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Non-Invasive Positive Pressure Ventilation: Indications & Patient Management

Instructor: Justine Fritzel

Justine has been a Registered Nurse for 10 years and has a Bachelor's of Science in Nursing degree.

Patients with acute or chronic respiratory failure may need assistance with ventilation. In this lesson, we will learn about different types of non-invasive positive pressure ventilation delivery systems.

What Is NPPV?

Sally is a nurse who works in the critical care unit of her hospital. It's not unusual to care for patients who are in acute or chronic respiratory failure. These are patients with COPD, asthma, pneumonia, or heart failure.

Non-invasive positive pressure ventilation (NPPV) is often used to help these patients breathe more comfortably. It is less invasive compared to endotracheal intubation to assist with ventilation. It also allows patients to maintain normal functions such as coughing, swallowing, eating, and speaking. Since it's not invasive, it decreases the likelihood of developing a respiratory infection compared to intubation. NPPV can also be used in the home setting.

Through the use of positive pressure, it promotes the alveoli in the lungs to remain open and avoid collapse. Patients who are appropriate candidates for NPPV have moderate respiratory failure. It is not appropriate for very mild respiratory issues or very severe. The patient should be cooperative and will have symptoms of dyspnea, tachypnea, and hypoxemia.

NPPV Delivery Systems

Sally is attending an in-service at her hospital to learn more about the different delivery systems for NPPV. A high-flow nasal cannula is the least invasive device to provide respiratory support that is easily tolerated by patients. It consists of a system to heat and humidify the oxygen that is being delivered to the patient, which allows for better tolerance of the high flow of oxygen. Oxygen can be delivered at up to 60 liters per minute. High-flow nasal cannulas do not augment the tidal volume, which is the volume of air breathed in and out.

A venturi mask is another option. This is a mask with a flexible tube that is connected to oxygen. This mask controls how much room air oxygen is breathed in and, therefore, can provide high levels of oxygen. The venturi mask can provide 24-60% of FiO2, which is the fraction or percentage of oxygen being administered. For comparison, room air FiO2 is approximately 21%.

A non-rebreather mask is a mask with an attached reservoir that can administer an FiO2 of 85-90%. It requires oxygen flow of 15 liters per minute for the mask to correctly work.

Depending on the patient's extent of respiratory failure and oxygen needs, the nurse can choose between these three options to meet their needs. There are also mechanical non-invasive positive pressure delivery systems.

Mechanical Delivery Systems

Continuous positive airway pressure (CPAP) is a continuous positive pressure of oxygen flow, and the patient is able to spontaneously breathe. This consists of a tight-fitting mask that needs to have a good seal to work effectively. CPAP is commonly used for sleep apnea and for patients with respiratory distress from pulmonary edema.

Bilevel positive airway pressure (BiPAP) provides positive pressure that is greater on inspiration than on exhalation. BiPAP senses the patient's breathing and adjusts the pressures according to the settings. BiPAP increases the tidal volume and improves ventilation. It decreases CO2 levels and reduces the work of breathing. BiPAP is often used for COPD exacerbations.

Nursing Management of NPPV

Sally wants to know her responsibility in caring for patients with different types of non-invasive positive pressure oxygen delivery systems. The nurse should regularly assess how the patient is tolerating the device. Assessment of respiratory status including oxygen saturation, respiratory rate and effort, cough, and secretions should be done. The different devices can cause skin irritation, so close monitoring of the patient's skin and appropriate fitting of the device is important.

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