironics).

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 Total face mask. Courtesy of
Philips Healthcare (previously
Respironics).

Total face mask. Courtesy of

Philips Healthcare (previously
Respironics).

Proper fitting of the mask or other interface is another key component to successful noninvasive
ventilation. The mask or interface may be held in place (without straps applied) by the patient
or therapist to familiarize the patient with the mask and ventilator. Typically, the smallest mask
providing a proper fit is the most effective. Straps hold the mask in place, with care to minimize
excess pressure on the face or nose. Leaks are the bane of all of the interfaces, but excess
pressure applied with the straps increases the risk of pressure necrosis and skin breakdown.
Straps should be tight enough to prevent leaks, but with enough slack to allow passage of one
or two fingers between the face and the straps.
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The nasal and orofacial masks may be first-line and second-line options, specifically in patients
who may have prior familiarity with these interfaces or in those who may have had difficulty
with orofacial or nasal masks. Clinical trials have not demonstrated the superiority of any
interface, although the nasal mask may be more effective in patients with a lower severity of
illness. [4] In patients with a higher severity of illness, the orofacial mask and total face mask
appear to result in comparable outcomes.
The main considerations regarding the choice of an orofacial mask or nasal mask are outlined
below.
Orofacial mask general advantages are as follows:
 Best suited for less cooperative patients
 Better in patients with a higher severity of illness
 Better for patients with mouth-breathing or pursed-lips breathing
 Better in edentulous patients
 Generally more effective ventilation
Orofacial mask cautions and disadvantages are as follows:
 Claustrophobic
 Hinder speaking and coughing
 Risk of aspiration with emesis
Nasal mask general advantages are as follows:
 Best suited for more cooperative patients
 Better in patients with a lower severity of illness
 Not claustrophobic
 Allows speaking, drinking, coughing, and secretion clearance
 Less aspiration risk with emesis
 Generally better tolerated
Nasal mask cautions and disadvantages are as follows:
 More leaks possible (eg, mouth-breathing or edentulous patients)
 Effectiveness limited in patients with nasal deformities or blocked nasal passages
While orofacial masks and nasal masks are the most commonly used interfaces, other patient
ventilator interfaces through which noninvasive ventilation can be applied include
mouthpieces, nasal pillows, total face masks, and even a helmet device, which encompasses
the entire head. Experience with helmet devices is limited but increasing, and it has been
successful in patients who are unable to tolerate the nasal or orofacial devices.
Ventilators
The choice of ventilators available to provide noninvasive ventilatory support has continued to
expand. Early noninvasive ventilatory support was applied using either large bedside critical
care volume ventilators or smaller volume or pressure specialty ventilators devoted to
noninvasive ventilation. While the critical care ventilators had more options, they were also
less tolerant of leaks. The specialty ventilators had fewer options and range, but they were more
leak tolerant.
Many critical care ventilators currently in use also have a noninvasive ventilation option, either
as part of the original device or available as an upgrade option. The ideal device is dependent
on a number of factors, including familiarity by staff and available options. The differences
between the bedside critical care ventilator and specialty noninvasive ventilator continue to
diminish as differences related to ventilator options, range of support, and leak tolerance are
corrected in both devices. The distinction in function and capability has blurred, and there are
devices that are capable of providing both invasive and noninvasive ventilation with a mere
switch of ventilator settings. Nevertheless, most hospitals continue to provide noninvasive
support with the specialty ventilator.

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Modes of ventilation
Choosing the initial mode of ventilation is based in part on past experience, in part on the
capability of ventilators available to provide support, and in part on the condition being treated.
Most patients who are provided noninvasive ventilation are provided support with pressure
ventilation, with continuous positive airway pressure (CPAP), which is the most basic level of
support. CPAP may be especially useful in patients with congestive heart failure or obstructive
sleep apnea.
Bilevel positive airway pressure (BiPAP) is probably the most common mode noninvasive
positive pressure ventilation and requires provisions for inspiratory positive airway pressure
(IPAP) and expiratory positive airway pressure (EPAP). The difference between IPAP and
EPAP is a reflection of the amount of pressure support ventilation provided to the patient, and
EPAP is synonymous with positive end-expiratory pressure (PEEP). Some noninvasive
ventilation is provided using proportional-assist ventilation (PAV), which provides flow and
volume assistance with each breath. Clinical trials have not demonstrated a significant
difference between PAV and pressure-support ventilation with BiPAP. [5, 6] However, BiPAP
is the most commonly available and more frequently used modality for noninvasive ventilation.
PAV remains available on many ventilator models, but use is much less common than BiPAP.
While volume ventilators can be used to provide noninvasive ventilatory support, the
previously described modes are preferred because they provide better patient comfort and
synchrony and are more tolerant of the leaks that accompany all noninvasive ventilatory
interfaces.
Initial ventilator settings and adjustments
Adequate ventilation and oxygenation, correction of respiratory failure, and adequate patient
tolerance and comfort are the primary goals of noninvasive ventilation, and adjustments are
made to achieve these endpoints. Initial settings focus on achieving adequate tidal volumes,
usually in the range of 5-7 mL/kg. Additional support is provided to reduce the respiratory rate
to less than 25 breaths/minute. Oxygen is adjusted to achieve adequate oxygenation, with a
pulse oximetry goal of greater than 90%. Serial arterial blood gas measurements are essential
to monitor the response to therapy and to guide further adjustments in the ventilator. The
following provides some guidance on titration of ventilator settings in patients with respiratory
distress and who have never been placed on noninvasive ventilation. In those patient who may
have chronic noninvasive support, the initial values should be based on prior support levels.
The listed levels may be inadequate and would thus increase the likelihood of intolerance or
failure. If there is uncertainty, it is important to perform a bedside titration with increasing
levels based on patient comfort or exhaled tidal volumes. These adjustments can be made
within minutes and can be done without obtaining blood gases.
Initial IPAP/EPAP settings are as follows:
 Start at 10 cm water/5 cm water
 Pressures less than 8 cm water/4 cm water not advised as this may be inadequate
 Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP)
Subsequent adjustments based on arterial blood gas values are as follows:
 Increase IPAP by 2 cm water if persistent hypercapnia
 Increase IPAP and EPAP by 2 cm water if persistent hypoxemia
 Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient
comfort)
 Maximal EPAP limited to 10-15 cm water
 FIO2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value
 Back up respiratory rate 12-16 breaths/minute

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Pressure control (PC) and average volume assured pressure support (AVAPS) ventilation
The above considerations and approach to adjustment are best suited for those with COPD or
chronic heart failure as the primary cause of their hypercapnia or hypoxemic respiratory
distress and failure. Patients with neuromuscular disorders (amyotrophic lateral sclerosis,
postpolio syndrome, muscular dystrophy) or thoracic cage disorders (severe kyphoscoliosis)
may fare better with other ventilatory modalities. The most current noninvasive ventilators
have PC or average AVAPS options. In PC ventilation, both the inspiratory pressure and the
inspiratory time are set and fixed. This differs from BiPAP in which the patient controls the
inspiratory time. This modality may be useful in the neuromuscular disease patient who does
not have the respiratory muscle strength to generate an adequate inspiratory time. Setting an
increased inspiratory time may increase the tidal volume provided, but it may also increase
patient-ventilator dyssynchrony if the set inspiratory time is longer than the patient's desired
inspiratory time.
AVAPS is another option in these neuromuscular disease patients and has also been used in
those with severe obesity-hypoventilation syndrome. It should be noted that AVAPS is not
generally used for those patients with acute respiratory distress and is better suited for
management as they recover or have recovered from their acute decompensated state. Although
most experience with AVAPS in COPD is with chronic respiratory failure, some investigators
have noted favorable outcomes when used in acutely decompensated COPD patients. [7]
As with any pressure-cycled mode, the dependent variable is volume and it may vary widely if
there is patient dyssynchrony, changes in lung compliance, or changes in resistance that can
occur with changes in body position that occurs in the very morbidly obese. [8] A fixed
pressure support setting will not compensate for these changes, and, as a result, delivered tidal
volume will fall. AVAPS allows a target tidal volume to be identified with a range of pressure
support settings that fluctuate to meet the target tidal volume. AVAPS uses an internal
algorithm to make changes in the pressure support supplied to achieve the target volume, but
these changes are small and occur over minutes (typically 1-2.5 cm water per minute). That is
why rapidly changing, acute respiratory conditions are not suited for AVAPS as the ventilator
adjustments may not be timely enough to meet the patient's requirements. Typically, the
pressure support required to produce the target volume during bedside titration is used to
identify the minimal pressure with the set minimal pressure (min P), typically 2-3 cm water
lower to allow flexibility for adjustment in the AVAPS mode. The maximal pressure (max P)
is typically set in the 20-25 cm water range as higher pressures are not well tolerated. The min
P is at least 8 cm water and usually higher. Additional parameters that are part of AVAPS
setting are the target tidal volume, respiratory rate, EPAP, and inspiratory time.
Predictors of successful noninvasive ventilation
Importantly, recognize that certain parameters may predict successful noninvasive ventilation
or failure of noninvasive ventilation, so that patients are not subjected to continued treatment
when optimal treatment requires intubation and mechanical ventilation. This includes changes
during a trial of noninvasive ventilation. The changes, in turn, are a reflection of the patient's
ability to cooperate with noninvasive ventilation, patient-ventilatory synchrony, and
noninvasive ventilation effectiveness. Trials of noninvasive ventilation are usually 1-2 hours
in length and are useful to determine if a patient can be treated with noninvasive ventilation.
Extended trials without significant improvement are not recommended because this only delays
intubation and mechanical ventilation (unless patients are do-not-intubate status).
Predictors of success, with a response to a trial of NIV (1-2 h), are as follows:
 Decrease in PaCO2 greater than 8 mm Hg
 Improvement in pH greater than 0.06
 Correction of respiratory acidosis
Predictors of failure are as follows:

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  Severity of illness - Acidosis (pH < 7.25), hypercapnia (>80 and pH < 7.25), Acute
Physiology and Chronic Health Evaluation II (APACHE II) score higher than 20
 Level of consciousness - Neurologic score (>4 = stuporous, arousal only after vigorous
stimulation; inconsistently follows commands), encephalopathy score (>3 = major
confusion, daytime sleepiness or agitation), Glasgow Coma Scale score lower than 8
 Failure of improvement with 12-24 hours of noninvasive ventilation
Late admission predictors of failure (>48 h after initiation of noninvasive ventilation) are as
follows:
 Lower functional status (Activity score < 2 = dyspnea light activity)
 Initial acidosis (pH ≤7.22)
 Hospital complications (pneumonia, shock, coma)
Certain patients may benefit from a trial of therapy; however, limiting trials is important to
avoid delays in definitive therapy. Trials may be as short as a few minutes, in patients with
immediate failure, and probably should not exceed 2 hours if patients fail to improve.
Objective criteria for discontinuation are important to limit trials in patients in whom
noninvasive ventilation ultimately fails. This specifically refers to intubation criteria, which
carry a subjective element but have been defined in the literature in investigational studies. All
these criteria are subject to some degree of interpretation in the context of the patient's clinical
status. Importantly, recognize the following as guidelines to assist with the decision to intubate
a patient. Most patients who meet these criteria are candidates for intubation, but a few may be
able to be managed with continued noninvasive ventilation.
Intubation criteria
Major criteria (any one of the following) are as follows [9, 10] :
 Respiratory arrest
 Loss of consciousness with respiratory pauses
 Gasping for air
 Psychomotor agitation requiring sedation
 Heart rate less than 50 bpm with loss of alertness
 Hemodynamic instability with systolic blood pressure less than 70 mm Hg
Minor criteria (two of the following) are as follows:
 Respiratory rate greater than 35 breaths/minute
 pH less than 7.25 and decreased from onset
 PaO2 less than 45 mm Hg despite oxygen
 Increase in encephalopathy or decreased level of consciousness

Intubation guidelines
Any one of the following [11] :
 pH less than 7.20
 pH 7.20–7.25 on 2 occasions 1 hour apart
 Hypercapnic coma (Glasgow Coma Scale score < 8 and PaCO2 >60 mm Hg)
 PaO2 less than 45 mm Hg
 Cardiopulmonary arrest
Two or more of the following in the context of respiratory distress:
 Respiratory rate greater than 35 breaths/minute or less than 6 breaths/minute
 Tidal volume less than 5 mL/kg
 Blood pressure changes, with systolic less than 90 mm Hg
 Oxygen desaturation to less than 90% despite adequate supplemental oxygen
 Hypercapnia (PaCO2 >10 mm increase) or acidosis (pH decline >0.08) from baseline
 Obtundation
 Diaphoresis
 Abdominal paradox

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Complications of Noninvasive Ventilation

Noninvasive ventilation (NIV) has a very different profile of complications compared with
complications associated with endotracheal intubation and mechanical ventilation. This is
directly attributable to the elimination of the endotracheal tube in patient management.
Complications associated with its placement, the duration of placement, and removal of the
tube all are averted. In addition, patients are usually not sedated as they would be if they were
intubated, which further reduces complications related to sedation. Even complications
common to both noninvasive ventilation and invasive ventilation occur less frequently
in patients undergoing noninvasive ventilation.
Complications of noninvasive ventilation
For facial and nasal pressure injury and sores, note the following:
 Result of tight mask seals used to attain adequate inspiratory volumes
 Minimize pressure by intermittent application of noninvasive ventilation
 Schedule breaks (30-90 min) to minimize effects of mask pressure
 Balance strap tension to minimize mask leaks without excessive mask pressures
 Cover vulnerable areas (erythematous points of contact) with protective
dressings
For gastric distension, note the following:
 Rarely a problem
 Avoid by limiting peak inspiratory pressures to less than 25 cm water
 Nasogastric tubes can be placed but can worsen leaks from the mask
 Nasogastric tube also bypasses the lower esophageal sphincter and permits
reflux
For dry mucous membranes and thick secretions, note the following:
 Seen in patients with extended use of noninvasive ventilation
 Provide humidification for noninvasive ventilation devices
 Provide daily oral care
For aspiration of gastric contents, note the following:
 Especially if emesis during noninvasive ventilation
 Avoid noninvasive ventilation in patient with ongoing emesis or hematemesis

Complications of both noninvasive and invasive ventilation

These include the following:
 Barotrauma (significantly less risk with noninvasive ventilation)
 Hypotension related to positive intrathoracic pressure (support with fluids)

Complications avoided by noninvasive ventilation

These include the following:
 Ventilator-associated pneumonia
 Sinusitis
 Reduction in need for sedative agents - Sedatives used in less than 15% of
noninvasive ventilation patients in one survey

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Appendix
https://en.wikipedia.org/wiki/Mechanical_ventilation
https://erj.ersjournals.com/content/20/4/1029
https://emedicine.medscape.com/article/304235-overview

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