Introduction to Non-Invasive Positive Pressure Ventilation (NIPPV)

Bilevel Positive Airway Pressure (BiPAP)

BiPAP is more complex than CPAP because it delivers two distinct levels of pressure:

1. Inspiratory Positive Airway Pressure (IPAP): A higher pressure delivered when the patient inhales to assist with ventilation (moving air in and out).
2. Expiratory Positive Airway Pressure (EPAP): A lower pressure (similar to CPAP) delivered when the patient exhales to keep the airways open.

BiPAP is particularly useful for patients with muscle weakness (such as Duchenne muscular dystrophy) or parenchymal lung disease, as it improves both oxygenation and ventilation. An example setting is $10/5\text{ cm H}_2\text{O}$ (IPAP/EPAP).

Respiratory Interfaces

The effectiveness of NIPPV is heavily dependent on the "interface"—the device that connects the patient to the ventilator. Common interfaces include:

• Nasal cannulas (primarily for HFNC)
• Nasal masks
• Oronasal (mouth and nose) masks
• Full-face masks

Clinical Applications

Indications

NIPPV is indicated for a variety of respiratory and physiological needs in neonates, infants, and children:

• Respiratory Conditions: Mild to moderate respiratory failure, bronchiolitis, severe asthma, pneumonia, or cystic fibrosis.
• Neuromuscular Disorders: Conditions like spinal muscular atrophy or Duchenne muscular dystrophy.
• Airway/Sleep Disorders: Obstructive sleep apnea or airway collapse (e.g., tracheomalacia).
• Physiological Support: To treat hypoxemia or hypercapnia, reduce the work of breathing (WOB), or recruit collapsed lung regions to improve ventilation/perfusion (V/Q) mismatch.

Contraindications

Clinicians must carefully screen patients to ensure they are safe candidates for NIPPV.

Exam Tip: Absolute vs. Relative Contraindications Always distinguish between when NIPPV is strictly forbidden (Absolute) and when it requires extreme caution (Relative).

Absolute Contraindications (Do not use):

• Respiratory arrest or apnea.
• Unstable cardiorespiratory status or multi-organ failure.
• Inability to protect the airway (impaired swallowing or cough).
• Facial trauma, burns, or recent facial/gastric surgery.
• Decreased consciousness or uncooperative patient.

Relative Contraindications (Use with caution):

• Hemodynamic instability.
• Poor secretion control.
• Extreme anxiety.

Monitoring and Complications

When using equipment like the Philips V60, clinicians must monitor alarm settings, graphics displays, and machine settings to ensure patient safety.

Potential Complications

While NIPPV is safer than intubation, it is not without risks. Complications can be categorized by the body system they affect: