NIV.

The basics of
noninvasive positive
pressure ventilation
Content overview 1/2

Synonyms and abbreviations ..................................... 04 What is the clinical relevance? ................................... 21

Physiologic effects of noninvasive ventilation 22
Your ventilation expert ................................................. 06
How to start a patient on NIV? ................................... 24
Introduction .................................................................... 07 How to start a patient on NIV 25
Conditions for initiating NIV 26
What are the benefits? ................................................. 08
Goals and benefits of using NIV 09 How to choose the right interface? ........................... 27
Selection of the interface 28
How does NIV work? .................................................... 10 Interface strategies for NIV in adult patients 30
How does it work 11
NIV modes 12 How to set up NIV? ......................................... 31
CPAP 13 NIV setup 32
NIV (PSV) 14 Humidification during NIV 33
NIV-ST 16 HAMILTON-H900 setting for NIV 34
Pressure-support mode versus CPAP/BPAP 17 Patient agreement and motivation 35
When to consider NIV? 18
Indications and recommendations for NPPV 19
Contraindications to noninvasive ventilation 20

Basics of NIV 2
Content overview 2/2

How to adjust settings? ............................................... 36 Question 1/2 - Clinical case 62

Initial ventilator settings 37 Question 3 - Clinical case 63
Alarm setup 40 Question 4 - Clinical case 64
Solutions - Clinical case 65
How to monitor treatment? ........................................ 41
Monitoring while on NIV 42 Appendix .......................................................................... 66
Monitoring failure during noninvasive ventilation 43 NIV recommendations 67
HACOR score 44 NIV weaning pathway 68
Updated HACOR score 45 References 69

How to monitor patient-ventilator synchrony? ....... 46

Monitoring patient-ventilator synchrony 47
Troubleshooting asynchronies 49

Test yourself ................................................................... 56

Test your knowledge 57
Question 1/2 58
Question 3/4 59
Solutions 60
Clinical case 61

3
Synonyms and abbreviations

The term noninvasive positive-pressure ventilation (abbreviated NPPV or NIPPV) was previously used
to distinguish it from noninvasive negative-pressure ventilation, but given the latter's rarity nowadays,
the simpler term NIV is more convenient.

As there is now a range of ventilators available for NIV (and the ICU-ventilator manufacturer Respironics uses it for
one of its modes), use of the proprietary product name BIPAP as a generic term for NIV should be avoided.

Basics of NIV 4
Synonyms and abbreviations

NPPV Noninvasive positive-pressure ventilation FiO2 Fraction of inspired oxygen

CPAP Continuous positive airway pressure RR Respiratory rate
PSV Pressure-support ventilation SpO2 Oxygen saturation
NIV Noninvasive ventilation COVID-19 Coronavirus disease-19
ST Spontaneous timed HME Heat moisture exchanger
FRC Functional residual capacity P-ramp Pressure ramp
PEEP Positive end-expiratory pressure Vt Tidal volume
Pinsp Inspiratory pressure ABG Arterial blood gases
COPD Chronic obstructive pulmonary disease DMD Duchenne muscular dystrophy
ΔPsupport Pressure support OHS Obesity hypoventilation syndrome
ETS Expiratory trigger sensitivity OSA Obstructive sleep apnea
TI max Maximum inspiratory time OI Oxygenation index
BIPAP Bilevel positive airway pressure KS Kyphoscoliosis
IPAP Inspiratory positive airway pressure NM Neuromuscular disease
EPAP Expiratory positive airway pressure CWD Chest wall disease
GCS Glasgow coma scale/score BMI Body mass index
PaO2 Partial pressure of oxygen

5
Your ventilation expert

Munir Karjaghli
Respiratory therapist

Affiliation
Hamilton Medical
Clinical Support Services

Basics of NIV 6
Introduction

Noninvasive positive-pressure ventilation involves the

delivery of oxygen into the lungs via positive pressure
without the need for endotracheal intubation. It is
used in both acute and chronic respiratory failure, but
requires careful monitoring and titration to ensure its
success and avoid complications1.

Over the past century, NIV has improved dramatically

and been used to treat respiratory failure from multiple
etiologies. It has been proven more effective in
preventing intubation compared to standard oxygen
therapy in the acute setting2.

Respiratory support may be delivered using continuous

positive airway pressure (CPAP) devices or those that
deliver bilevel positive airway pressure (pressure- This e-book focuses on the basics of noninvasive
support ventilation). For the purposes of this document, ventilation for your daily clinical practice.
the name NIV covers both CPAP and PSV2.

7
What are
the benefits?
Goals and benefits of using NIV

We can divide the goals and benefits of NIV into the acute and long-term care setting as follows:

Acute care setting3 Long-term care setting3

Improve gas exchange Relieve or improve symptoms
Avoid intubation Enhance quality of life
Decrease mortality Avoid hospitalization
Decrease length of time on the ventilator Increase survival
Decrease duration of hospitalization Improve mobility
Decrease incidence of ventilator-associated
pneumonia
Relieve symptoms of respiratory distress
Improve patient-ventilator synchrony
Maximize patient comfort

9
How does NIV
work?
How does it work

NIV works by creating positive airway pressure, i.e., the

pressure outside the lungs is greater than the pressure
inside the lungs. This causes air to be forced into the
lungs (down the pressure gradient), lessening the
respiratory effort and reducing the work of breathing.

It also helps to keep the chest and lungs expanded by

increasing the functional residual capacity (the amount
of air remaining in the lungs after expiration) after
normal (tidal) expiration; this is the air in the alveoli
available for gas exchange4.

11
NIV modes

The following modes are noninvasive:

NIV-ST
CPAP NIV (PSV) Spontaneous/timed (S/T)

Stands for continuous positive Also known as bilevel CPAP Stands for spontaneous/timed
airway pressure mode, or bilevel pressure noninvasive ventilation
mode

Basics of NIV 12
CPAP

• Aims to deliver one continuous level of positive

pressure throughout both the inspiratory and
expiratory phases of breathing

• Improves oxygenation by opening collapsed

airways, improving functional residual capacity
(FRC), and improving preload and afterload in
cardiogenic pulmonary edema5

• Improves lung compliance and therefore reduces

the effort required for breathing by preventing
alveolar collapse and counteracting the excessive
intrinsic PEEP seen in obstructive lung conditions
such as COPD5,6

When ΔPsupport /∆Pinsp is set to zero in NIV and NIV-ST, the ventilator functions like a conventional
CPAP system.

Adapted from Hess, Dean R., and Robert M. Kacmarek. Essentials of mechanical ventilation. McGraw Hill Education, 2019.

13
NIV (PSV)

• Aims to deliver two levels of positive airway

pressure support

• The lower level is similar to CPAP; however, it is

more commonly called positive end-expiratory
airway pressure (PEEP) as it is present only at the
expiratory phase of breathing

• The patient’s inspiratory effort is assisted by the

ventilator at a preset level of inspiratory pressure
(ΔPsupport). Inspiration is triggered and cycled by
the patient's effort

• During NIV, the patient determines the respiratory

rate, inspiratory time, and tidal volume

Adapted from Bellani, Giacomo. Mechanical ventilation from pathophysiology to clinical evidence. Cham, Switzerland: Springer, 2022.

Basics of NIV 14
NIV (PSV)

• The size of the breath (tidal volume) generated in a

particular patient is dependent on the ΔPsupport
setting – the higher the ΔPsupport setting, the
greater the tidal volume

• ETS determines the spontaneous inspiratory

time by cycling to expiration once the inspiratory
flow decreases to a preadjusted percentage of the
peak inspiratory flow
• In case the ETS criteria are not met (leakage), the
inspiratory time can also be limited by TI max

Adapted from Bellani, Giacomo. Mechanical ventilation from pathophysiology to clinical evidence. Cham, Switzerland: Springer, 2022.

15
NIV-ST

• In S/T mode, the clinician sets the inspiratory

pressure (∆Pinsp) and expiratory pressure (PEEP),
respiratory rate, and inspiratory time. The patient
may initiate breaths that are supported to the
∆Pinsp level, as in the NIV mode, but if the patient
fails to make an inspiratory effort within a set
interval (that is defined by the set respiratory rate),
the machine triggers inspiration to the set ∆Pinsp
level. ∆Pinsp then cycles to PEEP based on the
inspiratory time period

• NIV-ST with the backup rate is useful in the case of

apnea or periodic breathing7

Basics of NIV 16
Pressure-support mode versus CPAP/BPAP

• The NIV and NIV-ST modes are types of

noninvasive positive pressure ventilation. Pressure
support is generally considered to be the same as
CPAP/BIPAP, except that pressure support
is delivered by a ventilator and BIPAP through a
noninvasive ventilator

• In NIV and NIV-ST, the level of pressure support is

applied as pressure above baseline PEEP. However,
the approach is different with bilevel ventilators
where IPAP and EPAP are set. In this configuration,
the difference between IPAP and EPAP is the level
of pressure support

Comparison of pressure support ventilation (PSV), such as with critical care ventilators, and inspiratory positive airway pressure (IPAP) with a bilevel ventilator. Note
that IPAP is the peak inspiratory pressure (PIP) and includes the expiratory positive airway pressure (EPAP), whereas in PSV, pressure support is provided on top of
the positive end-expiratory pressure (PEEP).

17
When to consider NIV?

• In order to minimize the risk of failure or • Patients should be closely monitored during the
complications, every patient should be properly first 24 hours after initiating NIV, as this is the period
assessed for suitability to receive NIV safely. with the highest rate of treatment failure. Although
data points at presentation such as a high RR, low
Indications for NIV use include patients who have: arterial pH values or low PaO2/FiO2 can help
predict failure, the most robust predictor of
Dyspnea treatment failure during this period is failing to show
Tachypnea an improvement in these parameters at 1–2 h after
Accessory respiratory muscle use initiating NIV treatment9
Paradoxical abdominal “belly” breathing
PaCO2 > 45 mmHg and pH < 7.35 8, 9

Basics of NIV 18
Indications and recommendations for NPPV10, 11

Clinical indication Certainty of evidence Recommendation

Hypercapnia with COPD exacerbation High Strong recommendation for
Cardiogenic pulmonary edema (CPE) Moderate Strong recommendation for
Immunocompromised Moderate Conditional recommendation for
Post-operative patients Moderate Conditional recommendation for
Palliative care Moderate Conditional recommendation for
Trauma Moderate Conditional recommendation for
Weaning in hypercapnic patients Moderate Conditional recommendation for
Post-extubation respiratory failure Low Conditional recommendation against
Obesity hypoventilation syndrome (OHS) Low Conditional recommendation for
Neuromuscular disease and chest wall disease Low Conditional recommendation for
Prevention of hypercapnia in COPD exacerbation Low Conditional recommendation against
Post-extubation in high-risk patients (prophylaxis) Low Conditional recommendation for
De novo respiratory failure No certain evidence No recommendation made
Acute asthma exacerbation No certain evidence No recommendation made

19
Contraindications to noninvasive ventilation12

Absolute: Relative:

The need for emergent intubation (i.e., cardiac Non-respiratory organ failure that is acutely
or respiratory arrest, severe respiratory distress, life-threatening
unstable cardiac arrhythmia) Severe encephalopathy (i.e., GCS < 10)
Severe upper gastrointestinal bleeding
Hemodynamic instability
Facial or neurological surgery, trauma, or deformity
Significant airway obstruction (i.e., laryngeal mass
or tracheal tumor)
Inability to cooperate, protect airway, or clear
secretions (i.e., patients at high risk of aspiration)
Anticipated prolonged duration of mechanical
ventilation (i.e., ≥ 4 to 7 days)
Recent esophageal or gastric anastomosis*
Multiple contraindications
Insufficient staffing support

* GCS: Glasgow Coma Score and esophageal or gastric distension from air may increase the risk of anastomotic dehiscence

Basics of NIV 20
What is the
clinical
relevance?
Physiologic effects of noninvasive ventilation13

The primary desired effect of NIV is to maintain The physiologic effects of noninvasive ventilation are
adequate levels of PO2 and PCO2 in the arterial blood the following:
while also unloading the inspiratory muscles.
Augments minute ventilation
Unloads ventilatory muscles
Resets the ventilatory control system
Improves alveolar recruitment and gas exchange
Maintains upper-airway patency
Reduces triggering loads from Auto-PEEP
Reduces the risk of ventilator-induced lung injury

Basics of NIV 22
Physiologic effects of noninvasive ventilation13

Adapted from MacIntyre, Neil R. Physiologic effects of noninvasive ventilation. Respiratory care 64.6 (2019): 617-628

23
How to start
a patient on NIV?
How to start a patient on NIV14

1. Education: Plan adequate training for all staff with a calibrated protocol

2. Environment: Choose an appropriate setting for starting NIV according to the severity of ARF

3. Indication: Select patients according to the team's experience, location, availability of intubation, do-not-intubate
status, and likelihood of success

4. Information: Explain the technique to competent patients to improve their compliance

5. Equipment: Choose the interface(s) that best fits the facial anatomy; also consider rotating different interfaces
to enhance comfort. Choose a ventilator with good air-leak compensation that displays flow/pressure/volume curves

6. Starting ventilation: Choose a pressure mode (i.e., pressure support) with PEEP. Start with low pressures, then
increase gradually depending on comfort. Set adequate FiO2 and essential alarms. Tighten the straps of the
interface enough to avoid leaks, without making them too tight

7. Monitoring ventilation: Check clinical status, monitor SpO2, measure blood gases periodically. Reset the
ventilator according to patient–ventilatory synchrony, comfort, and leaks. Prevent skin lesions (i.e., protective
devices, rotating interfaces). Consider humidification. Carefully consider sedation. Consider management of
secretions, if required.

25
Conditions for initiating NIV

1. Choose a location with appropriate monitoring

based on the severity of the patient’s condition.
At a minimum, continuous pulse oximetry should
be provided.

2. Optimizing the patient’s position also plays a key

role in ensuring comfort during NIV15. A sitting
or semi-recumbent position is suggested during
NIV to ensure a high level of comfort to patients.
A side-lying position may help to remove pressure
from a pendulous abdomen, as in case of
pregnancy or obesity15. Recently, the use of the
prone positioning has been introduced in patients
with ARF, particularly those with COVID-19
disease16. The analysis of this rescue therapy is 3. Select a ventilator and an appropriately sized
better explained in the last paragraph on the interface, and ensure the interface is compatible
COVID-19 pandemic. with the type of ventilator to be used.

Basics of NIV 26
How to choose the
right interface?
Selection of the interface

Select the mask designed for use with a critical

care ventilator (without entrainment valves or leak
port)

Choose an interface that is the correct size for

the individual patient, evaluate the mask fit and
placement on the face, and reposition the mask as
needed to minimize air leaks

NIV interfaces with entrainment valves are designed for noninvasive ventilators that use a single-limb circuit. The
entrainment valve is required to prevent asphyxia if the ventilator fails or the tubing becomes disconnected. Masks
with leak ports should only be used with single-limb circuit ventilators and should not be used with Hamilton Medical
ventilators.

Basics of NIV 28
Selection of the interface

Standard elbow
For use with Hamilton
Medical ventilators

BiTrac MaxShield BiTrac NIV nasal mask* BiTrac NIV full face mask BiTrac MaxShield

Pediatric patients** Adult patients

Anti-asphyxia elbow
For use with BiLEVEL
or CPAP application

BiTrac MaxShield BiTrac NIV full face mask BiTrac MaxShield

Adult patients
Pediatric patients** Adult patients

* Only available in the US market

** Recommended for patients with a weight >7kg and over the age of 1-year old

29
Interface strategies for NIV in adult patients17

Adapted from Simonds, Anita K., ed. ERS practical handbook of noninvasive ventilation. European Respiratory Society, 2015.

Basics of NIV 30
How to set up NIV?
NIV setup

1. Turn on the ventilator and humidifier, then run the

calibration and tightness test

2. Connect the interface to the circuit

3. Explain the procedure and reason for therapy to the

patient, and answer any questions about NIV
before placing the mask on the patient

Basics of NIV 32
Humidification during NIV

Recommendations18, 19:

All NIV circuits are to be actively humidified

HMEs are not recommended for NIV

Gas temperatures during NIV are to be based on patient comfort

Humidified gas, heated to a temperature that is comfortable for the patient (usually about 30°C),
should be the standard when using NIV

33
HAMILTON-H900 setting for NIV

Select NIV mode with the mode key

When changing to NIV mode, the humidifier

automatically sets the control settings to Auto
noninvasive. Default temperature: 31°C

Temperature range for NIV mode: 30°C to 35°C

You can change to manual mode by changing the

Chamber exit temperature or Temperature gradient

Basics of NIV 34
Patient agreement and motivation

Dyspnea can cause feelings of anxiety and fear. For

this reason, the healthcare professional or the patient
should hold the mask in place when applying it for the
first time.

This way the mask can be removed quickly if the

patient begins to panic or needs to communicate.
A strategy of starting with low pressures can help
patients adjust to NIV more readily.

35
How to adjust
settings?
Initial ventilator settings20

1. Ventilating pressures should be set as low as

possible to start with, especially if the patient is
unfamiliar with the sensation of positive pressure
ventilation (PEEP 4–6 cmH2O, ∆Pinsp 6–10 cmH2O)

2. Ventilating pressures can then be adjusted in small

increments over 1 to 2 minutes until exhaled VT
is 6 to 8 ml/kg predicted body weight, or respiratory
distress improves

3. Adjust FiO2 to keep SpO2 in the desired range

(88%–95%)

37
Initial ventilator settings20

4. Flow trigger: Set trigger sensitive enough to allow

easy triggering without auto-triggering, even in the
presence of leaks

5. Peak airway pressures greater than 30 cmH2O

are rarely required and are best avoided. Airway
pressure settings greater than 30 cmH2O can force
air through the esophagus into the stomach*

6. Set the backup rate to 12–16 bpm (2 bpm below

resting respiratory rate)

7. Set an appropriate inspiratory time and I:E ratio for

the patient’s presenting condition**

* Plimit should not exceed 30 cmH2O or PEEP 8 cmH2O without expert review
** Ti and I:E ratio (1:2–1:3 (COPD) or 1:1 (NMD/OHS)) set by a competent practitioner

Basics of NIV 38
Initial ventilator settings20

8. ETS: 40%–50%

9. Pramp: Should be tailored for a faster slope while

avoiding excessive peak flow

10. Maximum inspiratory time is set 0.25 s above the

actual inspiratory time; if you are unsure start at 1.5 s

39
Alarm setup

Emergency alarms are important for recognizing a deterioration in the patient's condition and alert staff in
the following situations:

Apnea when the patient stops breathing

High respiratory rate when the patient’s respiratory rate goes above set value
Low respiratory rate when the patient’s respiratory rate goes below a set value
High tidal volume when the patient’s tidal volume goes above a target value
Low tidal volume when the patient’s tidal volume goes below a target value

Basics of NIV 40
How to monitor
treatment?
Monitoring while on NIV20

1. Reassess frequently for tolerance and efficacy of NIV (at least every 30 min) for the first 1 to 2 h

2. Continuous cardiac and SpO2 monitoring for at least the first 12 hours. Ensure PaCO2, PaO2, and SpO2
parameters are set

3. Alter NIV settings: If PaCO2 remains high, increase tidal volume (Vt) by increasing ∆Pinsp. If the patient remains
hypoxic, increase PEEP or FiO2 (remember you may need to increase ∆Pinsp to maintain Vt between 6–8 ml/kg
or signs of respiratory distress improve), update NIV prescription, and repeat ABG one hour after any settings are
changed*

4. Check the patient's tolerance with the initial settings, and assess for dyspnea and asynchrony

5. Monitor the patient for risk of possible NIV failure

6. Use prespecified criteria for escalation

7. Do not delay an indicated intubation

* Increase ∆Pinsp over 10-30 minutes. Ppeak should not exceed 30 cmH2O or PEEP 8 cmH2O without expert review

Basics of NIV 42
Monitoring failure during noninvasive ventilation

Failure of NIV has usually been defined as a need for intubation due to a lack of improvement in arterial blood gases
and clinical parameters, or death7. It is very important to identify patients who are at risk of failing NIV, because an
inappropriate delay in intubation may cause an increase in morbidity and mortality.

Success predictors Failure predictors

Increase in arterial oxygenation Stable or decrease in arterial oxygenation

Decrease in respiratory rate Stable or rise in respiratory rate
Decrease in dyspnea Stable or increase in dyspnea
Significant increase in PaO2/FiO2 Stable or decrease in PaO2/FiO2
Stable or increase in OI
Presence of contraindication(s) to NIV

43
HACOR score

• A comprehensive scale developed by Duan J, et al. including heart rate,

acidosis, consciousness, oxygenation, and respiratory rate21

• In a large prospective cohort study, the HACOR scale predicted NIV

failure after 1 h of treatment with high specificity (90%) and good
sensitivity (72%)21

• A HACOR score > 5 had a failure rate of 87.1% and hospital mortality of
65.2%21

• The original HACOR score was recently improved in a multicenter

prospective observational study by combining it with data on six
baseline variables (pneumonia, CPE, pulmonary ARDS, septic shock,
immunosuppression, and SOFA scores). When compared to the original
HACOR score, the updated HACOR score had significantly better
predictive power for NIV failure and can serve as an important reference Original HACOR score online
point for clinical staff managing NIV22 calculator

Basics of NIV 44
Updated HACOR score22

Early intubation can be considered when updated HACOR score assessed after 1–2 h of NIV is high.

Updated HACOR score Risk for NIV failure Rate of NIV failure

≤7 Low 12.4%

7.5–10.5 Moderate 38.2%

11–14 High 67.1%

≥ 14 Very high 83.7%

The updated HACOR score is as follows: Original HACOR score + 0.5 × SOFA + 2.5 if pneumonia is diagnosed – 4 if CPE
is diagnosed + 3 if pulmonary ARDS is present + 1.5 if immunosuppression is present + 2.5 if septic shock is present

45
How to monitor
patient-ventilator
synchrony?
Monitoring patient-ventilator synchrony

• Synchrony between the patient and ventilator should be checked frequently. Asynchronies can be detected by
observing the patient and asking them simple questions. The most practical method should be analysis of the
pressure and flow waveforms23.

• Hamilton Medical ventilators offer a functionality for leak compensation, IntelliTrig, during the full breath cycle
to increase patient-ventilator synchrony and reduce the risk of auto-triggering. Using IntelliTrig, the ventilator
identifies the leak by measuring the flow at the airway opening, and uses this data to automatically adjust the gas
delivery while remaining responsive to the set inspiratory and expiratory trigger sensitivity.

• Hamilton Medical ventilators also have the optional feature, IntelliSync+, which continuously analyzes waveform
shapes and is able to detect patient efforts immediately, then initiate inspiration or expiration in real-time*. For
maximum flexibility, IntelliSync+ can be activated for either the inspiratory trigger or the expiratory trigger, or
both.

* IntelliSync+ is available on the HAMILTON-G5/S1 and HAMILTON-C6.

47
Monitoring patient-ventilator synchrony

Patient-ventilator synchronization is an important issue that can influence the efficacy and success of NIV.

The most common phenomenon is ineffective triggering (patient effort is not recognized by the ventilator; may be
secondary to high AutoPEEP or inappropriate inspiratory trigger sensitivity), followed by auto-triggering (delivery of
preset pressure in the absence of patient effort) and double triggering (consecutive delivery of two preset pressure
support events within an interval of less than half the mean inspiratory time due to the patient’s continued effort)24, 25, 26, 27.

Basics of NIV 48
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

Inspiratory Ask your patient If no Ineffective Increase

trigger • Does the ventilator give you a breath each time you trigger inspiratory trigger
want one? sensitivity and/or
• When you breathe in, do you get a supporting PEEP
breath?

Waveform monitoring Ineffective inspiratory

efforts appear on the
flow curve as a sudden
deviation of the expiratory
flow toward the baseline
(upward convexity) and
a concomitant drop in
airway pressure toward
the baseline (upward
concavity)

49
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

Inspiratory Ask your patient If yes Auto- Decrease

trigger • Does the ventilator give you a breath when you don't triggering inspiratory trigger
want one? sensitivity

The inspiratory flow curve

Waveform monitoring
of an auto-triggered breath
differs substantially from
that of patient-triggered
breaths because the
patient doesn’t make an
active inspiratory effort -
the peak inspiratory flow is
lower, and the inspiratory
time is shorter

Basics of NIV 50
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

P-ramp Ask your patient If yes Overshoot Increase Pramp

• Do you feel like you get a blast of air? until slower
• Is the breath given too quickly? breath delivery
better matches
the patient's

Waveform monitoring inspiratory flow

At the start of inspiration,

the pressure waveform
shows a spike

51
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

P-ramp Ask your patient If yes Flow is too Decrease Pramp

• Is the breath delivered too slowly/too gently? slow until faster
breath delivery
better matches
the patient's

Waveform monitoring inspiratory flow

Downward concavity in
airway pressure usually
indicates the rise time is
too long (flow is too slow)

Basics of NIV 52
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

ETS Ask your patient If yes Early Reduce ETS

• Is the breath delivery time too short? cycling gradually until it
is better matched
with the patient's
breath cycling

Waveform monitoring

Flow waveform: Look

for a small bump at the
beginning of expiration
(after peak expiratory flow)
followed by an abrupt initial
reversal in the expiratory
flow

53
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

ETS Ask your patient If yes Delayed Increase ETS

• Is it the delivered breath too long or is it hard to cycle gradually until it
breathe out? is better matched
with the patient's
breath cycling
• Pressure waveform:
Waveform monitoring
curve rises above the
target at the end of
insufflation
• Flow waveform: Look for
a change in the slope of
the inspiratory flow: a
fast decrease followed
by an exponential (less
steep) decline

Basics of NIV 54
Troubleshooting asynchronies

Ventilator setting How to identify asynchrony Description Asynchrony Action

ETS Ask your patient If yes Double • Reduce ETS

• Does the ventilator give you two breaths? triggering gradually until
it is more in
sync with the
patient's breath

Waveform monitoring cycling

Flow waveform: Look
• Increase the
for two assisted breaths
pressure
without expiration between
support if it is
them or with an expiration
low
interval of less than half
of the mean inspiratory
time (often displayed
on the waveform as two
inspiratory peaks)

55
Test yourself
Test your knowledge

Now it is time to put your knowledge to the test. On

the following pages you can find several questions
about noninvasive positive pressure ventilation and
the concepts mentioned in this e-book.
A
For each question there is only one correct answer.

You can check your answers on page 60 and page 65 B

(for the clinical case).

Good luck!
C

57
Question 1 Question 2

Which of the following are indications for initiating Which of the following are contraindications to
NIV? initiating NIV because they will likely lead to NIV
failure?

a) Patient complaining of shortness of a) Severe upper GI bleed

breath b) Recent facial surgery
b) Arterial pH > 7.45 c) Refractory air leak
c) Accessory respiratory muscle use d) Hemodynamic instability
d) PaCO2 < 35 mmHg e) All of the above
e) All of the above

Basics of NIV 58
Question 3 Question 4

A patient presents with pneumonia and is initiated Which is the most frequent type of asynchrony during
on NIV. Which of the following is the most sensitive noninvasive mechanical ventilation?
predictor of NIV failure?

a) RR > 25 bpm a) Ineffective triggering

b) O2 saturation of < 88% on room air b) Double triggering
c) PaO2/FiO2 < 150 at the start of NIV c) Auto-triggering
d) PaO2/FiO2 < 150 after 1 h of NIV d) Premature cycling
e) All of the above are equal predictors of e) Delayed cycling
failure

59
Solutions

c) Accessory respiratory muscle

Question 1
use

Question 2 e) All of the above

Question 3 d) PaO2/FiO2 < 150 after 1 h of NIV

Question 4 a) Ineffective triggering

Basics of NIV 60
Clinical case

Scenario

A 56-year old man presented with congestive heart failure and signs of cardiac decompensation. Upon admission,
he was awake and oriented but had fever, tachycardia, hypotension, dyspnea, and oliguria.

Pneumonia was confirmed. Arterial blood gases showed severe hypoxemia with calculated PaO2/FiO2 ratio of 240
on 40% oxygen therapy.

He met all the criteria for NIV use: severe dyspnea with a respiratory rate of 32 breaths/min, apparent use of
accessory respiratory muscles, and severe hypoxemia.

61
Question 1 - Clinical case Question 2 - Clinical case

Which statement is true? Which ventilation modality usually results in more

effective NIV in this patient?

a) The patient has severe hypoxemia and a) CPAP

pneumonia, and should be intubated b) NIV-ST
immediately
c) DuoPAP
b) NIV can be used as a first-line therapy
d) NIV
with close supervision

Basics of NIV 62
Question 3 - Clinical case

Which of these initial settings is the most appropriate?

a) ∆Pinsp 12 cmH2O, PEEP 10 cmH2O, FiO2 100%, Rate 20, ETS 40%
b) ∆Pinsp 8 cmH2O, PEEP 5 cmH2O, FiO2 (adjust to keep SpO2 88%–95%), ETS 40%, RR 18 bpm
c) ∆Pinsp 10 cmH2O, PEEP 5 cmH2O, FiO2 (adjust to keep SpO2 88%–95%), ETS 40%, RR 12 bpm
d) ∆Pinsp 6 cmH2O, PEEP 5 cmH2O, FiO2 (adjust to keep SpO2 88%–95%), ETS 25 %, RR 12 bpm

63
Question 4 - Clinical case

With initial settings, the pressure and flow waveforms looked similar to the shapes below. How can this
asynchrony be corrected?

a) Increase ETS
b) Lower the setting for expiratory trigger
sensitivity
c) Increase the rise time
d) Increase PEEP

Basics of NIV 64
Solutions - Clinical case

Question 1 b) NIV can be used as a first-line therapy with close supervision

Question 2 b) NIV-ST

Question 3 c) ∆Pinsp 10 cmH2O, PEEP 5 cmH2O, FiO2 (adjust to keep SpO2 88%–95%), ETS 40%, RR 12 bpm

Question 4 b) Lower the setting for expiratory trigger sensitivity

65
Appendix
NIV recommendations:
Adapted from Davidson AC, Banham S, Elliott M, et. al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 (Suppl 2): ii1-35

67
NIV weaning pathway:
Adapted from Clinical Guidelines for Non-Invasive Ventilation (NIV) in Acute Respiratory Failure. South Tess Hospital. 2012.

Basics of NIV 68
References

1. Rochwerg B, Brochard L, et. al. Official ERS/ATS clinical practice guidelines: 8. Ozyilmaz E, Ugurlu AO, Nava S. Timing of noninvasive ventilation failure:
noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 causes, risk factors, and potential remedies. BMC Pulm Med. 2014;14(1):19.
Aug;50(2) https://doi.org/10.1186/1471- 2466-14-19.

2. Gong Y, Sankari A. Noninvasive Ventilation. 2022 Jun 17. In: StatPearls 9. Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: recipe for success? Eur Respir Rev. 2018;27(149):180029.
35201716.
10. Rochwerg B , Brochard L , Elliott MW et al . Official ERS/ATS clinical
3. Kacmarek, R. M., Stoller, J. K., & Heuer, A. (2019). Egan's fundamentals of practice guidelines: noninvasive ventilation for acute respiratory failure . Eur
respiratory care e-book. Elsevier Health Sciences. Respir J 2017 ; 50 .

4. Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, et al. 11. Davidson AC , Banham S , Elliott M et al . BTS/ICS guideline for the
The role for high flow nasal cannula as a respiratory support strategy in ventilatory management of acute hypercapnic respiratory failure in adults .
adults: a clinical practice guideline. Intensive Care Medicine. 2020 Dec Thorax 2016 ; 71 (Suppl 2): ii1-35.
17;46(12):2226–37.
12. Evans, Timothy W. "International Consensus Conferences in Intensive
5. Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic Care Medicine: non-invasive positive pressure ventilation in acute respiratory
pulmonary edema. Ann Transl Med. 2018 Sep; 6(18): 355. failure." Intensive care medicine 27.1 (2001): 166-178.

6.British Thoracic Society/Intensive Care Society (BTS/ICS) Acute 13. MacIntyre, Neil R. Physiologic effects of noninvasive ventilation.
Hypercapnic Respiratory Failure Guideline Development Group (2016). Respiratory care 64.6 (2019): 617-628.
BTS/ICS Guidelines for the Ventilatory Management of Acute Hypercapnic
14. Elliott, M., Nava, S., & Schönhofer, B. (Eds.). (2018). Non-invasive
Respiratory Failure in Adults. Thorax 71:ii1-ii35.
ventilation and weaning: principles and practice. CRC Press.
7. Esquinas, A. M. (Ed.). (2022). Teaching Pearls in Noninvasive Mechanical
Ventilation: Key Practical Insights. Springer Nature.

69
References

15. Sanchez D, Smith G, Piper A, Rolls K. Non–Invasive Ventilation Guidelines 22. Duan, Jun, et al. "An updated HACOR score for predicting the failure
for Adult Patients With Acute Respiratory Failure: A Clinical Practice Guideline. of noninvasive ventilation: a multicenter prospective observational study."
Agency for clinical innovation NSW government Version 1, Chatswood NSW, Critical Care 26.1 (2022): 1-11.
ISBN 978-1-74187-954-4 (2014).
23. Ergan, Begum, Jacek Nasiłowski, and João Carlos Winck. How should
16. Ehrmann S, Li J, Ibarra-Estrada M, Perez Y, Pavlov I, McNicholas B, et al. we monitor patients with acute respiratory failure treated with noninvasive
Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: ventilation? European Respiratory Review 27.148 (2018).
a randomised, controlled, multinational, open-label meta-trial. Lancet Respir
24. de Wit M, Miller KB, Green DA, et al. Ineffective triggering predicts
Med. (2021) 9:1387–95.
increased duration of mechanical ventilation. Crit Care Med 2009; 37:
17. Simonds, A. K. (Ed.). (2015). ERS practical handbook of noninvasive 2740–2745.
ventilation. European Respiratory Society.
25. Epstein SK. How often does patient-ventilator asynchrony occur and what
18. Holanda MA, Reis RC, Winkeler GF, Fortaleza SC, Lima JW, Pereira ED. are the consequences? Respir Care 2011; 56: 25–38
Influence of total face, facial and nasal masks on short-term adverse effects
26. Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M. Patient-ventilator trigger
during noninvasive ventilation. J Bras Pneumol. 2009;35(2):164-73.
asynchrony in prolonged mechanical ventilation. Chest 1997; 112: 1592–1599.
19. American Association for Respiratory Care, Restrepo R, Walsh B:
27. Thille AW, Lyazidi A, Richard JC, et al. A bench study of intensive-care-unit
Humidification during invasive and noninvasive mechanical ventilation, Respir
ventilators: new versus old and turbine-based versus compressed gas-based
Care 57:782–788, 2012.
ventilators. Intensive Care Med 2009; 35: 1368–1376.
20. Developed from BTS/ICS guidelines. https://www.brit-thoracic.org.uk/
document-library/clinical-information/acute-hypercapnic-respiratory-failure/
bts-guidelines-for-ventilatory-management-of-ahrf/

21. Duan, Jun, et al. "Assessment of heart rate, acidosis, consciousness,

oxygenation, and respiratory rate to predict noninvasive ventilation failure in
hypoxemic patients." Intensive care medicine 43.2 (2017): 192-199.

Basics of NIV 70
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