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Noninvasive positive pressure ventilation involves providing ventilatory support through the patient's upper airway using a mask or similar device, avoiding the need for endotracheal intubation. Noninvasive positive pressure ventilation minimizes complications such as ventilator-associated pneumonia and airway trauma associated with invasive methods. This form of ventilation is the standard intervention for respiratory distress in the prehospital setting. Clinicians must be aware of when noninvasive positive pressure ventilation may improve the work of breathing and oxygenation for patients with different cardiopulmonary complaints related to primary respiratory or cardiovascular complaints. Prehospital continuous airway pressure, a form of noninvasive positive pressure ventilation, improves breathing and oxygenation, reducing intubation rates and complications, and is now the standard care for acute respiratory distress. This activity describes the indications, contraindications, and potential complications of continuous airway pressure devices in the prehospital setting. The interprofessional team is highlighted in managing patients with respiratory, cardiac, and infectious conditions. Although other illnesses may vary in presentation, the underlying physiology is essential to understanding and ensuring effective and safe noninvasive positive pressure ventilation use. Objectives: Identify the indications for noninvasive positive pressure ventilation in the prehospital setting. Determine the contraindications for noninvasive positive pressure ventilation compared to other forms of ventilation. Interpret the physiology of noninvasive positive pressure ventilation to facilitate improved respiration. Implement care coordination among interprofessional team members to improve outcomes for patients treated with noninvasive positive pressure ventilation. Access free multiple choice questions on this topic.

Noninvasive ventilation involves providing ventilatory support through the upper airway using a mask or similar device, avoiding the need for endotracheal intubation. This method minimizes complications such as ventilator-associated pneumonia and airway trauma associated with invasive methods. Noninvasive positive pressure ventilation (NIPPV) has become a standard intervention for respiratory distress in the prehospital setting.[1] During the 1950s polio epidemic, Bjorn Ibsen pioneered positive pressure ventilation, significantly reducing mortality rates.[2] By the 1980s, noninvasive forms of continuous positive airway pressure (CPAP) were adopted for obstructive sleep apnea and chronic obstructive pulmonary disease (COPD).[3][4] Early NIPPV models used a control unit or flow generator attached to the oxygen source to produce the necessary positive pressure. Newer CPAP devices deliver a specific amount of pressure by either adjusting a control valve or the amount of flow supplied to produce the necessary positive end-expiratory pressure (PEEP). These newer models have all the necessary parts integrated into the device, costing much less compared to the original devices. Newer devices continue to decrease costs and improve simplicity. Using CPAP in the prehospital setting gained traction in the late 1990s as the primary form of NIPPV and an alternative to endotracheal intubation or supraglottic devices. CPAP is the most commonly used NIPPV modality in the prehospital setting and helps improve the work of breathing and oxygenation for patients with different cardiopulmonary complaints. The use of prehospital NIPPV has reduced rates of intubation and complications such as hypotension, hypoxia, and cardiac arrest.[5][6] Over the past several years, this type of ventilation has become the standard of care for patients with acute respiratory distress in the prehospital setting. A meta-analysis performed by Goodacre et al shows a reduction in mortality and intubation rates compared to standard care.[7]

Complications of NIPPV include patient discomfort, anxiety, and agitation. More severe complications may consist of pulmonary barotrauma or hypotension secondary to increased intrathoracic pressure and reduced preload. Gastric distention may result in abdominal compartment syndrome; this is most likely to occur with an IPAP greater than 20 cm H2O.[20] Many of these problems can be alleviated using the lowest, safest setting that provides results. Hypotension can be treated with intravenous fluids.

Prehospital clinicians have been conducting research to demonstrate the efficacy of noninvasive ventilation in the prehospital setting. The research has been overwhelmingly positive, where the 2018 EMS Scope of Practice Model concludes using CPAP at the EMT level and above. The EMS scope of practice model, along with the EMS agenda for the future, shows the value and need for prehospital clinicians to be educated to perform the skills, with most training programs being accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), then certified as competent with most states requiring an initial certification through the National Registry of emergency medical technicians. Most states allow prehospital clinicians to perform noninvasive ventilation as a minimum scope of practice, with medical directors credentialling the prehospital clinicians. The trend for using noninvasive ventilation in the prehospital setting has influenced emergency medicine clinicians, nurses, respiratory therapists, and hospitals to adopt a similar practice method of using noninvasive ventilation in the hospital setting. Education on noninvasive ventilation has become a collegial endeavor between prehospital and hospital clinicians.