Ventilation NIPPV

Sivak ED, Shefner JM, Mitsumoto H, et al. The use of non-invasive positive pressure ventilation (NIPPV) in ALS patients. A need for improved determination of intervention timing. Amyotroph Lateral Scler Other Motor Neuron Disord 2001 2 139-145. 

Simonds and Elliott (9) studied patients with CRF caused by either obstructive or restrictive diseases who required night nasal intermittent positive pressure ventilation (NIPPV). The results, summarized in Figure 1, illustrate that the NIPPV group had a significantly higher impairment in physical function compared to patients with other chronic diseases. General health and mental health were similar to those of patients with other chronic diseases, while physical role limitation and pain were less impaired than in other chronic diseases. Mental health was similar to that of normal subjects. 

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

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

Figure 1 Medical Research Council Short Form Questionnaire (SF3 ) scores in patients on NIPPV compared with normal subjects (NIPPV vs. normals) and patients with other chronic diseases (NIPPV vs. chronic disease). Positive values indicate a worse quahty of life in the NIPPV group. Abbreviation NIPPV, nasal intermittent positive jnessute ventilation. Source Modified from Ref. 10.

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.

Air stacking increases voice volume, maximizes CPF, improves pulmonary compliance, prevents atelectasis, and indicates effective use of NIPPV. Anyone who can air stack can be extubated to NIPPV. Such patients can be extubated without being ventilator... 

Ventilatory support can be provided with NIPPV from volume-cycled ventilators via an angled mouthpiece, lipseal, nasal, or oral-nasal interface. Simple 15- or 22-mm-angled mouthpieces are most convenient for daytime ventilatory support (Fig. 3). To use mouthpiece IPPV, adequate neck rotation and oral motor function are necessary to prevent leakage from the mouth or nose. In addition, the patient must open the glottis and vocal cords, dilate the hypopharynx, and maintain airway patency to receive the air. 

The benefits of NIPPV include respiratory muscle rest, increasing alveolar ventilation, lung compliance, chemosensitivity, and ventilation/perfusion matching (4). To accomplish optimal rest, high volumes or pressure spans are used. Assist-control mode is set at volumes... 

Intubation is often avoidable by using NIPPV and assisted coughing. It is the ability to successfully extubate ventilator-dependent patients to NIPPV that enables tracheostomy to be avoided in most patients with NMD (15,17). 

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. 

In a study of 91 ventilator users with DMD, 51 went on to require continuous NIPPV for 6.3 4.6 (range to 25) years. None of the 34 full-time NIPPV users who had access to MAC died from respiratory complications, whereas three died from severe cardiomyopathy. Five patients with no breathing capacity were extubated or decannulated to continuous NIPPV and five became continuously dependent on NIPPV for one year or more without ever being hospitalized (15). It has previously been reported that DMD patients undergoing tracheostomy tend to have a prolongation of survival of about seven years but also have a tendency to die from complications related to invasive mechanical ventilation (IMV) (24). 

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. 

Uncontrolled studies have shown that in patients with CF, NIPPV will unload respiratory muscles, increase alveolar ventilation, and improve oxygenation during wakefulness, sleep, and an acute exacerbation. Inspiratory and expiratory muscle strengths improve following NIPPV, which may be important in facilitating secretion clearance (32). NIPPV also improves tolerance of physiotherapy (33,34). 

Cheitcoff et al. (14) described patients from ICUs referred to LTMVUs. Between 1998 and 2002, out of 112 patients, 50 were weaned and decannulated. Their diagnoses included COPD (n = 23), NMD (n = 13), postoperative conditions (n = 9), and non-COPD pulmonary disease (n = 5). Planells et al. (15) also reported their experience with an LTMVU. Between 1997 and 2001, both NIPPV and TIPPV were established in a total of 62 patients. Their diagnoses included COPD 26%, CNS disease 35%, NMD 18%, spinal cord injury 6.6%, postoperative conditions 5%, and others 10%. Patients were enrolled for 64 days (9-150 days) after starting ventilation. Most candidates (n = 43) were identified in the category of weanable, some were clearly unweanable (n = 8) and others were using NIPPV (n = 11). Sixty five percent (n = 28) of the weanable patients were successfully weaned. 

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