Noninvasive Positive Pressure Ventilation in the Postextubation Period

Abstract

Noninvasive positive pressure ventilation (NPPV) has been demonstrated to be effective in various types of acute respiratory failure. Level I evidence has been established for its use for acute respiratory failure due to acute on chronic obstructive pulmonary disease (COPD) exacerbations [1, 2] or cardiogenic pulmonary edema [3], and in immunocompromised hosts [4]. By avoiding intubation, NPPV has many advantages and benefits. These include the ease of application; preservation of the airway defense mechanisms; maintenance of the patient’s ability to speak, eat, and cough; and reduction of complications related to intubation, especially ventilator-associated pneumonia [5]. These reasons sway physicians to utilize NPPV in other settings, including the postextubation period [6, 7]. In a cross-sectional postal survey, approximately 40% of 385 attending physicians and residents in four specialties at 15 Canadian teaching hospitals used NPPV for postextubation respiratory failure, which was the third most frequent indication after COPD and congestive heart failure (CHF) [6]. At Massachusetts General Hospital, 458 patients were treated with NPPV for acute or acute-on-chronic respiratory failure in 2001, the indication in 21% of them being postextubation respiratory failure [7]. This chapter discusses the evidence related to the use of NPPV in the postextubation period, which happens in one of three settings: 1. Facilitation of weaning from invasive ventilation and extubation 2. Prevention of postextubation respiratory failure and reintubation 3. Treatment of postextubation respiratory failure [7].