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Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask, nasal mask, or a helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out. It is termed "non-invasive" because it is delivered with a mask that is tightly fitted to the face or around the head, but without a need for
tracheal intubation Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer ce ...
(a tube through the mouth into the windpipe). While there are similarities with regard to the interface, NIV is not the same as
continuous positive airway pressure Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The ap ...
(CPAP), which applies a single level of positive airway pressure throughout the whole respiratory cycle; CPAP does not deliver ventilation but is occasionally used in conditions also treated with NIV. Non-invasive ventilation is used in acute respiratory failure caused by a number of medical conditions, most prominently
chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
(COPD); numerous studies have shown that appropriate use of NIV reduces the need for invasive ventilation and its complications. Furthermore, it may be used on a long-term basis in people who cannot breathe independently as a result of a chronic condition.


Medical uses

NIV for acute
respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
is used particularly for severe exacerbations of
chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
(COPD) but also for
acute decompensated heart failure Acute decompensated heart failure (ADHF) is a sudden worsening of the signs and symptoms of heart failure, which typically includes difficulty breathing (dyspnea), edema, leg or feet swelling, and Fatigue (medical), fatigue. ADHF is a common and ...
and other acute conditions. NIV can be used acutely and long-term. In some people who have presented with acute respiratory failure, there is an ongoing need for long-term use of NIV at home. Non-invasive ventilation has been suggested in the treatment for
coronavirus disease 2019 Coronavirus disease 2019 (COVID-19) is a contagious disease caused by a virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. The disease quickly ...
(COVID-19) where shortages of invasive ventilation equipment and facilities may arise. The risk of poorly fitting masks emitting aerosols can require full protection gear for caregivers.


COPD

The most common indication for acute non-invasive ventilation is for
acute exacerbation of chronic obstructive pulmonary disease An acute exacerbation of chronic obstructive pulmonary disease, or acute exacerbations of chronic bronchitis (AECB), is a sudden worsening of chronic obstructive pulmonary disease (COPD) symptoms including shortness of breath, quantity and color o ...
. The decision to commence NIV, usually in the emergency department, depends on the initial response to medication (
bronchodilator A bronchodilator or broncholytic (although the latter occasionally includes secretory inhibition as well) is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lun ...
s given by
nebulizer In medicine, a nebulizer (American English) or nebuliser (British English) is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Nebulizers are commonly used for the treatment of asthma, cystic fibro ...
) and the results of
arterial blood gas test An arterial blood gas (ABG) test, or arterial blood gas analysis (ABGA) measures the amounts of arterial gases, such as oxygen and carbon dioxide. An ABG test requires that a small volume of blood be drawn from the radial artery with a syringe an ...
s. If after medical therapy the lungs remain unable to clear
carbon dioxide Carbon dioxide (chemical formula ) is a chemical compound made up of molecules that each have one carbon atom covalently double bonded to two oxygen atoms. It is found in the gas state at room temperature. In the air, carbon dioxide is transpar ...
from the bloodstream (
respiratory acidosis Respiratory acidosis is a state in which decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood's pH (a condition generally called acidosis). Carbon dioxide is produced continuou ...
), NIV may be indicated. Many people with COPD have chronically elevated CO2 levels with metabolic compensation, but NIV is only indicated if the CO2 is acutely increased to the point that the acidity levels of the blood are increased (pH<7.35). There is no level of acidity above which NIV cannot be started, but more severe acidosis carries a higher risk that NIV alone is not effective and that
mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
will be required instead.


Other causes of AHRF

Bronchiectasis Bronchiectasis is a disease in which there is permanent enlargement of parts of the bronchi, airways of the lung. Symptoms typically include a chronic cough with sputum, mucus production. Other symptoms include shortness of breath, hemoptysis, co ...
may lead to acute hypercapnic respiratory failure (AHRF), and NIV may be used similarly as for COPD. This is particularly the case where the underlying cause is
cystic fibrosis Cystic fibrosis (CF) is a rare genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. O ...
. Cystic fibrosis also causes high volumes of
sputum Sputum is mucus that is coughed up from the lower airways (the trachea and bronchi). In medicine, sputum samples are usually used for a naked eye examination, microbiological investigation of respiratory infections and cytological investigations ...
(phlegm) which may require specialised physiotherapy assistance and sometimes the insertion of a mini-tracheostomy to clear this. In people with chest wall deformity or neuromuscular disease, NIV may be commenced if the CO2 level is elevated even if it has not yet caused acidosis. In neuromuscular disease, a breathing measurement known as the
vital capacity Vital capacity (VC) is the maximum amount of air a person can inhale after a maximum exhalation. It is equal to the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume. It is approximately equal to Forced Vital Capacity ( ...
is used to determine a need for breathing support.
Obesity hypoventilation syndrome Obesity hypoventilation syndrome (OHS) is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels. The syndrome is often associated with ...
(OHS) may cause acute hypercapnic respiratory failure. When this is the case, the criteria for commencing acute NIV are similar to those for COPD (decreased pH, elevated CO2), although there are some scenarios where NIV may be initiated in hospitalized people despite a normal pH; these include people with daytime somnolence, sleep-disordered breathing and/or evidence of right ventricle
heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...
. In acute cardiogenic pulmonary oedema caused by decompensated heart failure, the quality of evidence is poor but studies have shown a reduced risk of death and a decreased need for tracheal intubation for both NIV and
CPAP Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The ap ...
. Both CPAP and NIV may be used in the
prehospital Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. ...
care setting.
Acute severe asthma Acute severe asthma, also known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and corticosteroids. Asthma is caused by multiple genes, some having protective eff ...
may cause AHRF, when it is labelled "near-fatal asthma". There is limited evidence on whether NIV is effective in this situation, which carries a high risk of requiring mechanical ventilation. Professional guidelines therefore do not give a clear recommendation, and it is suggested that NIV is only used in an
intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
setting where further deterioration can be managed immediately, or not at all. Some people with chronic asthma develop fixed airways disease that resembles COPD, and NIV may be used in that setting. Respiratory failure may develop after major surgery. NIV may be used in this setting during the recovery period. In those who have undergone mechanical ventilation on the intensive care unit and are considered at high risk of recurrence, NIV may be used to prevent this. However, if respiratory failure does develop, recommencement of mechanical ventilation is recommended over NIV to treat this. In those who were ventilated for hypercapnic respiratory failure, NIV may be used to facilitate the weaning process.


Chronic/home use

Chronic use of NIV ("home NIV") may be indicated for severe COPD. A review from 2021 demonstrated that the chronic use of non-invasive ventilation improves daytime hypercapnia, In addition, in stable chronic obstructive pulmonary disease, survival seems to be improved and there might be a short term benefit of health-related quality of life. Home NIV may also be indicated in people with neuromuscular disease and chest wall deformity. People with obesity hypoventilation syndrome often require NIV initially in their care, but many can be switched to CPAP.
American Thoracic Society The American Thoracic Society (ATS) is a nonprofit organization focused on improving care for pulmonary diseases, critical illnesses and sleep-related breathing disorders. It was established in 1905 as the American Sanatorium Association, and ch ...
(ATS) clinical practice guidelines recommend that NIV is provided on discharge with a further sleep study assessment as an outpatient. With regards to initiation of positive pressure treatment, the ATS guidelines recommend that in people being investigated for possible
obstructive sleep apnea Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episod ...
(OSA, a related condition), measurement of arterial carbon dioxide (in high probability) or venous bicarbonate (in moderate probability) is performed to identify OHS and to determine an indication for treatment. In those with both severe OSA and OHS, initial treatment with CPAP is recommended although the quality of research supporting this over NIV is poor. In the 30% of people with OHS who do not also have severe OSA, NIV may be more effective but is also more cost- and resource-intensive. In those who have both OSA and OHS, poor response to CPAP despite good adherence may be an indication to switch to NIV. People with
motor neuron disease Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or Lou Gehrig's disease, is a neurodegenerative disease that results in the progressive loss of motor neurons that control voluntary muscles. ALS is the most comm ...
(MND) may require home NIV in the course of their illness. Guidelines in the United Kingdom stipulate that assessment of respiratory function is part of the multidisciplinary management of MND.


Terminology

A number of terms have been used in the medical literature to describe NIV. The more formal name "non-invasive positive pressure ventilation" (NPPV or NIPPV) has been used to distinguish it from the use of the now very rare
negative pressure ventilator A negative pressure ventilator (NPV) is a type of mechanical ventilator that stimulates an ill person's breathing by periodically applying negative air pressure to their body to expand and contract the chest cavity.Shneerson, Dr. John M., Newmarket ...
("
iron lung An iron lung is a type of negative pressure ventilator (NPV), a mechanical respirator which encloses most of a person's body, and varies the air pressure in the enclosed space, to stimulate breathing.Shneerson, Dr. John M., Newmarket General ...
"). The brand name BiPAP/BIPAP (for Bilevel Positive Airway Pressure) has also enjoyed a degree of popularity, after an early NIV machine produced by
Respironics Respironics is an American medical supply company owned by Philips that specializes in products that improve respiratory functions. It is based in the Pittsburgh suburb of Murrysville in Pennsylvania, United States. History In 1976, company fo ...
, but its use is now discouraged.


History

Non-invasive ventilation has been used since 1940s for various indications, but its present-day use for chronic breathing problems arose in the 1980s for people with chronic respiratory muscle weakness, and in the 1990s on intensive care units and other acute care settings for acute respiratory failure. Since 2000 acute NIV has been used widely in the treatment of acute respiratory failure, particularly in people with COPD, including on general wards rather than the intensive care unit setting. In the United Kingdom, a 2017 report by NCEPOD found that there were widespread problems in the delivery of high-quality care to patients.


References

{{Mechanical ventilation Modes of mechanical ventilation