Table 2.

—Ensuring Effective Noninvasive Ventilation

Assess for conditions that may reduce efficacy or increase harm from NIV, including hemodynamic instability, multiple organ failure, abdominal distension, agitation, excessive secretions, or upper GI bleeding.

Ensure appropriate mask fit. Most critically ill patients require oronasal or full-face masks.

Monitor and minimize leak.

Set initial bi-level PAP settings at 10/5 cm H2O to promote tolerance, but reassess frequently. Most patients require higher inspiratory and expiratory pressures to treat OSA and to achieve adequate ventilation.

Titrate IPAP to achieve effective minute ventilation (tidal volume of 6-8 mL/kg ideal body weight).

Administer supplemental oxygen to achieve saturation between 90% and 93%. (In a subgroup of patients with COPD and OHS excessive oxygen supplementation can worsen hypoventilation).79-82

Reassess patients at least every 30 min during the initial phase of NIV.

Monitor closely for NIV failure. Potential signs include hemodynamic instability, agitation, combativeness, persistent snoring or apneas, or lack of improvement in hypercapnia or hypoxia.

IPAP = inspiratory positive airway pressure; PAP = positive airway pressure. See Table 1 legend for expansion of other abbreviations.