Noninvasive Ventilation in the Perioperative Period

  • Kimberly M. Ramonell
  • Richard P. Ramonell
  • Kevin W. McConnellEmail author


Noninvasive ventilation (NIV) refers to the delivery of positive airway pressure in a spontaneously breathing patient without the use of endotracheal intubation. Many ventilation modes can be used for NIV, but the two most common modes include continuous positive airway pressure ventilation (CPAP) and bilevel positive airway pressure ventilation (BPAP). NIV has been shown to clearly benefit several acute medical conditions, but its role in the perioperative patient is less well defined and requires individual consideration of comorbidities and surgical anatomy. In select surgical populations, the use of NIV may preclude the need for endotracheal intubation and mechanical ventilation, thus reducing nosocomial infections and ICU length of stay while preserving mobility, speech, and cough. When considering NIV, appropriate patient selection and early recognition of NIV failure are integral to its success. Heightened recognition of postoperative vulnerability to hypercapnia, atelectasis, and undiagnosed sleep apnea, combined with accumulating data demonstrating safety and efficacy in multiple subsets of surgical patients, has contributed to the increasing use of NIV in the perioperative period. While further evidence is needed, current data suggests that NIV is safe in patients with proximal foregut anastomoses, without increasing the risk of an anastomotic leak.


CPAP BPAP BIPAP NIV NPPV Noninvasive positive pressure ventilation Noninvasive ventilation STOP-Bang Obstructive sleep apnea Postoperative respiratory failure 


  1. 1.
    Hillberg RE, Johnson DC. Noninvasive ventilation. N Engl J Med. 1997;337:1746–52.CrossRefGoogle Scholar
  2. 2.
    Marino W. Intermittent volume cycled mechanical ventilation via nasal mask in patients with respiratory failure due to COPD. Chest. 1991;99:681–4.CrossRefGoogle Scholar
  3. 3.
    Benhamou D, Girault C, Faure C, et al. Nasal mask ventilation in acute respiratory failure: experience in elderly patients. Chest. 1992;102:912–7.CrossRefGoogle Scholar
  4. 4.
    Soo Hoo GW, Santiago S, Williams AJ. Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure. Crit Care Med. 1994;22:1253–61.CrossRefGoogle Scholar
  5. 5.
    Mace SE. Bilevel positive airway pressure ventilation. J Clin Outcomes Manage. 1999;6:41–8.Google Scholar
  6. 6.
    Sanders MH, Kern N. Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask: physiologic and clinical implications. Chest. 1990;98:317–24.CrossRefGoogle Scholar
  7. 7.
    Strohl KP, Redline S. Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea. Am Rev Respir Dis. 1986;134:555–8.PubMedGoogle Scholar
  8. 8.
    Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares. Lancet. 1981;1:862–5.CrossRefGoogle Scholar
  9. 9.
    Gleeson K, Zwillich CW, White DP. The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis. 1990;142:295–300.CrossRefGoogle Scholar
  10. 10.
    Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito J. Noninvasive ventilation in acute cardiogenic pulmonary edema. Systematic review and meta-analysis. JAMA. 2005;294:3124–30.CrossRefGoogle Scholar
  11. 11.
    Weng CL, Zhao YT, Liu QH, et al. Meta-analysis: noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152:590–600.CrossRefGoogle Scholar
  12. 12.
    Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004;(3):CD004104.Google Scholar
  13. 13.
    Lawrence VA, Hilsenbeck SG, Mulrow CD, et al. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995;10:671–8.CrossRefGoogle Scholar
  14. 14.
    Ferreyra GP, Baussano I, Squadrone V, Richiardi L, Marchiaro G, Del Sorbo L, Mascia L, Merletti F, Ranieri VM. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg. 2008;247(4):617–26.CrossRefGoogle Scholar
  15. 15.
    Carteaux G, Lyazidi A, Cordoba-Izquierdo A, et al. Patient-ventilator asynchrony during noninvasive ventilation: a bench and clinical study. Chest. 2012;142(2):367–76.CrossRefGoogle Scholar
  16. 16.
    Mas A, Masip J. Noninvasive ventilation in acute respiratory failure. Int J Chron Obstruct Pulmon Dis. 2014;9(1):837–52.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Munckton K, Ho KM, Dobb GJ, Das-Gupta M, Webb SA. The pressure effects of facemasks during noninvasive ventilation: a volunteer study. Anaesthesiology. 2007;62:1126–31.Google Scholar
  18. 18.
    Vignaux L, Vargas F, Roeseler J, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med. 2009;35:840–6.CrossRefGoogle Scholar
  19. 19.
    Antonelli M, Conti G, Moro ML, et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med. 2001;27:1718–28.CrossRefGoogle Scholar
  20. 20.
    L’Her E, Deye N, Lellouche F, Taille S, Demoule A, Fraticelli A, et al. Physiologic effects of noninvasive ventilation during acute lung injury. Am J Respir Crit Care Med. 2005;172:1112–8.CrossRefGoogle Scholar
  21. 21.
    Perrin C, Jullien V, Vénissac N, et al. Prophylactic use of noninvasive ventilation in patients undergoing lung resectional surgery. Respir Med. 2007;101:1572–8.CrossRefGoogle Scholar
  22. 22.
    American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology. 2014;120(2):268–86.CrossRefGoogle Scholar
  23. 23.
    Jaber S, Michelet P, Chanques G. Role of non-invasive ventilation (NIV) in the perioperative period. Best Pract Res Clin Anaesthesiol. 2010;24(2):253–67.CrossRefGoogle Scholar
  24. 24.
    Harbut P, Gozdzik W, St Jernfalt E, Marsk R, Hesselvik J. Continuous positive airway pressure/pressure support pre-oxygenation of morbidly obese patients. Acta Anaesthesiol Scand. 2014;58(6):675–80.CrossRefGoogle Scholar
  25. 25.
    Carron M, Freo U, BaHammam AS, Dellweg D, Guarracino F, Cosentini R, Feltracco P, Vianello A, Ori C, Esquinas A. Editor’s choice: complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110(6):896–914.CrossRefGoogle Scholar
  26. 26.
    Michelet P, D’Journo XB, Seinaye F, Forel JM, Papazian L, Thomas P. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg. 2009;96(1):54–60.CrossRefGoogle Scholar
  27. 27.
    Huerta S, DeShields S, Shpiner R, et al. Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after roux-en-y gastric bypass. J Gastrointest Surg. 2002;6(3):354–8.CrossRefGoogle Scholar
  28. 28.
    Ramirez A, Lalor PF, Szomstein S, Rosenthal RJ. Continuous positive airway pressure in immediate postoperative period after laparoscopic Roux-en-Y gastric bypass: is it safe? Surg Obes Relat Dis. 2009;5(5):544–6.CrossRefGoogle Scholar
  29. 29.
    Raman V, MacGlaflin CE, Erkmen CP. Noninvasive positive pressure ventilation following esophagectomy. Chest. 2015;147(2):356–61.CrossRefGoogle Scholar
  30. 30.
    Aguilo R, Togores B, Pons S, Rubi M, Barbe F, Agusti AG. Noninvasive ventilatory support after lung resectional surgery. Chest. 1997;112:117–21.CrossRefGoogle Scholar
  31. 31.
    Rocco M, Conti G, Antonelli M, et al. Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation. Intensive Care Med. 2001;27:1622–6.CrossRefGoogle Scholar
  32. 32.
    Gunduz M, Unlugenc H, Ozalevli M, et al. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J. 2005;22:325–9.CrossRefGoogle Scholar
  33. 33.
    Hurst JM, DeHaven CB, Branson RD. Use of CPAP mask as the sole mode of ventilatory support in trauma patients with mild to moderate respiratory insufficiency. J Trauma. 1985;25:1065–8.CrossRefGoogle Scholar
  34. 34.
    Chiumello D, Coppola S, Froio S, Gregoretti C, Consonni D. Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med. 2013;39:1171–80.CrossRefGoogle Scholar
  35. 35.
    Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21.CrossRefGoogle Scholar
  36. 36.
    Antonelli M, Conti G, Bufi M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283:235–41.CrossRefGoogle Scholar
  37. 37.
    Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001;344:481–7.CrossRefGoogle Scholar
  38. 38.
    Confaloreni M, Calderni E, Terraciano S, et al. Noninvasive ventilation for treating acute respiratory failure in AIDS patients with PCP pneumonia. Intensive Care Med. 2002;28:1233–8.CrossRefGoogle Scholar
  39. 39.
    Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350:2452–60.CrossRefGoogle Scholar
  40. 40.
    Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk. Am J Respir Crit Care Med. 2006;173:164–70.CrossRefGoogle Scholar
  41. 41.
    Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33:2465–70.CrossRefGoogle Scholar
  42. 42.
    Su CL, Chiang LL, Yang SH, et al. Preventive use of noninvasive ventilation after extubation: a prospective, multicenter randomized controlled trial. Respir Care. 2012;57:204–10.PubMedGoogle Scholar
  43. 43.
    Azoulay E, Demoule A, Jaber A, et al. Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med. 2011;37:1250–7.CrossRefGoogle Scholar
  44. 44.
    Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004;32:2002–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial 2.5 International License (, which permits any noncommercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Authors and Affiliations

  • Kimberly M. Ramonell
    • 1
  • Richard P. Ramonell
    • 2
  • Kevin W. McConnell
    • 1
    Email author
  1. 1.Department of General SurgeryEmory University HospitalAtlantaUSA
  2. 2.Department of Internal MedicineEmory University HospitalAtlantaUSA

Personalised recommendations