From the Guidelines
Non-Invasive Ventilation (NIV) is a crucial breathing support method that delivers air or oxygen through a mask, commonly used for patients with respiratory failure who need ventilatory assistance but don't require full mechanical ventilation. According to the official ERS/ATS clinical practice guidelines published in the European Respiratory Journal in 2017 1, NIV includes noninvasive variable positive airway pressure devices, such as bilevel devices, and continuous positive airway pressure (CPAP) delivered using various nasal, oronasal, and facial interfaces. The two main types of NIV are CPAP, which delivers constant pressure to keep airways open, and BiPAP, which provides two pressure levels—higher during inhalation and lower during exhalation.
Key Applications of NIV
- COPD exacerbations
- Acute cardiogenic pulmonary edema
- Sleep apnea
- As a bridge for patients coming off mechanical ventilation
Initial Settings for BiPAP
Typical initial settings for BiPAP might include an inspiratory pressure (IPAP) of 8-12 cmH2O and expiratory pressure (EPAP) of 3-5 cmH2O, adjusted based on patient response, as suggested by the guidelines 1. NIV works by reducing the work of breathing, improving gas exchange, and decreasing respiratory muscle fatigue.
Advantages of NIV
- Avoids complications associated with intubation
- Allows patients to eat, speak, and cough
- Can be intermittently applied However, NIV requires patient cooperation and a proper mask fit to be effective, highlighting the need for careful patient selection and monitoring, as emphasized in the guidelines 1.
From the Research
Definition and Purpose of NIV
- Non-invasive ventilation (NIV) is a positive pressure ventilation method employed across various disease processes, utilizing noninvasive interfaces such as helmets and facemasks rather than invasive methods such as endotracheal intubation 2.
- The benefits of NIV are significant in both the acute care setting, such as improving work of breathing and avoiding the need for endotracheal intubation, as well as in the chronic care setting, improving quality of life and mortality 2.
Indications for NIV
- Severe acute exacerbation of chronic obstructive pulmonary disease (COPD) and acute cardiogenic pulmonary edema are the most common NIV indications; in these conditions NIV advantages are clearly documented 3.
- NIV is also beneficial in respiratory failure in immunocompromised patients or chest trauma patients 3.
- Use of NIV in acute hypercapnic respiratory failure due to exacerbation of COPD has been shown to decrease the risk of mortality and need for endotracheal intubation 4.
Modalities of NIV
- Commonly used modalities for treatment of respiratory failure include: CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) or NIPSV (noninvasive pressure support ventilation) 5.
- Newer methods, such as adaptive servo-ventilation, have been developed to treat central and complex sleep apnea and the NAVA (neutrally adjusted ventilatory assist) to improve the trigger and cycle asynchrony 5.
- High-flow nasal cannula is a non-invasive technique that does not provide respiratory support, but provides a mixture of oxygen to the patient 5.
Clinical Practice Guidelines
- The German Society of Pneumology and Ventilatory Medicine recommends NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications 6.
- NIV has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality 6.
- Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions 6.