Monitoring of noninvasive ventilation: comparative analysis of different strategies

Marjolaine Georges,Elise Monin,Guillaume Beltramo,Claudio Rabec,Philippe Bonniaud,Serge Aho,Jean-Paul Janssens

doi:10.1186/s12931-020-01586-8

Abstract

BackgroundNoninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure. However, empirically determined NIV settings may not achieve optimal ventilatory support. Therefore, the efficacy of NIV should be systematically monitored. The minimal recommended monitoring strategy includes clinical assessment, arterial blood gases (ABG) and nocturnal transcutaneous pulsed oxygen saturation (SpO2). Polysomnography is a theoretical gold standard but is not routinely available in many centers. Simple tools such as transcutaneous capnography (TcPCO2) or ventilator built-in software provide reliable informations but their role in NIV monitoring has yet to be defined. The aim of our work was to compare the accuracy of different combinations of tests to assess NIV efficacy.MethodsThis retrospective comparative study evaluated the efficacy of NIV in consecutive patients through four strategies (A, B, C and D) using four different tools in various combinations. These tools included morning ABG, nocturnal SpO2, TcPCO2 and data provided by built-in software via a dedicated module. Strategy A (ABG + nocturnal SpO2), B (nocturnal SpO2 + TcPCO2) and C (TcPCO2 + builtin software) were compared to strategy D, which combined all four tools (NIV was appropriate if all four tools were normal).ResultsNIV was appropriate in only 29 of the 100 included patients. Strategy A considered 53 patients as appropriately ventilated. Strategy B considered 48 patients as appropriately ventilated. Strategy C misclassified only 6 patients with daytime hypercapnia.ConclusionMonitoring ABG and nocturnal SpO2 is not enough to assess NIV efficacy. Combining data from ventilator built-in software and TcPCO2 seems to represent the best strategy to detect poor NIV efficacy.Trialregistration Institutional Review Board of the Société de Pneumologie de Langue Française (CEPRO 2016 Georges)

Highlights

Noninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure
We simultaneously recorded overnight for each patient four monitoring tools: (1) morning arterial blood gases (ABG) measured during spontaneous breathing by puncture of the radial artery during the first hour after disconnection from the ventilator, (2) nocturnal pulsed oxygen saturation (SpO2; Nonin model 8500 oximeter, Nonin Medical, Plymouth, MN, USA), (3) transcutaneous capnography (TcPCO2: Tosca®, Radiometer, Copenhagen, Denmark) and (4) data from a simplified monitoring module coupled to their portable ventilator (ReslinkTM, ResMed)
We evaluated the efficacy of NIV through four strategies (A, B, C and D) using the results of four different tools, in different combinations: strategy A combined ABG and nocturnal Transcutaneous pulsed oxygen satura‐ tion (SpO2), the minimal recommended monitoring combination [19]; strategy B combined nocturnal SpO2 and T cPCO2: since transcutaneous capnography provides SpO2 and T cPCO2 simultaneously, both parameters could be analyzed concurrently; strategy C combined Transcutaneous carbon dioxide partial pressure (TcPCO2) and data from built-in ventilator software and strategy D associated all the available tools (i.e. ABG, nocturnal S pO2, TcPCO2 and data from ventilator software)

Summary

Introduction

Noninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure. Polysomnography is a theoreti‐ cal gold standard but is not routinely available in many centers Simple tools such as transcutaneous capnography (TcPCO2) or ventilator built-in software provide reliable informations but their role in NIV monitoring has yet to be defined. Non-invasive ventilation (NIV) is recognized as an effective treatment of chronic hypercapnic respiratory failure (CHRF) [1]. Reduction of ventilatory drive with or without glottic closure, residual upper airway obstruction and patient-ventilator asynchrony can all compromise the efficacy of NIV [7]. Leaks during NIV can interfere with patient-ventilator interaction [9] These respiratory events are frequent under NIV [8, 10,11,12,13] and may have an impact on prognosis [14,15,16]

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