How to successfully initiate noninvasive ventilation (NIV)

Michael Allison, MD
26th Nov 2020

Meryl is a 72-year-old woman with a history of chronic obstructive pulmonary disease (COPD) who presents to you with an acute exacerbation. She has increased cough, sputum production, and a fever. She doesn’t use noninvasive ventilation (NIV) at home. 

Older woman with grey hair and a hat, coughing, thermometer. Cartoon.

Figure 1. Meryl, a 72-year-old woman with a history of chronic obstructive pulmonary disease (COPD) with an acute exacerbation.

In the emergency department, she is wheezing, breathing at a rate of 26 breaths / minute, and is using accessory muscles to exhale. 

A blood gas sample is sent to the laboratory for analysis. The results show that she has acute respiratory acidosis.

You deftly diagnose her as having an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and decide to place her on NIV to decrease her likelihood of intubation and death. After discussion with the respiratory therapist, you choose a face mask to deliver NIV. You discuss the plan with Meryl who, upon questioning, tells you she’s never had a tight-fitting mask before and is nervous to have it applied.

So what do you do next?

You consider administering an anxiolytic to help with her adherence to the mask, but you then consider the risks of sedation, worsening her hypercapnia, and potentially leading to the need for endotracheal intubation. You wonder, are there any other tips or tricks to help with applying the NIV interface to allow patients to adjust to this form of breathing?

 

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The key maneuver that will help you initiate noninvasive ventilation

One key maneuver is to hand the patient the mask to hold up to their face lightly before strapping it on. This can prevent a feeling of helplessness or claustrophobia that some patients report. This allows the patient to have a level of control prior to the initiation of this therapy.

Once the patient has gotten the feel for the mask, start out with 2–3 cmH2O of continuous positive airway pressure (CPAP) to allow the patient to get used to this level of positive pressure. 

Older woman with grey hair and ventilator mast. Text and icon for setting of CPAP. Cartoon.

Figure 2. Allowing the patient to hold a noninvasive ventilation (NIV) mask to their face with a low pressure before strapping on can allow the patient to get used to the experience.

Once the patient is comfortable with this feeling, you or the respiratory therapist can strap on the mask to ensure a proper fit. Allow the patient to adjust for a few more minutes to this low-pressure setting before titrating up slowly. 

The key here is to avoid the mistake of starting with too much pressure that will make the patient intolerant from the start!

So remember, if time allows, coach your patients through the initiation of NIV to improve their adherence. Allow them to try out the mask, start low, and go slow with your titration.

 

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Recommended reading

  • Allison, MG and Winters, ME. 2016. Noninvasive ventilation for the emergency physician. Emerg Med Clin North Am. 34: 51–62. PMID: 26614241
  • Antonelli, M, Pennisi, MA, and Conti, G. 2003. New advances in the use of noninvasive ventilation for acute hypoxaemic respiratory failure. Eur Respir J Suppl. 42: 65s–71s. PMID: 12946003
  • Meyer, TJ and Hill, NS. 1994. Noninvasive positive pressure ventilation to treat respiratory failure. Ann Intern Med. 120: 760–770. PMID: 8147550
  • Patel, BK, Wolfe, KS, Pohlman, AS, et al. 2016. Effect of noninvasive ventilation delivered by helmet vs face mask on the rate of endotracheal intubation in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 315: 2435–2441. PMID: 27179847