Positive Pressure Ventilation in Acute Respiratory Failure 4/21/2017 Use of Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Mehrdad Ghaffari M.D Pulmonary/critical care/Sleep medicine The University of Tennessee Health Science Center Memphis

European Respiratory Monograph 2001; pages106-124. 4/21/2017 European Respiratory Monograph 2001; pages106-124.

Aims of Positive Pressure Ventilation 4/21/2017 Aims of Positive Pressure Ventilation To improve the pathophysiology of ARF To reduce the work of breathing To correct gas exchange abnormality To ameliorate dyspnea

Endotracheal Intubation 4/21/2017 Endotracheal Intubation Invasive procedure Potential complications Discomfort Confines the use of PPV to severe ARF

Endotracheal Tube Complications 4/21/2017 Endotracheal Tube Complications

4/21/2017

Endotracheal Tube vs Mask 4/21/2017 Endotracheal Tube vs Mask Since 1989 there has been a rapid increase in both published and clinical use of an alternative interface 1997-2007: > 1,500 papers and 14 meta-analyses Chest 1996;109: 179-93

Endotracheal Tube vs Mask Complimentary role 4/21/2017 Endotracheal Tube vs Mask Complimentary role Mask Early ARF Mask Resolving ARF ET Respiratory failure Evolving ARF Resolving ARF

Evidence for NPPV in ARF 4/21/2017 Evidence for NPPV in ARF Strong evidence COPD exacerbation Acute cardiogenic pulmonary edema Immunocompromised patients Facilitate weaning in COPD patients Less strong evidence Asthma Cystic fibrosis Postoperative respiratory failure Avoidance of extubation failure Do-not-intubate patients Weak evidence Upper airway obstruction ARDS Trauma OSA, obesity, hypoventilation

Advantages of NPPV in ARF 4/21/2017 Advantages of NPPV in ARF Flexibility in initiating and removing MV Avoids ETI-associated complications Decreases the need for invasive monitoring Preserves airway defense mechanisms Preserves speech and swallowing Improves patient comfort Decreases sedation requirements

4/21/2017 Reduction in VAP Respiratory Care 2004; 49: 810-829.

Outline  Patient Selection  Ventilator Settings 4/21/2017 Outline  Patient Selection  Ventilator Settings  Interface  Adjustments for air leak  Modes of ventilation  Communication  Initial setup  Monitoring  Comfort  Criteria to discontinue NPPV

Patient Selection Alert and cooperative 4/21/2017 Patient Selection Alert and cooperative  COPD and CO2 narcosis  Anxious patients may improve with NPPV Absence of contraindications (next slide) Managed only by experienced personnel Morbidly obese Acute myocardial infarction

Contraindications Hypoxemia refractory to 100% FiO2 by NRM 4/21/2017 Contraindications Cardiac or respiratory arrest Hypoxemia refractory to 100% FiO2 by NRM Nonrespiratory organ failure Severe encephalopathy (e.g, GS < 10) Severe upper gastrointestinal bleeding Hemodynamic instability or unstable cardiac arrhythmia Facial surgery, trauma, or deformity Upper airway obstruction, excluding vocal cords edema Inability to cooperate/protect the airway Inability to clear copious amount of secretions High risk for aspiration Am J Respir Crit Care Med 2001; 163:283-291.

Interface: Nasal vs. Facial Mask 4/21/2017 Interface: Nasal vs. Facial Mask Hess D. Respiratory Care 2004; 49: 810

Interface: Facial Masks 4/21/2017 Interface: Facial Masks Type of seals contoured cushion bladder cushion foam cushion double spring Positions of prongs central peripheral

4/21/2017 Newer masks

Italian perspectives: Helmet 4/21/2017 Italian perspectives: Helmet A B C D E Latex-free transparent PVC Secured by 2 arm = pit braces (A) at two hooks (B) of the metallic ring (C) joining helmet with a soft collar (D) A seal connection (E) allows the passage of NGT Courtesy of Dr Massimo Antonelli (Rome)