Non-Invasive Positive Pressure Ventilation (NiPPV)

Non-Invasive Positive Pressure Ventilation (NiPPV)

 • CPAP (continuous positive airway pressure): provides PEEP, which prevents upper airway collapse (e.g. OSA) and lower airway collapse (e.g. atelectasis) while raising intrathoracic pressure and decreasing venous return (e.g. helpful in cardiogenic pulmonary edema). In CHF, ↓ intubation, ↓ mortality 

 • BiPAP (bi-level positive airway pressures): Provides both inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP = PEEP). In COPD, ↓ mortality, ↓ intubation, ↓ length of stay. IPAP decreases respiratory fatigue, especially in obstructive lung disease and neuromuscular disease.

Strong Indications for NIPPV:

 • Cardiogenic pulmonary edema (CPAP)

 • COPD exacerbation with acute resp acidosis (BiPAP)

 • Ppx against extubation failure in high risk pts (“Extubate to CPAP or BPAP”)

 • Respiratory failure in immunocompromised pts

Weak Indications for NIPPV:

 • Hypoxemic respiratory failure (other than CHF/COPD)

 • Patient is DNI with indication for intubation

 • Palliation for increased WOB, dyspnea

 • Asthma exacerbation with acute resp acidosis (poor data in adults)

Contraindications for NIPPV:

 • Risk of Delay: Emergent indication for intubation, acute life-threatening non-respiratory organ failure

 • Risk of Aspiration: Cannot clear secretions, AMS if pt cannot remove mask (exception: AMS due to hypercarbia)

 • Risk of Injury: Pneumothorax (can induce tension physiology), recent esophageal anastomosis or tear, patient cannot tolerate decreased preload (↓venous return), facial trauma or recent facial surgery

 • Will Not Work: Patient cannot initiate breath, anatomic deformity or facial hair interrupting seal

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