1. 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

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

3. 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

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

5. Endotracheal Tube Complications
4/21/2017
Endotracheal Tube Complications

6. 4/21/2017

7. 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
: > 1,500 papers and 14 meta-analyses
Chest 1996;109:

8. 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

9. 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

10. 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

11. 4/21/2017
Reduction in VAP
Respiratory Care 2004; 49:

12. 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

13. 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

14. 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:

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

16. 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

17. 4/21/2017
Newer masks

18. 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)