Noninvasive ventilation patient

Nervous System A case of anisocoria has been affribufed to iprafropium [46 ]. A 7-year-old child with severe refractory asthma was admitted in the pediatric intensive care xmit. The patient was started on noninvasive ventilation (NIV) and received nebulised salbutamol and ipratropium. Eighteen hours after the admission anisocoria was noted, which gradually subsided once ipratropium was stopped. Nebulised ipratropium leaking from the NIV may be transferred to the conjunctiva, causing the anticholinergic side effects. 

Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to jnevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005 33 2465-2470. 

Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk a randomized trial. Am J Respir Crit Cate Med 2006 173 164-170. Ezingeard E, Diconne E, Guyomarch S, et al. Weaning fiom mechanical ventilation with pressure support in patients failing a T-tube trail of spontaneous breathing. Intensive Care Med 2006 32 165-169. 

Single organ respiratory failure Acute respiratory failure— monitoring but not necessarily mechanical ventilation Tracheotomy patients from ICU-post acute or weaning Noninvasive ventilation Availability of life suppmt— invasive ventilation followed by ICU transfer Minimum monitraing requited— oximetry, vital signs, etc. 1 4 nursing for 24 hours MD available 24 hr/day Unit supervised by an MD with expertise in... 

Stoller described ICU-discharge survival rate as 32% at two years, with a slower decline up to five years for ventilator-independent patients (43). We found the use of NIV at home in 31.5% of patients following PMV (16). Survival rates were poor (49% at one year and worse) in patients with COPD. In a research series by Pilcher, 38% of patients were fully weaned and 35% required HMV, most of the latter needing only nocturnal noninvasive support. Patients with NMD and transfusion-related diseases (TRD) were less likely to be weaned but had a reduced mortality, compared with those with COPD in whom survival rate was 58% at one year and 47% at three years (17). 

Clini E, Sturani C, Rossi A, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients. Eur Respir J 2002 20 529-538. 

It is useful to define the disease category in order to predict the natural history and specific intervention. It is well known that patients with primarily restrictive disorders can have both inspiratory and expiratory muscle weakness, and apart from noninvasive ventilation (NIV), they also need cough assistance (4,5). On the other hand, patients with obstructive disorders rarely need mechanical expiratory aids except when they have a severe infectious exacerbation at which time difficulties in clearing copious secretions can occur (4,6,7). 

Bach JR. Continuous noninvasive ventilation for patients with neuromuscular disease and spinal cord injury. Semin Respir Crit Care Med 2002 23 283-292. 

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. 

Madden BP, Kariyawasam H, Siddiqi AJ, et al. Noninvasive ventilation in cystic fibrosis patients with acute or chronic respiratory failure. Eur Respir J 2002 19 310-313. 

Successful assisted ventilation depends critically upon adapting mechanical ventilation to the patient s needs. This is particularly true when the noninvasive mode is used, because the patient is conscious and if ventilation is ineffective or uncomfortable, the patient may reject it. In patients with chronic respiratory failure (CRF), noninvasive ventilation (NIV) is performed during sleep and comfort is particularly important if sleep is not to be compromised. An understanding of the technical equipment, in partieular the elassiQeation and modes of ventilation and the potential problems with each, is cmcial, as is the selecticm of an appropriate interface. This chapter deals with the equipment needs for home mechanical ventilation (HMV), in particular the major ventilator types and modes, interfaces, accessories, and monitoring. 

Figure 7 Duchenne muscular dystrophy patient, dependent on noninvasive ventilation using daytime mouthpiece ventilation mounted on his electric wheelchair.

Patients with thoracic restriction or advanced parench)mial diseases, who develop respiratory failure, represent a heterogeneous group. For such patients, nocturnal noninvasive ventilation is the preferred alternative. The results are very encouraging among those with stable thoracic restriction and less clear among those with advanced parenchymal diseases. The development of specialized facilities for long-term ventilation is described elsewhere in this book. 

Patient-Ventilator Interfaces for Invasive and Noninvasive Ventilation... 

Figure 1 Rate of use of three different noninvasive interfaces (oro-nasal mask, nasal mask, nasal pillows), as reported by the studies where noninvasive ventilation was utilized to treat acute left) and chronic (right) patients. The oro-nasal mask is the interface of choice in patients with acute or acute on chronic ventilatory failure, while it is less commonly employed for domiciliary treatment of stable chrcniic ventilatory failure. The nasal mask is preferred for long-term treatment of chronic patients. Source From Refs. 39 and 40.

Some studies suggest that liberation from mechanical ventilation is a requirement for decannulation (6), but this precludes the provision of noninvasive ventilation (NIV) as part of decannulation and may be impossible for some patients who could otherwise be dec-annulated. Other reports recognize that decannulation may proceed to NIV 24 hours a day without the requirement of an artificial airway (7) provided bulbar function is adequate and airway clearance is achieved (8). 

There is an important distinction between dependence on an artificial airway and mechanical ventilation, which can be provided noninvasively (9). The requirement for an artificial airway may reflect bulbar impairment as, in those with adequate bulbar function, noninvasive ventilation will sustain adequate ventilation even with veiy limited respiratory muscle function. Therefore, tracheostomized patients with preserved bulbar control can undergo decannulation. Airway secretions are important determinants of dependence on mechanical ventilation through an artificial airway, and aspiration pneumonia may result from an impaired level of consciousness, poor bulbar function, or inability to cough effectively. Such issues must be addressed by airway clearance techniques, prior to decannulation. 

In patients with COPD there is a persistent and permanent dyspnea and airway obstruction, with incomplete reversibility with therapy. Normally, in these patients, the mucociliary transport is not so impaired, until an acute exacerbation occurs. During an acute exacerbation of COPD, hypersecretion is usually present and may be induced by bacterial infections. Secretion encumbrance and ineffectiveness of airway clearance is associated with failure of noninvasive ventilation (NIV), whereas endotraqueal intubation and mechanical ventilation is necessary in acute exacerbations of COPD. The duration of mechanical ventilation was correlated with hospital mortality (22). 

Ishikawa Y, Bach JR. Nocturnal respiratory failure as an indication of noninvasive ventilation in the patient with neuromuscular disease. Respiration 1998 65(3) 226. 

OHS, previously called the Pickwickian syndrome (6), is defined as the association of obesity, sleep-disordered breathing (SDB) with daytime h)q)ersomnolence, and hypercapnia (Pacc>2 > 45 mmHg) in the absence of any other respiratory disease (Fig. 1). SDB can present as obstructive apneas and hypopneas, obstructive hypoventilation due to increased upper airway resistance, and/or central hypoventilation (7). The prevalence of OHS is 36% in patients with BMI between 35 and 40 kg/m, and 48%, if BMI equals or exceeds 50 (8). Without adequate treatment, patients with OHS develop cor pulmonale and recurrent episodes of hypercapnic respiratory failure, and loss of survival (Fig. 2). OHS is one of the many etiologies of CRF and has become a growing indication to initiate longterm noninvasive ventilation (NIV) in most European countries (9,10). 

Cazzolli PA, Oppenheimer EA. Use of nasal and tracheostomy positive pressure ventilation in patients with amyotrophic lateral sclerosis (ALS). Abstracts of Papers, 7th International Conference on Noninvasive Ventilation Across the Spectrum from Critical Care to Home Care, Orlando, Florida, March 14-17, 1999. 

During the 1970s, more patients with respiratory failure due to neuromuscular disorders and chest wall deformities received long-term ventilatory assistance at home, either via tracheostomy or body ventilators, which provided effective nocturnal noninvasive ventilation (NIV) (5,6). In the 1970s, the development of home respiratory therapy companies improved support for home mechanical ventilation (HMV). Respiratory therapists could now set up ventilatory equipment, educate the patient and caregivers about using the equipment, and be available to deal with problems. 

Figure 1 The management of respiratory failure in the United States. Many patients are admitted initially to an acute care hospital. If they wean ptomptiy, they may spend time in an LTAC hospital for rehabilitation, and eventually return home. If they fail to wean, they undergo tracheostomy and are transferred to an LTAC when stable. Weaning attempts continue, and a mincnity of patients return home the rest remain at the LTAC or are transferred to a SNF. Patients who deteriorate while at LTACs or at home return to the acute care hospital fOT stabilization. Some patients with chronic respiratory failure do not require acute care but are ventilated noninvasively and remain home. Abbreviations COPD, chronic obstructive pulmonary disease NIV, noninvasive ventilation LTAC, long-term acute care SNF, skilled nursing facility.

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. 

Kishiya R. Coordinating the management of home mechanical ventilation. In Ishikawa Y, ed. Manual for the care of patients using noninvasive ventilation. Neuromuscular Disorders. Chiba Japan Planning Center Inc., 2005 223-228. 

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