View source for Noninvasive ventilation

==Background==
===Mechanism of Action===
*Augments inspiratory/expiratory pressures throughout a spontaneous respiratory cycle.
**Recruits compressed alveoli to reduce atelectasis.
**Prevents small airway collapse during inspiration.
**Counteracts intrinsic PEEP (Positive End Expiratory Pressure).
**Decreased both preload and afterload in heart failure exacerbations.
**Improves lung compliance and V/Q matching.
**Decreases the work of breathing.
*Reduces need for [[intubation]] and mortality in acute cardiogenic [[pulmonary edema]]<ref>Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet. 2006;367(9517):1155-1163. doi:10.1016/S0140-6736(06)68506-1</ref> and acute [[COPD exacerbation]]<ref>Ambrosino N, Vagheggini G. Non-invasive ventilation in exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2007;2(4):471-476.</ref>

===CPAP vs. BiPAP===
[[File:CPAPvsBiPAP.jpg|thumb|Illustration of difference between CPAP and BiPAP.]]
*CPAP = PEEP = EPAP
**Use for isolated hypoxia
**Increasing CPAP increases oxygenation
*BPAP = PEEP + (IPAP = Inspiratory Pressure Support)
**Use for hypoxia and hypoventilation (decreases work of breathing)
**Increasing IPAP (specifically IPAP-CPAP) increases ventilation
***Note: BiPAP is a brand name of one of the BPAP machines. Both names are often used interchangeably.

==Indications==
*[[CHF]]
*[[COPD]]
*[[Asthma]]
*OSA
*[[Pulmonary edema]]
*[[Pneumonia]]

==Contraindications==
*Obtunded patients
*Uncooperative patients
*Vomiting or inability to protect the airway (aspiration risk)
*Facial trauma or burns
*Facial, esophageal, or gastric surgery
*Poor mask fit

==Procedure==
#Prepare intubation equipment in case of BPAP/CPAP failure.
#Position the patient in a 30-90° upright position.
#Apply the mask.
#*Select the appropriately-sized mask.
#*Secure it in place by fastening the Velcro straps.
#*Note: Some experts recommend allowing the patient to get used to the mask first, PRIOR TO starting the positive airway pressures.
#Prepare the patient.
#*Patients will often require frequent coaching throughout this process.
#*In moderately anxious patients, consider low-dose [[fentanyl]], a [[benzodiazepine]] or [[ketamine]] to assist with patient-ventilator synchrony.
#Adjust the settings.
#*For BPAP, begin with an IPAP of 8-10 cm H2O and an EPAP of 2-4 cm H2O.
#*Gradually titrate upward IPAP and EPAP 1-2 cm every 5-15 minutes with a goal IPAP 10-16 cm H2O and EPAP of 8-10 cm H2O depending upon patient response.
#Continue close monitoring.
#*A doctor, nurse, or respiratory therapist should be with the patient at all times during BPAP/CPAP use.

==Complications==
*Skin irritation
*Nasal bridge pain
*Mucosal dryness
*Eye irritation
*Gastric distention
*Decreased cardiac output
*Barotrauma (rarely)

==See Also==
{{Mechanical ventilation pages}}

==External Links==
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-do-noninvasive-positive-pressure-ventilation?query=noninvasive%20ventilation Merk Manual - How To Do Noninvasive Positive Pressure Ventilation]
*[https://www.nuemblog.com/blog/nippv NUEM - Non-Invasive Positive Pressure Ventilation in the ED]

==References==
<references/>
[[Category:Critical Care]]
[[Category:Pulmonary]]