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Noninvasive Positive Pressure Ventilation (NPPV)
AND
Oxygen Therapy
กภ. สุวรรณ ศรีดาทองกุล
The aims of rehabilitation
*to mobilize patients early
**to facilitate weaning from mechanical ventilation
***to improve function by increasing strength and
endurance
Outcome:
Decreased Cost and Length of stay
Intervention
Approach
Active
Passive
IPPB BiPAP CPAP
Cough assist
Non-invasive ventilation
Management of breathlessness
Respiratory muscle training
IMT
Breathing techniques
Breathing / coughing
Airway clearance techniques
Postural drainage and manual Suctioning
techniques
Cough assist
Airway clearance devices
PEP therapies
PEP Acapella
Breath Max
Oxygen therapy and
humidification
Ultraneb
Flutter
Breath Max
Humidified High Flow
IBBP with Heat
Before treatment : Precaution
Action
Prevention
GERD
Check gastric content or 2hr.after meal
Hypoxia
Oxygenation
Sticky sputum , dry airway
NSS nebulizer or heat nebulizer*
Wheezing
Bronchodilator *
Restless ( intubated)
Sedative drug*
Wound pain
Pain killer *
Nasal bleeding (edema)
Iliadin *
* Under doctor prescription
Condition
Chronic lung disease
eg. Bronchiectasis
Clinical features
- Hypersecretion
Physical therapy program
- PD , percussion,vibration
- Acapella
- Cough assist machine
- ± suction
The intubated
pediatric
- Ineffective cough
by tube
- Hypersecretion
- atelectasis
- Modified PD ,
percussion,vibration
- chest expansion
- chest mobilization
- suction
Post extubation
- Increase WOB
- Hypersecretion
- Atelectasis
- EzPAP , IPPB Avoid deep
suction eg.subglottic edema
- Gently PD with vibration
- Wound pain
- Hypersecretion
- Mechanical or manual vibration
- Cliniflow ,acapella
- Atelectasis
- Cough assist machine
Post surgery
- Breathing exercise
- ± suction
Condition
Clinical features
Physical therapy program
Neuromuscular
disease
- Poor respiratory
muscles strength and
stamina + low FRC =
- PD ,Percussion or vibration
- Manually assisted cough or
ineffective cough
- ± suction
Bronchiolitis
- Productive cough
with wheezing
- nasal congestion
- Clear upper airway
- No percussion if wheezing
Asthma
- Severe
bronchospasm
- hypersecretion
- atelectasis
- Avoid percussion and suction
- PEP or PEP with oscillation to
prevent distal airway collapse
- Breathing exercise : relaxation
Atelectasis
- Non specific
respiratory symptoms
- IPPB, EzPAP , Incentive
mechanical cough assist
spirometry ,breathing exc.
Passive Techniques Practical concern
Postural drainage
Percussion and
vibration
- According to pathological lobes
- Avoid prone and head down
:Abdominal distention, GERD
- Wound pain
- Tube care
- No percussion in age < 1 months : use
vibration technique
- Avoid aggressive percussion especially <
8 months
- If PEEP > 5cmH2O NO percussion
- Mechanical vibration 10-15Hz
Postural Drainage / Percussion / Vibration
Vibrator
Passive Techniques
Practical concern
PSE: prolonged slow
expiration
(is a slow passive and progressive
expiration from FRC to ERV)
- Useful for bronchiolitis patient
- Head up 30 degree
- No gastric content
Provoked cough
- Easily induce trauma
(Briefly pressure on trachea at
Suprasternal notch)
Cough ,huffing and
Breathing exercise
- Poor cognitive ability
- Passive or active or assistive devices
Passive
Techniques
Practical concern
Suction
-
Oxygenation to prevent hypoxia
No use lubricate gel in Neonate and Infant to
prevent airway obstruction
- NSS : aspiration , infection
- 5-10sec., 3-5 times to prevent arrthymia
- Sterile technique to prevent infection
- limit pressure to prevent atelectasis and bleeding
- Type
1. nasal aspiration :upper airway
2. nasopharyngeal or oropharyngeal : upper airway or
3.
4.
lower airway ( stimulated coughing)
nasotracheal :neuromuscular disease
suction in tube
Definition: Noninvasive Positive Pressure Ventilation (NPPV) is a
ventilatory-assist technique used in the management of impending
respiratory failure as an alternative to endotracheal intubation.
Acute respiratory failure The primary objective of NIV is avoiding
intubation and
subsequently reducing mortality
Acute or chronic
respiratory insufficiency
Secondary end points have faster
improvement in gas exchanging and
acid-base status, and reducing ICU and
hospital stays
Intermittent Positive Pressure Breathing
IPPB with Heat humidifier
Machine settings
•
•
•
•
Sensitivity of 1 – 2 cm H2O
Initial pressure between 10 – 20cm H20
I:E ration of 1:3 to 1:4
Flow and pressure will need subsequent adjustment
to patient’s needs and goal
Indications
- Atelectasis not responsive to other therapies
[cough deep breath, and IS]
-Inability to clear airways due to inability to take
deep breaths
IPPB(Cont.)
Contraindications
–
–
–
–
–
–
–
–
–
–
Tension pneumothorax
ICP > 15 mm Hg
Hemodynamic instability
Recent facial, oral or skull
surgery, Tracheoesophageal
fistula
Recent esophageal surgery
Active hemoptysis
Nausea
Air swallowing
Active, untreated TB
Radiographic evidence of bleb
Hazards and Complications

Increased airway resistance
 Pulmonary barotrauma
 Nosocomial infection
 Respiratory alkalosis
 Impaired venous return
 Gastric distension
 Air trapping, auto-PEEP,
overdistension
 Psychological dependence
What does CoughAssist E70 do?
Non invasive alternative to deep suction
Can be given via facemask, mouthpiece,
endotracheal or tracheostomy tube
Experiencing a natural cough
Simulates a cough
By applying a positive pressure (deep
insufflation) to the airway followed by a rapid shift
to a negative pressure to produce expiratory
flow from the lungs and effectively remove
secretions
Approved for adult and pediatric populations
Mechanical cough assist
: Providing inspiratory pressure then fast expiratory flow = stimulates
cough
: Apply oscillation
: For a patient using this device for the first time, it is advisable to begin
with lower pressures, such as 10 – 15 cmH2O positive and negative
pressure, and low inhale flow. It will familiarize the patient with the feel of
mechanical insufflation-exsufflation.
: As the patient becomes more comfortable with the therapy,
progressively increase the inspiratory and expiratory pressures by 5 – 10
cmH2O each sequence of 4 – 6 breaths. Effective pressures may be around
35 – 45 cmH2O
Mechanical Insufflator-Exsufflator (Cough Assist)
Contraindication
 • Bullous emphysema
 • Pneumothorax or pneumo-mediastinum
 • Recent Barotrauma
*Note*Patients with hemodynamic instability should
be carefully monitored
Humidifier with integrated flow generator
Physiological effects of HFNC
Humidification great comfort and better tolerance
Reduction of nasopharyngeal resistance
Pharyngeal dead space washout
Positive expiratory pressure (PEEP effect)
Alveolar recruitment
Better control of FiO 2 and bettets mucociliary clearance
Ultraneb
Acapella : PEP + oscillation
• Flutter ve Acapella
• Utilizes internal expiratory
vibrations
• Oscillating endobronchial
pressure clears mucus from
small airways
Flutter
Acapella
PEP Therapy
Clear acapella with nebulizer
INDICATIONS
-Patients
with chronic pulmonary conditions, such
as Cystic Fibrosis and Chronic Bronchitis, which
predispose them to large volume sputum
production.
-To reduce air trapping in asthma and COPD.
-To optimize delivery of bronchodilators in patients
receiving bronchial hygiene therapy.
EzPAP
– Lung expansion
therapy during
inspiration and
PEP therapy
during
exhalation
– Used for the
treatment or
prevention of
atelectasis and
the mobilization
of secretions
– Aerosol drug
therapy may be
added to a PEP
session to
improve the
efficacy of
bronchodilator
• 1. Patients unable to tolerate the increased work of
breathing (acute asthma, COPD)
• 2. Intracranial pressure (ICP) > 20 mm Hg
• 3. Hemodynamic instability
• 4.Recent facial, oral, or skull surgery or trauma
• 5. Acute sinusitis
• 6. Epistaxis
• 7. Esophageal surgery
• 8.Active hemoptysis
• 9. Nausea
• 10. Known or suspected tympanic membrane rupture
or other middle ear pathology
• 11. Untreated pneumothorax
BreatheMAX
•
•
•
•
•
•
Humidifier
IS
Intrabronchial vibrator
PEP
IMT
EMT
CHEST PT
Incentive spirometer
Sustained maximum inspiration
• There are 2 types
• Flow meter type
• Volume type
• Indications
1.To improve atelectasis
2.To prevent atelectasis
(post-op, COPD,
other pulmonary complications)
3.Mobilize secretions
No
Force or hold
breathing
Inspiratory muscle training device
•  Respiratory muscle
endurance and strenght
•  Cough efficiency
Contraindication
•
•
•
•
Spontaneous pneumothorax
Traumatic pneumothorax after
complete recovery
Asthma patients who have low
symptom perception and who
suffer from frequent sever
exacerbations
Recently experienced a
perforated eardrum
Causes of Oxygen Desaturation
Mechanism
Examples
Disorders of ventilation
Decreased ventilatory drive
Decreased mental status (eg, caused by head injury,
oversedation, sepsis, shock, or stroke)
Obstructed ventilation
Bronchospasm
Dislodgement of endotracheal tube
Mucus plugging of the airways or endotracheal tube
Severe pain in the chest,
abdomen, or both
Rib fractures
Thoracic or abdominal surgery
Disorders of oxygenation
Pulmonary causes
Nonpulmonary causes
Acute respiratory distress syndrome
Atelectasis, pneumonia, pneumothorax, pulmonary embolus,
pulmonary contusion, aspiration pneumonitis
Iatrogenic fluid overload
Heart failure (eg, due to exacerbation of underlying disease
or to acute MI
Oxygen Therapy
AIM
1. Correct Hypoxemia
2. Reduce work of breathing.
3. Reduce Myocardial work
PaO2 < 60 mmHg หรือ oxygen saturation < 90%
arterial hypoxemia
tachypnea,
tachycardia, agitation,
confusion, cyanosis
Oxygen Therapy
INDICATIONS:
• Hypoxemia PaO2 ≤ 60 torr or SaO2 ≤ 90 %
• Acute care situation:
– Find the problem
– Find the appropriate treatment
• Severe trauma
• Acute myocardial infarction.
• Short-term therapy, surgical intervention,
post-anesthesia recovery or HBO
Oxygen therapy
To ensure safe and effective treatment
remember:
 Oxygen is a prescription drug.
 Prescriptions should include
1. Flow rate.
2. Delivery system.
3. Duration.
4. Instructions for monitoring.
Oxygen Therapy
Consideration factors
– Severity of hypoxia and symptoms.
– Oxygen consumption and equipment.
– Moisture content
Oxygen Therapy
SETTING
 The oxygen through normal airway.
 The oxygen through artificial airway:
•
•
Endotracheal tube
Tracheostomy tube
Oxygen Therapy
Oxygen sources
– Oxygen Cylinder
– Oxygen Pipeline
– Oxygen Concentrator
Characteristics of oxygen
delivery system
1. Low flow oxygen delivery system
“Variable performance”
• Nasal cannula
• Simple mask
• Mask with reservoir bag
Low flow oxygen
Type
Nasal cannula
Flow
FiO2
1
2
3
4
5
6
0.24
0.28
0.32
0.36
0.40
5–6
6–7
7-8
0.40 – 0.50
0.50 – 0.60
0.60
6
7
8
9
10
0.60
0.70
0.80
≥ 0.90
≥ 0.90
0.44
Simple Mask
Partial
rebreathing
Mask
Characteristics of oxygen
delivery system
2. High flow oxygen delivery system
“Fixed performance”
• Venturi mask
• Non-rebreathing mask
• Oxygen tent
• Incubator
• Mechanical ventilator
Oxygen Therapy
Type
FiO2
Humidifier
<2
Baby : < 6
0.24 – 0.40
Bubble humidifier
Simple Mask
5 - 10
0.35 – 0.50
Bubble humidifier
Partial rebreathing Mask
6 - 10
0.40 – 0.60
Bubble humidifier
Non rebreathing Mask
≥ 10
0.60 – 0.80
Bubble humidifier
O2 Hood
≥7
0.30 – 0.70
Jet humidifier
10 - 15
0.40 – 0.50
Jet humidifier
Nasal cannula
O2 Tent
Flow rate
Infant :
Humidification
Humidifier Vs. Nebulizer
Humidifier
Nebulizer
Gas
Aerosol
Characteristics of
O2 delivery system
Low flow
High flow
FiO2
Variable
Fixed
Cost
Less
More
Infection
Less
More
Humidity
MONITORING
 Skin colors
 Conscious
 Breathing pattern
 Respiratory rate
 Chest and Abdominal
movement
 Accessory muscle breathing
 Breath sound Lung sound
 SaO2
 Other symptoms.
Oxygen Therapy : Weaning
Tolerance of Weaning
– Consciousness
– O2 > 90 %
– HR change
• ± 20, limit at 50 < HR < 120
– SBP change
• ± 20, limit at 90 < SBP < 180
– RR < 35 / min
– Dyspnea
– Lung sound
– Accessory muscle
breathing
Physical Therapy in Oxygen Weaning
Prophylaxis O2 Therapy
Acute hypoxemia
Dyspnea
During Suction
Lung disease
Cardiac disease
Neuro disease
Post operative
Pre/Post Exercise
Ambulate
Night Support
Fit to fly
COMPLICATIONS
– Cut of hypoxemic ventilatory drive
• Chronic hypoxic lung disease
• COPD
• Severe chronic asthma
• Bronchiectasis / Cystic fibrosis
• Chest wall disease
–
–
–
–
–
• Kyphoscoliosis
• Thoracoplasty
• Neuromuscular disease
• Obesity hypoventilation
Denitrogenation absorption atelectasis
Oxygen toxicity
Drying of secretion
Fire hazard
Retinopathy of prematurity
RESPIRATORYCARE•FEBRUARY2009 VOL54 NO2
Peter C Gay MD. Complications of Noninvasive Ventilation in Acute Care.
Respiratory. 2009; 54 NO2:246-258 .
PHILIP Respironic. Evaluation of Cough Assist (CA) Device with Adult Intensive
Care Units (ICU)
J Bott, S Blumenthal, M Buxton S Ellum, C Falconer, R Garrod, A Harvey, T Hughes,
M Lincoln, C Mikelsons, C Potter, J Pryor, L Rimington, F Sinfield, C Thompson,
P Vaughn, J White, on behalf of the British Thoracic Society Physiotherapy Guideline
Development Group . Guidelines for the physiotherapy management of the adult,
medical, spontaneously breathing patient :Joint BTS/ACPRC guideline.