Non Invasive Ventilation
Non Invasive Ventilation
Non Invasive Ventilation
ABSTRACT
Treatment of chronic respiratory failure with noninvasive
ventilation (NIV) is standard pediatric practice, and NIV
systems are commonly used in the home setting. Although
practice guidelines on the perioperative management of children supported with home NIV systems have yet to be published, increasingly these patients are referred for consultation regarding perioperative management. Just as knowledge
of pharmacology underlies the safe prescription of medication, so too knowledge of biomedical design is necessary for
ONINVASIVE ventilation (NIV) refers to a technique of augmenting alveolar ventilation without the
requirement for an invasive artificial airway. The use of NIV
in the home was introduced in the 1980s for the long-term
treatment of sleep apnea, and has more recently been used for
the management of chronic hypercapnic respiratory failure.
Management of acute respiratory failure may also include
NIV, both to avoid invasive ventilation and to facilitate
weaning from mechanical ventilation. Interested readers are
referred to a recent review in Lancet.1 This review focuses on
the use of NIV in the home for the management of chronic
stable respiratory failure and/or obstructive sleep apnea.
Children with Duchenne muscular dystrophy were
among the first patients to be managed with domiciliary NIV
therapy. Children currently represent 10% of patients managed in home ventilation programs.2 Children on home NIV
therapy are now presenting to anesthesiologists for diagnostic
and surgical procedures. There are substantial questions concerning the optimal management of these children: Should
they be permitted the use of their own domiciliary NIV
medical devices? Are they eligible for ambulatory surgical
programs? With respect to their own NIV medical devices,
the ECRI Institute (formerly Emergency Care Research Institute) has cautioned hospitals against the use of patientsupplied medical equipment.3,4 The answers to the above
require a working understanding of the indications for home
NIV therapy, the medical devices used to deliver it, and the
impact of sedative and analgesic medications on NIV therapy. This review provides an overview of the indications for
NIV therapy, an overview of the medical devices available to
Anesthesiology, V 117 No 3
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September 2012
deliver NIV therapy, and a specific discussion of management conundrums facing anesthesiologists. The discussion
focuses on children, because the use of NIV therapy in the
pediatric patient exposes the limitations of NIV systems.
However, these pediatric concerns may also be relevant to
small adults and patients with poor respiratory muscle
strength and reduced respiratory neural drive.
The technique of noninvasive ventilation has two unique
features that distinguish it from invasive ventilation with a
endotracheal tube. First, noninvasive ventilation employs a
nonhermetic technique, and the mask interface is deliberately designed to leak. Second, whereas invasive ventilation
bypasses the upper airway with a endotracheal tube, the noninvasive ventilation system incorporates the upper airway
into the breathing pathway.5 NIV modalities include continuous positive airway pressure (CPAP) and noninvasive positive airway pressure ventilation (NIPPV), both of which deliver a therapeutic positive airway pressure. NIPPV is also
referred to by the acronym NPPV (noninvasive positive pressure ventilation) and BiPAP (bilevel positive airway pressure), and BiPAP is also the name of a NIV medical device
manufactured by Philips Respironics (Murrysville, PA).
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uriCELEX:
31993L0042:EN:HTML. Accessed April 30, 2012.
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Table 1. Design Features of Class I and Class II Medical Devices Available for Home Noninvasive Ventilation
Sleep Apnea Breathing
Therapy Equipment:
Continuous Positive
Airway Pressure Device
Home-care Ventilatory
Support Devices
Home-care
Ventilators for
Ventilator-dependant
Patients
ISO standard
Medical devices
classification
Design
Intended to deliver
Yes
Yes
Yes
No
No
No
Yes
No
No
No
Yes
Yes
Yes
No
No
Mandatory
Optional
Mandatory
Optional
Mandatory
Optional
Specified accuracy
for the expiratory
volume monitor
Protection Devices
Means to allow
spontaneous breathing
during device
failure
Maximum NIV system
pressure
Means to prevent
rebreathing
Alarm conditions
High-inspiratory pressure
Continuing positive
pressure
High and low expiratory
tidal volume and
minute ventilation
Hypoventilation
High and low end-tidal
CO2
Purchase price (USD)
No
No
If volume monitor
provided, accuracy
20% actual value
Mandatory
Mandatory: Expiratory tidal
volume or expiratory
minute ventilation or
expiratory end-tidal
carbon dioxide
20% actual value
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
Mandatory
Not required
Not required
Not required
Not required
Mandatory
Not required
Mandatory
Mandatory
Not required
Not required
Not required
Mandatory
Not required
Not required
Not required
Not required
Not required
Not required
Mandatory
If a capnometer present,
alarms are mandatory
More than $15,000
$2,000$5,000
$6,000
Brown et al.
vices and Class II ventilators with NIV capabilities. Delivery of NIV therapy relies on a nonhermetic technique
and requires a high-resistance exhaust port/expiratory
valve located on the mask or mask connection. The exhaust port discharges a continuous intentional leak during
normal operating conditions. In addition, the imperfect
seal of the mask to the face is an additional source of
leakage: the unintentional leak. The magnitude of the
unintentional leak varies with the phase of respiration,
with shifts in the mask position and with changes in the
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compliance and resistance of the upper airway and respiratory system. Modern NIV devices are equipped with
microprocessors and sophisticated proprietary algorithms
that adjust the rate of gas flow to compensate for the
variable unintentional leak.
Although NIV systems will fit a 15 mm/22 mm connector, they are not intended for use with tracheal tubes. The
leak around an invasive uncuffed tracheostomy tube is insufficient to adequately discharge the high rate of inspiratory gas
flow, in excess of 20 l/min, without injury. Home ventilators
for invasive ventilation are indicated in tracheostomized
patients.23
NIV systems have three additional design features. First,
all NIV devices are equipped with a pressure sensor located in
the flow generator to detect high airway pressure. Second, all
NIV systems are equipped with a pressure regulation valve in
the flow generator and design features to limit the maximum
pressure to 40 cm H2O in Class 1 NIV devices and to 60 cm
H2O in Class II ventilators with NIV capabilities (table 1).
And third, home NIV devices are intended for dedicated use
in single patient and are not designed to function with in-line
filters.
CPAP Devices. CPAP devices are designed to deliver a
continuous distending pressure throughout the patients
respiratory cycle.26 The minimum performance for the
delivery of positive airway pressure is 1.5 cm H2O of
the set pressure.22,27
NIPPV Systems. NIPPV devices are designed to deliver a
cyclical application of two levels of positive pressure: IPAP
and EPAP. This requires design features that sense the phase
of respiration8,26 and trigger the transitions between IPAP
and EPAP.
The sensitivity of the trigger function represents an important limit to the use of NIPPV in small children, particularly those with poor respiratory muscle strength,18,26,28
because their low rates of inspiratory flow may be insufficient
to initiate the inspiratory trigger.8 This is one of the reasons
NIV devices are not intended for use in patients weighing less
than 30 kg. For these children, ventilators with NIV capabilities offer a better option.
Pressure-targeted NIPPV Systems
Most bilevel pressure NIV systems achieve the IPAP level by
increasing the rate of gas flow during inspiration, until the
predefined positive airway pressure target is attained. It is
beyond the scope of this review to discuss all NIV modalities,
and readers are directed to a comprehensive review in Thorax.5 The two basic NIV modalities are pressure-targeted
NIPPV and volume-targeted NIPPV. The majority of home
NIV systems use pressure-targeted modalities.
The EPAP is titrated to eliminate obstructive airway
events, and IPAP is titrated to attenuate hypercarbia during
sleep. The usual levels of IPAP and EPAP range from 10 to
16 cm H2O and from 4 to 5 cm H2O, respectively. NIPPV
devices have less pressure-generating capacity than ventilators.7 The magnitude of inspiratory assist depends on the
difference between IPAP and EPAP.18 However, the NIV
systemlung assembly does not behave as a single compartment model, because the upper airway presents a variable
resistance. Increasing the airway pressure may not increase
the effective ventilation to the patient.5
Volume-targeted Devices
Volume-targeted NIPPV devices deliver a set flow to the
airway for a defined time interval or until a preset volume is
obtained. The presence of leaks at the mask interface requires
a design feature capable of delivering very large gas flows
during the inspiratory phase of the respiratory cycle.8 These
gas flow rates may exceed 150 l/min.
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Fig. 3. Representative tracing showing the response to a noninvasive ventilation system with a minimum guarantee mode to
a perturbation. The inspiratory positive airway pressure increased in order to achieve the minimum guaranteed tidal volume. The
onset and offset response times ranged from 1 to 51 breaths. The tidal volume decreased transiently during the onset and
increased transiently during the offset. The specific responses to three types of perturbations are shown in the accompanying
table. IPAP inspiratory positive airway pressure; NIV noninvasive ventilation; VT tidal volume. Adapted from Fauroux et
al.29 and reprinted with permission.
For children, nasal masks are preferred, in part to minimize the apparatus dead space and facilitate the trigger functions of the NIV systems. During normal operation, mouth
breathing increases the gas leakage, and parents may devise
ways and means to ensure the mouth remains closed during
sleep (i.e., chin straps).
In pressure-targeted NIV systems, the magnitude of the
inspiratory assist decreases during perturbations such as increased upper airway resistance, decreased lung compliance,
or increased unintentional leak. Modern NIV systems offer a
volume guarantee mode that will deliver a minimum level
of ventilation when such perturbations occur. The efficacy of
the volume guarantee mode was recently tested in six NIV
systems.29 Perturbations sufficient to decrease tidal volume
(VT) were determined. The ventilators were set in the volume guarantee mode to deliver a minimum VT. The response to a perturbation was to increase IPAP (fig. 3). With
perturbations in airway resistance or lung compliance, five of
six NIV systems achieved the guaranteed minimum VT.
However, when the unintentional leak increased, only one
NIV system achieved it. Auto-triggering, or the delivery of a
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common conduit (fig. 4). As the exhaust port purposely offers a high resistance, the expiratory pathway may include the
low-resistance breathing tube. A high rate of gas flow is required to prevent rebreathing during normal use.30 The risk
of rebreathing decreases with increasing airway pressure
(higher gas flows). The NIV systems are designed such that
during normal use, the time-weighted average for inspired
carbon dioxide is 1%, a limit which harmonizes with that
allowed in occupational health exposure.25 A minimum
mandatory EPAP level of 3 or 4 cm H2O (gas flow around 20
l/min) is needed to ensure adequate washout of exhaled carbon dioxide.
The risk of rebreathing is maximal when inspiratory gas
flow ceases. In the event of a power failure, the inspired
carbon dioxide level will rise precipitously, coincident with a
fall in inspired oxygen (fig. 5). Although a battery reserve
should protect from electrical power failure, battery life is
difficult to predict and often brief. Class I medical devices
may not be equipped with a battery backup. Therefore, the
design of NIV equipment incorporates a means to allow
spontaneous breathing in the event of a device failure. This
may be accomplished by including an antiasphyxiation valve
in the NIV mask. A nasal NIV mask should have less risk of
asphyxiation because the child can initiate mouth breathing.
However, mouth breathing may not be possible if chin straps
are used. In NIV systems, the short-term exposure limit for
inhaled carbon dioxide is 3% (about 22 mmHg), a limit that
assumes that the physiologic arousal response will be sufficient to rouse the patient.22,25
Fig. 5. Rebreathing potential in noninvasive ventilation systems. During normal use, elimination of exhaled carbon dioxide depends on a high rate of gas flow. In the conventional
continuous positive airway pressure system (A), an electrical
power-off scenario results in rebreathing of exhaled gas.
There is a rapid rise in inspired carbon dioxide and fall in
inspired oxygen concentration. Design features that include
nonrebreathing valves (B) mitigate the risk for rebreathing.
NIV noninvasive ventilation. Reproduced with permission
from Farre et al.30
tion, including the NIV modality, the rate of gas flow rate,
the minute ventilation, and the location at which oxygen is
delivered into the NIV system. In healthy volunteers on NIV
therapy, a maximum inspired oxygen concentration of 67% was
reported.31 However, the inspiratory oxygen concentration
achieved in patients on NIV devices is often less than 50%.
Perioperative Management Conundrums in Patients
Supported with Domiciliary NIV
Patient Selection. The safe use of NIV to support ventilation following surgery requires selection of both appropriate patients and NIV systems, and a recognition that the
clinical scenario in the hospital differs from that in the
home environment.
In hospitalized patients, eligibility criteria for NIV support are the ability to call for help, to pass 15 min off NIV
without respiratory decompensation, and to maintain oxygen saturation with modest inspired oxygen concentrations.1,32 Health Canada advises that patients who have a
limited ability to adjust or remove the NIV mask should be
attended at all times.# NIV therapy is contraindicated if
children are apneic, unable to protect their own airway, unable to maintain the patency of the upper airway, have a
reduced level of consciousness, or have an unstable respiratory status.33
# http://hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2012/
index-eng.php. Accessed April 30, 2012.
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intravenous sedation. The respiratory status further deteriorated, requiring invasive ventilation.17
Because NIV devices are used in a home environment,
their use on hospital wards might seem reasonable. However,
mishaps during NIV therapy have been reported in hospitalized patients. In one case, the CPAP device was misassembled.35 Another patient died because of NIV system failure, and a third death was linked to NIV system-related
infection.3 Health Canada advises that medical staff caring
for patients supported by NIV systems should be knowledgeable of the capacities and limitations of NIV systems.# The
safe use of NIV therapy on the wards requires the selection of
patients with stable respiratory failure, the availability of expert and adequately trained staff throughout a 24-h period,
adequate monitoring, and immediate access to invasive ventilation in the event of respiratory deterioration.1,32
In addition, the settings for NIV systems that are adequate in the home environment may not be therapeutic in
the postoperative period, as illustrated in figures from three
consecutive nocturnal NIV recordings (figs. 7 and 8). Figure
7A is a representative baseline trace of internally logged data
from a home NIV system; the set EPAP and IPAP levels of 4
and 15 cm H2O, respectively, were achieved throughout
13 h of use. During the majority of the record, there were no
patient-triggered breaths, and ventilation was supported entirely with the NIV system, at a backup rate of 25 breaths/
min. The estimated tidal volume was 277 ml and the estimated minute ventilation was 6.8 l/min. Following surgery
(fig. 7B), the set EPAP and IPAP levels were identical and
achieved throughout 18 h of use. However, patient-triggered
breaths are now present throughout the record, likely reflecting a combination of wakefulness and pain. The recorded
tidal volume has decreased to 202 ml. During the following
night (fig. 8), the set EPAP and IPAP levels were unchanged
and achieved throughout the 22 h of use, but the recorded
tidal volume has now decreased to 98 ml. The levels of positive airway pressure, which were therapeutic in the home
environment, are now inadequate.
NIV systems rely on the patients reflex and arousal mechanisms to monitor the function of the NIV system. Sedative
and analgesic medication may blunt arousal and reflex defenses. Because the safe use of NIV systems is predicated on
an intact physiologic defense system, children on domiciliary NIV systems should not be discharged home until
these protective and defense mechanisms have returned13
(fig. 6). Children with continuous home NIPPV therapy
have a limited respiratory reserve and are at extreme risk
for respiratory complications following anesthesia and
surgery. These children are poor candidates for ambulatory programs.13
Which Surgical Procedures?
As NIV systems include the upper airway in the breathing
pathway, compromise of nasopharyngeal airway patency
may limit the efficacy of NIV therapy. Surgeries associated
with upper airway edema, bleeding, nasal congestion, and
surgical packings may obstruct the upper airway, and affect
the efficacy of NIV therapy. Pulmonary function may be
affected in the postoperative period, and supplemental oxygen may be required. In addition, the settings for the NIV
system may require adjustment. IPAP levels of 10 16 cm
H2O usually provide sufficient support. Children become
uncomfortable if IPAP settings exceed 20 cm H2O.18 The
maximum IPAP for preadolescent children is 20 cm H2O,
and for adolescents the maximum is 30 cm H2O.34 Higher
levels of IPAP may increase the gas leak, and the straps securing the NIV mask may require adjustment.
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Fig. 7. Representative figures illustrating the limitations of a noninvasive positive pressure ventilation system in the hospital
environment. In both the home (A) and hospital (B) use scenarios, the set levels of inspiratory positive airway pressure and
expiratory positive airway pressure were identical. However, the efficacy of the ventilatory support differed. EPAP
expiratory positive airway pressure; IPAP inspiratory positive airway pressure; NIPPV noninvasive positive pressure
ventilation.
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Fig. 8. Representative figure in a postoperative scenario showing the limitation of the same noninvasive positive pressure ventilation
system illustrated in Fig. 7. The set levels of inspiratory positive airway pressure and expiratory positive airway pressure remain
unchanged from those in figs. 7A and 7B; however, the level of ventilatory support is much lower. EPAP expiratory positive airway
pressure; IPAP inspiratory positive airway pressure; NIPPV noninvasive positive pressure ventilation.
Summary
Treatment of refractory obstructive sleep apnea and chronic
respiratory failure with home NIV is now standard pediatric
practice. Anesthetic and analgesic medications induce apnea,
depress respiratory drive, decrease compliance of the respira-
Recommendations
Anesthesiologists increasingly encounter children who are
supported on home NIV therapy and are asked for advice on
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