Noninvasive Positive Pressure Ventilation an Alternative to Intubation?

At 3:30 p.m., Mesa Fire and Medical Department (MFMD) Engine 218 was dispatched for a 54-year-old male with difficulty breathing. Upon arrival, we encountered a small singlewide trailer with limited access. Our patient was in the back bedroom complaining of difficulty breathing while on his home bi-level positive airway pressure (BiPAP) machine.

He was in obvious distress, utilizing his accessory muscles to breathe and speaking in two- to three-word sentences. His distress worsened when speaking. He had diminished lung sounds in all fields and prolonged expiratory wheezing and rhonchi.

Because of his excessive weight–over 500 lbs.–we requested a bariatric ambulance–code three–through alarm, and were given a 30-minute estimated time of arrival. However, alarm then reported the availability of a bariatric-capable transitional response vehicle (TRV) less than 10 minutes away.

Due to the patient’s deteriorating condition, we chose the TRV to be dispatched to our location to transport the patient to the closest ED. This particular unit would also provide us with two additional fire personnel to assist with extricating him from his small mobile home.

Patient Assessment & Treatment
During assessment, we determined we had two ways to stabilize the patient prior to transport: intubate using rapid sequence intubation (RSI) or utilize noninvasive positive pressure ventilation (NPPV).

Intubation wasn’t an option because of the patient’s previous malignant hyperthermia reaction to succinylcholine, but, in
addition to his inability to tolerate our paralytic drug, his morbid obesity also posed a real challenge to intubate, even in a controlled environment.

Our crew initiated additional ALS treatment even before attempting patient extrication. We started a peripheral IV and placed the patient on a non-rebreather (NRB) mask until NPPV could be administered.

The patient was then rapidly moved out of the trailer utilizing his bariatric wheelchair and placed in the TRV for his emergent transport. This extrication required the assistance of the additional crew members from the TRV.

His level of respiratory distress was exacerbated during the extrication process. Once in the ambulance, we replaced the NRB mask with bi-level NPPV, using the CareFusion ReVel ventilator. The patient tolerated the ventilation well, and within minutes his condition improved in conjunction with additional ALS treatments.

The patient was given 125 mg slow IV push methylprednisolone sodium succinate and magnesium sulfate drip 2 grams in 50cc normal saline over five minutes. The patient tolerated transport well and appeared to be comfortable with a noticeable decrease in his level of respiratory distress.

The patient was then placed on the ventilator and two puffs of albuterol were given in line with a metered-dose inhaler.

NPPV was administered with pressure support of 10 cmH2O titrated up to 12 cmH2O. Fraction of inspired oxygen (FiO2) was 100% and weaned to 40% upon arrival at the ED. Inspiratory peak airway pressure (IPAP) of 18 cmH2O and expiratory positive airway pressure (EPAP) of 6 cmH2O.

NPPV was a modality that prevented a prehospital intubation on an extremely difficult patient to manage. Upon arrival at the ED, the patient was acutely ill but stable. A detailed report was given at the bedside to the ED staff.

Our patient was kept on our ventilator for approximately another 15 minutes due to a hospital equipment shortage. After an NPPV was located, the respiratory therapist placed the patient on similar settings and he appeared to tolerate the transition well.

Teaching Points
NPPV has been utilized in the prehospital setting for many years, mainly continuous positive airway pressure (CPAP) for congestive heart failure with pulmonary edema. Depending on the literature referenced, CPAP isn’t always considered noninvasive ventilation. Yes, it does utilize a mask (interface), but it doesn’t ventilate; it just creates continuous positive airway pressure in the airway.

Bi-level NPPV actually assists the patient’s spontaneous efforts and decreases the work of breathing by giving a positive pressure breath when it senses a spontaneous effort or is able to deliver a machine-initiated breath if indicated. This increases the tidal volume the patient is able to take and helps decrease the work of breathing and increases alveolar ventilation.

Typically the IPAP is increased in 2 cmH2O increments titrated to meet the patient’s needs. Standard initial settings are different based on the doctor’s orders and the patient’s disease process.

NPPV Implementation
One of the most challenging obstacles with MFMD’s implementation of NPPV in the prehospital setting was the absence of any provider protocols. We had to start from scratch, utilizing current best practices from hospital-based medicine since no research has been published on NPPV use and application in the prehospital setting. We also had to teach concepts that hadn’t been taught to paramedics in the past. Initially it was like driving with the headlights off down a dark winding road.

The MFMD was faced with the challenge to provide our paramedics an offline algorithm that would encompass the majority of respiratory ailments/sequela that may present in the field. A continual assessment of chest rise, breath sounds, oxygen saturation (SpO2) and quantitative capnography is used to help titrate the appropriate settings to the patient’s needs.

The prehospital utilization of bi-level NPPV is in its infancy. There are several reasons for this. Affordable portable prehospital equipment that provides bi-level NPPV was previously unavailable, and research supporting its benefits and use in the prehospital setting hasn’t been well-studied.

Additionally, this is a treatment modality that isn’t traditionally taught in the paramedic curriculum. Therefore, the medical terminology, pathophysiology and concepts of invasive and noninvasive ventilation needed to be taught prior to rolling out this new program.

With rapidly expanding technology, bi-level NPPV devices are now more readily available. These portable devices are capable of providing various modes of invasive and noninvasive ventilation. The numerous risks of prehospital intubation versus the minimal risks associated with NPPV should support the justification of its trial use. In the past, if the patient failed to improve on an NRB mask the only other treatment modality the paramedic had was intubation.

MFMD has been collecting data on NPPV since starting this new treatment modality in August 2012. Our EMS department performs quality assurance on 100% of our calls when a provider utilizes NPPV. We’ve had many positive reports from our members and hospital staff after its application.

In addition, our elective out-of-hospital intubation attempts have decreased significantly and we’re tracking this trend. Since we initiated the program, the most common statement we hear from the provider is, “We would’ve had to intubate that patient.” We also hear, “Using the vent prevented an out-of-hospital RSI.” The challenge we all face is maintaining our advanced airway management skills when NPPV has provided such a large decrease in intubation numbers.

Keep in mind this is just another option in our toolbox to help patients get relief from respiratory distress and impending respiratory failure. Most evidence has demonstrated the biggest complication associated with the application of NPPV is the healthcare provider’s inability to recognize when it’s not working and that the patient’s condition is worsening. The message has to be clear when teaching NPPV: “If it’s not working, don’t force it; take it off and go to plan B.”

Medical Director’s Support Statement
NPPV has been shown to decrease intubation rates, mortality and morbidity rates in patients presenting with chronic obstructive pulmonary disease, cardiogenic pulmonary edema, asthma and immunocompromised patients in respiratory failure. The benefits of this respiratory adjunct is that it’s technically easier to use than intubation; avoids the administration of paralytics, sedation, and the complications that may come from intubation, such as nosocomial infections; it decreases morbidity/mortality and the cost associated with patient care. The patient selection is one who’s unable to speak in full sentences, has an SpO2 less than 90%, using accessory muscles, with a respiratory rate greater than 24 and altered mental status.

The use of NPPV is a tool that should be considered for routine use for out-of-hospital emergency medical care provided by well-trained paramedics with appropriate EMS medical director oversight.

More Case of the Month from


  • Aehlert B: Division 3: Airway management. In Paramedic practice today, above and beyond, volume 1. Jones & Bartlett Learning: Burlington, Mass., pp. 548-549, 2011.
  • Branson RD, Johannigman JA. Pre-hospital oxygen therapy. Respir Care. 2013;58(1):86—97.
  • Daily JC, Wang HE. Noninvasive positive pressure ventilation: Resource document for the National Association of EMS Physicians position statement. Prehosp Emerg Care. 2011;15(3):432—438.
  • Hess DR. Noninvasive ventilation for acute respiratory failure. Respir Care. 2013;58(6):950—972.
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