HWN Suggests

NIPPV for CHF Works, ACLS Algorithms Do Not

NIPPV for CHF appears to save lives, though the data only includes roughly 1000 subjects from both ICUs and EDs. Noninvasive positive pressure ventilation (NIPPV) has been theorized to offer the advantages of respiratory assistance and improved gas exchange without the disadvantages associated with sedation, paralysis, and endotracheal intubation. This Cochrane Review includes 21 trials (n = 1071) in both the ICU and emergency department settings. Some compared bilevel positive airway pressure (BIPAP) devices, or continuous devices (CPAP) to standard therapy, while others compared the two. There was no advantage to one over the other. Exclusion criteria were consistent across studies, and…

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 Critical Care Device Series: Noninvasive Positive Pressure Ventilation

During a normal breath cycle, a person’s diaphragm is pulled downwards to allow for lung expansion. This causes a decrease in intrathoracic pressure, allowing air to fill the lungs. When a patient is in respiratory failure, NPPV increases mean airway pressure, relieves dynamic hyperinflation, improves work of breathing, and in certain patient populations, decreases need for invasive mechanical ventilation and mortality. Additionally, NPPV decreases left and right ventricular preload and left ventricular afterload, making it an ideal therapy for cardiogenic pulmonary edema causing respiratory failure. Ultimately, the role of noninvasive support is to help reduce the patient’s work of breathing to avoid exhaustion from overworking the diaphragm as well as to improve oxygenation and ventilation. Appropriate patient selection is critical, as inappropriate use of NPPV may delay time to intubation and worsen patient outcomes.

Articles of Interest

Non-Invasive Positive Pressure Ventilation in the ED

NPPV can decrease work of breathing, improve oxygenation, improve alveolar ventilation, and counteract auto-PEEP. All of these can and should be monitored at the bedside as the pressure requirements to achieve these goals will differ with each patient depending on the mechanics of their respiratory system and the severity of their disease.

Choosing Wisely: Non-invasive ventilation in patients with acute respiratory failure from pneumonia

Non-invasive positive pressure ventilation (NiPPV) is increasingly being used in ED patients with respiratory failure of all types, including pneumonia. Frequently, pneumonia can be managed with appropriate antibiotics and supportive care, but some patients progress to respiratory failure. The best non-invasive respiratory support for hypoxemic respiratory failure from pneumonia is controversial, but data suggest it may notalways be NiPPV, i.e. BiPAP™ or CPAP.

Non-Invasive Positive Pressure Ventilation for Pre-Hospital Respiratory Distress

Non-invasive positive pressure ventilation is a reasonable out of hospital treatment option for adult patients with undifferentiated severe respiratory distress.

Non-invasive positive pressure ventilation with average volume assured pressure support may benefit patients with acute hypercapnic respiratory failure

The advent of NIPPV has had a dramatic impact on the management and outcomes of patients presenting to the hospital with acute COPD and congestive heart failure exacerbations. While the use of traditional BPAP settings should be applied to the broadest swathe of such patients, BPAP with AVAPS may more rapidly reverse pure hypercapnic encephalopathy.

Non-Invasive Ventilation – Understanding the Physiology

Our two most common patient populations that benefit the most from NIPPV are: COPD (Chronic Obstructive Pulmonary Disease) and decompensated heart failure. In COPD, NIPPV can help alleviate work of breathing and improve oxygenation and ventilation. Decompensated heart failure patients, on the other hand, characterized by fluid accumulation on the lungs, leading to respiratory distress. NIPPV can help remove excess fluid by reducing after load and increasing positive end respiratory pressure (PEEP) to stent alveoli open.

Noninvasive positive pressure ventilation in the acute care setting: where are we?

Strong evidence supports the use of NPPV for ARF to prevent endotracheal intubation (ETI), as well as to facilitate extubation in patients with acute exacerbations of chronic obstructive pulmonary disease and to avoid ETI in acute cardiogenic pulmonary oedema, and in immunocompromised patients.

Noninvasive Positive Pressure Ventilation In the Emergency Department

NIPPV has been shown, in specific disease processes, to decrease intubation rates, as well as mortality and various indicators of morbidity. The evidence for usage in COPD, congestive heart failure, asthma, and respiratory failure in the immunocompromised patient is very compelling, and noninvasive positive pressure has become standard therapy. Support for NIPPV in other disease processes is also growing as the evidence continues to mount.

Noninvasive positive-pressure ventilation: Who and when

Best uses include acute hypercarbic respiratory failure in patients with chronic obstructive pulmonary disease (COPD), and acute cardiogenic pulmonary edema.

Positively Useful: A Brief ED Guide to NIPPV

NIPPV is a broad term used to describe several methods of ventilation management. It often refers to positive pressure delivered by air-tight facial or nasal mask. Two common modes are continuous positive airway pressure (CPAP) and BiPAP.1 CPAP provides a constant positive pressure on inspiration and expiration. BiPAP provides a baseline pressure, as well as a second, elevated inspiratory pressure triggered by the patient's inspiratory effort. The lower pressure delivered on expiration is referred to as expiratory positive airway pressure (EPAP) and is analogous to positive end-expiratory pressure (PEEP) delivered by a traditional ventilator.

Vapotherm Shows Noninferiority to NIPPV for Undifferentiated Respiratory Distress in the Emergency Department

The results of the prospective, multi-center randomized controlled trial were published by Doshi and colleagues in January 2018 in Annals of Emergency Medicine titled High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. The trial found no difference between the therapies in intubation rates or treatment failure rates. The authors conclude that Vapotherm High Velocity Nasal Insufflation is noninferior to NIPPV for the treatment of adult patients experiencing undifferentiated respiratory failure in the Emergency Department.