Noninvasive positive-pressure ventilation NIPPV

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. 

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). 

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

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.

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. 

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

Abbreviations-. Sp02, saturation of oxygen in arterial blood NIPPV, noninvasive intermittent positive pressure ventilation MAC, mechanically assisted cough CO2, carbon dioxide IPAP, inspiratory positive airway pressure BiPAP, bi-level positive airway pressure. 

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