Non-invasive Ventilation
Non-invasive Ventilation
US Respiratory Care 2006
Published: October 2008
Published: October 2008
Reference Section a report by Sat Sharma, MD, FRCPC, FCCP, FACP Associate Professor, Sections of Respirology and Critical Care, Department of Internal Medicine, University of Manitoba Non-invasive ventilation (NIV) is the delivery of ventilatory support without the need for an invasive artificial airway. Mechanical ventilation via intubation is associated with many complications, including upper airway trauma, arrhythmia, hypotension, aspiration of gastric contents, sinusitis, pneumonia, and patients loss of ability to eat and communicate verbally.
The concept of mechanical ventilation first evolved with negative-pressure ventilation when the iron lung was initially developed in the early 1900s and was used extensively during the polio epidemics of the 1940s and 1950s. The iron lung works by augmenting the tidal volume by applying negative extrathoracic pressure.
These ventilators fell out of favor as the use of invasive positive-pressure ventilation (PPV) increased during the 1960s. Fueled by the development of PPV delivered through a nasal or face mask, a dramatic resurgence has occurred in the use of NIV over the past decade. NIV currently has a definite and emerging role in the management of acute and chronic respiratory failure of many etiologies.1,2 Non-invasive PPV Non-invasive PPV (NPPV) is delivered through a nasal or face mask, eliminating the need for intubation or tracheostomy. NPPV can be given through a volume ventilator, a pressure-controlled ventilator, a bi-level positive airway pressure (BIPAP or bi-level ventilator) device, or a continuous positive airway pressure (CPAP) device. BIPAP, the most commonly used modality, provides continuous high-flow positive airway pressure that cycles between a high inspiratory positive airway pressure (IPAP) and a lower expiratory positive airway pressure (EPAP).1,2 Although positive pressure support is usually well tolerated by patients, mouth leaks or other difficulties are sometimes encountered. NIV may be used as a continuous or intermittent mode of assistance depending on the patient s clinical situation.
Instantaneous and steady support is given to patients in acute respiratory distress. As the underlying condition improves, ventilator-free periods are increased as tolerated, and support is discontinued when the patient is deemed stable. The total duration of ventilator use varies with the underlying disease approximately six hours for acute pulmonary edema, but more than two days for chronic obstructive pulmonary disease (COPD) exacerbation.
Mechanisms of Action NPPV decreases the work of breathing and thereby improves alveolar ventilation while simultaneously resting the respiratory musculature. The improvement in gas exchange with BIPAP occurs because of an increase in alveolar ventilation. Externally applied EPAP decreases the work of breathing by partially overcoming the auto-positive end-expiratory pressure (PEEP) as patients generate less negative inspiratory force to initiate the breathing cycle. In spontaneous mode, higher pressure is delivered upon detection of inspiration until the flow rate falls below the threshold level. The expiratory pressure with bi-level pressure support is equivalent to the PEEP, and the inspiratory pressure is equivalent to the sum of the PEEP and the level of pressure support. In timed mode, bi-phasic positive airway pressure ventilation alternates between the inspiratory and expiratory pressures at fixed time intervals, which allows unrestricted breathing at both pressures. Supplemental oxygen can be connected to the device, but a higher flow of oxygen therapy is then usually required.
Effectiveness of NIV should be determined clinically through amelioration of respiratory distress, patient discomfort and improved results from arterial blood gas determinations.The decision to use a nasal mask or a full face mask depends on the patient s preference and tolerance.
Patient Selection Patients who are in acute respiratory distress and are at risk of needing intubation should be selected for NIV if they have a reversible cause of acute respiratory failure.3,4 Most patients requiring NPPV should be managed in the intensive care unit (ICU) setting. Once stabilized, weaning from NPPV may be accomplished either by progressively decreasing the levels of positive airway pressure or by withholding NIV for increasing lengths of time.A combination of Non-invasive Ventilation Sat Sharma, MD, FRCPC, FCCP, FACP, is Associate Professor in the Sections of Respirology and Critical Care of the Department of Internal Medicine at the University of Manitoba, Winnipeg, Canada. He is also Program Director of post- graduate education in respirology at the same university and Site Director of respiratory medicine at St Boniface General Hospital.
Professor Sharma s other national and international appointments include Chair of the Specialty Committee in Respirology of the Royal College of Physicians and Surgeons of Canada (RCPSC), Governor of the Manitoba chapter of the American College of Chest Physicians (ACCP), member of the Health and Science Policy Committee of the ACCP, and member of the Canadian Thoracic Society Board. Professor Sharma s research interests involve studying the epidemiology of respiratory diseases, perioperative respiratory care, exercise-induced hypoxemia, and therapeutic clinical research.
1 B USINESS BRIEFING: US RESPIRATORY CARE 2006 both strategies can also be used. Indications, contraindications, and factors predicting success are listed in Tables 1, 2, and 3.
NIV in Acute Exacerbation of COPD Patients with acute exacerbation of COPD (AECOPD) develop deterioration of gas exchange accompanied by rapid shallow breathing, severe dyspnea, right ventricular failure, and encephalopathy.
Respiratory mechanical abnormalities lead to inadequate alveolar ventilation, shortened inspiratory time, diminished tidal volume, and increased respiratory frequency. NIV increases alveolar ventilation and reduces the loads imposed on the respiratory muscles. In acute respiratory failure in patients with COPD, NPPV offers a number of potential advantages over invasive PPV.5,6 These advantages include avoidance of intubation-related trauma, a decreased incidence of nosocomial pneumonia, enhanced patient comfort, a shorter duration of ventilator use, a reduction in hospital stay, and, ultimately, reduced healthcare costs.
References:
References 1. Sharma S,; Non invasive Ventilation; , http://www.emedicine.com/med/topic3371.htm (accessed on November 30 2005).
2. Mehta S, Hill N S, ; Noninvasive Ventilation: State of the art; , Am. J. Respir. Crit. Care Med. (2001);163: pp. 540 577.
3. Brochard, Mancebo J, Elliot M W,; Noninvasive ventilation for acute respiratory failure; , Eur.Respir.J. (2002);19(4):pp.712 721.
4. Phua J, Kong K, Lee K H et al., ; Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure; , Intensive Care Med. (2005);31(4): pp. 533 539.
Non-invasive Ventilation B USINESS BRIEFING: US RESPIRATORY CARE 2006 4 5. Ambrosino N, Foglio K, Rubini F et al.,; Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success; , Thorax (1995);50(7): pp. 755 757.
6. Keenan S P, Kernerman P D, Cook D J et al.,; Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis; , Crit. Care Med. (1997);25: pp. 1,685 1,692.
7. Brochard L, Mancebo J,Wysocki M et al., ; Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease; , N. Engl. J. Med. (1995);333: pp. 817 822.
8. Plant P K, Owen J L, Elliot M W,; Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial; , Lancet (2000);355: pp. 1,931 1,935.
9. Appendini L, Patessio A, Zanaboni S et al.,; Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease; , Am. J. Respir. Crit. Care Med. (1994);149(5): pp. 1,069 1,076.
10. Bott J, Carroll M P, Conway J H et al.,; Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease; , Lancet (1993);341(8,860): pp. 1,555 1,557.
11. Bersten A D, Holt A W,Vedig A E et al.,; Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask; , N. Engl. J. Med. (1991);325(26): pp. 1,825 1,830.
12. Brochard L, Isabey D, Piquet J et al.,; Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask; , N. Engl. J. Med. (1990);323(22): pp. 1,523 1,530.
13. Celikel T, Sungur M, Ceyhan B et al.,; Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure; , Chest (1998);114(6): pp. 1,636 1,642.
14. Ferrer M, Esquinas A, Leon M et al., ; Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial; , Am. J. Respir. Crit. Care Med. (2003);168(12): pp. 1,438 1,444.
15. Delclaux C, L Her E,Alberti C, Mancebo J,Abroug F, Conti G et al.,; Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial; , JAMA (2000);284(18): pp. 2,352 2,360.
16. 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(7): pp. 481 487.
17. Antonelli M, Conti G, Rocco M et al.,; A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure; , N. Engl. J. Med. (1998);339: pp. 429 435.
18. Wood K A, Lewis L,Von Harz B et al.,; The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial; , Chest (1998);113: pp. 1,339 1,346.
19. Meduri G U, Cook T R, Turner R E et al., ; Noninvasive positive pressure ventilation in status asthmaticus; , Chest (1996);110(3): pp. 767 774.
20. Granton J T, Kesten S, ; The acute effects of nasal positive pressure ventilation in patients with advanced cystic fibrosis; , Chest (1998);113(4): pp. 1,013 1,018.
21. Ferrer M, Esquinas A, Arancibia F et al.,; Noninvasive ventilation during persistent weaning failure: a randomized controlled trial; , Am. J. Respir. Crit. Care Med. (2003);168(1): pp. 70 76.
22. Nava S, Carbone G, DiBattista N et al.,; Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial; , Am. J. Respir. Crit. Care Med. (2003);168(12): pp. 1,432 1,437.
23. Mehta S, Jay G D,Woolard R H et al.,; Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema; , Crit. Care Med. (1997);25(4): pp. 620 628.
24. Crane S D, Elliot M W, Gilligan P et al.,; Randomised controlled comparison continuous positive airways pressure, bilevel non- invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary edema; , Emerg.
Med. J. (2004);21: pp. 155 161.
25. Mossip J, Paez J, Merino M et al.,; Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema; , Intensive Care Med. (2003);29: pp. 1,921 1,928.
26. Masa J F, Celli B R, Riesco J A et al., ; The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation; , Chest (2001);119(4): pp. 1,102 1,107.
27. Perez de Llano L A, Golpe R, Ortiz Piquer M et al.,; Short-term and long-term effects of nasal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome; , Chest (2005);128(2): pp. 587 594.
28. Nickol A H, Hart N, Hopkinson N S et al.,; Mechanisms of improvement of respiratory failure in patients with restrictive thoracic disease treated with non-invasive ventilation; , Thorax (2005);60(9): pp. 754 760.
29. Ergun P,Aydin G,Turay UY et al.,; Short-term effect of nasal intermittent positive-pressure ventilation in patients with restrictive thoracic disease; , Respiration (2002);69(4): pp. 303 308.
30. Leger P, Jennequin J, Gerard M et al.,; Home positive pressure ventilation via nasal mask for patients with neuromusculoskeletal disorders; , Eur. Respir. J. Suppl. (1989);7: pp. 640s 644s.
2. Mehta S, Hill N S, ; Noninvasive Ventilation: State of the art; , Am. J. Respir. Crit. Care Med. (2001);163: pp. 540 577.
3. Brochard, Mancebo J, Elliot M W,; Noninvasive ventilation for acute respiratory failure; , Eur.Respir.J. (2002);19(4):pp.712 721.
4. Phua J, Kong K, Lee K H et al., ; Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure; , Intensive Care Med. (2005);31(4): pp. 533 539.
Non-invasive Ventilation B USINESS BRIEFING: US RESPIRATORY CARE 2006 4 5. Ambrosino N, Foglio K, Rubini F et al.,; Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success; , Thorax (1995);50(7): pp. 755 757.
6. Keenan S P, Kernerman P D, Cook D J et al.,; Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis; , Crit. Care Med. (1997);25: pp. 1,685 1,692.
7. Brochard L, Mancebo J,Wysocki M et al., ; Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease; , N. Engl. J. Med. (1995);333: pp. 817 822.
8. Plant P K, Owen J L, Elliot M W,; Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial; , Lancet (2000);355: pp. 1,931 1,935.
9. Appendini L, Patessio A, Zanaboni S et al.,; Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease; , Am. J. Respir. Crit. Care Med. (1994);149(5): pp. 1,069 1,076.
10. Bott J, Carroll M P, Conway J H et al.,; Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease; , Lancet (1993);341(8,860): pp. 1,555 1,557.
11. Bersten A D, Holt A W,Vedig A E et al.,; Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask; , N. Engl. J. Med. (1991);325(26): pp. 1,825 1,830.
12. Brochard L, Isabey D, Piquet J et al.,; Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask; , N. Engl. J. Med. (1990);323(22): pp. 1,523 1,530.
13. Celikel T, Sungur M, Ceyhan B et al.,; Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure; , Chest (1998);114(6): pp. 1,636 1,642.
14. Ferrer M, Esquinas A, Leon M et al., ; Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial; , Am. J. Respir. Crit. Care Med. (2003);168(12): pp. 1,438 1,444.
15. Delclaux C, L Her E,Alberti C, Mancebo J,Abroug F, Conti G et al.,; Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial; , JAMA (2000);284(18): pp. 2,352 2,360.
16. 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(7): pp. 481 487.
17. Antonelli M, Conti G, Rocco M et al.,; A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure; , N. Engl. J. Med. (1998);339: pp. 429 435.
18. Wood K A, Lewis L,Von Harz B et al.,; The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial; , Chest (1998);113: pp. 1,339 1,346.
19. Meduri G U, Cook T R, Turner R E et al., ; Noninvasive positive pressure ventilation in status asthmaticus; , Chest (1996);110(3): pp. 767 774.
20. Granton J T, Kesten S, ; The acute effects of nasal positive pressure ventilation in patients with advanced cystic fibrosis; , Chest (1998);113(4): pp. 1,013 1,018.
21. Ferrer M, Esquinas A, Arancibia F et al.,; Noninvasive ventilation during persistent weaning failure: a randomized controlled trial; , Am. J. Respir. Crit. Care Med. (2003);168(1): pp. 70 76.
22. Nava S, Carbone G, DiBattista N et al.,; Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial; , Am. J. Respir. Crit. Care Med. (2003);168(12): pp. 1,432 1,437.
23. Mehta S, Jay G D,Woolard R H et al.,; Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema; , Crit. Care Med. (1997);25(4): pp. 620 628.
24. Crane S D, Elliot M W, Gilligan P et al.,; Randomised controlled comparison continuous positive airways pressure, bilevel non- invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary edema; , Emerg.
Med. J. (2004);21: pp. 155 161.
25. Mossip J, Paez J, Merino M et al.,; Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema; , Intensive Care Med. (2003);29: pp. 1,921 1,928.
26. Masa J F, Celli B R, Riesco J A et al., ; The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation; , Chest (2001);119(4): pp. 1,102 1,107.
27. Perez de Llano L A, Golpe R, Ortiz Piquer M et al.,; Short-term and long-term effects of nasal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome; , Chest (2005);128(2): pp. 587 594.
28. Nickol A H, Hart N, Hopkinson N S et al.,; Mechanisms of improvement of respiratory failure in patients with restrictive thoracic disease treated with non-invasive ventilation; , Thorax (2005);60(9): pp. 754 760.
29. Ergun P,Aydin G,Turay UY et al.,; Short-term effect of nasal intermittent positive-pressure ventilation in patients with restrictive thoracic disease; , Respiration (2002);69(4): pp. 303 308.
30. Leger P, Jennequin J, Gerard M et al.,; Home positive pressure ventilation via nasal mask for patients with neuromusculoskeletal disorders; , Eur. Respir. J. Suppl. (1989);7: pp. 640s 644s.
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