Michelle Abbott

Overview
• Revise the physiological mechanism & processes of
respiration (including principles of V/Q, airway
inflation, relevant anatomy)

• Identify differences between airway inflation

patterns under –ve and +ve pressure

• Explain the terminology and concepts of non-

invasive ventilation
How do we breathe?
 Normal breathing
Diaphragm contracts
Intercostals contract http://i-biology.net/ibdpbio/06-human-health-physiology/03-gas-exchange/

Chest wall increases in size

Intrapleural pressure becomes more negative
Negative pressure passed onto the intrapulmonary
regions (within the lungs) via transpulmonary pressures
Air is drawn in to the lungs/alveoli via the pressure
gradient
As air enters lungs/alveoli, intrapulmonary pressures
increase becoming closer to atmospheric pressure
After inhalation the muscles relax causing the rib cage to
retract and air re-travels down the pressure gradient out
of the lungs back to the atmosphere
http://www.answers.com/topic/breathi
ng

http://sciencewithme.com/wp-
content/uploads/2012/01/respirationC.png
Our lungs and ventilation (V)
 The lower-most alveoli are smaller (due to the
weight of the lung) making them more
compliant (distensible)
 The upper most alveoli are being stretched
open by the downward weight of the lung (so
they are already partially expanded)
 The smallest (lowermost) alveoli have the
biggest capacity for expansion and ventilate
more efficiently (i.e. they expand more than
the alveoli which are already partially
expanded)
 Hence, ventilation increases as you travel down the upright
lung
Our lungs and perfusion (Q)
•Fluid obeys the laws of physics ie is affected by gravity

•Fluids (e.g. blood) will be drawn downward (with

gravity)

• Hence, perfusion increases down the upright lung

• This increase is larger than for ventilation

V/Q relationship summary
•Both increase down the lung

•Perfusion increases more

•V/Q matching is equal approx. 2/3 down the lung

•V/Q ratio/matching is ideal when V/Q = 1 (ie equal)

•Areas of lung will have a high, normal or low ratio

V/Q relationship High V/Q ratio (higher ventilation
than perfursion)

Optimal V/Q
matching

low V/Q ratio (higher

perfusion than ventilation)

West JB, Respiratory Physiology,

The Essentials, 6th ed. 2000,
Lippincott, p. 54.
Considerations
•V/Q matching may not be the primary aim of your
treatment

•But it is likely to be a consideration (for safety,

monitoring etc)

•Is it acceptable to compromise V/Q matching for the

sake of other intervention (e.g. lung re-expansion or
sputum clearance)
Positive pressure breathing
 The BALLOON analogy…
 Blowing up a balloon uses positive pressure

 Balloons (and alveoli) are easier to inflate when

already started

 Hence, the alveoli which are already slightly

open (e.g. the uppermost ones) will fill up
preferentially over the lower ones when there is a
positive driving pressure

 V/Q ratio/relationship changes (becomes

exaggerated – high becomes higher, low
becomes lower)
Perfusion Changes in Positive
Pressure Ventilation
•Increased airway pressure causes collapse of capillaries

•Reduced venous return

•Reduced circulating blood volume

•Exaggerated effects on perfusion down the lung and

greater inequality of V/Q
What are positive pressure devices?

• Ventilator
• CPAP
• BiPAP
• IPPB*
CPAP
 Constant positive airway pressure
 Constant flow of air blown into the lungs,
in excess of inspiratory requirements
 A positive pressure develops in lungs (O2
may need to be delivered too)
 Increases FRC (collateral ventilation
channels open, optimises O2)
 Improves compliance and therefore may
reduce WOB
Insp. Exp. Insp.
pressure
What CPAP level to set?
•Think about the patients pathophysiology

• Floppy lungs (eg COPD) will need higher amount

• Large external forces on lungs (eg APO, effusions, body

size) will need higher numbers

•Shouldn’t go below 5
BiLevel
 Bilevel positive airways pressure
 2 pressures provided
 IPAP = inspiratory positive airway pressure – assists the breath
in
 EPAP – expiratory positive airway pressure – keeps airways
open
 Provides a wave of positive pressure that is synchronised to
the timing of a patient’s breathing pattern
 Increases FRC (like CPAP), increases depth of breathing,
and can reduce WOB and increase minute ventilation
Insp. Exp. Insp.
pressure
What levels to set?
•EPAP as for CPAP rules

•IPAP – EPAP = pressure support

• Larger pressure support will increase TV and decrease WOB
therefore think about what your patient needs

•Do they need a back up rate?

•Use feedback from the machine and the patient to adjust

settings
• TV
• RR
• WOB
IPPB / ‘Bird’
 Intermittent positive pressure breathing
 Intermittent periods of positive pressure breathing
completely instigated by a patient’s own effort/trigger
 Augments inspiration only, no expiratory pressure at all
and therefore returns to atmospheric pressure
 Reduces work of breathing and augments tidal volume
(larger breaths)
Insp. Exp. Insp.
pressure
 Considerations when applying NIV
•Think about the interface
• Face mask
• Nasal mask
• Full face mask
• Mouth mask
http://www.lakesidepress.com/CPAP/CPAP.htm
• Helmet?
http://www.directhomemedical.com/res
med-mirage-liberty-cpap-mask-
fitpack.html

http://www.cpaptalk.com/viewtopic.php?f=1
&t=64971&start=225
http://www.clipsta.com/a-smaller-
cpap-alternative/
http://www.northatlanticmedical.co
m/sleep-cpap-masks-nasal.html
•Ensure you measure the
interface for appropriate size
ensuring it sits just below the
Lips

•Explanation to the patient – MOST IMPORTANT

PART!!!!
• Ensure they are aware why you are applying it
• Educate them that the mask is firm and it will feel
uncomfortable
• Explain you will hold the mask to them first until they feel
comfortable, then will connect the straps
Questions
Q1) Explain the difference between normal ventilation and NIV

Q2) What is the purpose of CPAP?

Q3) Why would you use BiLevel over CPAP?

Q4) How do you determine the PS provided when in BiLevel?

Q5) How do you determine what values to start with?

Q6) In what patient group would IPPB be most effective?

Q7) You have a patient with skin breakdown on the bridge of their nose –
what mask options do you have for this patient?