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non-invasive positive pressure ventilation (NPPV)

Indications: - respiratory failure due to a) COPD exacerbation b) heart failure - cardiogenic pulmonary edema - may decrease mortality [1] c) obesity hypoventilation syndrome d) neuromuscular disease e) immunosuppression - non-invasive ventilation is associated with lower mortality & length of ICU stay in immunocompromised patients [1] f) postoperative hypoxemia [9] - step down from mechanical ventilation (immediately following endotracheal extubation) in patient who tolerated a weaning trial Contraindications: 1) medical instability a) cardiopulmonary arrest b) severe respiratory acidosis (pH < 7.0 or < 7.25 with failure to improve within 1.2 hours) [1] c) hemodynamic instability d) cardiogenic shock e) life-threatening cardiac arrhythmia f) upper gastrointestinal bleeding 2) unable to protect airway a) excessive secretions, inability to clear secretions b) severe bulbar dysfunction c) recent gastrointestinal surgery d) altered mental status - excessive somnolence or encephalopathy 3) uncooperative or agitated patient 4) airway obstruction a) burns b) extreme obesity 5) unable to fit mask or large air leak a) recent facial trauma or surgery b) facial deformity [1] 6) NPPV does not prevent re-intubation - not for use as step down in patients who fail a weaning trial Benefit/risk: - acute pulmonary edema [4] - number needed to treat (NNT) = 13 to save 1 life - number needed to treat (NNT) = 8 to prevent 1 endotracheal intubation [4] - no harms identified [4] - COPD exacerbation [5] - number needed to treat (NNT) = 8 to save 1 life - number needed to treat (NNT) = 5 to prevent 1 endotracheal intubation [5] - no harms identified [5] Procedure: - high-pressure NPPV may result in the need for fewer intubations than standard low-pressure NPPV in patients with COPD exacerbation [15] - no weaning necessary [10) - 3 additional nights of NPPV did not benefit patients with COPD exacerbation who met clinical criteria for unassisted breathing [10] Complications: - may worsen outcomes by excessively delaying, rather than preventing endotracheal intubation - failure to respond to NPPV with 1-2 hours is an indication for endotracheal intubation [1] - positive pressure may diminish venous return - bedside ultrasound to assess vena cava dimensions predicts responsiveness to volume replacement eliminating need for pulmonary artery catheter [1] - not an aerosol-generating procedure [14] Notes: - provides ventilatory support in addition to continuous positive airway pressure - NPPV is time intensive & requires trained personnel [1] - helmet noninvasive ventilation confers lower risks for mortality & endotracheal intubation than Venturi mask noninvasive ventilation [12] - Venturi mask noninvasive ventilation confers lower risks for mortality & endotracheal intubation than high-flow nasal oxygen or standard nasal oxygen [12]

Related

mechanical ventilation (assisted ventilation)

Specific

adaptive servo-ventilation (ASV) auto-adjusting positive airway pressure (APAP) bilevel positive airway pressure (BiPAP) continuous positive airway pressure (CPAP) intermittent positive pressure breathing (IPPB)

General

non-invasive ventilation

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2015 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Khilnani GC, Banga A. Noninvasive ventilation in patients with chronic obstructive airway disease. Int J Chron Obstruct Pulmon Dis. 2008;3(3):351-7. PMID: 18990962
  3. Journal Watch 24(14):115, 2004 Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D'Empaire G, Alia I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 10;350(24):2452-60. PMID: 15190137
  4. The NNT: Non-Invasive Positive Pressure Ventilation for Acute Pulmonary Edema. http://www.thennt.com/nnt/non-invasive-positive-pressure-ventilation-for-pulmonary-edema/ - Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013 May 31;5:CD005351 PMID: 23728654 - Masip J, Roque M, Sanchez B et al Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005 Dec 28;294(24):3124-30. PMID: 16380593
  5. The NNT: Non-Invasive Positive Pressure Ventilation for COPD Exacerbation http://www.thennt.com/nnt/non-invasive-ventilation-for-copd-exacerbation/ - Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004;(3):CD004104 PMID: 15266518
  6. Keenan SP, Sinuff T, Burns KE et al Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011 Feb 22;183(3):E195-214. PMID: 21324867 Free PMC Article
  7. Berg KM, Clardy P, Donnino MW. Noninvasive ventilation for acute respiratory failure: a review of the literature and current guidelines. Intern Emerg Med. 2012 Dec;7(6):539-45. Review. PMID: 23054404
  8. Carrillo A, Ferrer M, Gonzalez-Diaz G et al Noninvasive ventilation in acute hypercapnic respiratory failure caused by obesity hypoventilation syndrome and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1279-85. PMID: 23103736
  9. Jaber S et al. Effect of noninvasive ventilation on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: A randomized clinical trial. JAMA 2016 Mar 15; PMID: 26975890
  10. Sellares J, Ferrer M, Anton A et al. Discontinuing noninvasive ventilation in severe chronic obstructive pulmonary disease exacerbations: A randomised controlled trial. Eur Respir J 2017 Jul 05; 50:1601448 PMID: 28679605
  11. Gregoretti C, Pisani L, Cortegiani A, Ranieri VM. Noninvasive ventilation in critically ill patients. Crit Care Clin. 2015 Jul;31(3):435-57. Review. PMID: 26118914
  12. Ferreyro BL, Angriman F, Munshi L et al Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory Failure. A Systematic Review and Meta-analysis. JAMA. Published online June 4, 2020 PMID: 32336293 Free PMC article. https://jamanetwork.com/journals/jama/fullarticle/2767025
  13. Munshi L Mancebo J, Brochard LJ. Noninvasive Respiratory Support for Adults with Acute Respiratory Failure. N Engl J Med 2022; 387:1688-1698 PMID: 36322846 https://www.nejm.org/doi/full/10.1056/NEJMra2204556
  14. Zhang MX, Lilien TA, van Etten-Jamaludin FS et al Generation of Aerosols by Noninvasive Respiratory Support Modalities. A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(10):e2337258 PMID: 37819660 PMCID: PMC10568354 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810485
  15. Luo Z et al. Effect of high-intensity vs low-intensity noninvasive positive pressure ventilation on the need for endotracheal intubation in patients with an acute exacerbation of chronic obstructive pulmonary disease: The HAPPEN randomized clinical trial. JAMA 2024 Sep 16; [e-pub] PMID: 39283649 https://jamanetwork.com/journals/jama/fullarticle/2823763