Noninvasive positive-pressure ventilation

Noninvasive positive-pressure ventilation (NPPV) provides ventilatory support with oxygen and pressurized airflow using a face or nasal mask with a tight seal but without endotracheal intubation. In patients with acute respiratory failure due to COPD exacerbations, NPPV was associated with lower mortality, lower intubation rates, shorter hospital stays, and greater improvements in serum pH in 1 hour compared with usual care. Use of NPPV reduces the complications that often arise with invasive mechanical ventilation. NPPV is not appropriate for patients with altered mental status, severe acidosis, respiratory arrest, or cardiovascular instability. 

Lightowler JV, Wedzicha JA, Elhott MW, et al. Noninvasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease Cochrane systemic review and meta-analysis. Br Med J 2003 326 185-189. 

Goldberg A, Leger P, Hill NS, et al. Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation-a consensus conference report. Chevy Chase, MD National Association for Medical Direction of Respiratory Care, 1999 521-534. 

Esteban A, Frutos-Vivar F, Feiguson ND, et al. Noninvasive positive pressure ventilation for respiratory failure after extubation. N Engl J Med 2004 350 2452-2460. 

Abbreviations NIPPV, noninvasive positive pressure ventilation TIPPV, tracheotomy invasive positive pressure ventilation RT, respiratory thaapist PT, physiotherapist MD, medical doctor. 

Krachman SL, Quaranta AJ, Berger TJ, et al. Effects of noninvasive positive pressure ventilation on gas exchange and sleep in COPD patients. Chest 1997 112 623-628. 

Butz M, Wollinsky KH, Wiedemuth-Catrinescu U, et al. Longitudinal effects of noninvasive positive-pressure ventilation in patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2003 82 597-604. 

Aboussouan LS, Khan SU, Meeker DP, et al. Effect of noninvasive positive -pressure ventilation on survival in amyotrophic lateral sclerosis. Ann Intern Med 1997 127 450-453. Gruis KL, Brown DL, Schoennemann A, et al. Predictors of Noninvasive ventilation tolerance in patients with amyotrophic lateral sclerosis. Muscle Nerve 2005 32 808-811. 

Wijkstra PJ, Lacasse Y, Guyatt GH, et al. A meta-analysis of nocturnal noninvasive positive pressure ventilation in patients with stable COPD. Chest 2003 124(l) 337-343. 

Nava S, Ceriana P. Patient-ventilator interaction during noninvasive positive pressure ventilation. Respir Care Clin N Am 2005 11 281-293. 

Figure 2 Comparison of Medical Research Council Shrat Form Questionnaire (SFag) scores in hypoxic patients and in patients on NIPPV. Positive values indicate a worse quaUty of hfe in the NIPPV group. Abbreviations COPD, chronic obstructive pulmonary disease NIPPV, noninvasive positive pressure ventilation. Source Modified from Ref. 26.

Windisch W, Kostic S, Dreher M, et al. Outcome of patients with stable COPD receiving controlled noninvasive positive pressure ventilation aimed at a maximal reduction of Pa(C02). 

Meyer TJ, Hill NS. Noninvasive positive pressure ventilation to treat respiratory failure. Ann Intern Med 1994 120 760-770. 

Meduri GU, Turner RE, Abou-Shala N, et al. Noninvasive positive pressure ventilation via face mask. First-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. Chest 1996 109 179-193. 

Schettino GP, Chatmongkolchart S, Hess DR, et al. Position of exhalation port and mask design affect CO2 rebreathing during noninvasive positive pressure ventilation. Crit Care Med 2003 31 2178-2182. 

Hess DR. Noninvasive positive-pressure ventilation and ventilator-associated pneumonia. Respir Care 2005 50(7) 924—929, discussion 929-931. 

Burns KEA, Adhikari NKJ, Meade MO. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev 2003, Issue 4. Art. No. CD004127. DOI 10.1002/14651858.CD004127. 

Pankow W, Hijjeh I, Sehutder F, et al. Influenee of noninvasive positive pressure ventilation on inspiratory musele aetivity in obese subjects. Eur Respir J 1997 10 2847-2852. de Lucas-Ramos P, de Miguel-Diez J, Santaeruz-Siminiani A, et al. Benefits at 1 year of nocturnal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome. Respir Med 2004 98 %l-967. 

Chronic ventilatory support is currently a well-accepted therapy in patients with chronic respiratory failure due to thoracic cage abnormalities or in patients with neuromuscular disease. In contrast, the evidence to use chronic ventilatory support in patients with obstructive lung disease is less clear. Most of studies in this area have been in patients with chronic obstructive pulmonary disease (COPD) and only a few in patients wiA cystic fibrosis (CF) and bronchiectasis. In this chapter, we will focus primarily on COPD, discussing first the rationale of noninvasive positive pressure ventilation (NIPPV) in these patients and second all randomized controlled studies. Thereafter, we will elaborate on different issues that might be important in making NIPPV more effective in patients with COPD. Finally, we will discuss the effeets of ehronie ventilatory support in patients with CF and bronchiectasis. 

Abbreviations-. IPAP/EPAP, ratio of inspirat(xy positive airway pressure and expiratory positive airway pressure NP ABG, arterial blood gas 6-MWD, six-minute walking distance 6-MWT, six-minute walk test HRQL, health-related quaUty of Ufe RVEL, right ventricular ejection fraction LVEF, left ventricular ejection fraction NIPPV, noninvasive positive pressure ventilation O2, oxygen Til, tension time index. 

Abbreviations. NIPPV, noninvasive positive pressure ventilation Cl, cardiac index FEVi, forced respiratory value in 1 second FVC, forced vital capacity Pa02, partial pressure of oxygen in arterial blood Pac02, partial pressure of carbon dioxide in arterial blood. 

Criner GJ, Brennan K, Travaline JM, et al. Efficacy and compliance with noninvasive positive pressure ventilation in patients with chronic respiratory failure. Chest 1999 116(3) 667-675. 

Abbreviation. NPPV, noninvasive positive pressure ventilation. 

Essouri S, Nicot F, Clement A, et al. Noninvasive positive pressure ventilation in infants with upper airway obstruction comparison of continuous and bilevel positive pressure. Intensive Care... 

Fauroux B, Lavis JF, Nicot F, et al. Facial side effects during noninvasive positive pressure ventilation in children. Intensive Care Med 2005 31 965-969. 

A 53-year-old woman with severe chronic obstructive pulmonary disease, on home oxygen, had been admitted to the ICU on three occasions in 2003, for acute respiratory failure consequent upon an acute exacerbation, always unresponsive with a Glasgow Coma Scale 8/15 (Table 9). She received noninvasive positive pressure ventilation (NIPPV) by mask on each admission and after 24 hours had greatly improved. On each occasion, her LOS was 17 days before discharge home, representing acute care cost of 8880 (seven days ICU = 6300 plus 10 days ward = 2580, for a total of 8880 per admission). 

Kacmarek R, Hill NS. Ventilators for noninvasive positive pressure ventilation technical aspects. In Muir JR, Simonds A, Ambrosino N, eds. Noninvasive Mechanical Ventilation. European Respiratory Monograph Series. Sheffield, UK, 2001. 

In May 2002, Vianna et al. (9) evaluated LTV in patients with a stay >30 days, in 77 ICUs in Rio de Janeiro, noting by telephone interview that 26 were publicly funded and 51 were in the private system. There were 645 patients of whom 62 (9.6%) met the criteria for prolonged stay. The main causes were pulmonary and neurological illness. Invasive ventilation was used in 93% of public and 79% of private units. Noninvasive ventilation was not registered in public units, but used in 12% of private patients. The authors noted that noninvasive positive pressure ventilation (NIPPV) in specialized respiratory units would reduce costs as well as length of stay in the ICU. A study conducted by nurses (10) in the ventilator-dependent pediatric population improved the process of family care during their ICU stay and when at home. 

By 1994, fees paid by medical insurance increased to cover medical services provided by the hospital, clinic, or home care nurse as well as the costs of medical equipment, such as the ventilator rental. This led to rapid growth in the population of patients receiving HMV (2). In April 1995, of the 536 HMV cases 65% had NMD, 20% had parenchymal disease (PD), such as sequelae of tuberculosis and chronic obstructive pulmonary disease (COPD), and 15% had thoracic restriction or central hypoventilation syndrome (3,4). In June 1995, of the 1006 patients undergoing LTV for at least three months, 215 (21%) could have been discharged to a home care setting if an appropriate public assistance program had been established (3,4). By January 1997, there were 1250 patients receiving HMV of whom 461 (1.2 people/million) used noninvasive positive pressure ventilation (NIPPV) (5). 

Abbreviations. TIPPV, tracheal invasive positive pressure ventilation NIPPV, noninvasive positive pressure ventilation ALS, amyotrophic lateral sclerosis NMD, neuromuscular diseases LTV, long-term ventilation. 

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