Non-Invasive Ventilation: Definition, Types, And Indications

What is Non-Invasive Ventilation?

Question:

Discuss about the Noninvasive Ventilation for Ventilator Assistance.

Non-Invasive ventilation technique is a method that entails the use of ventilator assistance in the affected patient’s nasal way (nasal passage way/nostril) using a mask or similar devices and not through surgical means. It may also be identified as the technique that provides and enhances alveolar ventilation without the use of an endotracheal intubation (Linda Gray-Clinical Specialist). Popularly abbreviated as NIV, it is very different from other ventilation methods. Noninvasive ventilation is majorly used to adult patients. The method does not involve the use of a tracheal tube, laryngeal mask or tracheostomy. While all other methods are considered invasive, Non-Invasive Ventilation as its name suggests is not invasive. It does not involve tubes being put in your nasal airway or body. It is divided in two ways; one is the NPV meaning negative pressure ventilation while the other is NIPPV to mean non-invasive positive pressure ventilation. This ventilation method is used to help adults with difficulty in gas exchange in the lungs, chronic hypercapnia respiratory failure and COPD meaning chronic obstructive pulmonary disease. In this case BiPAP or CPAP is applied. BiPAP means Bilevel Positive Airway Pressure, while CPAP means Continuous Positive Airway Pressure.  Each of these models i.e. BiPAP and CPAP requires a certain machine. The machine is connected to an electrical outlet which allows air under pressure to enter into the respiratory system of the patient, with respiratory problem. The air under increased pressure passed through a tube to a patients mouth whereby a tightly fitted mask to ensure that no air is leaking to the environment, and thus all air is entering the patient’s respiratory system. This is done to ensure that the patient’s lungs do not dilate hence the live of the patient is saved. In addition to mouth mask, a nose mask is also used. In order to keep the mask tightly placed at the mouth or the nose, a string is connected to the mask and tied at the back of the patient’ head

Respiratory failure is the inability to maintain the required air circulation and change in gas. It mostly is characterized by abnormal tensions of gases in the arterial blood (Bourke, Bullock, Williams, Shaw and Gibson, 2011). Non-invasive ventilation has a number of benefits which includes avoiding intubation with its accompaniment of death rates and prevalent sicknesses that include pneumonia. It also allows for intermittent ventilator assistance thus allowing for gradual weaning and eating normally. When NIV is applied, they mostly consider the Continuous Positive Airway Pressure (CPAP), that is, for sick individuals who have reduced functional residual capacity (FRC), type 1 respiratory failure and acute LVF. Bilevel Positive Airway Pressure (BiPAP) can also be considered for sick individuals with type 1 respiratory failure where these patients are tiring PaCO₂↑ TV↑ LOC↑ and type 2 failure with patients of acute episodes. Although it is a preferable method for ventilation, it is not advisable for every sick individual who has respiratory failure. It should only be applied by a trained technician or physician using an optimal ventilator on appropriate clinical environment.

Types of Non-Invasive Ventilation Machines

Consider a scenario whereby adult patient at the advanced levels of neuromuscular illness that is progressive with breathlessness at arrival in hospital. Deep breathes of difficulty followed by tiring gasps (Brochard, Mancebo, Wysocki, Lofaso, Rauss and Isabey,2009). Such respiratory illnesses show some certain indications and contraindications that the medical practitioners use to determine whether to use the non-invasive techniques or use the past ventilation techniques.

Non-invasive indications are conditions that satisfy or allow for use of the non-invasive ventilation techniques on patients. They mostly are like symptoms that are shown by the patient to allow for such treatment ( Confalonieri, Potena, Carbone, Porta, Tolley and Umberto Meduri,  2008). For a patient to qualify for the non-invasive ventilation method they should pass through a screening process and the indications should include; obstructive sleep apnea syndrome, which is a proper candidate for the technique, chronic obstructive pulmonary disease with exacerbation qualify for the technique, bilateral pneumonia are proper candidates.

There are also other syndromes to be considered in order to determine a patient who need noninvasive ventilation. These includes, A patient with acute congestive heart failure with pulmonary edema is also a proper candidate, neuromuscular disorders, a patient with acute lung injury is a potential candidate, asthma also qualifies to be a candidate for the technique (Girou, Schortgen, Delclaux, Brun-Buisson, Blot, Lefort and Brochard, 2008). Patients with difficulty in gas exchange in the lungs accepting lung resection surgery may allow for use the non-invasive ventilation technique, patient with obesity hypoventilation syndrome is a qualified candidate for the technique, weaning from ventilator.

Non-Invasive Ventilation method also has its contraindications. Contraindications are signs that disqualify the use of the Non-Invasive Ventilation method on a patient. These are the signs and symptoms that the patient portrays that make the use of this method harmful to the patient’s health (Gray, Goodacre, Newby, Masson, Sampson and Nicholl, 2008). There are two types of contraindications when it comes to Non-Invasive Ventilation. There is both absolute contraindications and relative contraindications.

The absolute contraindications of this method are quite a number and they include; Respiratory arrest or unstable cardiorespiratory status (Hilbert, Gruson, Vargas, Valentino, Gbikpi-Benissan, Dupon and Cardinaud, 2008). In case a patient is about to go on a respiratory shock or has unstable cardio flow; it is mostly advisable to resist application of the NIV. It may result in lots of complications which may include death. Such a state may require the use of invasive techniques in order to stabilize the respiratory system.

Other absolute contraindications include, uncooperative patients. Some patients may not prefer the use of Non-Invasive Ventilation equipment due to some discomfort. Most patients will refuse the use of facial or nasal masks. Inability to protect airway (Kramer, Meyer, Meharg, Cece,  Hill, 2008). When the patient has impaired swallowing and coughing, that is, the food may leave the esophagus into the trachea. This may cause lots of complications. Trauma or burns involving the face. When the patient has burns or injuries involving the face, the toxic gases released by the wound may cause skin irritation or many other unintended diseases. Facial, esophageal or gastric surgery. In case the patient has had facial, esophageal or gastric surgery, it is very much advised not to use the non-invasive ventilation because it may make upsets to the unhealed wounds. This may lead to lots of complications.

Indications of Non-Invasive Ventilation

In addition to absolute contraindications include Patients with Apnea (poor respiratory drive) should not be encouraged to follow through on application of Non Invasive Ventilation technique. Sick individuals with reduced or low consciousness are not advisable patients to be put under such a technique because it may lead to the suffocation and choking of the patients (Shneerson and Simonds, 2009). When a patient has air leak syndrome, it is strongly advised to use invasive ventilation method and not the non-invasive method. Life threatening dysrhythmias in a patient is severe and thus the use of invasive technique encouraged over the use of its counterpart. Continuous Positive Airway Pressure (CPAP) in lung injury is also a disqualification from the non-invasive ventilation technique. 

The non-invasive ventilation method commonly preferred is the BiPAP which is used by individuals suffering from sleep apnea. It prevents the lungs from collapsing and allows for relaxed breathing during sleep. The comparative advantage of BiPAP is that the breaths can be timed for maximum delivery of gaseous exchange in the lungs thus providing comfort. This allows for the individual to get greater air in and out during breathing reducing clogging. An indication that BiPAP is superior to CPAP is that BiPAP is quite oftenly used when CPAP is not successful in treating a patient. BiPAP machines come in different sizes allowing for easy movement and storage and self-operation after understanding its use and operation. BiPAP is mostly referred to candidates with breathing problems.

The steps to be taken or procedures to be followed while using BiPAP masks may include: Within 24 hours of initiation of therapy, a clear plan for the nursing care should be provided and documented while the patient is getting Non Invasive Ventilation (Nava, Ambrosino, Clini, Prato, Orlando, Vitacca and Rubini, 2008). The Oral hygiene of the patient should be maintained at an interval of two hours as long as the patient’s tolerance to cessation of the non-invasive ventilation is greater than or over five minutes. The patient’s eye care is to be checked at an interval of two hours by the proper clinical physicians. This should be done without hesitance or delay. A full body wash, including shaving the patient’s face, is to be done every single day or many times as instructed or requested and required in response to the patient diaphoresis and the patient’s level of tolerance.

Other steps are, all patients are to receive pressure injury prevention management as instructed by the practitioners, professionals and supervisors. This is to reduce the fatality and complications that sometimes arise from the use of the non-invasive ventilation method. Every Patient is should be advised and encouraged to sit out of bed as allowed by the technique. When in bed they are to be put in an upright position to facilitate and allow for chest wall expansion to give way for comfort in the ventilation process for the patient (Murgu, Pecson and Colt, 2010. The mobility or movement of the patient should be encouraged, assessed and monitored as per the guidelines provided by the medical practitioners and the doctors of the hospital. Assistance should be provided during such exercises. On clinical presentation or initiation of therapy, Pharmacotherapies are to be noted down and implemented as required in response to patient evaluation and assessment. Any referral to an allied health professional is to be implemented where services are available in the clinical environment to support the patients and their significant others’ psychosocial wellbeing.

Contraindications of Non-Invasive Ventilation

Every human method ever invented has its pros and cons, and the Non-Invasive Ventilation method including the BiPAP machine has no exception. As much as Non-Invasive Ventilation may be used to support respiratory failure disease, it may cause problems. The use of Non-Invasive Ventilation such as BiPAP may not be 100% or even 90% accurate for solution to the health care problem. It may even result to certain complications which may deteriorates the patient’s health. Non-invasive ventilation technique is associated with frequent life-threatening and frequent adverse effects which are very severe. This should encourage thorough screening of patients before suggestion or referral to the technique. This will reduce the number of severe complications experienced. The complications are strongly correlated with the degree of pulmonary and cardiovascular involvement.

Non-Invasive Ventilation is to be applied with great care in sick individuals with pulmonary process such as lobar pneumonia. BiPAP being a form of ventilation method that is non-invasive is very useful. One of its uses is by sick individuals with sleep apnea. Its function is very similar to the CPAP. It is of two levels that is time-pedaled to achieve maximum efficiency in its functions. These machines can be used in a controlled environment which includes hospitals and homes but with close supervision and maintenance to date of the equipment and machines.

Distention of the stomach because of aerophobia aspiration following vomiting while still negative pressure ventilation (Mehta and Hill, (2010). This may cause preload reduction and hypertension. This also includes Inability to or difficulty in relieving dyspnea and Inability to or difficulty in improving gas exchange in the respiratory system. However, failure of the Non-invasive ventilation technique depends on factors such as delayed application of the Non-invasive ventilation treatment. Whereby it may worsen the patient’s respiratory illness and create some complications that the non-invasive ventilation cannot be useful. Other failure includes inappropriate or unwanted ventilation pressures, Low or inexperience of the clinical staff or team and also, the patient’s clinical state or condition which maybe be as a result of two or more organ failures.

In conclusion, the application of the Non Invasive Ventilation method is widely accepted and used in many clinical environments. It has proven to reduce mortality than its invasive counterpart and still provide respiratory comfort to the patient. Despite its complications, the method is quite effective and very efficient. If every procedure for its application is followed to the latter, then the success stories will be its only tale to tell. Much improvement still needs to be implemented and that will be done with more researches as time passes. But all in all, the non-invasive ventilation method should be administered in all clinical settings.

References

Bourke, S. C., Bullock, R. E., Williams, T. L., Shaw, P. J., & Gibson, G. J. (2011). Noninvasive ventilation in ALS Indications and effect on quality of life. Neurology, 61(2), 171-177.

Brochard, L., Mancebo, J., Wysocki, M., Lofaso, F., Conti, G., Rauss, A., ... & Isabey, D. (2009). Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. New England Journal of Medicine, 333(13), 817-822.

Confalonieri, M., Potena, A., Carbone, G., Porta, R. D., Tolley, E. A., & Umberto Meduri, G. (2008). Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation. American Journal of Respiratory and Critical Care Medicine, 160(5), 1585-1591.

Girou, E., Schortgen, F., Delclaux, C., Brun-Buisson, C., Blot, F., Lefort, Y., ... & Brochard, L. (2008). Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. Jama, 284(18), 2361-2367.

Gray, A., Goodacre, S., Newby, D. E., Masson, M., Sampson, F., & Nicholl, J. (2008). Noninvasive ventilation in acute cardiogenic pulmonary edema. New England Journal of Medicine, 359(2), 142.

Hilbert, G., Gruson, D., Vargas, F., Valentino, R., Gbikpi-Benissan, G., Dupon, M., ... & Cardinaud, J. P. (2008). Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. New England Journal of Medicine, 344(7), 481-487.

Kramer, N., Meyer, T. J., Meharg, J., Cece, R. D., & Hill, N. S. (2008). Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. American journal of respiratory and critical care medicine, 151(6), 1799-1806.

Masip, J. (2010). Non-invasive ventilation. Heart failure reviews, 12(2), 119-124.

Mehta, S., & Hill, N. S. (2010). Noninvasive ventilation. American journal of respiratory and critical care medicine, 163(2), 540-577.

Murgu, S. D., Pecson, J., & Colt, H. G. (2010). Bronchoscopy during noninvasive ventilation: indications and technique. Respiratory care, 55(5), 595-600.

Nava, S., Ambrosino, N., Clini, E., Prato, M., Orlando, G., Vitacca, M., ... & Rubini, F. (2008). Noninvasive Mechanical Ventilation in the Weaning of Patients with Respiratory Failure Due to Chronic Obstructive Pulmonary DiseaseA Randomized, Controlled Trial. Annals of internal medicine, 128(9), 721-728.

Nava, S., Gregoretti, C., Fanfulla, F., Squadrone, E., Grassi, M., Carlucci, A., ... & Navalesi, P. (2010). Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Critical care medicine, 33(11), 2465-2470.

Nava, S., Navalesi, P., & Carlucci, A. (2009). Non-invasive ventilation. Minerva Anestesiol, 75(1-2), 31-36.

Ozyilmaz, E., Ugurlu, A. O., & Nava, S. (2014). Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies. BMC pulmonary medicine, 14(1), 19.

Shneerson, J. M., & Simonds, A. K. (2009). Noninvasive ventilation for chest wall and neuromuscular disorders. European Respiratory Journal, 20(2), 480-487.

Vianello, A., Arcaro, G., Battistella, L., Pipitone, E., Vio, S., Concas, A., ... & Iliceto, S. (2014). Noninvasive ventilation in the event of acute respiratory failure in patients with idiopathic pulmonary fibrosis. Journal of critical care, 29(4), 562-567.