Noninvasive Mechanical Ventilation - sepeap

Noninvasive Mechanical Ventilation
Rani Ganesan, MD, ⁎ Kim D. Watts, MD,y Steven Lestrud, MD ⁎ z
Patients with respiratory distress and respiratory failure presenting to the emergency
department provide a diagnostic and therapeutic challenge. Developing technologies in
noninvasive positive pressure ventilation (NIPPV) have improved the ability to administer
significant respiratory support to these patients. Research and protocols for NIPPV are
expanding in adult medicine but are only slowly increasing in pediatrics. NIPPV has
successfully been used for obstructive sleep apnea, asthma, cystic fibrosis, and
neuromuscular disorders in both acute and chronic settings. Early administration of this
support may benefit patients presenting to emergency departments by improving
oxygenation, ventilation, and muscle fatigue; avoiding short- and long-term complications
of invasive mechanical ventilation; and improving patient outcomes.
Clin Ped Emerg Med 8:139-144 C 2007 Published by Elsevier Inc.
KEYWORDS mechanical ventilation, continuous positive airway pressure, obstructive sleep
apnea, bimodal positive airway pressure
Respiratory distress and respiratory failure are common
life-threatening conditions presenting to the pediatric
emergency department (ED) requiring prompt recognition
of symptoms and concurrent management. As diagnostic
testing is initiated, different modes of support are used to
relieve symptoms. Modes of respiratory support range
from blow-by oxygen to mechanical ventilation via
endotracheal intubation. Symptoms of mild respiratory
insufficiency often respond to supplemental oxygen via
nasal cannula or simple face mask. More severe disease
may require positive pressure ventilation administered
through noninvasive modalities or endotracheal intubation.
Noninvasive positive pressure ventilation (NIPPV)
has been used in chronic and acute conditions in all age
groups. It provides respiratory support without the
complications commonly associated with endotracheal
⁎Critical Care Medicine, Children's Memorial Hospital, Northwestern
University Feinberg School of Medicine.
†Pulmonary Medicine, Children's Memorial Hospital, Northwestern
University Feinberg School of Medicine.
‡Pulmonary and Critical Care Medicine, Children's Memorial Hospital,
Northwestern University Feinberg School of Medicine.
Reprint requests and correspondence: S. Lestrud, MD, Pulmonary and
Critical Care Medicine, Children's Memorial Hospital, 2300
Children's Plaza, Box 73, Chicago, IL 60614.
(E-mail: slestrud@childrensmemorial.org)
intubation and ventilation while maintaining the physiologic
advantages of spontaneous respirations. We suggest
NIPPV should be considered early in the course of
management of respiratory distress and even in some
forms of respiratory failure.
History of Modalities
During the 1930s, Poulton [1] reported the first usage of
continuous positive airway pressure (CPAP) in patients
with pulmonary edema, asthma, and pneumonia [2]. The
investigators used a household vacuum, which provided a
high inspiratory flow through an airtight mask. An Ambu
valve close to the patient was used as an expiratory
pressure-relief valve [1,2]. Because of the use of intubation
during anesthesia in the 1930s, the use of CPAP was not
common. However, in the 1960s, CPAP was found to be
successful in the treatment of pediatric patients with
postcardiac and neonatal hyaline membrane disease [2-4].
Soon after, CPAP was being used in adult patients with
acute respiratory distress syndrome [5,6]. Today, CPAP is
used in all age groups in patients with chronic illnesses
such as obstructive sleep apnea (OSA) and chronic
obstructive pulmonary disease as well as acute illnesses
such as pneumonia and pulmonary edema.
In the 1980s, flow and pressure sensors were developed
to identify the commencement and cessation of a patient's
1522-8401/$ - see front matter C 2007 Published by Elsevier Inc. 139
doi:10.1016/j.cpem.2007.08.013

140 R. Ganesan et al.
respiratory efforts. Pressure support ventilation proved to
be beneficial in invasive mechanical ventilation by Kacmarek
[7]. These technological advances were then applied
to noninvasive mechanical ventilation modalities. The use
of flow-triggered inspiratory support with continuous
positive airway pressure has proven beneficial.
More recently, bimodal positive airway pressure (BiPAP)
provides inspiratory positive airway pressure (IPAP) and
expiratory positive airway pressure (EPAP). This mode of
ventilation is similar to the combination of CPAP and
pressure support ventilation. IPAP delivers positive pressure
during the inspiratory phase of the respiratory cycle.
EPAP delivers end-expiratory positive pressure during the
expiratory phase. This differs from CPAP, as CPAP provides
end expiratory positive pressure during the entire respiratory
cycle.
Modern-day CPAP/BiPAP machines (Respironics Inc,
Murrysville, PA) are electrically controlled, pneumatically
powered, low-pressure ventilators [8]. These machines are
designed to augment the patient's respiratory effort. Flow
transducers in the patient's circuit are used to sense the
patient's effort. The data collected by the flow transducer is
analyzed to determine the amount of pressure needed to
generate the tidal volume or pressure preset by the clinician.
The machine continuously recalibrates to adjust for leaks
and changes in lung compliance and airway resistance.
In recent years, systems developed to provide high-flow,
high-humidity nasal cannula supplemental gas has supplanted
the use of CPAP. These systems deliver 1 to 40
L/min of flow rate, producing positive pressure support
as well as supplemental oxygen. This mode of
noninvasive positive pressure supplementation has
been used more typically in newborns and infants but
likely will find increased usage in all patients with
respiratory distress.
Physiology of Modalities
Respiratory disease may involve the upper airway, lower
airway, or both. Regardless of location of disease in the
respiratory tract, airway resistance and lung compliance
can be affected. Increased inflammation, debris, and
bronchospasm associated with respiratory disease result
in a higher transpulmonary pressure (difference between
proximal airway pressure and alveolar pressure) required
to produce a unit flow of gas through the airways of the
lung. This is demonstrated by an increased airflow
resistance [8]. As the properties of the alveoli may change
during disease, the amount of unit lung volume change
decreases for unit change in transalveolar pressure (the
difference between alveolar pressure and pleural pressure).
This is defined as a decrease in lung compliance [8]. The
resultant decrease in lung compliance and increase in
airway resistance in respiratory disease also require the
patient to generate higher intrathoracic pressures to
maintain alveolar ventilation and oxygenation. Muscle
fatigue from increased work of breathing leads to inability
to augment minute ventilation and adjust for increasing
carbon dioxide.
The combination of increased airway resistance and
decreased lung compliance lead to a decrease in functional
residual capacity (FRC). When the FRC drops below the
critical closing volume, alveolar collapse occurs [9]. Critical
closing volume is altered by age, disease, and position [9].
With exhalation, intrathoracic pressure changes will result
in airway closure. This occurs first in dependent areas of the
lungs around the level of residual volume. During disease
states, increased transpleural pressures result in increased
closing volumes. These closing volumes may occur at the
level of FRC, which result in atelectasis, subsequent
ventilation/perfusion (V/Q) mismatch, and eventual
hypoxemia and hypercarbia [9].
Noninvasive positive-pressure ventilation has been
shown to improve oxygenation, alveolar ventilation, and
work of breathing [10,11]. The flow provided by NIPPV
bypasses upper airway obstruction. The increase in upper
airway pressure leads to a drop in airway resistance.
NIPPV also promotes recruitment of collapsed alveoli.
When effective alveolar recruitment is achieved, FRC
increases and surpasses the critical closing volume [9].
This leads to alveolar patency, alveolar stability, increase
in lung compliance, and improvement in V/Q mismatch.
To recruit alveoli effectively, the pressure delivered must
be higher than the critical opening pressure of the alveoli
[9]. The delivery of fixed FIO 2 through a closed circuit
improves patient oxygenation. The increase in open
alveoli leads to redistribution of pulmonary blood flow
to these areas of improved ventilation. This also improves
patient ventilation and oxygenation. The addition of
CPAP/BiPAP may decrease work of breathing by several
mechanisms including relief of upper airway obstruction,
alteration of thoracic closing volumes, and decrease
in diaphragmatic work. All of these factors together
improve oxygenation, ventilation, and overall systemic
and cellular acidosis.
Administration and Monitoring of
Modalities
Modern NIPPV ventilators provide different modes to
accommodate different patient physiology. The spontaneous
mode can provide IPAP, EPAP or both, but only in
response to the patient's respiratory effort. In the
spontaneous/timed mode, pressure delivery is also controlled
by patient effort. However, if no effort is detected
within a set time, a breath is delivered to the patient. In
timed mode, a breath is delivered at a set interval regardless
of patient effort.
The decision to use BiPAP, CPAP, or high-flow nasal
cannula is dependent on the patient, specific disease, and

Noninvasive mechanical ventilation
141
clinical expertise. NIPPV may be delivered via nasal or fullface
mask. Both modes of administration can deliver
adequate support. However, full-face masks provide more
constant and reliable pressure delivery. Nasal masks are best
suited for patients who are able to comfortably keep their
mouths closed. These masks are considered more comfortable
by patients. Infants, who are obligate nose breathers,
generally benefit more from nasal prong CPAP or high-flow
nasal cannula.
Patients requiring NIPPV are generally critically ill.
These patients need to be closely monitored for worsening
respiratory failure. Patients should be monitored with
serial lung exams, continuous pulse oximetry, and
transcutaneous carbon dioxide monitoring. If a patient's
status worsens or does not improve, endotracheal intubation
with mechanical ventilation is warranted.
Clinical Uses of NIPPV
Noninvasive positive pressure ventilation is used in the
pediatric population to address both acute and chronic
respiratory compromise. It is important for the ED physician
to be knowledgeable about the uses of NIPPV. Understanding
the indications for NIPPV will facilitate its use as a
treatment modality in the acute setting. By understanding
the limitations of NIPPV, better care can also be given to
those children with chronic respiratory conditions requiring
mask ventilation who present to the ED with a change in
clinical status. The use of home ventilation is therefore an
important part of patient history taking in the ED setting.
In the acute setting, the benefits of NIPPV over
endotracheal intubation include reduced risk of nosocomial
infection, shorter intensive care unit (ICU) and
hospital stay, and decreased mortality [12]. It is important
to note that NIPPV is not a replacement for endotracheal
intubation in patients who require airway protection and
have hypercarbia or life-threatening hypoxemia (PAO 2
b60 mm Hg on rebreathing facemask). NIPPV should
not be attempted in patients who are rapidly deteriorating
or who are somnolent or confused. It should also be
avoided in patients who are hypotensive or have cardiac
dysrhythmias [13]. Previous studies have demonstrated
that BiPAP will lead to improvement of symptoms within
hours, so trials of NIPPV should remain short in nature and
intubation with subsequent mechanical ventilation should
be instituted if indicated for the clinical situation.
Literature supporting the use of NIPPV in the pediatric
population primarily emanates from either the pediatric
intensive care unit (PICU) as a treatment of respiratory
distress or from the home setting as a management for
chronic respiratory conditions such as OSA and neuromuscular
disorders. Studies of NIPPV use in the ED are
mostly confined to the adult literature.
A 2006 article by Maheshwari et al [14] sought to
investigate the use of noninvasive mechanical ventilation
in acute care hospitals in the United States [14]. This
survey showed great variation in use among hospitals
within the same region. In this study, use of NIPPV for
acute respiratory failure varied from less than 5% to greater
than 50% of patients. Of those who used this modality in
less than 15% of the patients, lack of physician knowledge
and equipment availability were cited as the top reasons for
this practice pattern. The site of initiation of NIPPV was
most often the ICU (55%) followed by the ED (26%).
Other studies have shown ED use to be higher [15]. In
these facilities, protocol-driven application and monitoring
were associated with better success.
Factors that influenced success of noninvasive ventilation
were also examined in a 2005 article by Merlani et al
[16]. In this retrospective analysis, patients admitted to the
ED for acute respiratory failure and treated with NIPPV
were studied. Failure of NIPPV was defined as the need to
undergo endotracheal intubation. In this study, 31% failed
NIPPV. Factors associated with failure included a pH less
than 7.35 and a respiratory rate greater than 20 after 1 hour
of NIPPV. In adult ED patients, NIPPV is most often
instituted for cardiogenic pulmonary edema, acute asthma,
chronic obstructive pulmonary disease, immunocompromised
states, and pneumonia [14,17,18].
Studies evaluating treatment failure of NIPPV in the
pediatric population have been conducted primarily in the
pediatric intensive care setting. A small prospective study
of infants and children in the ICU undergoing NIPPV for
respiratory failure demonstrated that inspired oxygen
(FIO 2 ) after 1 hour of NIPPV may be a predictor for
outcome, with a requirement for an FIO 2 greater than 80%
being associated with NIPPV failure [19]. A larger study of
NIPPV in PICUs found that acute respiratory distress
syndrome and a high pediatric logistic organ dysfunction
(PELOD) score were independent predictive variables of
NIPPV failure [11]. This study noted that there was
improvement in breathing pattern and in gas exchange in
some patients on NIPPV in the first few hours. Most of the
patients who failed did so within the first 48 hours. These
findings support the need for close monitoring of patients
on NIPPV and the need to consider discontinuation if
improvement is not noted in the short term.
A similar study of predictive factors for success of
NIPPV in the pediatric ED does not exist to our knowledge
beyond small disease-specific cohorts. Therefore, it is
important to understand the specific indications for NIPPV
in pediatrics and the literature that supports its use in
certain disease states.
Asthma
Noninvasive mechanical ventilation functions to bridge the
gap between maximal medical management and mechanical
ventilation in asthma. By avoiding intubation in an
asthmatic, complications such as bronchospasm, barotrauma,
ventilator-induced lung injury, cardiovascular
instability, and nosocomial infection can be reduced. The

142 R. Ganesan et al.
use of NIPPV in asthmatic patients works by applying
positive pressure, which decreases the workload of fatigued
muscles used for inspiration including the diaphragm and
accessory muscles. The positive pressure relieves the need
for the patient to “auto-positive end expiratory pressure”
(PEEP) to keep airways open during exhalation. This allows
for improvement in V/Q mismatch by a direct bronchodilator
effect and recruitment of smaller airways and collapsed
alveoli. Noninvasive ventilation may also improve delivery of
bronchodilators to smaller lung airways. This modality can
be a reasonable alternative for the 5% to 10% of patients with
acute asthma who fail conventional therapy.
There are some studies to support the use of BiPAP
for acute asthma exacerbations in the pediatric population
[20,21]. In a descriptive, 1-year, retrospective chart
review of ED patients with acute asthma refractory to
conventional treatment subsequently treated with BiPAP,
safety, tolerance, and benefit were studied. Nasal BiPAP
and continuous albuterol were applied to these otherwise
healthy pediatric asthma patients. Most of the
patients tolerated the device; more than 70% had
improvement in respiratory rate and almost 90%
improved their oxygen saturation. Most patients were
subsequently transferred to the PICU; however, almost
25% were weaned off BiPAP in the ED and transferred to
the pediatric general ward without any complications,
adverse events, or deaths.
These patients were started at an inspired positive
airway pressure of 10 cm H 2 O and an expired positive
airway pressure at 5 cm H 2 O with inspiratory pressure
adjusted to achieve an exhaled tidal volume of 6 to
9 mL/kg. A nasal mask was used to reduce the risk of
gastric insufflation, vomiting, and aspiration. Albuterol
was placed in the circuit between the whisper valve and
nasal mask. This study was limited, however, because of its
retrospective nature, differences in administration of
magnesium and terbutaline, and the lack of an objective
measure on when to start BiPAP therapy [22].
In 2004, a prospective crossover study was performed
involving 20 children in the PICU randomized to either
2 hours of nasal BiPAP (10cm/5cm) followed by 2 hours of
standard therapy or the reverse. A clinical asthma score
was used to evaluate patients. All patients were on
continuous albuterol and intravenous steroids but other
therapies were at the treating physician's discretion. This
study found that there were decreased signs of work of
breathing and dyspnea in the BiPAP group as compared
with the standard therapy group. Discontinuation of BiPAP
after 2 hours in the group who initially received it was
associated with an increase in respiratory rate and the
clinical asthma score. In the group receiving conventional
therapy first, only 2 children showed improvements in
respiratory rate and clinical asthma score, and only with a
BiPAP trial. BiPAP was not associated with significant
differences in oxygen saturation and transcutaneous
carbon dioxide monitoring [23].
A prospective, randomized, placebo-controlled trial of
BiPAP in an adult ED patient population with acute asthma
has been reported. It was found that in these adult patients,
the use of BiPAP for 3 hours improved lung function,
alleviated symptoms of the asthma attack more quickly than
in the control group, and reduced the rate of admission [24].
Neuromuscular Disorders
A variety of studies and case reports have supported the use of
NIPPV in neuromuscular diseases such as spinal muscular
atrophy, myasthenia gravis, congenital myopathies, and
muscular dystrophies [25-28]. In neuromuscular disorders,
the discussion regarding ventilation, invasive or noninvasive,
should ideally be made at a nonemergent time. This scenario,
however, is not always possible. It is important to recognize
the role that NIPPV can serve in patients with respiratory
failure and neuromuscular disorders. NIPPV works in
neuromuscular patients by improving ventilatory mechanics,
resting fatigued respiratory muscles, enhancing ventilatory
sensitivity to carbon dioxide, and improving sleep stage
disturbances [28]. The initiation of NIPPV in these patients
has been found to reduce symptoms, such as sleepiness and
headaches, hospitalizations, and health care costs in those
who use the device [26]. In patients with neuromuscular
disorders, care should be given when initiating NIPPV. BiPAP,
rather than CPAP, is the mode of choice because high
continuous pressure may be difficult for weak muscles to
overcome to generate a breath.
Obstructive Sleep Apnea/Airway Obstruction
Obstructive sleep apnea is the major indication for NIPPV
in airway obstruction. It is estimated that OSA syndrome
affects about 2% of children. This can be secondary to
neuromuscular airway control or from anatomic narrowing
of the airway. In most children, obstruction is caused
by enlarged tonsils and adenoids, and surgical intervention
generally improves the condition. However, with increasing
rates among children, obesity is playing a greater role in
pediatric OSA.
If pediatric OSA is not alleviated by tonsillectomy and
adenoidectomy, CPAP or BiPAP can be used. A review
article from Guilleminault et al [29] in 2005 gives an
overview of the symptoms of OSA associated with different
age groups. These clinical symptoms along with findings on
polysomnography confirm the diagnosis of sleep-disordered
breathing. The use of nasal CPAP for OSA in children
has been studied, and the training of parents and patients,
frequent reevaluation and fitting, and attention to midface
growth are important. A recent study investigating
adherence and effectiveness of these modalities in children
with OSA found poor compliance even with intensive home
support by health care professionals. They also found that
of those who do use the equipment, the duration was less
than prescribed. This study did show that NIPPV was
effective in improving clinical symptoms of OSA and was
associated with improved polysomnographic findings [30].

Noninvasive mechanical ventilation
143
There are case reports and studies that investigate the
use of NIPPV in children with laryngomalacia, tracheomalacia,
and bronchomalacia [31-33]. NIPPV was found to
relieve the load on respiratory muscles caused by severe
laryngomalacia and was associated with clinical improvement
in sleep and growth when upper airway obstruction
is associated with alveolar hypoventilation [31].
In the ED, it is important to recognize severe upper
airway obstruction, especially in infants, as an etiology for
respiratory distress and failure to thrive. Prompt intervention
with NIPPV can provide acute relief until further
studies and possible surgical interventions can be applied.
Bronchiolitis
Bronchiolitis is a common diagnosis in the ED with only a
small percentage of children worsening into respiratory
failure. Little research has been done to investigate the use
of NIPPV in bronchiolitis in the ED. A randomized
crossover trial comparing CPAP to standard therapy
found that CPAP decreased hypercarbia in infants with
bronchiolitis compared to standard therapy [34]. A study
by Martinon-Torres et al [35] found that there was an
improvement in clinical score, tachypnea and hypercarbia
in patients with refractory bronchiolitis treated with heliox
and CPAP.
Postoperative
A retrospective study of patients undergoing tonsillectomy
and adenoidectomy found that BiPAP was safe and effective
in patients that were predisposed to postoperative postobstructive
airway complications. These factors include
obesity, young age, asthma, and neurologic compromise
[36]. It was also found that the use of NIPPV in pediatric
patients after liver transplantation helped resolve atelectasis
and improved outcomes [37]. NIPPV has also been
found to be useful postoperatively in patients with spinal
cord surgery and laryngotracheal reconstruction procedures
[38,39].
Cystic Fibrosis
The use of NIPPV in cystic fibrosis has been found to be
beneficial not only in those patients with end-stage
disease awaiting lung transplant but also earlier in the
course of the disease to improve nocturnal oxygenation
and sleep quality and rest respiratory muscles [40,41].
These findings suggest that there may be a short-term
benefit of NIPPV in cystic fibrosis. In the ED setting, in
the case of severe respiratory distress not necessitating
intubation, it may be reasonable to try NIPPV as a means
of improving oxygenation as well as improving work of
breathing [42].
Mediastinal Mass
There is no current evidence to support the use of
noninvasive mask ventilation in the case of respiratory
distress caused by obstruction secondary to a mediastinal
mass. This type of obstruction, resulting in compression of
the bronchi, may cause wheezing that could be misinterpreted
as asthma. It is important to note that
wheezing caused by a fixed obstruction is monophonic,
rather than polyphonic. A chest x-ray could help to
differentiate if needed. Currently, there is no indication for
NIPPV in this setting.
Ingestion/Toxin
Ingestion and poisoning causing respiratory failure are not
indications for NIPPV. A full face mask device puts patients
at a high risk for aspiration if vomiting occurs. If
consciousness is impaired, NIPPV is of little use unless
BiPAP with a physiological back-up rate is applied. However,
if this is needed, conventional ventilation with protection of
the airway with an endotracheal tube is indicated.
Foreign Body Aspiration
The size and location of an aspirated foreign body dictate
treatment. However, if a foreign body is producing
significant respiratory distress with concern of impending
respiratory failure, NIPPV is not indicated and will not
provide significant relief past a fixed tracheal obstruction.
Summary
Patients presenting to pediatric EDs with respiratory
distress represent an array of diagnostic and therapeutic
challenges. With the development of NIPPV, there is an
effective tool in our armamentarium to provide significant
respiratory support. NIPPV has demonstrated benefits in
decreasing work of breathing, relieving fatigued muscles of
respiration, improving oxygenation, and possibly avoiding
common complications of endotracheal intubation. There
are clear clinical scenarios in which NIPPV is contraindicated,
such as an obtunded patient, certain postoperative
patients, patients with vomiting, and patients in
which mask ventilation is not tolerated. More frequently, it
is the patient with pulmonary disease resulting in
respiratory distress that is amenable to this therapy. It is
important to obtain any history of NIPPV usage in the ED.
Increasing numbers of children are on nocturnal settings
for OSA and support settings for chronic respiratory
insufficiency with diseases such as myopathies, cystic
fibrosis, and bronchiectasis. Advancements in the knowledge
of NIPPV management strategies for respiratory
distress and early initiation of mask ventilation in the ED
will enable the emergency physician to approach respiratory
distress in a similar manner as sepsis; using goaldirected
therapies to improve oxygenation, ventilation, and
comfort of breathing.
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