EM · Non-invasive ventilation
Non-invasive ventilation in the emergency department (CPAP and BiPAP)
Also known as NIV · CPAP · BiPAP · Non-invasive positive pressure ventilation
Non-invasive ventilation — the CPAP (continuous) and the BiPAP (bilevel), the evidence-based indications (the COPD type 2 acidosis and the cardiogenic pulmonary oedema — the two strongest), the contraindications (the unprotected airway, the cardiac arrest), the settings (IPAP 12 to 20, EPAP 4 to 6 for the BiPAP; 5 to 10 cm water for the CPAP), the monitoring, the failure-to-respond escalation to the intubation, and the palliative NIV. ACEM-primary, globally tagged.
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Red flags
- The patient on NIV who becomes drowsy or loses the respiratory effort is failing — prepare for the intubation, do not increase the EPAP
- NIV is contraindicated in the patient who cannot protect the airway — the aspiration risk is real
- The COPD exacerbation with a pH under 7.35 is the strongest single evidence-based indication for the BiPAP — start it within 60 minutes of the ABG
- The cardiogenic pulmonary oedema responds rapidly to the CPAP — the preload and the afterload reduction, the alveolar recruitment and the work-of-breathing reduction
- The NIV mask must fit properly — the mask leak is the commonest cause of the failure, and the skin breakdown is the commonest complication
Meet the patient
A 68-year-old man with known COPD arrives with a three-day viral cold and worsening breathlessness. He is using every accessory muscle, the respiratory rate is 32, the SpO2 is 88 per cent on room air, and he is drowsy but rousable. The venous gas shows pH 7.28, PaCO2 75, HCO3 32. The chest X-ray shows hyperinflation and no pneumothorax. The clock started moment gas was drawn — and the strongest single evidence in ED respiratory medicine says he needs BiPAP within the hour.[3]
The two questions that decide his next hour are the two that decide every NIV encounter: is this the right modality? (the pH under 7.35 says BiPAP, not CPAP) and is the patient tolerating it and improving? (the falling respiratory rate and the rising pH at one hour say yes; the falling GCS says no — intubate now).[1]
References9ShowHide
- [1]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings Thorax, 2017.PMID 28507176
- [2]Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema N Engl J Med, 2008.PMID 18614781
- [3]Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial Lancet, 2000.PMID 10859037
- [4]Ram FSF, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease Cochrane Database Syst Rev, 2004.PMID 15266518
- [5]Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease N Engl J Med, 1995.PMID 7651472
- [6]Bersten AD, Holt AW. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask N Engl J Med, 1991.PMID 1961221
- [7]Vital FMR, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema Cochrane Database Syst Rev, 2013.PMID 23728654
- [8]Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure Eur Respir J, 2017.PMID 28860265
- [9]Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure N Engl J Med, 2001.PMID 11172189