Non-Invasive Ventilation

and Modes of Non-

Invasive Ventilation

Dr. Syed Mohammad Mehdi

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Learning Objectives
1. Define NIV?
2. How does NIV work?
3. Interfaces used for NIV.
4. What are the Advantages and disadvantages of NIV?
5. What are the indications and contraindications of NIV?
6. How to monitor patients for NIV failure?
7. Basic Settings of NIV.
8. Modes of NIV and their applications.
9. Advanced and Newer Modes of NIV.

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What is Non-Invasive Ventilation?
• Delivery of positive pressure ventilation through a non-invasive
interface (e.g. nasal mask, face mask, or nasal plugs) rather than an
invasive interface (endotracheal tube, tracheostomy tube).
• Delays in NIV implementation can result in detoriation and increase
the risk of NIV failure.

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How does NIV work?
• Creates positive airway pressure i.e. the pressure outside the lungs is
greater than the pressure inside the lungs.
• Causes air to be forced into the lungs (down the pressure gradient),
reducing the respiratory effort and reducing the work of breathing.
• Helps to keep the chest and lungs expanded by increasing the
functional residual capacity (the amount of air remaining in the lungs
after expiration) after normal expiration, this is the air in the alveoli
available for gas exchange.

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What are the interfaces used for
NIV?

Oronasal Mask
• Covers nose and the mouth (But not
the eyes)
• Most commonly used mask
• Well tolerated and eliminates CO2
effectively.

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Nasal Mask
• Covers just the nose.
• Alternative to those who do not
tolerate Oronasal mask.
• May result in large air leak through
the mouth.

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Nasal Prongs
• Nasal prongs are inserted into the
nares.
• Alternative to Oronasal and nasal
masks.
• A chin strap is often needed to
minimize oral air leak.

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Full face mask
• Covers eyes, nose and mouth
• Although superior in terms of
delivering NIV and minimize air
leak, it is poorly tolerated.

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Helmet Interface
• Allows patient to talk, read and
drink through a straw.
• Less complications such as skin
necrosis, gastric distension and eye
irritation.
• Drawbacks include accumulation of
CO2 and noise exposure can cause
hearing damage.

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What are the benefits?
Goals and benefits of NIV can be divided into the acute and long-term
care setting as follows:
Benefits of NIV in acute care settings:
1. Improves gas exchange
2. Avoids intubation
3. Decreases mortality
4. Decreases length of time on ventilator
5. Decreased duration of hospitalization
6. Decreased incidence of ventilator-associated pneumonia
7. Relieves symptoms of respiratory distress
8. Maximizes patient comfort

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Benefits of NIV in long-term care settings:
1. Relieve or improve symptoms
2. Enhance quality of life
3. Avoids hospitalization
4. Increases survival
5. Improves mobility

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What are the disadvantages of NIV?
1. Lack of airway access and protection
2. Increased risk of aspiration
3. Facial skin necrosis
4. Claustrophobic
5. Slow correction of gas exchange
abnormalities
6. Gastric distension
7. Eye Irritation
8. Needs supervision and increased work
load
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When to consider non-invasive ventilation?

Severe Dyspnea Acute Respiratory Acute Exacerbation Congestive Heart

Failure Of COPD Failure

Pulmonary Do Not Intubate To avoid Obstructive

Edema Patients Re intubation Sleep Apnea
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How to monitor patients on NIV?
Monitoring is important not only for optimizing ventilator settings, but
also to warn against impending NIV failure.

Success predictors of NIV include:

1. Increase in arterial oxygenation
2. Decrease in respiratory rate
3. Significant increase in PaO2 / FiO2
4. Younger age
5. Lower acuity of illness (APACHE
score)
6. Able to cooperate, better
neurologic score
7. Less air leaking, intact dentition
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Failure predictors of NIV include:
1. Stable or decrease in arterial
oxygenation
2. Stable or rise in respiratory rate
3. Stable or increase in dyspnea
4. Stable or decrease in PaO2/FiO2
5. Presence of contraindications to NIV
(discussed later)

The HACOR scale can also be used to predict NIV Failure.

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 Heart Rate, beats/min ≤120bpm 0
≥120bpm +1
HACOR Scale Acidosis (pH) ≥7.35
7.30-7.34
0
+2
7.25-7.29 +3
Used in patients who have <7.25 +4
undergone 1 hour of NIV to assist in Consciousness (GCS) 15 0

predicting failure of NIV. 13-14

11-12
+2
+5
≤10 +10
Oxygenation (PaO2/FiO2), ≥201 0
Facts & Figures mmHg 176-200 +2
151-175 +3
Interpretation: 126-150 +4
101-125 +5
HACOR Score Risk of NIV Failure ≤100 +6
Respiratory Rate, ≤30 0
≤5 Low breaths/min 31-35 +1
36-40 +2
>5 High
41-45 +3
≥46 +4

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 What are the contraindications?

Cardiac / Respiratory Severe Encephalopathy / Facial trauma, neurological Hemodynamic instability

Arrest Low GCS surgery, or deformity

Inability to
Severe upper GI clear secretions Uncooperative Recent esophageal or
bleeding and protect airway patients gastric anastomosis
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MODES OF NIV
There are various modes of NIV, each offering different support based
on the patient’s needs. The commonly used modes include:
1. S Mode (Spontaneous Mode)
2. T Mode (Timed Mode)
3. ST Mode (Spontaneous / Timed Mode)
4. AVAPS (Average Volume-Assured Pressure Support)

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Basic settings of NIV
1. IPAP (Inspiratory Positive Airway Pressure)
2. EPAP (Expiratory Positive Airway Pressure)
3. Back up Rate (Respiratory Rate)
4. VT (Tidal Volume)
5. FiO2 (Fraction of inspired oxygen)

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1. IPAP (Inspiratory Positive Airway
Pressure)
Definition:
• The pressure delivered during inspiration to help augment the
patient’s tidal volume.
Normal Range:
• Typically 8-12 cmH2O (may increase based on patient
requirements).
Purpose:
• To improve ventilation, reduce CO2 levels, and enhance
alveolar recruitment.
Clinical Application:
• Higher IPAP improves ventilation for patients with
hypercapnic respiratory failure, such as in COPD exacerbation.

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How to Adjust IPAP:

Typically, IPAP is set between 8–12 cmH2O initially.

When to Increase IPAP:
• If the patient has signs of hypercapnia (elevated CO2).
• If tidal volume is low, or if the patient is struggling to breathe
deeply.
• If the patient has an elevated work of breathing or shallow
breaths.
When to Decrease IPAP:
• If the patient experiences discomfort due to high pressures.
• If the patient is over-ventilated (low CO2 levels or hypocapnia).

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2. EPAP (Expiratory Positive Airway
Pressure)
Definition:
• The pressure maintained during exhalation to
prevent airway collapse.
Normal Range:
• Typically 4-6 cmH2O.
Purpose:
• To improve oxygenation, reduce work of breathing,
and prevent upper airway obstruction.
Clinical Application:
• Commonly used in patients with sleep apnea to
keep the airways open during expiration and
improve oxygenation.
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How to Adjust EPAP:
Starting Setting: EPAP typically starts at 4–6 cmH2O.
When to Increase EPAP:
• Patient has signs of hypoxemia (low oxygen saturation).
• Evidence of airway collapse or obstructive events (e.g., in obstructive sleep
apnea).
• If there is a need to increase functional residual capacity (FRC) in conditions
like pulmonary edema or atelectasis.
When to Decrease EPAP:
• If the patient finds it difficult to exhale or complains of increased work of
breathing during exhalation.
• If the increase in EPAP leads to over-inflation of the lungs (hyperinflation),
particularly in patients with COPD.

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Relationship Between IPAP and EPAP (Pressure Support)

Definition: The difference between IPAP and EPAP is referred to as Pressure Support (PS).

PS = IPAP – EPAP
Determines the amount of ventilatory assistance provided during inspiration.
How PS Affects Ventilation:
• Higher PS: Results in larger tidal volumes, improving ventilation and CO2 clearance.
• Lower PS: Provides less ventilatory assistance and may result in smaller tidal volumes.
Adjusting IPAP and EPAP Together:
• Increase PS: If the patient is not ventilating adequately or has high CO2 levels (e.g.,
hypercapnia).
• Decrease PS: If the patient is over-ventilated or has discomfort with high pressure levels.

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 3. Backup Rate (Respiratory Rate)
Definition:
• The minimum respiratory rate the ventilator will deliver if
the patient’s spontaneous rate drops below a preset
threshold.
Normal Range:
• Typically set at 10-16 breaths per minute.
Purpose:
• Ensures the patient continues to receive a minimum
number of breaths even during periods of apnea or
reduced spontaneous breathing.
Clinical Application:
• Essential for patients with central respiratory drive failure
or those at risk of apnea.
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4. Tidal Volume (VT)
Definition:
• The volume of air delivered with each breath.
Normal Range:
• Calculated as 6-8 mL/kg of ideal body weight.
Purpose:
• To ensure adequate ventilation and prevent
hypoventilation or hyperventilation.
Clinical Application:
• Adjusted based on patient conditions, ensuring
enough ventilation while minimizing the risk of
barotrauma.

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5. FiO2 (Fraction of inspired oxygen)
Definition:
• The percentage of oxygen in the gas mixture
delivered to the patient.
Normal Range:
• Set between 21% (room air) and 100% based on
the patient's oxygen needs.
Purpose:
• To improve oxygenation in patients with hypoxic
respiratory failure.
Clinical Application:
• Adjust FiO2 to maintain an SpO2 of ≥90%, while
minimizing oxygen toxicity.
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Spontaneous (S) Mode

Mechanism:
• The patient initiates all breaths, and the machine provides
support by delivering preset IPAP during inhalation. EPAP is
maintained between breaths.
Settings:
• IPAP and EPAP are set, but there is no backup rate, as the patient
controls their own rate.

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Application:
• Ideal for patients who can breathe spontaneously but need assistance for
maintaining adequate ventilation.
• Commonly used in Obstructive sleep Apnea (OSA) or mild COPD exacerbation.

Advantages:
• Allows patient full control over breathing.
• Encourages use of respiratory muscles.
• Suitable for patients with good respiratory drive.

Limitations:
• Not suitable for patients with irregular or insufficient respiratory effort.

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Timed Mode (T Mode)
Mechanism:
• The machine controls both the rate and the pressure delivered, independent of
the patient's spontaneous breathing efforts.
• A specific respiratory rate (backup rate) is set.
Settings:
• IPAP, EPAP, and a fixed respiratory rate are set by the clinician.

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Applications:
• Suitable for patients with minimal or no ability to breathe spontaneously.
• Used in severe respiratory muscle fatigue or central hypoventilation syndromes
where patients can’t initiate breaths.
Advantages:
• Ensures consistent ventilation even in patients with no respiratory effort.
• Provides complete respiratory effort when necessary.
Limitations:
• No synchronization with patient effort, which may cause discomfort.
• May lead to patient-ventilator dyssynchrony if the patient starts to breathe
spontaneously.

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Spontaneous / Timed Mode (ST
Mode)
Mechanism:
• A combination of S and T modes. The patient can breathe spontaneously, but
the ventilator will deliver mandatory breaths if the patient’s respiratory rate
falls below the set backup rate.
Settings:
• IPAP: Set to assist patient driven breaths (10-15 cmH2O for moderate support,
higher if needed).
• EPAP: Maintains airway patency (4-8 cm cmH2O).
• Backup Respiratory Rate: Set at a lower range (e.g. 10-16 bpm to ensure
sufficient ventilation).

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Applications:
• Commonly used in patients with COPD, Obstructive sleep Apnea or
neuromuscular disorders.
• Effective for patients with inconsistent, irregular or unreliable respiratory
effort.
Advantages:
• Provides both flexibility and safety by allowing spontaneous breathing with a
safety net of mandatory breaths.
• Reduces the risk of hypoventilation.
Limitations:
• May require careful adjustment to balance spontaneous and timed breaths to
prevent discomfort.

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AVAPS (Average Volume-Assured Pressure support)

Function:
• A volume targeted mode that automatically adjusts inspiratory pressure (IPAP) to maintain a
consistent tidal volume.
Mechanism:
• AVAPS continuously monitors the patient’s breathing patterns and adjusts the inspiratory
pressure to maintain a set target tidal volume.
• The machine uses both pressure support and volume control strategies to optimize ventilation.
Settings:
• Targeted tidal volume: The clinician sets a target tidal volume (typically 6-8ml/kg of ideal body
weight)
• IPAP Range: The machine will adjust IPAP between a minimum and maximum set value to meet
the tidal volume target. Usually, the IPAP minimum is around 10 – 15 cmH2O and the maximum
can go up to 20-30 cmH2O.
• EPAP: Set typically between 4-8cm H2O 35
Applications:
• Useful in patients with progressive neuromuscular diseases, obesity
hypoventilation syndrome or restrictive thoracic disorders.
• Effective in chronic respiratory insufficiency where consistent tidal volumes
are required.
Advantages:
• Provides stable and reliable ventilation with adjustments tailored to patient’s
condition.
• Maintains adequate ventilation even if the patient’s lung mechanics change.
• Reduces risk of hypoventilation and CO2 retention.
Limitations:
• Requires close monitoring and precise settings.
• Pressure adjustments may take a few breaths to stabilize.
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Comparing NIV Modes
Mode Breath Trigger Breath Type Patient Control Used For

S Mode Patient Spontaneous Full Sleep Apnea, Mild

Respiratory Failure

T Mode Machine Mandatory None Severe Muscle Weakness,

Central Hypoventilation

ST Mode Patient/Backup Hybrid Partial COPD, Neuromuscular

disease, Irregular breathing

AVAPS Patient/Machine Variable Adjusted Support Progressive Neuromuscular

diseases, Chronic failure

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Newer Modes in NIV
1. Intelligent Volume-Assured Pressure Support (iVAPS)
2. NAVA (Neurally Adjusted Ventilatory Assist)

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iVAPS (Intelligent Volume-Assured
Pressure Support)
• It is similar to AVAPS, but more advanced.
• iVAPS adapts to the patient’s changing needs by adjusting not only the pressure but
also the target volume based on real time monitoring of the patient’s lung compliance
and respiratory effort.
• iVAPS also targets alveolar ventilation (how much air reaches the alveoli) instead of just
tidal volume.
Settings:
• Targeted alveolar ventilation: Set by clinician to maintain a specific level of CO2 removal.
• IPAP Range: Automatically adjusted to maintain target ventilation (minimum and maximum limits
can be set by clinician).
• EPAP: Set to maintain baseline airway patency
Applications:
• Beneficial for patients with highly variable lung conditions.
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NAVA (Neurally Adjusted Ventilatory
Assist)
Mechanism:
• Uses the electrical activity of the diaphragm (Edi) to synchronize the ventilator with the
patient’s neural respiratory drive.
• A catheter with electrodes is placed in the esophagus to detect diaphragmatic signals,
and the ventilator adjusts its support based on the patient’s respiratory effort.
Use Case:
• Ideal for patients who need highly sensitive and precise ventilatory support, such as
those with weak or inefficient respiratory muscles but still have intact neural drive.
Settings:
• Edi signal guides the ventilator to deliver proportional support; other settings like EPAP,
FiO2, and backup rate can also be adjusted.
Clinical Application:
• NAVA is beneficial in patients with complex or variable respiratory demands, such as
preterm infants, those with neuromuscular diseases.
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