Page 95 - JSOM Summer 2022

Airway Management With

Noninvasive Positive Pressure Ventilation

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Wayne Papalski *; John Siedler ; David Callaway, MD 3

ABSTRACT
Noninvasive positive-pressure ventilation (NPPV) is a form gravity’s force during inspiration and expiration. The first de-
of ventilatory support that does not require the placement of vice developed was the “pneumobelt,” which utilized a blad-
an advanced airway. The authors discuss the use of NPPV on der attached to the patient’s abdomen and incorporated a large
patients who will likely benefit. The use of NPPV has reduced ventilator that delivered positive pressure.Further into the his-

the need for patients to require intubation and/or mechanical tory of NIV and possibly the most recognizable would be con-
ventilation in some cases, as well as benefits. sidered the “iron lung.” The “iron lung” was a device that was
used predominantly during the polio epidemic as support for
Keywords: noninvasive positive-pressure ventilation (NPPV); those with respiratory failure secondary to the disease. This
continuous positive airway pressure (CPAP); bilevel positive device utilized negative pressure within a closed chamber in an
airway pressure (BiPAP); noninvasive ventilation (NIV); acute effort to keep the patient’s lungs from developing atelectasis
respiratory failure (ARF) and to prevent total failure of the diaphragm. Whenever the
pressure within the chamber would decrease, the thorax of
the patient would expand, allowing for the intraalveolar pres-
sure to decrease, imitating the action of the diaphragm in a
Introduction
physiologically normal human.
Noninvasive positive-pressure ventilation (NPPV) is a form of
ventilatory support that does not require the placement of an
advanced airway. NPPV has also been called continuous posi- What Is NPPV?
tive airway pressure (CPAP) or bilevel positive airway pressure NPPV is a form of mechanical ventilatory support that delivers
(BiPAP). All of these ultimately fall into the category of non- positive pressure with a mix of atmospheric air and oxygen via
invasive ventilation (NIV), a means of delivering ventilatory a noninvasive device for patients that can maintain their own
support without using an invasive mode of ventilation. The airway. 4,6–8 The use of NPPV can be delivered via ventilators
use of NPPV has reduced the need for patients to require intu- found in the hospital setting, transport ventilators (i.e., Ham-
bation and/or mechanical ventilation in some cases, ultimately ilton T1, Hamilton MR1, Zoll EMV+), and portable devices
limiting them from further complications. In addition, NPPV that can be used via attachment to oxygen tanks. CPAP and
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has shown to reduce mortality and intensive level care for pa- BIPAP are specific treatment modalities under the umbrella of
tients with chronic obstructive pulmonary disease (COPD) NPPV, which is further defined within NIV and respiratory
and congestive heart failure (CHF). 1,2 support. 8–10 These are modes that are delivered via facemask,
endotracheal tube, or tracheostomy.
There are over 100,000 traumatic deaths in the United States
every year and chest traumas are the cause of death for over a CPAP delivers a constant set pressure. This set pressure is com-
quarter of polytrauma patients. Pulmonary contusions, inter- monly referred to as PEEP (positive end expiratory pressure),
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stitial, and intraalveolar fluids are common causes of posttrau- which may also be referred to as EPAP (expiratory positive
matic respiratory failure. The severity of those posttraumatic airway pressure). By flowing at a constant pressure, the CPAP
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injuries and their pathology correlate with the development mode overpowers residual pressure that prevents the lungs
of pulmonary infections, respiratory failure, and mortality. from fully emptying on exhalation in reactive airway disease
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First-line treatment in COPD and acute respiratory failure (RAD) and COPD. 11,12 Breaths are triggered by the patient,
(ARF) is to use NPPV, as long as there are no contraindica- which drives tidal volume (Vt) to be fully dependent on the
tions. NIPPV was historically limited to in-hospital settings, effort and compliance of the patient and their lung mechan-
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but it is now a first-line treatment in prehospital medicine, ul- ics. 11, 12 CPAP creates an increase of alveolar pressure, allow-
timately lowering the need for advanced airway management ing for better oxygenation at the end-alveolar plateau. Some
and mechanical ventilation in higher echelons of care. 4,5 negative impacts of CPAP include decreased patient comfort
and increased anxiety due to large amounts of air being forced
into their face and increased intra-thoracic volume, potentially
Development and History
causing hypercapnia and baro- and volutrauma. These po-
11
In the 1930s, noninvasive ventilation devices delivered breaths tential negative impacts can largely be avoided with pharma-
by squeezing the abdomen, gently applying pressure and using cologic assistance or utilization of BiPAP when available. 11
*Correspondence to papadoc5324@gmail.com
1 Wayne Papalski is a search and rescue corpsman/flight paramedic serving as the Trauma & Medical Education Manager with Naval Special
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Warfare Group Two, Little Creek, VA. John Siedler is a flight/tactical paramedic with the Anacortes Fire Department Fire Fighter/Paramedic, Ana-
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cortes, WA. David Callaway is a physician and professor of emergency medicine, Atrium Health, Carolinas Medical Center Main, Charlotte, NC.
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