Documente Academic
Documente Profesional
Documente Cultură
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura faculty of medicine
Non-invasive ventilation
• Non-invasive ventilation refers to the application of
ventilatory assistance without the use of an invasive
airway.
• In the vast majority of cases therapy will be delivered
with positive pressure devices , although a few
individuals still use negative pressure devices.
• Negative pressure devices present a number of
difficulties with regard to home ventilation including
bulkiness, fit ,comfort, they can induce significant
upper airway obstruction , rendering therapy
ineffective.
Non-invasive ventilation
• Positive pressure therapy may be delivered with
either volume or pressure preset ventilators .
1-Volume preset ventilation delivers a stable tidal
volume irrespective of the patient’s pulmonary
system mechanics (compliance, resistance and
active inspiration) .
2- Pressure preset ventilation delivers a set
pressure during inspiration and expiration, and
changes in the patient’s pulmonary mechanics
directly influence the flow and the delivered tidal
volume .
What is a mode
• A mode of mechanical ventilation has three essential
components :
1- The control variable (the mechanical breath goal e.g. a set
pressure or a set volume )
2- The breath sequence
3- The target scheme
• Inspiration is an active process ,driven either by the patients
effort ,the ventilator or both .
• The machine can control only the volume (and flow) or the
pressure given.
• The breath can be described on the basis of what triggers the
breath what limits it (the maximum value of a control
variable)and what ends (cycles ) it.
Modes of ventilation
• Volume controlled breath is triggered by the patients or
by the machine , limited by flow and cycled by volume.
• Pressure controlled breath is triggered by the patients
or by the machine , limited by pressure and cycled by
flow or time.
The breath sequence
1- Control mode (timed) : all breaths are controlled by the
machine (but can be triggered by the patient)
2- Assisted mode (spontaneous) :all breaths are
spontaneous .
3- Assisted /control (spontaneous/ timed): patient can take
spontaneous breaths between mandatory breaths .
The target scheme
• The ventilator settings and programming that
dictate its response to the patients lung
compliance ,lung resistance ,and respiratory
effort.
• The regulation can be
1-simple as controlling pressure in pressure
controlled mode or
2- can be based on a complicated algorithm as in
dual mode of ventilation ( AVAPS).
Non-invasive ventilation
• Most studies evaluating these two modes in patients with
chronic respiratory failure have shown equivalent effects
with respect to maintaining nocturnal gas exchange and
improving daytime blood gases.
• Due to lower cost and greater patient comfort , most
patients in the majority of centres are now prescribed
pressure preset devices, mostly commonly , bi-level
machines.
• Volume ventilators are recommended for patients with the
most severe respiratory failure including those with
tracheostomy and when continuous or near continuous
ventilatory support is needed.
• A switch from pressure to volume preset ventilation may
also be required in patients who are adherent to pressure
preset ventilation but who fail to respond to treatment .
Non-invasive ventilation
• Volume preset ventilators are usually set in an
assist/control or control mode of support.
• No difference in blood gas improvement, lung
function or compliance with therapy was seen
between the two modes.
• Pressure preset ventilators may be set in an assist
(“spontaneous”) mode where each breath is patient
triggered; an assist/control (“spontaneous /
timed”) mode where breaths may be patient or
machine triggered; and a control (“timed”) mode
where all breaths are machine triggered only .
Non-invasive ventilation
• The spontaneous mode has been used in patients able to
trigger the ventilator consistently, whereas the
spontaneous/timed mode is used when the ability of the
patient to trigger the device reliably is reduced due to poor
or absent inspiratory flows being generated (e.g.
respiratory muscle weakness, drive to breathe is reduced
or absent, or specific characteristics of the patient’s
pulmonary mechanics), where the goal of therapy is to
control the respiratory pattern .
• The pressure settings used in bilevel devices include the
inspiratory positive airway pressure (IPAP) and expiratory
positive airway pressure (EPAP), with the difference
between the two determining the level of pressure support
Bi-level Positive Airway Pressure
• Bi-level PAP (BiPAP) was developed in mid 1990's by
Respironics Corporation, trademarked 'BiPAP'.
• Since BiPAP is a trademark, other companies use
different terms, such as 'bilevel', VPAP (variable positive
airway pressure), and "duo."
• One internet ad shows 4 different bilevel machines from
4 different manufacturers; only Respironics' machine is
"BiPAP."
• Whereas CPAP sets a single pressure above the ambient
pressure, BiPAP sets two pressures above the ambient,
a higher (IPAP) and a lower (EPAP), e.g., 10/5 cm H2O .
Note that both pressures are always above ambient.
Pressure curve when BiPAP = 10/5 cm H2O; now the pressure is
higher on inspiration than on expiration, but both pressures are above
ambient.
NOTE: BiPAP is equivalent to PSV (pressure support ventilation) +
PEEP (positive end-expiratory pressure) in the intubated patient; in
that situation PEEP is the same as EPAP.
Bi-level Positive Airway Pressure
• Bi-level Positive Airway Pressure therapy with a variable
pressure setting would conceivably decrease the amount of
pressure against which the patient exhales, thereby decreasing
abdominal muscle recruitment and consequent respiratory
discomfort during the expiratory cycle
• During the inspiratory cycle, the greater level of pressure assist
would combat the inspiratory flow limitation suffered by the
upper airway . An additional benefit with bi-level PAP is the
greater tidal volume ( VT) and unloading of the respiratory
muscles, when compared to CPAP.
• The difference between the IPAP and EPAP could be
considered as pressure support level that could augment the
inspired VT. This feature can be exploited to combat “non-
obstructive” hypoventilation that may occur due to a host of
conditions.
Bi-level Positive Airway Pressure
• In adults, the maximum IPAP setting for bi-level PAP is not to exceed
30 cm H2O, and the minimum difference between IPAP and EPAP level
should not be < 4 cm H2O.
•A transition from CPAP to bilevel PAP is encouraged when the CPAP
level approaches 15 cm H2O. This is because exhalation against CPAP
levels approaching 15 cm H2O can be uncomfortable for most patients.
•Bi-level PAP therapy was not superior to conventional CPAP therapy
from an adherence standpoint.
•The cycling of the device from IPAP to the EPAP and vice-versa may
be triggered by the spontaneously breathing patient (spontaneous
mode) or by a set respiratory rate programmed into the device (timed
mode).
•The sensitivities or the triggering threshold for causing the device to
cycle in the spontaneous mode may be based on pressure, flow-
contour, hardwired timing, or a proprietary combination of such
measures.
Rise time , trigerring and cycling
Bi-Flex comfort feature
Ramp comfort feature
Bi-level Positive Airway Pressure
• Dys-synchronous cycling between the patient and the device can be
uncomfortable and could lead to hyperinflation and further dys-
synchrony.
• In some older devices the triggering sensitivities could be adjusted
by the physician, but in most modern bi-level PAP devices for home
use the technology has veered in favor of automation and higher
levels of sensitivity.
• The rate of pressurization from EPAP to IPAP level (the “rise time”)
can be adjusted to climb more briskly or more slowly. Such a feature
may need to be adjusted for individual patient comfort .
• Some reports suggest that a brisk response (or shorter rise time)
may have some inherent oscillatory behavior that may set the stage
for “emergent” central ,However, the effect of rise time on emergent
central apneas has not been demonstrated in clinical studies outside
of mathematical or bench models.
Autotitrating bilevel devices
• A recent innovation is that of autotitrating bilevel devices. The
algorithms of these machines are designed to automatically
titrate pressure support levels, and in some devices EPAP,
based on minute ventilation or flow targets.
• There is mounting evidence for the use of these devices in
managing sleep disordered breathing in patients with central
sleep apnea / Cheyne–Stokes respiration .
• There is currently a paucity of data and clinical experience with
the algorithms and technology to automatically titrate
ventilatory support in patients with chronic respiratory failure .
Consequently, it is not possible to make recommendations
about the role and effectiveness of autotitrating bilevel devices
for chronic respiratory failure at the present time
The administration of a backup rate (timed mode) during bi-
level PAP therapy may be considered under 2 circumstances.
1- The backup rate could be considered in patients with alveolar
hypoventilation, with or without chronic respiratory insufficiency
(elevated arterial PCO2 ) of various etiologies, which is primarily
aimed at increasing minute ventilation (VE) and resolving the
hypoventilation.
2- Another circumstance would be to treat central sleep apnea or
prevent the appearance of emergent central apneas in patients
undergoing PAP therapy for OSA.
• In both cases, the choice of the backup rate seems arbitrary and is
probably best guided by polysomnography resolution of central
apneas or persistent hypoxemia due to alveolar hypoventilation
(SpO2 < 88% in the absence of obstructive hypopneas or apneas as
an indirect measure of hypoventilation).
• In general, a backup rate set at 2 breaths below the patient’s
spontaneous rate during calm wakefulness breathing with titration
upwards at 2-breath increments can be considered.
Auto-bilevel positive airway pressure with a
minimum (EPAP) of 6 cm H2O and a maximum
(IPAP) of 25 cm H2O.
Principal Indications
• Non-acute setting:
1) When CPAP doesn't work for sleep apnea.
2) For patients with chronic CO2 retention who
also have sleep apnea ( OHS).
3) For patients with neuromuscular disease who
need some assistance with nocturnal
ventilation.
• Acute setting: Pulmonary edema or COPD
exacerbation, when there is CO2 retention and a
desire to avoid endotracheal intubation.
How is the pressure applied non-invasively?
• Same as with CPAP, but machine used is designed to deliver BiPAP.