Abstract
Chronic respiratory failure (CRF) should be considered a syndrome defined by arterial blood gas abnormalities. Domiciliary non-invasive ventilation (NIV) is an increasingly used intervention to curtail the detrimental effects of CRF in individuals with a broad range of cardiorespiratory disorders. Progress in the provision, monitoring and improvement in patient centred outcomes with NIV has simply been staggering over the last decade. Despite this, questions still remain in terms of the ideal mode of delivery, the most efficient techniques to monitor its effectiveness, and the timing of NIV initiation for several of the more common diseases which can require NIV support. There are a number of mechanisms accounting for the reduced ventilation that is apparent during sleep, even in normal subjects. This represents a particularly unique physiological state whereby changes in upper airway resistance control of respiration and changes in lung mechanics have an impact on the adequacy of tidal volume breathing. Abnormal respiratory events tend to occur specifically during sleep, and so NIV which is appropriate for the awake patient may not be suitable when asleep at night. These factors need to be kept in mind both for the optimal timing of NIV, and the manner in which it should be monitored. This article aims to provide an overview of current concepts in the appropriate mode of delivery of NIV, discusses the patient groups who benefit from its application, highlights challenges with interface design, and aspects that need to be kept in mind in terms of the optimal monitoring of NIV
Highlights
The purpose of domiciliary non-invasive ventilation (NIV), in its essence, is to mitigate nocturnal hypoventilation, control any associated symptoms, and to strive to achieve adequate and consistent nocturnal oxygen saturation
During non-rapid eye-movement (NREM) sleep, during which time the impetus to breath becomes more dependent on the metabolic control of breathing, there tends to be a heightened vulnerability to apnoeas and hypopnoeas
The selection of the most appropriate mode of NIV must be based upon patient characteristics and the ventilatory assist should be tailored to individual patient characteristics keeping in mind the underlying cardiorespiratory disorder
Summary
The purpose of domiciliary non-invasive ventilation (NIV), in its essence, is to mitigate nocturnal hypoventilation, control any associated symptoms, and to strive to achieve adequate and consistent nocturnal oxygen saturation. During rapid eye-movement sleep (REM), on the other hand, a reduction in accessory muscle contraction occurs in conjunction with an erratic respiratory drive These changes can result in the development of apnoeas, hypopnoeas, alveolar hypoventilation, and ventilation perfusion mismatching (Figure 1) [1]. As well as an improvement in nocturnal gas exchange, there is in additional rationale for NIV to provide a sustained period of rest for the muscles of respiration, for those subjects who have a heightened work of breathing when asleep This is based on ameliorating the increased work of breathing while asleep, and so improving muscle strength, contractility, and overall ventilatory mechanics, and, as a consequence, reducing the decline in muscle strength and so improving overall functional ability in patients who have primarily neuromuscular weakness [2]. The use of domiciliary NIV during the daytime, and so not necessarily sleep related, has been shown to have a similar efficacy as compared to nocturnal NIV on daytime physiological measurements in patients with chronic hypoventilation [3,4,5,6,7,8]
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