The Lancet NPPV July18, 2009 Non-invasive ventilation in acute respiratory failure ( Review)The Lancet, vol. 374, July 18, 2009 H22.9 The Lancet 2009

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1 The Lancet NPPV July18, 2009 Non-invasive ventilation in acute respiratory failure ( Review)The Lancet, vol. 374, July 18, 2009 H22.9 The Lancet NPPV NIV: non-invasive ventilation review NPPV(Non-invasive positive pressure ventilation) 2 3 Instituto scientifico di Pavia ICU NPPV NPPV NPPV NPPV full-face mask total-face mask Total-face mask total-face mask NPPV

2 total-face mask full-face mask total-face mask nasal mask( ) Nasal mask full-face mask total-face mask nasal mask NPPV random control trials 4 COPD COPD weaning COPD 4 NPPV VAP Ventilator associated pneumonia 1

3 9 5 NPPV COPD NPPV NPPV autopeep COPD NPPV 24/30/ PaCO2 45mmHg Ph PaO /FiO2 200 Ph 7.30 NPPV NPPV PaCO2 45mmHg Ph7.30 PaO2/FiO2 oxygenation index 100/ ALI acute lung injury 200 ARDS NPPV IPAP inspiratory positive airway pressure 8cm EPAP(expiratory positive airway pressure) 4 5cm TV 6ml/kg IPAP IPAP EPAP PS pressure support EPAP PEEP(positive endexpiratory pressure) PEEP CPAP(continuous positive airway pressure) 90 EPAP PEEP ARDS PEEP NPPV

4 NPPV 6 The Lancet NPPV 25 ICU The Lancet NPPV July18, 2009 NPPV 4 COPD COPD weaning, 4 COPD NPPV NPPV weaning NPPV NPPV 24/30/ PaCO2 45mmHg,Ph ,PaO2/FiO2<200 Ph 7.30 NPPV. NPPV VAP NPPV COPD COPD NPPV PH full-face mask, total- face mask, nasal mask full-face mask nasal mask full-face, total-face mask nasal mask IPAP8cm EPAP4 5cm 6ml/kg IPAP 90 EPAP PEEP interface

5 1 6 Non-invasive ventilation in acute respiratory failure ( Review) The Lancet, vol. 374, July 18, 2009 H22.9 Stefano Nava M.D., ICU Fondazione S Maugeri Istituto Scientifico di Pavia, Nicholas Hill M.D.,Pulmonary, Critical Care and Sleep Medicine, Non-invasive mechanical ventilation COPD COPD weaning Introduction 1980 non-invasive ventilation NIV NPPV 20 1 Non-invasive ventilationnppvmechanical ventilation NPPV NPPV ventilator-associated pneumonia NPPV ICU

6 CPAP(continuous positive airway pressure) non-invasive mode NIV NPPV COPD weaning ICU 35 NPPV ICU 60 ER NPPV NIV NPPV ICU NPPV ICU weaning NPPV weaning ICU NPPV Level 1 RCT 4 COPD exacerbations COPD weaning NPPV NPPV abdominal paradox

7 NPPV PaCO2 45mmHg PH<7.35 PaO2/FiO2 200 NPPV 24 / 30 / ICU NPPV COPD PH7.30 NPPV subgroup PH 7.30 PH7.30 COPD PH NPPV 1 PH NPPV ICU close monitoring NPPV NPPV NPPV NPPV hypercapnea NPPV 1 Cardiology NPPV CPAP 1 CPAP gastroplasty NPPV HIV NPPV

8 ICU NPPV ICU ICU ICU face mask helmet NIV CPAP NPPV COPD NPPV NPPV 6, NPPV NPPV PaO2 Full face mask CPAP NPPV NPPV ICU NPPV ICU PH 7.3 COPD Hypercapnea NPPV PH acute physiology score>34 Hypoxemia NIV PaO2/FiO2 40 acute physiology score(apache)>34 ARDS ±MOF ±COPD NPPV NPPV subgroup COPD

9 observational study COPD NPPV NPPV weaning CHF CO2 acidemia NPPV NPPV hypercapnea CHF SARS severe acute respiratory syndrome NPPV NPPV CPAP FRC(functional residual capacity) flooded alveoli CPAP transmural pressure afterload PSV(pressure support ventilation) Bilevel ventilation pressure support extrinsic PEEP positive end-expiratory pressure intrinsic PEEP Pressure control ventilation(pcv)pressure support vetilation PSV PCV Proportional-assist ventilation(pav ) Pressure support PSV PCV PAV extrinsic PEEP

10 a. Interface 6 full-face mask total face mask nasal mask Full-face (oronasal) mask: Total face mask: Nasal mask: Mouthpieces: interface Nasal plugs pillows : interface 1 Helmet: Pressure support ventilation asynchrony

11 nasal bridge strongly discouraged Nasal mask( ) full face mask( ) Nasal mask full face mask nasal mask b. NPPV interface IPAP8cm EPAP4 5cm interface NPPV 90 PEEP EPAP 1 TV 6ml/kg pressure support(ipap) 90 PEEP EPAP interface interface caregivers NPPV NPPV ICU 15 weaning test 60

12 Heated passover humidifier Heat and moisture exchanger NPPV NPPV ICU NPPV VAP ventilator- associated pneumonia VAP The Lancet NPPV NPPV 4 COPD COPD weaning, 4 level-2 COPD NPPV NPPV weaning NPPV NPPV 24/30/ PaCO2 45mmHg,Ph ,PaO2/FiO2<200 Ph 7.30 NPPV. NPPV VAP NPPV COPD COPD NPPV PH full-face mask, total- face mask, nasal mask full-face mask nasal mask full-face, total-face nasal mask IPAP8cm EPAP4 5cm 6ml/kg IPAP

13 90 EPAP PS interface

2

1 65 ARDS 2 3 ARMA by ARDS Network 1 12ml/kg 6ml/kg RCT ARDS 4 Low Tidal Volume Amato Stewart Brochard Brower ARMA Lower Higher Lower Higher Lower Higher Lower Higher Lower Higher N 29 24 60 60 58 58 26