22: Non‐Invasive Positive Pressure Ventilation

Non‐Invasive Positive Pressure Ventilation

Anirban Basu1, Raymonde Jean2, and Fulvia Milite3

1 Weill Cornell Medical College, New York, NY, USA

2 Icahn School of Medicine at Mount Sinai, New York, NY, USA

3 White Plains Hospital, White Plains, NY, USA


  • NPPV is defined here as positive pressure ventilation delivered without an endotracheal airway, through a non‐invasive interface.
  • HFNC is a form of high flow O2 support. Minimal ventilatory support is provided with this device.
  • NPPV support has gained acceptance in the last three decades and its use has increased over time.
  • Improved outcomes with specific diseases have been definitively shown.
  • Decreased cost has been shown compared with the use of invasive mechanical ventilation.

Principles of action


  • The positive pressure administered via the non‐invasive mask reduces the transthoracic pressure requirements for generating tidal breaths and thereby reduces the work of breathing.
  • Improves ventilation and gas exchange by enabling better tidal volumes.
  • Allows rest for the respiratory muscles (diaphragm, accessory muscles).
  • Decreases left ventricular afterload.
  • Decreases right ventricular and left ventricular preload.
  • Increases hydrostatic pressures within the alveoli to mobilize pulmonary edema fluid.
  • Prevents airway collapse in obstructive lung diseases.
  • Maintains upper airway patency (especially during sleep) in patients with obstructive sleep apnea.

Benefits in acute respiratory failure

  • Reduces the need for endotracheal intubation.
  • Prevents intubation‐associated complications (airway trauma, ventilator‐associated events).
  • Shortens length of stay in the ICU and hospital.
  • Improves patient comfort.
  • Reduces sedation requirements.


  • Delivers higher oxygen flow rates via large bore nasal cannula compared with conventional nasal cannula devices.
  • In patients with a high respiratory workload, inspiratory flow rates are high and room air is entrained. The high flow rates provided with HFNC lead to less room air dilution of the administered oxygen, therefore higher FiO2 is delivered.
  • Provides a minimal amount of positive pressure secondary to its high flow rates. It has been shown that with the mouth closed, pharyngeal pressure (end‐expiratory pressure) increases as flow increases. End‐expiratory lung volume is higher.
  • Provides good humidification which can reduce airway irritation and improve mucous clearance.
  • Decreased anatomic dead space compared with use of NPPV due to increased carbon dioxide washout.

Benefits in acute respiratory failure

  • Reduces the need for endotracheal intubation.
  • Prevents intubation‐associated complications (airway trauma, ventilator‐associated events).
  • Improves patient comfort.
  • Reduces sedation requirements.
  • Allows for continuation of activities such as talking and eating.
  • Can be used in the presence of secretions.

Indications and contraindications

  • NPPV is effective in patients with ARF due to acute COPD exacerbation and cardiogenic pulmonary edema.
  • HFNC is emerging as an effective therapy in selected patients with hypoxemic respiratory failure.
  • Patients must be carefully selected (Tables 22.1 and 22.2).

Table 22.1 Indications and contraindications for NPPV.

Indications Contraindications
Ventilatory failure (acute exacerbations of COPD, OHS)
Cardiogenic pulmonary edema
Acute exacerbation of asthma
Post extubation ARF
Postoperative ARF
Patients at high risk for complications of intubation (older age, obesity)
Do not intubate status
Need for emergent intubation
Cardiac arrest
Respiratory arrest
Inability to protect airway due to altered mental status
Presence of secretions
Sinusitis/otitis media
Ileus/gastric distention
Recent facial trauma or surgery
Hemodynamic instability

Table 22.2 Indications and contraindications for HFNC.

Indications Contraindications
Acute hypoxemic respiratory failure with mild to moderate work of breathing
Presence of secretions preventing NPPV use
Post extubation
Primary ventilatory failure (hypercapnic failure)
Markedly increased work of breathing
Respiratory arrest
Hemodynamic instability

Basic terminology and settings

  • Mode (NPPV):

    • Bilevel spontaneous: the set inspiratory/expiratory pressures are delivered with each patient‐generated breath. This is the most common mode of NPPV in ARF.
    • Bilevel spontaneous timed (ST): in addition to spontaneous mode, the machine mandates the time for delivery of inspiratory positive pressure, and also a minimum number of mandatory breaths per minute.
    • CPAP: the machine delivers a continuous level of pressure throughout the respiratory cycle (inspiration and expiration).


    • IPAP is the inspiratory positive airway pressure, defined as the positive airway pressure delivered during the inspiratory phase (as determined by cessation of airflow or maximal inspiratory time). It is usually titrated to achieve a desired tidal volume VT and ensure adequate ventilation.
    • EPAP is the end‐expiratory positive airway pressure. This is analogous to PEEP during mechanical ventilation, and is defined as the pressure delivered during each expiratory phase and during the pause until the next inspiration.

  • Rate (NPPV):

    • Rate on bilevel mode serves as the backup rate (minimum breaths per minute).

  • Flow rate (HFNC):

    • The flow rate can be set in liters per minute, and higher flow rates enable the delivery of greater concentrations of O2, as well as slightly higher positive pressures.

  • FiO 2 (NPPV, HFNC):

    • Both NPPV and HFNC use high flow, closed O2 delivery systems with an oxygen blender that enable precise titrations of FiO2, similar to a mechanical ventilator.

  • Patient interfaces (NPPV, HFNC):

    • While several interfaces are available for NPPV machines, the most commonly used interface in ARF settings is the nasal–oral mask which covers the apertures of both nares and mouth with a tight seal to ensure adequate delivery of FiO2 and pressures (Figure 22.1).
    • High flow oxygen is most commonly delivered by nasal prongs similar in appearance to low flow nasal cannulas, but with a larger bore to accommodate the higher flow rates (Figure 22.2).

Use of NPPV in disease states

NPPV in acute exacerbation of COPD (AECOPD)

  • This is the most common indication for NPPV use with the largest body of evidence.
  • Considered first line ventilatory support in patients with AECOPD.
  • Strong evidence for:

    • Decreased mortality.
    • Reduced rates of endotracheal intubation.
    • Less treatment failure and faster resolution of clinical symptoms compared with oxygen therapy alone.
    • Reduction in ICU and hospital length of stay and treatment complications compared with invasive mechanical ventilation.
    • More cost effective than invasive mechanical ventilation.

  • Can be utilized in the ICU or in closely monitored non‐ICU settings.
  • Can be used in patients with AECOPD and encephalopathy due to CO2 narcosis.

NPPV in acute cardiogenic pulmonary edema (CPE)

  • There is a robust and growing body of data supporting the use of NPPV in CPE.
  • CPAP mode generally first line; patients with concurrent ventilatory failure may benefit from bilevel NPPV.
  • Data show improved SpO2, decreased work of breathing, reduced rates of intubation, and faster clinical improvement.
  • Trend towards decreased mortality.
  • Contraindicated in patients with cardiogenic shock or altered consciousness.

NPPV in acute exacerbation of asthma

  • There is a mixed body of evidence for this indication.
  • In early phase of exacerbation can temporize impending respiratory failure by allowing time for medical intervention to work.
  • Trend towards quicker reduction in dyspnea, and reduced length of stay.
  • No evidence to support reduced rates of intubation or long‐term morbidity/mortality benefits.

NPPV in neuromuscular disorders with ARF

  • Patients with neuromuscular disease states, whether acute (Guillain–Barré syndrome) or chronic (myasthenia gravis, amyotrophic lateral sclerosis) often present with ARF.
  • The use of NPPV in these patients has been shown to reduce the rates of intubation and therefore reduce complications of mechanical ventilation and length of stay.
  • Patients with neuromuscular disease in ARF must be watched in a monitored setting with frequent reassessment of respiratory status, since they can worsen and require mechanical ventilation.
  • Parameters for monitoring include negative inspiratory force (NIF) and vital capacity. Forced vital capacity (FVC) <20 mL/kg and/or a NIF <30 cmH2O are considered indications for intubation and mechanical ventilation.

    • Patients meeting these criteria may be monitored closely on NPPV while treatment for the underlying conditions commences; however, they should be promptly intubated if any further deterioration occurs.

NPPV and HFNC in acute hypoxemic respiratory failure

  • NPPV had not been recommended for patients with pure hypoxemic respiratory failure, especially those meeting ARDS criteria, for fear of delaying intubation and increasing morbidity and mortality.
  • However, there is evidence to support the use of NPPV in immunocompromised patients with hypoxemic respiratory failure.
  • NPPV and HFNC are also used for respiratory support in patients with interstitial lung disease in acute respiratory distress with beneficial outcomes including decreased length of stay.
  • New studies suggest that HFNC in acute hypoxemic respiratory failure can reduce intubation rates and mortality.
  • There are ongoing trials to evaluate whether extubation to HFNC improves outcomes.

Special considerations for NPPV

  • Post‐extubation ARF:

    • Data suggest that NPPV can forestall reintubation in patients at risk of ARF post extubation; particularly patients with pre‐existing cardiac or pulmonary dysfunction.
    • NPPV should be applied pre‐emptively to patients with a high likelihood of post‐extubation ARF; application of NPPV after onset of ARF shows no benefit and may inappropriately delay reintubation.
    • Appropriate selection of patients is essential: not all patients would benefit with application of NPPV post extubation.

  • Postoperative ARF:

    • Cardiothoracic surgery: in thoracic resections, extubation to NPPV has led to a decrease in reintubation rates, shorter length of stay, and improved oxygenation and ventilation. In cardiac surgery, the rate of postoperative pulmonary complications is decreased but there is no significant reduction in reintubation rates. To prevent surgical complications, lower pressure settings are advisable.
    • Abdominal surgery: data show that the postoperative use of NPPV can prevent atelectasis and associated complications (hypoxia, postoperative pneumonia). Decreased reintubation rates are also evident.

  • Patients with a DNR order:

    • NPPV can be used to relieve dyspnea.
    • Use depends on the goals of care: either for palliation or as the maximal level of respiratory support.
    • HFNC may also be used in palliation and may be better tolerated.

  • NPPV as a bridge to extubation:

    • In patients with COPD, extubation directly to NPPV may be an option. These patients are often borderline during their spontaneous breathing trials and thus their extubation can often be delayed.
    • Extubating these patients directly to NPPV has been successful, without increased rates of reintubation and with decreased length of mechanical ventilation.

  • NPPV as a preoxygenation modality prior to Intubation:

    • Patients with ARF are often initially placed on NPPV and subsequently progress to intubation.
    • In these patients, the NPPV device may be used as a preoxygenation tool.
    • The FiO2 should always be set to 100% when NPPV is used for this indication.

  • NPPV during procedures in patients at risk for respiratory failure:

    • Patients undergoing bronchoscopy can be at risk for respiratory failure and have increased respiratory demands; the use of NPPV in these patients peri‐procedure has been successfully described throughout the literature.
    • Patients undergoing GI endoscopy with a tenuous respiratory status may also benefit from peri‐procedure NPPV; however, the data are more scant and the risk of complications, including aspiration, are higher when invasive GI procedures are undertaken on NPPV. Nevertheless, several cases have been described and this may be an option for a patient with contraindications to intubation (such as DNI status).

Predictors of success and failure of NPPV

Predictors of success

  • Higher level of consciousness.
  • Younger age.
  • Lower severity of illness.
  • Less severe gas exchange abnormalities.
  • Lack of severe acidosis pH 7.10–7.35.
  • Minimal air leak around the interface.

Predictors of failure

  • On admission:

    • Encephalopathy (except AECOPD patients).
    • Low pH (especially <7.1).
    • Older age.
    • Multiple comorbidities.
    • Multiorgan dysfunction.
    • Respiratory arrest.
    • Hemodynamic instability.
    • Patient dyssynchrony with NPPV.

  • On reassessment (0.5–2 hours):

    • No improvement in mental state.
    • No improvement in pH/PaCO2.
    • No improvement in respiratory rate or work of breathing.

Guidelines for use

Protocol for initiation of NPPV

  • Monitor in ICU or other closely monitored settings, such as step down or respiratory care units.
  • Oximetry and vital signs monitoring as clinically indicated, preferably continuous.
  • Position patient at >30° angle.
  • Select the appropriate interface based on face size and patient comfort.
  • Select ventilator and mode of ventilation.
  • Avoid excessive strap tension from headgear to prevent discomfort and potential skin ulceration.
  • In spontaneously triggered mode with backup rate:

    • Initial settings: IPAP 8–12 cmH2O, EPAP 3–5 cmH2O, RR 6–10/min.
    • COPD/asthma: start IPAP 8 cmH2O, EPAP 4 cmH2O.
    • Congestive heart failure: start CPAP 8–10 or bilevel 8/4 (if hypercapnic).

  • Increase IPAP in increments of 2–4 cmH2O (up to 10–20 cmH2O) as tolerated with goals:

    • Alleviation of dyspnea.
    • Decreased respiratory rate.
    • Adjust to deliver VT 6–8 mL/kg of predicted body weight.
    • Patient–ventilator synchrony.

  • Add supplemental oxygen, as needed, to keep SpO2 >90%.
  • Humidification may be necessary for comfort.
  • Agitated patients may benefit from mild sedation:

    • Requires a closely monitored setting (i.e. ICU).
    • Persistent or worsening agitation is a sign of failure of the NPPV trial.

  • Clinical reassessment every 15 minutes for the first 2 hours, and make adjustments as necessary.
  • Evaluate arterial blood gas.
  • Consider endotracheal intubation if no improvement or deterioration within 2 hours of NPPV trial.

Protocol for initiation of HFNC

  • Begin with FiO2 100% and flow rate of 50 L/min.
  • Titrate FiO2 down as tolerated, maintaining SpO2 >90%.
  • Clinical reassessment to ensure improvement and comfort.

Managing the patient on NPPV

Daily monitoring and weaning

  • Daily evaluation for continued need for NPPV. Is condition improved or is patient stabilized?
  • If NPPV has been successful in achieving goals, NPPV support may be necessary for only 24–72 hours.
  • Currently there is no universally accepted protocol for weaning.
  • Algorithm 22.1 outlines an approach to initiation and weaning.


  • Achieving patient comfort will allow the patient to tolerate NPPV and ultimately may prevent intubation. Intolerance to NPPV is one of the main causes of NPPV failure.
  • Use of a ventilator that minimizes leaks, the choice of interface, the humidification system, and appropriate sedation can all improve tolerance.

    Algorithm 22.1 Daily evaluation and weaning of NPPV

    Schematic illustration of daily evaluation and weaning of NPPV.

  • Leaks: ensuring good mask fit is integral to the success of NPPV:

    • Poor mask fit may lead to an unacceptably large leak and cause suboptimal ventilation.
    • Masks which leak cannot deliver adequate pressure.
    • Patient discomfort is increased with leak.
    • Using a ventilator with good leak compensation can be helpful. Bilevel ventilators have good leak compensation capabilities.
    • Newer ICU ventilators have NPPV modes which detect leak and automatically adjust.

  • Patient dyssynchrony is one of the main limiting factors and is determined by the underlying disease process and the leak.
  • Humidification: although the need for humidification is controversial, a dry nasal airway increases resistance and patient discomfort:

    • Humidification is provided by a heated humidifier or moisture exchanger.
    • No significant difference has been found with the use of either method of humidification.

  • Sedation: low dose sedation can be considered to control anxiety and improve patient’s tolerance of NPPV. A monitored setting is usually required. The following medications can be used:

    • Benzodiazepines (most commonly lorazepam 0.5 mg initial dose).
    • Remifentanil 0.5 μg/kg/min.

    Dexmedetomidine 0.2 μg/kg/min.

  • Claustrophobia: use of a nasal mask may be beneficial in claustrophobic patients.


  • Adverse hemodynamic effects are unusual but have been reported.
  • Very low risk of barotrauma.
  • Aerophagia:

    • Mild gastric distention, incidence 10–50%.
    • Aspiration of gastric contents, rarely significant at routinely applied levels of inspiratory pressure support.
    • Addition of agents that accelerate intestinal transit (domperidone or simethicone).
    • Decrease in IPAP may be beneficial.

  • Airway dryness sinus or ear pain, decreased sputum clearance, or nasal congestion.
  • Skin breakdown due to pressure: most common location of skin breakdown is the bridge of the nose:

    • Alternating between different masks helps to prevent skin breakdown.

Reading list

  1. Bersten AD, et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 1991; 325:1825–30.
  2. Keenan SP, et al. Noninvasive positive pressure ventilation in the setting of severe, acute exacerbations of chronic obstructive pulmonary disease: more effective and less expensive. Crit Care Med 2000; 28:2094–102.
  3. Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA 2002; 287:3238–44.
  4. Lim WJ, et al. NIPPV for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2012;12:CD004360.
  5. Meduri GU, et al. Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure. Chest 1991; 100:445–54.
  6. Meduri GU, et al. Noninvasive positive pressure ventilation in status asthmaticus. Chest 1996; 110:767–74.
  7. Meeder AM, Tjan DH, van Zanten AR. Noninvasive and invasive positive pressure ventilation for acute respiratory failure in critically ill patients: a comparative cohort study. J Thorac Dis 2016; 8(5):813–25.
  8. Mehta S, et al. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit Care Med 1997; 25:620–8.
  9. Pelosi P, Jaber S. Noninvasive respiratory support in the perioperative period. Curr Opin Anaesthesiol 2010; 23:233–8.
  10. Stefan MS, et al. Trends in mechanical ventilation among patients hospitalized with acute exacerbations of COPD in the United States 2001 to 2011. Chest 2015; 147(4):959–6.
  11. Xu X, et al. Noninvasive ventilation for acute lung injury a meta‐analysis of randomized controlled trials. Heart Lung 2016; 45(3):249–57.


Type of evidence Title and comment Date and reference/weblink
Consensus guideline statement International Consensus Conferences in Intensive Care Medicine: Non‐invasive Positive Pressure Ventilation in Acute Respiratory Failure. Organized jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise, 2000
The guidelines establishing general principles of use as adopted by several leading respiratory societies throughout the world. Guidelines are based on analysis of various metadata and review articles
Consensus guideline statement British Thoracic Society/Intensive Care Society Guideline for the ventilatory management of acute hypercapnic respiratory failure in adults 2002
Meta‐analysis Noninvasive ventilation and survival in acute care settings: a comprehensive systematic review and metaanalysis of randomized controlled trials
Use of NPPV in acute care settings and patient outcomes. The meta analysis data show increased survival rates for patients in whom NPPV was used as primary support therapy and used post extubation
Crit Care Med 2015;43(4):880–8
Review article Clinical practice guidelines for the use of noninvasive positive‐pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting
An analysis of multiple studies and guidelines. Conclusions supported the early use of NPPV in AECOPD, CPE, and to prevent reintubation in these patients
CMAJ 2011;183(3):195–214
RCT Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask
The landmark trial of NPPV use and outcomes in patients with AECOPD
N Engl J Med 1990;323:1523–30
RCT Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask
The landmark trial of NPPV use and outcomes in patients with cardiogenic pulmonary edema
N Engl J Med 1991;325:1825–30
RCT High flow oxygen through nasal cannula in acute hypoxemic respiratory failure
Discusses the benefits of HFNC in patients with acute hypoxemic respiratory failure
N Engl J Med 2015;372:2185–96


Photo depicts NPPV nasal of oral mask.

Figure 22.1 NPPV nasal–oral mask.

Photo depicts a high flow nasal cannula.

Figure 22.2 High flow nasal cannula.

Nov 20, 2022 | Posted by in ANESTHESIA | Comments Off on 22: Non‐Invasive Positive Pressure Ventilation

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