Noninvasive Positive-Pressure Ventilation (NIPPV)

Indications

Respiratory Failure Due to Chronic Obstructive Pulmonary Disease (COPD) (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]])

  • Clinical Efficacy of NIPPV
    • NIPPV Decreased pCO2, Heart Rate, Respiratory Rate, and Dyspnea within the First Hour of Treatment
    • NIPPV Decreased Encephalopathy Scores
      • The presence of hypercapneic encephalopathy or coma in COPD exacerbation is not a contraindication to NIPPV
    • NIPPV Decreased Complication Rates and Hospital Length of Stay
    • NIPPV Decreased Intubation Rate from 75% -> 25%
    • NIPPV Decreased Mortality Rate from 30% -> 10%
      • Decreased mortality rate may not be observed with the USE of NIPPV in milder COPD exacerbations (Eur Resir J, 1996) [MEDLINE]
      • NIPPV decreased mortality rate in the setting COPD exacerbation with concomitant pneumonia (Am J Respir Crit Care MED, 1999) [MEDLINE]
      • Mortality rate may not be decreased in the subset of patients with pH <7.30 (at least in patients treated on general medical wards, outside of the ICU): this study suggested that patients with moore severe COPD exacerbation might have better outcomes if treated in the ICU, suggesting the importance of appropriate monitoring of NIPPV (Lancet, 2000) [MEDLINE]
  • Clinical Efficacy of Combination of HELIOX + NIPPV
    • HELIOX + NIPPV Decreased Airway Resistance and More Rapidly Improved Gas Exchange in COPD Exacerbation (Am J Respir Crit Care MED, 2000) [MEDLINE]
    • HELIOX + NIPPV Had No Benefit (in Terms of Intubation Rate, Mortality Rate, or Hospital Length of Stay) over NIPPV Alone in Randomized, Prospective Trial in COPD Exacerbation (Crit Care Med, 2003) [MEDLINE]
  • Recommendations
    • NIPPV is Beneficial in COPD Exacerbation: if no specific contraindicatons exist

Respiratory Failure Due to Cardiogenic Pulmonary Edema (see Congestive Heart Failure, [[Congestive Heart Failure]])

  • Clinical Efficacy
    • Meta-Analyses/Systematic Reviews Indicated that Both CPAP and NIPPV Decreased Intubation and Mortality Rates (JAMA, 2005) [MEDLINE] (Crit Care, 2006) [MEDLINE] (Ann Emerg Med, 2006) [MEDLINE]: however, mortality rate was statistically significantly decreased in only a third of these analyses
  • Recommendations
    • NIPPV is Beneficial in Cardiogenic Pulmonary Edema: if no specific contraindicatons exist

Respiratory Failure in Immunocompromised Host

  • Immunocompromised Hosts: hematologic malignancies, AIDS, or solid-organ transplant, and bone marrow/stem cell transplant
  • Clinical Efficacy
    • NIPPV Decreased the Intubation Rate and ICU Mortality Rate with Respiratory Failure in Patients with Solid Organ Transplants (JAMA, 2000) [MEDLINE]
    • NIPPV Decreases the Intubation Rate and Mortality Rate with Respiratory Failure in Patients with Hematologic Malignancy (Predominantly), Solid Organ Transplant, and AIDS (NEJM, 2001) [MEDLINE]
  • Recommendations
    • NIPPV May Be Considered in Immunocompromised Hosts

Respiratory Failure Due to Pneumonia (see Pneumonia, [[Pneumonia]])

  • Clinical Efficacy
    • NIPPV Has Been Reported to Both Increase the Mortality Rate (Thorax, 1995) [MEDLINE] or Decrease the Mortality Rate (Am J Respir Crit Care Med, 1999) in Pneumonia [MEDLINE]
      • Latter study suggests that NIPPV decreases mortality in subset of patients with COPD with concomitant pneumonia

Respiratory Failure Due to Asthma

  • Clinical Efficacy
    • Role of NIPPV in the Management of Respirtory Failure due to Asthma Exacerbation is Not Well-Defined, But Can be Considered in Select Patients (Respirology, 2010) [MEDLINE]
  • Recommendations
    • Role of NIPPV in Asthma Exacerbation is Not Well-Defined

Respiratory Failure Due to Neuromuscular Disease

  • Clinical Efficacy
    • As of 2009 Review, There Were No Published Trials Using NIPPV in Acute Respiratory Failure Due to Neuromuscular Disease (Respir Care, 2009) [MEDLINE]
    • However, NIPPV is the Preferred Treatment of Nocturnal Hypoventilation and Chronic Respiratory Failure in Neuromuscular Disease (Curr Opin Neurol, 2005) [MEDLINE] [MEDLINE]
      • Tracheostomy/mechanical ventilation is required in cases with bulbar dysfunction or uncontrolled aspiration
  • Recommendations
    • NIPPV Has Undefined Role in Acute Respiratory Failure Due to Neuromuscular Disease
    • NIPPV is the Preferred Treatment of Nocturnal Hypoventilation and Chronic Respiratory Failure in Neuromuscular Disease

Respiratory Failure Post-Abdominal Surgery

  • Clinical Efficacy
    • French Randomized NIVAS Trial of NIPPV in Respiratory Failure Following Abdominal Surgery (JAMA, 2016) [MEDLINE]: randomized, multi-center trial (n = 293); trial excluded patients who required immediate reintubation
      • As Compared to Standard Oxygen Therapy, NIPPV Decreased the Rate of Endotracheal Intubation Within 7 Days
      • NIPPV Increased the Number of Ventilator-Free Days
      • NIPPV Decreased the Health Care-Associated Infection Rate
      • No Difference in 90-Day Mortality Rate
      • There Were No Significant Differences in Gas Exchange Between the Groups
      • Criticism: Trial Had a Lower Than Expected Reintubation Rate
  • Recommendations
    • NIPPV Can Be Considered for the Treatment of Respiratory Failure Following Abdominal Surgery

Respiratory Failure Post-Lung Resection

  • Clinical Efficacy
    • Small Randomized Trial of NIPPV in Respiratory Following Lung Resection (Am J Resp Crit Care Med, 2001) [MEDLINE]
      • NIPPV Decreased Intubation Rate, Length of Stay, and Mortality Rate
    • Systematic Review of NIPPV Following Lung Resection for Lung Cancer (Cochrane Database Syst Rev, 2015) [MEDLINE]
      • No Benefit in Terms of Rate of Pulmonary Complications, Rate of Non-Pulmonary Complications, Post-Operative Antibiotic Use, Length of ICU Stay, Length of Hospital Stay, Rate of Intubation, Adverse Effects Related to NIPPV, and Mortality Rate
      • Criticism: Quality of Evidence is Moderate, Low, and Very Low
  • Recommendations
    • Role of NIPPV Post-Lung Resection is Undefined, Due to Low Quality Data

Facilitation of Early Extubation

  • Clinical Efficacy
    • Systematic review/meta-analysis of early extubation with transition to NIPPV in studies of predominantly COPD patients demonstrates decreased mortality and ventilator-associated pneumonia rates [MEDLINE]
  • Recommendations
    • Good Candidates for Early Extubation to NIPPV
      • Abscence of Major Co-Morbidities
      • Alertness
      • Manageable Secretions
      • Presence of COPD
    • Poor Candidates for Early Extubation to NIPPV
      • Cardiac/Hemodynamic Instability
      • Facial/Upper Airway Abnormalities
      • High FIO2 or PEEP Requirement
      • Poor Cough
      • Significant Secretions

Post-Extubation Prophylaxis

  • Clinical Efficacy
    • After Thoracoabdominal Surgery, Prophylactic Post-Extubation NIPPV Decreased Pulmonary Morbidity and Length of Stay (Chest, 2005) [MEDLINE]
    • In At-Risk Patients (with Risk Factors Such as Hypercapnia, Congestive Heart Failure, Ineffective Cough and Excessive Tracheobronchial Secretions, More Than One Failure of a Weaning Trial, More Than One Comorbid Condition, and Upper Airway Obstruction), Prophylactic NIPPV for First 48 hrs After Extubation Decreased Reintubation Rate and Mortality Rate (Am J Respir Crit Care Med, 2006) [MEDLINE]
    • Post-Abdominal Surgery, Prophylactic NIPPV (CPAP) Decreased Post-Operative Pulmonary Complications, Atelectasis, and Pneumonia (Ann Surg, 2008) [MEDLINE]
    • In Chronically Hypercapnic Patients, Early Prophylactic NIPPV After Extubation Decreased the 90-day Mortality Rate (Lancet, 2009) [MEDLINE]
    • Meta-Analysis of NIPPV in Post-Extubation Respiratory Failure (Indian J Crit Care, 2013) [MEDLINE]
      • Prophylactic NIPPV Improved Reintubation and Hospital Mortality Rates
      • Therapeutic NIPPV Only Improved ICU Length of Stay, But Did Not Impact the Reintubation or Mortality Rate
  • Recommendations
    • Use of NIPPV as Post-Extubation Prophylaxis May Be Used in Selected Patients

Extubation Failure

  • Background
    • Extubation Failure Occurs After 5-20% of Planned and After 40-50% of Unplanned Extubations
    • Extubation Failure is Associated with Increased Mortality Rate of 43%, vs 12% Mortality in Those with Successful Extubations
  • Clinical Efficacy
    • In COPD, NIPPV Decreased Reintubation Rate and ICU Length of Stay (Eur Respir J, 1998) [MEDLINE]
    • In Randomized Trial (Which Excluded COPD Patients After the First Year of the Study, Due to Ethical Concerns), NIPPV Did Not Decrease Reintubation Rate, Duration of Mechanical Ventilation, Length of Hospital Stay, or Mortality (JAMA, 2002) [MEDLINE]
    • In Study (with Only 10% COPD Patients), NIPPV Increased the Mortality Rate (NEJM, 2004) [MEDLINE]: in this study, longer delay to reintubation was likely the reaosn for the observed increased mortality rate
      • Also 25% of the control subjects were crossed-over to NIPPV when they deteriorated and met criteria for intubation -> cross-overs had only only a 25% reintubation rate (which was half of that in the-to-treat NIPPV group (raising the concerns about the study design)
    • In Subgroup of Chronically Hypercapnic Patients, NIPPV Decreased the Reintubation Rate and Mortality (Am J Respir Crit Care MED, 2006) [MEDLINE]
    • Meta-Analysis of NIPPV in Post-Extubation Respiratory Failure (Indian J Crit Care, 2013) [MEDLINE]
      • Prophylactic NIPPV Improved Reintubation and Hospital Mortality Rates
      • Therapeutic NIPPV Only Improved ICU Length of Stay, But Did Not Impact the Reintubation or Mortality Rate
  • Recommendations
    • NIPPV Can be Selectively Used for Extubation Failure: NIPPV is beneficial in COPD and other hypercapnic conditions
      • However, if NIPPV fails to rescue patient, reintubation should be achieved without delay

Respiratory Failure in “Do Not Intubate” (DNI) Patients

  • Clinical Efficacy
    • NIPPV Improved Survival to Discharge to >50% in COPD and CHF Patients (Crit Care Med, 2004) [MEDLINE] (Crit Care Med, 2005) [MEDLINE]
      • However, survival to discharge was only 14-25% in patients with pneumonia or cancer
    • NIPPV Has Been Extensively Used as a Pallative Treatment for Dyspnea (Intensive Care Med, 2011) [MEDLINE]
  • Recommendations
    • NIPPV Can Be Considered Where There is a Rapidly Reversible Component of Respiratory Failure (COPD, CHF)
    • NIPPV Can Be Considered as a Pallative Treatment for Dyspnea

Contraindications to NIPPV

  • Respiratory or Cardiac Arrest
  • Medical Instability
    • Acute Myocardial Infarction Requiring Intervention
    • Arrhythmias
    • Hypotension/Shock
    • Uncontrolled Myocardial Ischemia
  • Excessive Secretions
  • Inability to Protect Airway
  • Vomiting/Aspiration Risk
  • Inability to Achieve NIPPV Mask Fit
  • Recent Upper Airway/Esophageal/Gastric Surgery
  • Untreated Pneumothorax
  • Psychosis/Agitated Delirium/Inability to Cooperate

Physiology

  • Physiologic Effects
    • Increased Functional Residual Capacity (FRC): increases lung compliance and reduces the elastic work of breathing -> more efficient ventilation
    • Decreased Preload
    • Decreased Afterload

Predictors of Successful NIPPV [MEDLINE]

  • Illness-related Factors
    • Presence of COPD or Cardiogenic Pulmonary Edema
    • Lack of Pneumonia or ARDS
    • APACHE II Score <29 (X)
    • Minimal Secretions
    • Adequate Neurologic Status (Glasgow Coma at least 15) (X)
  • Patient-Related Factors
    • Dentate + Compatible Facial Structure with Minimal Air Leakage Around Mask
    • Patient Ability to Tolerate
  • Clinical Assessment-Related Factors
    • RR < 30 (X)
    • pH > 7.30 (X)
    • pO2/FIO2 Ratio >146 After First Hour (In Hypoxemic Respiratory Failure)
    • Good Synchronization with NIPPV
    • Good Response to NIPPV Within First 1-2 Hrs
      • Decreased RR
      • Improved pO2 + Decreased pCO2
      • Improved pH
  • (X) Presence of All Four in COPD Patients at Baseline -> 94% Success Rate
  • (X) Presence of All Four After 2 Hrs -> 97% Success Rate

Clinical

Bilevel Pressure Ventilation (BiPAP) (or Continuous Positive Airway Pressure, CPAP) via Full-Face Mask

  • Full-face Mask : preferred interface, as it does not allow oral air leakage that nasal masks allow
    • However, nasal masks may be more comfortable for long-term use (or in patients who are able to keep their mouth closed during NIPPV)
  • Choice of Ventilator: bilevel ventilation can be delivered using either via a BiPAP-type NIPPV device (with an oxygen blender and waveform display) or via a conventional ventilator
  • Initial Settings: start with low pressures, typically 8/4 cm H2O or 10/4 cm H2O , (to allow patient to accomodate) and gradually ramp pressure up
  • Inspiratory Flow Rate: adjust “rise time” (inspiratory flow rate) to patient comfort: COPD patients typically prefer shorter inspiratory times (faster ispiratory flow rates), which allow longer expiratory times
  • Oxygen Delivery
    • Bilevel devices without an oxygen blender: max FIO2 that can be achieved is 45-50%
    • Bllevel device with an oxygen blender: necessary when higher FIO2 is required
      = Humidification: routinely used (to decrease work of breathing and enhance patient tolerance)

Monitoring

  • Clinical monitoring is crucial (especially early in the application of NIPPV) and is best done in the ICU setting
  • Serial ABG/Pulse Oximetry: routine
  • Capnography: may be used

Sedation

  • May be used judiciously to facilitate patient cooperation with NIPPV

Common Problems

  • Mask Discomfort/Ulceration on Bridge of Nose
  • Sinus/Ear Pain: due to excessive air pressure
  • Gastric Insufflation: frequent, but not typically severe
  • Air Leak from Mask: requires mask adjustment

References

General

  • Noninvasive ventilation in acute respiratory failure. Crit Care Med. 2007;35:2402-2407 [MEDLINE]

Respiratory Failure Due to Chronic Obstructive Pulmonary Disease (COPD)

  • Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med. 1990;323:1523-1530 [MEDLINE]
  • Noninvasive ventilatory support does not facilitate recovery from acute respiratory failure in chronic obstructive pulmonary disease. Eur Respir J. 1996 Jun;9(6):1240-5 [MEDLINE]
  • Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med. 1999 Nov;160(5 Pt 1):1585-91 [MEDLINE]
  • Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000 Jun 3;355(9219):1931-5 [MEDLINE]
  • Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. 2003 Jan 25;326(7382):185 [MEDLINE]
  • Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med. 2003 Jun 3;138(11):861-70 [MEDLINE]
  • Noninvasive ventilation with helium-oxygen in acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 1):1191-200 [MEDLINE]
  • Helium-oxygen versus air-oxygen noninvasive pressure support in decompensated chronic obstructive disease: A prospective, multicenter study. Crit Care Med. 2003 Mar;31(3):878-84 [MEDLINE]
  • Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failure. Chest. 2005;127:952-960 [MEDLINE]
  • Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness. Chest. 2005;128:1657-1666 [MEDLINE]

Respiratory Failure Due to Cardiogenic Pulmonary Edema

  • Noninvasive ventilation in acute cardiogenic pulmonary edema. JAMA 2005; 294: 3124-3130 [MEDLINE]
  • Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema: a systematic review and meta-analysis. Crit Care 2006; 10:R69 [MEDLINE]
  • The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: a systematic review. Ann Emerg Med 2006; 48:260-269 [MEDLINE]

Respiratory Failure in Immunocompromised Host

  • Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA 2000; 283:2239-2240 [MEDLINE]
  • Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, and acute respiratory failure. N Engl J Med 2001; 344:481-487 [MEDLINE]

Respiratory Failure Due to Pneumonia

  • Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax 1995 Jul;50(7):755-7 [MEDLINE]
  • Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999; 60(5 Pt 1):1585-91 [MEDLINE]

Respiratory Failure Due to Asthma

  • The use of non-invasive ventilation for life-threatening asthma attacks: Changes in the need for intubation. Respirology. 2010 May;15(4):714-20. doi: 10.1111/j.1440-1843.2010.01766.x. Epub 2010 Apr 7 [MEDLINE]
  • Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial. Respiratory Care February 1, 2013 vol. 58 no. 2 241-249 [MEDLINE]

Respiratory Failure Due to Neuromuscular Disease

  • Noninvasive Ventilation for Patients Presenting With Acute Respiratory Failure: The Randomized Controlled Trials. Respir Care 2009;54(1):116-124 [MEDLINE]
  • Respiratory function assessment and intervention in neuromuscular disorders. Curr Opin Neurol. 2005 Oct;18(5):543-7 [MEDLINE]
  • Pulmonary issues in patients with chronic neuromuscular disease. Am J Respir Crit Care Med Vol 187, Iss. 10, pp 1046-1055, May 15, 2013 [MEDLINE]

Respiratory Failure Post-Abdominal Surgery

  • NIVAS Trial. Effect of Noninvasive Ventilation on Tracheal Reintubation Among Patients With Hypoxemic Respiratory Failure Following Abdominal Surgery: A Randomized Clinical Trial. JAMA. 2016 Apr 5;315(13):1345-53. doi: 10.1001/jama.2016.2706 [MEDLINE]

Respiratory Failure Post-Lung Resection

  • Noninvasive ventilation reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med. 2001 Oct 1;164(7):1231-5 [MEDLINE]
  • Non-invasive positive pressure ventilation for prevention of complications after pulmonary resection in lung cancer patients. Cochrane Database Syst Rev. 2015 Sep 25;9:CD010355. doi: 10.1002/14651858.CD010355.pub2 [MEDLINE]

Facilitation of Early Extubation

  • Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2003;(4):CD004127[MEDLINE]
  • Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009 May 21;338:b1574. doi: 10.1136/bmj.b1574 [MEDLINE]
  • Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD004127. doi: 10.1002/14651858.CD004127.pub2 [MEDLINE]

Post-Extubation Prophylaxis

  • Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest. 2005 Aug;128(2):821-8 [MEDLINE]
  • Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg. 2008 Apr;247(4):617-26. doi: 10.1097/SLA.0b013e3181675829 [MEDLINE]
  • Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009 Sep 26;374(9695):1082-8. doi: 10.1016/S0140-6736(09)61038-2. Epub 2009 Aug 12 [MEDLINE]
  • Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005 Nov;33(11):2465-70 [MEDLINE]

Extubation Failure

  • Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997 Jul;112(1):186-92 [MEDLINE]
  • Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med. 1998 Jun;26(6):1049-53 [MEDLINE]
  • Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J. 1998 Jun;11(6):1349-53 [MEDLINE]
  • Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002 Jun 26;287(24):3238-44 [MEDLINE]
  • Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 10;350(24):2452-60 [MEDLINE]
  • Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006 Jan 15;173(2):164-70. Epub 2005 Oct 13 [MEDLINE]
  • The role of non-invasive positive pressure ventilation in post-extubation respiratory failure: An evaluation using meta-analytic techniques. Indian J Crit Care Med. 2013 Jul;17(4):253-61. doi: 10.4103/0972-5229.118477 [MEDLINE]

Respiratory Failure in “Do Not Intubate” (DNI) Patients

  • Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004 Oct;32(10):2002-7 [MEDLINE]
  • Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. Crit Care Med. 2005 Sep;33(9):1976-82 [MEDLINE]
  • Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med. 2011 Aug;37(8):1250-7. doi: 10.1007/s00134-011-2263-8. Epub 2011 Jun 9 [MEDLINE]