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Noninvasive Ventilation: Continuous Positive Air Pressure Ventilation (CPAP) and Pressure Support Ventilation (PSV)

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Teaching Pearls in Noninvasive Mechanical Ventilation

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Abstract

Background and objectives: Acute Respiratory Failure (ARF) in Idiopathic Pulmonary Fibrosis (IPF) patients (pts) is associated with poor prognosis, therefore a noninvasive approach, such as noninvasive ventilation (NIV) may represent a good option to turn to. NIV modes: Continuous positive airway pressure (CPAP) in spontaneous breathing (SB) (range 8–10 cmH2O level) is applied in the absence of respiratory acidosis in order to treat hypoxemia with tachypnea. FiO2 is set at the lowest value to keep PaO2 at more than 60 mmHg. Hypercapnia, hypoventilation and respiratory fatigue are treated in assisted/controlled ventilation by face-mask (FM) in Pressure Support ventilation (PSV). Pressure Support (PS) and Positive End Expiratory Pressure (PEEP) level are generally imposed respectively equal to 12–18 and 4–9 cmH2O, titrated to provide a moderate tidal volume (TV) (6–8 mL/kg of predicted body weight). When NIV-Helmet is applied, PS and PEEP baseline levels are respectively set at 10 and 5 cmH2O, both raising in increments of 2–3 cmH2O. FM advantages: higher efficacy in improving CO2 elimination and reducing work of breathing while applying PSV in pts with high respiratory muscle load. Disadvantages: not tolerated in pts who need prolonged MV. Helmet advantages over FM: improved tolerability and lesser air leaks as with a new helmet that can be performed for prolonged periods of time. Disadvantages: because of its larger inner volume, standard helmet is characterized by less efficient rates of pressurization and triggering function, worsening patient–ventilator synchrony. In pts with high respiratory drive and intense inspiratory effort, the risk of patient self-inflicted lung injury (P-SILI) is highly considerable. Conclusions: NIV by helmet in CPAP mode and face-mask in PSV provides relief from dyspnoea and avoids endo-tracheal intubation (ETI).

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Notes

  1. 1.

    Hypoxaemic respiratory failure is usually defined as significant hypoxaemia (P/F ≤ 200), tachypnoea (respiratory rate > 30–35 breaths·min−1) or use of accessory respiratory muscles or paradoxical abdominal motion, and a non-COPD diagnosis (e.g. pneumonia and/or acute respiratory distress syndrome (ARDS) [19].

Abbreviations

% pred:

Percent of predicted value

AE-IPF:

Acute exacerbation of IPF

ARDS:

Acute respiratory distress syndrome

ARF:

Acute respiratory failure

CPAP:

Continuous positive airway pressure

DAD:

Diffuse alveolar damage

DNR:

Do not resuscitate

DP:

Driving pressure

ECCO2R:

Extracorporeal CO2 removal

ETI:

Endotracheal intubation

FEV1:

Forced expiratory volume in the 1st second

FEV1/FVC ratio:

Forced expiratory volume in the 1st second/Forced Vital capacity

FiO2:

Inspired oxygen fraction

FMV:

Face-mask ventilation

FVC:

Forced Vital capacity

GCS:

Glasgow Coma Scale score

HFOT:

High flow oxygen therapy

HRCT:

High resolution computed tomography

ICU:

Intensive care unit

ILD:

Interstitial lung disease

IMV:

Invasive mechanical ventilation

IPF:

Idiopathic pulmonary fibrosis

MOF:

Multiple organ failure

MV:

Mechanical ventilation

NIV:

Noninvasive mechanical ventilation

NMBAs:

Neuromuscular blocking

P/F:

PaO2/FiO2: ratio of PaO2 to fraction of inspired oxygen

PaCO2:

Carbon dioxide arterial pressure

PaO2:

Oxygen arterial pressure

PBW:

Predicted body weight

PEEP:

Positive end expiratory pressure

P-SILI:

Patient self-inflicted lung injury percentage (%)

PSV:

Pressure support ventilation

pts:

Patient/s

RICU:

Respiratory intensive care unit

RR:

Respiratory rate

SaO2:

Arterial oxygen saturation

SAPS:

Simplified acute physiology score

SB:

Spontaneous breathing

TLC:

Total lung capacity

TV:

Tidal volume

UIP:

Usual interstitial pneumonia

VAP:

Ventilator-associated pneumonia

VILI:

Ventilator-induced lung injury

WOB:

Work of breathing

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Acknowledgements

Fabrizio Bigotti, PhD, and Francesca Niutta for revising the final draft of this paper.

Author information

Authors and Affiliations

  1. Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Rome, Italy

    Edoardo Piervincenzi

  2. Pediatric Intensive Care Unit, Emergency Department, Ospedale Pediatrico Bambino Gesù-IRCCS, Rome, Italy

    Giorgio Zampini

  3. Pediatric Intensive Care Unit, Children’s Hospital “Bambino Gesù”, Rome, Italy

    Daniela Perrotta

Authors
  1. Edoardo Piervincenzi
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Corresponding author

Correspondence to Edoardo Piervincenzi .

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Editors and Affiliations

  1. Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain

    Antonio M. Esquinas

1 Electronic Supplementary Material

Ventilatory mode, basic presssure, volume and flow waveforms_1 (MOV 30802 kb)

Ventilatory mode, basic presssure, volume and flow waveforms_2 (MOV 11819 kb)

Ventilatory mode, basic presssure, volume and flow waveforms_3 (MOV 18342 kb)

Ventilatory mode, basic presssure, volume and flow waveforms_4 (MOV 15689 kb)

Ventilatory mode, basic presssure, volume and flow waveforms_5 (MOV 14039 kb)

Ventilatory mode, basic presssure, volume and flow waveforms_6 (MOV 19727 kb)

Ventilatory mode, basic presssure, volume and flow waveforms: BIPAP Mode_1 (MOV 20894 kb)

Ventilatory mode, basic presssure, volume and flow waveforms: BIPAP Mode_2 (MOV 58798 kb)

Ventilatory mode, basic presssure, volume and flow waveforms: CPAP Mode_1 (MOV 33981 kb)

Ventilatory mode, basic presssure, volume and flow waveforms: CPAP Mode_2 (MOV 78519 kb)

Ventilatory mode, basic presssure, volume and flow waveforms: CPAP Mode_3 (MOV 21043 kb)

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Piervincenzi, E., Zampini, G., Perrotta, D. (2022). Noninvasive Ventilation: Continuous Positive Air Pressure Ventilation (CPAP) and Pressure Support Ventilation (PSV). In: Esquinas, A.M. (eds) Teaching Pearls in Noninvasive Mechanical Ventilation. Springer, Cham. https://doi.org/10.1007/978-3-030-71298-3_7

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  • DOI: https://doi.org/10.1007/978-3-030-71298-3_7

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