1. Non Invasive Ventilation 呼吸治療科 李俊德 醫師

2. Invasive ventilation
Non invasive ventilation
Positive-pressure ventilation
Negative-pressure ventilation

3. 1864 Jones

4. 1876 Woillez

6. Negative Pressure Ventilation
Full body ventilator (tank or iron lung)
Raincoat ventilator (pneumowrap or pneumosuit)
Cuirass ventilator (chest shell)

8. Corrado A. Iron lung versus mask ventilation in acute exacerbation of COPD: a randomised crossover study.
Intensive Care Med 2009;35:
Randomised multicentre study. A total of 141 patients were assigned: 70 to ILV and 71 to NPPV. On admission, PaO2/FiO2, 198 (70) and 187 (64), PaCO2, 90.5 (14.1) and 88.7 (13.5) mmHg, and pH 7.25 (0.04) and 7.25 (0.05), were similar for ILV and NPPV groups. When used as first line, the success of ILV (87%) was significantly greater (P = 0.01) than NPPV (68%), due to the number of patients that met minor criteria for EI; after the shift of the techniques; however, the need of EI and hospital mortality was similar in both groups. The total rate of success using both techniques increased from 77.3 to 87.9% (P = 0.028).
Conclusion: The sequential use of NPPV and ILV avoided EI in a large percentage of COPD patients with ARF; ILV was more effective than NPPV.

12. Non Invasive Positive Pressure Ventilation (NIPPV) (NPPV)

13. Case Presentation Chen XX, 59 y/o, male, Dx:COPD
PFT in 90-6:0.39(16%)/0.90(29%)/43%
(27)CM (3)RT
(5)RT
(4)CS
(8)RT#
(11)RT
(50)RT#
(38)RT#
(41)RT#
~920402(85)RT# @:IMV #:NIPPV

14. 8704~9204 19 Admission, Total 696 Days(Mean 36 ± 27 days)
No MV: 5 (1,2,3,6,12)
IMV : 9 (4,5,7,9,10,11,14,15,18)
NIPPV: 5 (8,13,16,17,19)
PaO2 / PaCO2 / pH
16:910625#
17:910817#
19:920107# (0106)
(0107)
(0108)

15. Case Presentation Fu XX, 17 y/o, male Dx:Otopalatodigital syndrome
PaO2 / PaCO2 / pH
(BiPAP)

16. BiPAP

18. Vision

19. 年 度
呼吸器台數
(T)
NPPV台數(N)
呼吸器人次(Ti)
NPPV人次
(Ni)
N/T
(%)
Ni/Ti(%) 89 82 2
2836 22
2.4
0.8 90
2856 35
2.2
1.2 91
102 6
3270
101
5.9
3.1 92
116 12
3128 96
10.3 93
117
3110
3.8 94
120
2968
100 10
3.4 95
122
3000
166
9.8
5.5
125
3087
201
9.6
6.5 97
126
2907
190
9.5 98
130
2841
244
9.2
8.6

21. Absolute contraindications
Coma
Cardiac arrest
Respiratory arrest
Any condition requiring immediate intubation

22. Relative contraindications
Cardiac instability
Shock and need for pressor support
Ventricular dysrhythmias
Complicated acute myocardial infarction
GI bleeding - Intractable emesis/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

23. Patient inclusion criteria
Patient cooperation (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 )
Hypoxemia (PaO2/FIO2 <200 mm Hg, best in rapidly
reversible causes of hypoxemia)

24. Suitable clinical conditions for non invasive ventilation (most patients)
Chronic obstructive pulmonary disease
Cardiogenic pulmonary edema

25. Suitable clinical conditions for non invasive ventilation (selected patients)
After discontinuation of mechanical ventilation
Community-acquired pneumonia
Asthma
Immunocompromised state
Postoperative respiratory distress
Do-not-intubate status
Neuromuscular respiratory failure
Decompensated obstructive sleep apnea/
cor pulmonale
Cystic fibrosis
Acute respiratory distress syndrome
Mild Pneumocystic carinii pneumonia

26. Location of application
ICU (especially if possibility of intubation)
Step-down unit (lower severity of illness)  
Moderately severe COPD (pH >7.30)
Do-not-intubate status
Intermittent or nocturnal ventilatory support
Ward setting (not recommended if intubation is indicated) 
Suitable in specialized units
Same considerations as step-down unit
Emergency department - Local considerations, expertise may mirror ICU or step-down unit

27. Patient interfaces
Nasal mask
Face mask
Total face mask

28. Nasal mask

29. Face mask

30. Total face mask

31. Nasal masks (general advantages)
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

32. Nasal masks (cautions, disadvantages)
More leaks possible (eg, mouth-breathing or edentulous patients)
Effectiveness limited in patients with nasal deformities or blocked nasal passages

33. Orofacial masks (general advantages)
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

34. Orofacial masks (cautions, disadvantages)
Claustrophobic
Hinder speaking and coughing
Risk of aspiration with emesis

35. Modes of BiPAP Spontaneous (S)
IPAP (inspiratory positive airway pressure)
EPAP (expiratory positive airway pressure)
Timed (T)
BPM (breaths per minute)
% IPAP Time
S/T
CPAP (continuous positive airway pressure)

36. Initial IPAP/EPAP settings
Start at 10 cm H2O/5 cm H2O
Pressures less than 8 cm H2O/4 cm H2O not advised as this may be inadequate
Initial adjustments to achieve tidal volume of 5-7 mL/kg

37. Subsequent adjustments based on arterial blood gas values
Increase IPAP by 2 cm H2O if persistent hypercapnia
Increase IPAP and EPAP by 2 cm H2O if persistent hypoxemia
Maximal IPAP limited to cm H2O (avoids gastric distension, improves patient comfort)
Maximal EPAP limited to cm H2O
FIO2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value
Back up respiratory rate breaths/minute

38. Predictors of success – Response to trial of NIV (1-2h)
Decrease in PaCO2 greater than 8 mm Hg
Improvement in pH greater than 0.06
Correction of respiratory acidosis

39. Predictors of failure Severity of illness Acidosis (pH <7.25)
Hypercapnia (>80 and pH <7.25)
APACHE II score higher than 20
Level of consciousness
Stuporous, arousal only after vigorous stimulation; inconsistently follows commands
Major confusion, daytime sleepiness or agitation
Glasgow Coma Scale score lower than 8
Failure of improvement with hours of noninvasive ventilation

40. Intubation guidelines
Any 1 of the following:
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 > 35 breaths/minute or < 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

41. Complications of noninvasive ventilation
Facial and nasal pressure injury and sores
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
Cover vulnerable areas (erythematous points of contact) with protective dressings
Gastric distension
Avoid by limiting peak inspiratory pressures to less than 25 cm H2O
Nasogastric tubes can be placed but can worsen leaks from the mask
Nasogastric tube also bypasses the lower esophageal sphincter and permits reflux

42. Complications of noninvasive ventilation
Dry mucous membranes and thick secretions
Seen in patients with extended use of noninvasive ventilation
Provide humidification for noninvasive ventilation devices
Provide daily oral care
Aspiration of gastric contents
Especially if emesis during noninvasive ventilation
Avoid noninvasive ventilation in patient with ongoing emesis or hematemesis

43. Complications avoided by noninvasive ventilation
Ventilator-associated pneumonia
Sinusitis
Reduction in need for sedative agents

44. Cost-analysis of noninvasive ventilation
Demonstrated to be cost-effective in patient management – Even greater cost savings if patients managed in a ward setting
Avoids costs of endotracheal intubation and mechanical ventilation
Shorter ICU and hospital stays
Eliminates costs associated with infectious complications – Episodes of ventilator-associated pneumonia reduced by half or more

46. Noninvasive Ventilation in COPD
COPD is the most suitable condition for noninvasive ventilation.
Noninvasive ventilation is most effective in patients with moderate-to-severe disease
Hypercapnic respiratory acidosis may define the best responders (pH ).  
Noninvasive ventilation is also effective in patients with a pH of , but no added benefit is appreciated if the pH is greater than 7.35.
The lowest threshold of effectiveness is unknown, but success has been achieved with pH values as low as 7.10.
Obtunded COPD patients can be treated, but the success rate is lower.
Improvement after a 1- to 2-hour trial may predict success.

47. Lightowler JV. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of COPD: Cochrane systematic review and meta-analysis. BMJ 2003;326:185.
The eight studies included in the review showed that, compared with usual care alone, NPPV as an adjunct to usual care was associated with a lower mortality (relative risk 0.41), a lower need for intubation (relative risk 0.42), lower likelihood of treatment failure (relative risk 0.51), and greater improvements at 1 hour in pH (weighted mean difference 0.03), PaCO2 (weighted mean difference −0.40 kPa), and respiratory rate (weighted mean difference −3.08 breaths per minute). NPPV resulted in fewer complications associated with treatment (relative risk 0.32) and shorter duration of stay in hospital (weighted mean difference −3.24 days).
Conclusion: NPPV should be the first line intervention in addition to usual medical care to manage respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease in all suitable patients.

48. Noninvasive Ventilation After Extubation
Noninvasive ventilation is effective as a bridge support after early extubation.
Noninvasive ventilation is an adjunct to weaning (substitutes noninvasive support for invasive support).
Patients with underlying COPD are most likely to benefit from noninvasive ventilation after early extubation.
Noninvasive ventilation is not as effective in patients with postextubation respiratory distress.
COPD patients are a subgroup who may benefit in that situation.

49. Burns KE. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ 2009;338:b1574.
We identified 12 trials enrolling 530 participants, mostly with chronic obstructive pulmonary disease. Compared with invasive weaning, non-invasive weaning was significantly associated with reduced mortality (relative risk 0.55, 95% confidence interval 0.38 to 0.79), ventilator associated pneumonia (0.29, 95% 0.19 to 0.45), length of stay in intensive care unit (weighted mean difference −6.27 days, −8.77 to −3.78) and hospital (−7.19 days, −10.80 to −3.58), total duration of ventilation, and duration of invasive ventilation. Non-invasive weaning had no effect on weaning failures or weaning time.
Conclusion: Current trials in critically ill adults show a consistent positive effect of non-invasive weaning on mortality and ventilator associated pneumonia.

50. Postoperative patients
Postoperative hypoxemia related to atelectasis or pulmonary edema
Occurrence following multiple types of surgery (eg, lung, cardiac, abdominal)
Randomized trials with postoperative continuous positive airway pressure (CPAP) demonstrate benefit
Applied as prophylactic support or with development of hypoxemia
Benefit noted with level CPAP levels in cm H2O range
Lower intubation rates, days in ICU, and pneumonia

51. Zarbock A. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 2009;135:
Following extubation, patients were allocated to standard treatment (control) including 10 min of intermittent nCPAP at 10 cm H2O every 4 h or prophylactic nCPAP (study) at an airway pressure of 10 cm H2O for at least 6 h. Results: Prophylactic nCPAP significantly improved arterial oxygenation. Pulmonary complications including hypoxemia, pneumonia, and reintubation rate were reduced in study patients compared to controls (12/232 patients vs 25/ 236 patients, p=0.03). The readmission rate to the ICU was significantly lower in nCPAP-treated patients (7/232 patients vs 14/236 patients, p=0.03). Conclusion: The administration of prophylactic nCPAP following cardiac surgery improved arterial oxygenation, reduced incidence of pulmonary complications including pneumonia and reintubation rate, and reduced readmission rate to the ICU.

52. Ferreyra GP. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg 2008;247:
We evaluated the potential benefit of continuous positive airway pressure (CPAP) to prevent postoperative pulmonary complications (PPCs), atelectasis, pneumonia, and intubation in patients undergoing major abdominal surgery. RESULTS: The meta-analysis was carried out over 9 randomized controlled trials. Overall, CPAP significantly reduced the risk of (1) PPCs (risk ratio, 0.66; 95% confidence interval [CI], ) with a corresponding NNTB of 14.2 (95% CI, ); (2) atelectasis (RR, 0.75; 95% CI, ; NNTB, 7.3; 95% CI, ); (3) pneumonia (RR, 0.33; 95% CI, ; NNTB, 18.3; 95% CI, ).
Conclusion: This systematic review suggests that CPAP decreases the risk of PPCs, atelectasis, and pneumonia and supports its clinical use in patients undergoing abdominal surgery.

53. Acute respiratory distress syndrome
Not recommended as first-line therapy in management
Limited experience, but may benefit those who do not require immediate intubation
Noninvasive ventilation provided via mask or helmet; able to avoid intubation in approximately half
Ventilator settings in successful noninvasive ventilation – Pressure support ventilation of 14 cm H2O; PEEP of 7 cm H2O
Successfully treated patients found to have lower severity of illness (Simplified Acute Physiology Score II <34 or improvement of PaO2/FIO2 >175 after 1 h)

54. Antonelli M. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007;35:18-25.
Prospective, multiple-center cohort study. Between March 2002 and April 2004, 479 patients with ARDS were admitted to the intensive care units. 332 ARDS patients were already intubated, so 147 were eligible for the study. Results: NPPV improved gas exchange and avoided intubation in 79 patients (54%). Avoidance of intubation was associated with less ventilator-associated pneumonia (2% vs. 20%; p < .001) and a lower intensive care unit mortality rate (6% vs. 53%; p < .001). Intubation was more likely in patients who were older (p = .02), had a higher SAPS II (p < .001), or needed a higher level of PEEP (p = .03) and pressure support ventilation (p = .02). Only SAPS II >34 and a Pao2/Fio2 < or =175 after 1 hr of NPPV were independently associated with NPPV failure and need for endotracheal intubation.
Conclusion: In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients.

55. Journal of Respiratory Therapy 2009;8(2):13-25
住院之慢性阻塞性肺疾病患
使用非侵性正壓呼吸器之成效
林碧華 陳寶貝 李俊德
高雄榮民總醫院 呼吸治療科
Journal of Respiratory Therapy 2009;8(2):13-25

56. 結果
符合研究條件的患者共有82 人次，平均年齡為76±12 歲，成功者脫離NPPV有62人次(75.6%)、失敗插回氣管內管使用呼吸器者有15 人次 (18.3%)、病危自動出院或院內死亡者有5 人 (6.1%)。

57. 三種不同使用因素(呼吸性酸血症、拔管脫離呼吸器或濱臨呼吸衰竭卻拒絕插管)皆不影響成功率，但拒絕插管者其院內死亡率較高，拔管脫離呼吸器後使用NPPV患者其住院天數偏高。

58. 不同嚴重度呼吸性酸血症(PH>7. 35組、PH≤7. 35至PH≥7. 3組及PH<7
不同嚴重度呼吸性酸血症(PH>7.35組、PH≤7.35至PH≥7.3組及PH<7.3組)使用NPPV 治療後其插氣管內管率及院內死亡率均無統計意義。

59. PS: 組間相較，*,表示和使用前相較P<0.05，
,表示和NPPV治療二天內相較P<0.05，
#,表示和結束時相較P<0.05。
二組經治療前、後及結束之交互作用P值為0.002。

60. PS: 組間相較，*,表示和使用前相較P<0.05，
,表示和NPPV治療二天內相較P<0.05，
#,表示和結束時相較P<0.05。
二組經治療前、後及結束之交互作用P值為0.019。

61. 結論
NPPV對COPD的患者而言，可應用於不同嚴重度的呼吸性酸血症、拔管脫離呼吸器或拒絕插氣管內管等患者，可以成功的逆轉呼吸衰竭且減少患者因插氣管內管使用侵襲性呼吸器而帶來一連串的合併症。患者無法自行清除痰液會影響治療成敗，此外使用NPPV治療時其呼吸、心跳、GCS、ABG的反應值對治療成敗具有影響性，因此醫護人員必須謹慎評估患者的變化，務必使患者在第一時間得到最佳的治療與照護。