REBEL Core Cast – Pediatric Respiratory Emergencies: Beyond Viral Season
Welcome to the Rebel Core Content Blog, where we delve ...
REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow
REBEL Cast
00:00
Intro
Frank Lodacerto introduces the episode and welcomes Dr. Eric Acker, outlining the show's focus on non-invasive respiratory support.
Play episode from 00:00
Transcript
Transcript
Episode notes
🧭 REBEL Rundown
🗝️ Key Points
- 💨 NIV = Support without a tube: CPAP, BiPAP, and HFNC improve oxygenation and reduce the work of breathing.
- 🫁 CPAP = Continuous pressure: Best for hypoxemic patients (e.g., pulmonary edema, OSA).
️ BiPAP = Two pressures (IPAP/EPAP): Great for hypercapnic failure (e.g., COPD, obesity hypoventilation).- 🌬️ HFNC = Heated, humidified high flow: Reduces effort, improves comfort, and enhances oxygen delivery.
- 🩺 Supportive, not definitive: NIV stabilizes patients while the underlying cause is treated.
📝 Introduction
Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation.
💨 CPAP and BiPAP
- CPAP delivers a single, continuous pressure during inspiration and expiration. This pressure (commonly 5–10 cm H₂O) helps recruit atelectatic alveoli, reduce shunt, and improve oxygenation. It is commonly used for conditions like pulmonary edema, obstructive sleep apnea, or mild hypoxemia without significant ventilatory failure.
- BiPAP alternates between two pressures:
- Inspiratory positive airway pressure (IPAP), augments tidal volume and unloads inspiratory muscles.
- Expiratory positive airway pressure (EPAP), maintains alveolar recruitment and improves oxygenation.
The differential between IPAP and EPAP is critical for reducing hypercapnia in patients with COPD exacerbations or acute hypercapnic respiratory failure.
- Indications
- CPAP: hypoxemia without major ventilatory failure (e.g., cardiogenic pulmonary edema, atelectasis, OSA).
- BiPAP: hypercapnia with increased work of breathing (e.g., COPD exacerbation, neuromuscular weakness, obesity hypoventilation).
A helpful way to conceptualize CPAP and BiPAP is through the hairdryer analogy. Imagine placing a hairdryer in your mouth:
🩺 Clinical Considerations
- Masks can be uncomfortable, impair secretion clearance, and limit oral intake.
- Some patients require sedation to tolerate NIV, but this carries risks in patients with unprotected airways.
- NIV is thus a high-stakes intervention requiring close monitoring.
- Common starting dose to understand titration, but start at the level appropriate for your patient: IPAP 10 cm H₂O / EPAP 5 cm H₂O (“10/5”) and are titrated:
- Increase IPAP to improve tidal volume and CO₂ clearance.
- Increase EPAP to recruit alveoli and improve oxygenation.
- Both may be raised simultaneously if the patient is both hypoxemic and hypercapnic.
🚀 High-Flow Nasal Cannula (HFNC)
- H: Heated & humidified – improves mucociliary clearance, prevents airway drying, and enhances tolerance. I: Inspiratory flow – high flow meets or exceeds patient demand, reducing respiratory rate and effort.
- F: Functional residual capacity – modest generation of positive end-expiratory pressure (PEEP), promoting alveolar recruitment.
- L: Lighter – generally more comfortable and less restrictive than mask-based NIV.
- O: Oxygen dilution – minimizes entrainment of room air, delivering higher and more predictable FiO₂.
- W: Washout – flushes anatomical dead space, reducing CO₂ rebreathing.
- HFNC delivers heated, humidified oxygen at high flow rates (30–60 L/min) through wide-bore nasal prongs. A mnemonic, H-I-F-L-O-W, helps summarize its mechanisms:
- Indications: Traditionally used for acute hypoxemic respiratory failure (e.g., pneumonia), HFNC is increasingly studied for hypercapnic failure as well, with trials suggesting non-inferiority to BiPAP in select populations.
Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)
👤 Show Notes
Syed Moosi Raza, MD
PGY 3 Internal Medicine Resident
Cape Fear Valley Internal Medicine Residency Program
Fayetteville NC
Aspiring Pulmonary Critical Care Fellow
🔎 Your Deep-Dive Starts Here
REBEL Core Cast 143.0–Ventilators Part 3: Oxygenation & Ventilation — Mastering the Balance on the Ventilator
When you take the airway, you take the wheel and ...
REBEL Core Cast 142.0–Ventilators Part 2: Simplifying Mechanical Ventilation – Most Common Ventilator Modes
Mechanical ventilation can feel overwhelming, especially when faced with a ...
REBEL Core Cast 141.0–Ventilators Part 1: Simplifying Mechanical Ventilation — Types of Breathes
For many medical residents, the ICU can feel like stepping ...
REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine
The sicker the patient, the more likely an IO line ...
REBEL Core Cast 139.0: Pneumothorax Decompression
On this episode of the Rebel Core Cast, Swami takes ...
The post REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow appeared first on REBEL EM - Emergency Medicine Blog.
The AI-powered Podcast Player
Save insights by tapping your headphones, chat with episodes, discover the best highlights - and more!
