Mastering Non-Invasive Positive Pressure Ventilation in the ED

OVERVIEW

This podcast covers a comprehensive discussion on the use of non-invasive positive pressure ventilation (NIPPV) in the emergency department. Colin McCloskey, MD, an EM physician and intensivist, and EMRA*Cast host Blythe Fiscella, MD, an EM/IM resident at ChristianaCare, delve into the practical applications and benefits of CPAP, BiPAP, and high flow nasal cannula for patients experiencing respiratory distress. The episode covers the evidence base for these modalities, impact on the physiology of the heart and lungs, the importance of being able to operate NIPPV machinery independently, and techniques to optimize patient care.

TAKE-HOME POINTS

• NIPPV, when used effectively,  prevents intubation and death in patients with COPD and CHF.
• NIPPV buys time for the treatments to work (ie: bronchodilators in COPD, diuretics or nitroglycerin in CHF, insulin and fluids in DKA) and is not a definitive strategy for managing respiratory distress. 
• Preoxygenating with NIPPV decreases risk of hypoxia during intubation.
• NIPPV includes CPAP (which involves only delivering a constant end-positive expiratory pressure (EPAP=PEEP), BiPAP (which involves both a constant EPAP plus an inspiratory positive pressure (IPAP) the difference between these two settings is your pressure support also known as the delta), and High Flow Nasal Cannula (which when used with a closed mouth can generate 1 of PEEP for every 10L of flow)
• It is worth knowing where your NIPPV supplies are kept and how to set up a basic machine and mask for your patient because Respiratory Therapy can’t be there 100% of the time to do these tasks for you. 
• Ketamine and Dexmetatomadine can help your patient tolerate the mask.
• EPAP delivered via NIPPV can improve cardiac function in patients with LV dysfunction and EPAP at range between 5-10 can improve cardiac function in patients with RV dysfunction too (by decreasing hypoxia and thereby decreasing pulmonary vascular resistance)
• You’ll know your patient is on the “right” settings or rather that they are improving on NIPPV by looking at them (rather than the venous blood gas): Are they using less accessory muscles to breathe? Are they no longer sweating? Are they less tachypneic? Are they getting good tidal volumes? Pay attention to mask fit and leak.

Great Reading

• Gibbs KW, Semler MW, Driver BE, et al., for the PREOXI Investigators and the Pragmatic Critical Care Research Group. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024;390(23): 1068-1070.
• Lucas A, Wild AJ, Colon G, Qiao L, Slagle D. Critical Care Alert: Noninvasive Ventilation for Preoxygenation During Emergency Intubation. EM Resident. 2024;online-ahead-of-print:July 2024.