Noninvasive Positive Pressure Ventilation (NIPPV) in Hypercapnic Respiratory Failure

Abstract

Acute respiratory failure can present as acute-on-chronic respiratory failure in patients with preexisting pulmonary or cardiac disease or de novo respiratory failure secondary to acute disease states. Hypercapnic respiratory failure is associated with significant mortality and morbidity, including the need for ICU admission, endotracheal intubation, and increased length of hospitalization; the need for endotracheal intubation is also associated with morbidity and mortality. The use of NIPPV successfully to avoid endotracheal intubation has demonstrated a mortality benefit in certain patient populations. In particular, COPD patients presenting with hypercapnic acute respiratory failure and patients being weaned from mechanical ventilators after endotracheal extubation experience beneficial outcomes with NIPPV. For conditions such as obstructive sleep apnea, obesity hypoventilation syndrome, and cardiogenic pulmonary edema, moderate strength evidence exists for use of NIPPV in certain clinical situations. In conditions such as neuromuscular diseases and chest wall disorders, asthma, hypercapnic pneumonia, and bronchiectasis, weaker and varying levels of evidence exist for NIPPV use. Although no guidelines exist for optimal NIPPV settings, assist control with gradual increase of IPAP with a goal of slowing respiratory rate is recommended. A larger amount of strong trials is necessary before establishing specific guidelines for NIPPV use in hypercapnic respiratory failure.