1. Indications for starting Noninvasive Ventilation (NIV)
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Acute exacerbation of COPD (pH<7.35, PaCO 2 >45 mmHg). |
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Acute hypoxemic Respiratory Failure. |
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Acute Respiratory failure due to chest wall deformity/ neuromuscular disease/ immune-compromised patient. |
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Acute cardiogenic pulmonary edema. |
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Dyspnea in palliative care or Do Not Intubate scenario. |
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Weaning of high-risk patient. |
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Post bariatric surgery patients with pre-existing Obstructive Sleep Apnea or Obesity. |
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Prevention use after planned extubation. |
2. Contraindications for NIV
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Uncooperative or extremely anxious patient. |
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Reduced conscious and inability to protect their airway. |
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Unstable cardiorespiratory status or respiratory arrest. |
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Trauma or burns involving the face. |
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Air leak syndrome (Pneumothorax with bronco-pleural fistula). |
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Severe vomiting or Acute intestinal obstruction. |
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Fixed upper airway obstruction. |
3. Setting up the NIV
3.1. Patient selection and Prerequisites
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Patient should be conscious and cooperative. |
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Patient should be able to control his airway and secretions. |
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Patient should have adequate cough reflex. |
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Patient should be hemodynamically stable. |
3.2. Interfaces
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Appropriate size Vented or Non-Vented Mask along with its straps (choose Vented mask for single limb circuit +/-Exhalation valve and non-vented mask for dual limb circuit). |
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Interfaces can be as Oro-Nasal mask, Nasal mask, Total Face Mask, Helmet device. |
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Adequate size and length ventilator circuit (2 limb), BiPAP (1 limb), HME device. |
3.3. Method of putting on the mask
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Introduce yourself with the patient. |
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Keep the patient on upright sitting position. |
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Explain the patient its discomfort but give emphasis on its importance to treatment of their disease. |
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Choose appropriate size mask, its type and mode of ventilation. |
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Attach the interface and circuit to ventilation required with power source ON and backup battery life. |
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Apply mask gently to the face at a low pressure to start. |
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Position the mask near the patient’s face so that the patient can feel the air blowing into the face without the mask touching the face. |
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Then hold part of the mask to their face and give the patient time to adjust. |
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When ready, bring the mask near the face letting the patient get use to the pressure. |
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When adjusted, tighten the straps properly to ensure a proper fit (you can use cotton behind straps to prevent pressure sores). |
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Check for leaks and adjust the straps as necessary for good seal (minimal leaks). |
3.4. Select mode
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CPAP – start with 5-8 cm H2O (can increase to 10-15 cm H2O). |
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BiPAP- IPAP: Start with 10 cm H2O (Increase by 2-5 cm H2O every 10 min till you reach therapeutic response or Pressure target < 20 cm H2O or patient tolerability has been reached). Set Inspiratory trigger = 2. |
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BiPAP- EPAP: Start with 4-5 cm H2O and increase for desired effect but keep IPAP at least 5cm H2O above EPAP). Set Expiratory trigger =2 with Rise time =1. |
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For portable machine, select S or ST mode. |
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Give supplemental Oxygen titrating FiO 2 to achieve SpO 2 around 88-92%. |
3.5. Monitor
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GCS, cooperation to the treatment and leaks. |
ECG, HR, BP, SpO2, ETCO 2 |
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Respiratory rate, pattern and effort |
ABG at 1, 4 Hrs. and as required. |
4. Suspect NIV Failure if
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No improvement in acidosis. |
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Worsening hypoxia. |
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No reduction in CO 2 level. |
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Patient not tolerating or refusal. |
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Hemodynamic instability. |
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Inability to clear secretions. |
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Worsening agitation /encephalopathy. |
In the above condition change to invasive ventilation.
5. Weaning criteria of Non-Invasive ventilation
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Arterial pH >7.35 |
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SpO2> 90 % with FiO2<35%. |
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Respiratory rate at rest ≤ 25/min. |
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Heart rate ≤ 120/ min. |
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Systolic blood pressure > 90 mmHg. |
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No agitation, diaphoresis, anxiety or signs of respiratory distress. |
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Awake and alert. |
6. Nursing care of the patients who are on NIV ventilation
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Oral hygiene should be maintained every four hourly as long as the patient tolerance to cessation of NIV. |
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Oral suctioning for the clearance of secretion as needed. |
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Eye care to be attended routinely so that the patients must not experience any irritation. |
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Patient are more vulnerable to pressure injury via tightened mask so routine observation should be done focusing on preventive measures and care too. |
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Patient should be encouraged to positioned in an upright position to facilitate chest wall expansion. |
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Oral feeding is to be initiated if the patient is able to tolerate small periods off NIV. |
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Nasogastric tube feeding should be started if the patient develops the risk of aspiration and after feeding via NG tube make sure off NIV for 15 min to prevent any regurgitation. |
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Documentation of monitoring, plan and events should be done. |
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Look for Complications ● Pressure injury/ulceration of face, nose or above ears. ● Conjunctival irritation. ● Dry mouth and irritation. ● Nasal congestion and thick secretion. ● Aspiration pneumonia. ● Gastric distention and bloating. ● Pneumothorax. ● Hemodynamic compromises. ● Claustrophobia. |
Further Readings:
1. Chawla, R., Dixit, S. B., Zirpe, K. G., Chaudhry, D., Khilnani, G. C., Mehta, Y., & Kulkarni, A. P. (2020). ISCCM guidelines for the use of non-invasive ventilation in acute respiratory failure in adult ICUs. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 24(Suppl 1), S61.
2. Elliott, M. W., Confalonieri, M., & Nava, S. (2002). Where to perform noninvasive ventilation?. European Respiratory Journal, 19(6), 1159-1166.
3. Caples, S. M., & Gay, P. C. (2005). Noninvasive positive pressure ventilation in the intensive care unit: a concise review. Critical care medicine, 33(11), 2651-2658.
4. Moga, A. M. (2011). Acute effect of noninvasive ventilatory support on maximum exercise capacity in patients with Chronic Obstructive Pulmonary Disease (COPD): A pilot study. McGill University (Canada).
5. Royal College of Physicians, British Thoracic Society, Intensive Care Society. (2008). Chronic obstructive pulmonary disease: non‐invasive ventilation with bi‐phasic positive airways pressure in management of patients with acute type 2 respiratory failure. Concise Guidance to Good Practice series, No 11.
