**8. Complications of NPPV**

342 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

recommended rather than nasal mask in patients who have ARF. Although there was no difference in endotracheal intubation or mortality rates, the oronasal mask was better tolerated (Keenan et al. 2011). The use of an oronasal mask seem a logical solution to maximize the NPPV efficacy, presumably due to lower leakage with oronasal mask compared to nasal mask in dyspneic patients who are mostly mouth-breathers (Carrey, Gottfried, & Levy 1990). However during long-term use the face mask can be poorly

**Total face mask:** Total face mask covers mouth, nose and eyes. Advantages of this type of masks are minor air leaks, little cooperation required and easy fitting application. Risks of

**Helmet:** Helmet mask covers whole head and all or part of the neck without a contact with face. Advantages of this type of masks are minor air leaks, little cooperation required and absence of nasal or facial skin damage. The risk of vomiting, worsening of C02 clearance due to rebreathing, asynchrony with pressure support ventilation and discomfort of axillae are

**Nasal pillow or plugs:** These masks are inserted into the nostrils. This type of the mask may be suitable for claustrophobic patients with chronic stable COPD who do not need high

**Mouthpieces:** They are placed between lips and held in place by lip seal. Mouthpieces can be applied with other interfaces. The risk of vomiting and salivation, possible air leaks, gastric distension and speaking difficulty are the disadvantages of the mouthpieces.

The first hours of NPPV are associated with an increased workload for health care personnel that requires a specific management protocol, including monitoring mask ventilation and monitoring the patient (Nava and Hill 2009). Recommended application, setting and adjustments of NPPV in the ICU, HDU, respiratory wards and emergency departments

3. Set pressure starting from low levels (minimum starting IPAP and EPAP should be 8

5. When patient is tolerant, tighten straps just enough to avoid major leaks, but not keep it

9. Reset pressures (pressure support increased to obtain inspired tidal volume 6mL/kg or higher, achieving a respiratory rate <25 breaths/min, PaC02 <45 mmHg and also raise EPAP to obtain S02 of 90% or higher). The recommended maximum IPAP should be 30 cm H20 for patients ≥ 12 years. The recommended minimum and maximum levels of PS

6. Set Fi02 on ventilator or add low-flow oxygen into the circuit, aiming for S02>90%.

Mouthpiece ventilation is mainly used in patients with neuromuscular disease.

4. Place mask gently over face, holding it in place and start ventilation.

7. Set alarms-low pressure alarm should be above PEEP level.

8. Be mindful of and try to optimise patient's comfort.

tolerated, thus causing a premature NPPV interruption (Carlucci et al. 2001).

asphyxia, claustrophobia, speaking difficulty are the main disadvantages.

the disadvantages of the helmet.

pressures. Nasal irritation is the main disadvantage.

**7. Application, setting and adjustments of NPPV** 

(EDs) are summarised as in the following:

2. Choose correct interfaces and size.

too tight.

1. Explain technique to patient (if competent).

cm H20 and 4 cm H20, respectively).

Complications of NPPV therapy are minor and preventable. Major complications of NPPV such as pneumothorax and pneumocephalus are so rare (Grunstein 2005). The most common complications effecting almost half of the patients who are administered NPPV are due to mask leak and/or mask pressure injury (Pepin et al. 1999; Hoffstein et al. 1992; Abisheganaden et al. 1998; Lojander, Brander, & Ammala 1999; Sanders, Gruendl, & Rogers 1986). The main complications of NPPV therapy are listed in Table 2.


Table 2. Complications of NPPV Therapy

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