Bilevel Positive Airway Pressure Mode Research Articles

Impact of Pressure Targeted Modes of Ventilation on Diaphragmatic Function as Assessed Using Ultrasonography in Critically Ill Patients with Cerebral Insult

Abstract Background Mechanical ventilation (MV) causes diaphragmatic atrophy and reduces diaphragmatic efficiency. Patients with diaphragmatic dysfunction (DD) have longer MV durations and intensive care unit (ICU) stay. There is currently a scarcity of data on the effect of different modes of MV on diaphragmatic function and ultrasound-guided assessment of diaphragmatic efficiency. Methodology Sixty mechanically ventilated patients were randomly divided into four equal groups (15 each), patients were ventilated using either Assist Control Pressure Controlled mode (ACPC group)(Group A), Synchronized Intermittent Mandatory Ventilation Pressure Controlled mode (SIMV)(Group S), Bi-level Positive Airway Pressure mode (BiPAP)(Group B), or Pressure Support Ventilation mode (PSV)(Group P). The primary outcomes were diaphragmatic motion & structure in terms of Diaphragmatic Excursion (DE) & Diaphragmatic Thickness Fraction (DTF) respectively. The duration of the ICU stay was the secondary outcome. Results The PSV group had the highest DE indicating better diaphragmatic function. In addition, MV for longer durations led to diaphragmatic thinning and decreased DTF resulting in DD. Conclusion Among the various modes of ventilation employed in the study, PSV was found to be the mode with the lowest risk of DD. Trial Registry PACTR202112653971335.

Role of Average Volume Assured Pressure Support Mode (AVAPS) in the Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Type 2 Respiratory Failure.

Background Non-invasive ventilation (NIV) is a well-established approach in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) with type 2 respiratory failure. Average volume-assured pressure support (AVAPS) mode integrates the characteristics of both volume and pressure-controlled modes of NIV. In bilevel positive airway pressure (BiPAP) mode, volume is the dependent variable, whereas in AVAPS mode, pressure is the dependent variable. In this study, we aimed to compare the role of AVAPS mode with BiPAP spontaneous/timed (S/T) mode for the management of patients with acute exacerbation of COPD with type 2 respiratory failure. Methodology A hospital-based comparative and analytical study was carried out on 100 patients with acute exacerbation of COPD with type 2 respiratory failure admitted to respiratory disease hospital, Sardar Patel Medical College, Bikaner (Rajasthan, India). Patients were randomly divided into two groups of 50 patients each. Group A patients were treated with AVAPS mode and group B patients with BiPAP (S/T) mode. Arterial blood gases, average duration of hospital stay, and need for invasive mechanical ventilation were compared between the two groups. Results There was a statistically significant difference in favor of group A in terms of improvement in pH andpCO2as compared to group B at 6 h (pH, p=0.027; pCO2, p=0.012) and 24 h (pH, p=0.032; pCO2, p=0.013). The duration of hospital stay was found to be lower in group A(p=0.003). However, no significant difference was found in terms of need for invasive mechanical ventilation between both groups (p=0.338). Conclusion Application of AVAPS mode results inmore rapid and steady improvement inpatients of COPD as compared to BiPAP (S/T) mode. Thus, managementthrough non-invasive ventilation AVAPS mode should be considered inpatients with acute exacerbation of COPD with type 2 respiratory failure.

Тривалість штучної вентиляції легень та функціонування діафрагми у дітей з гострою дихальною недостатністю

Актуальність. Пацієнти з комбінованими формами дихальної недостатності часто мають довготривале чи навіть невдале відлучення від штучної вентиляції легень (ШВЛ). Мета дослідження: порівняти тривалість проведення ШВЛ, а також показники функціонування діафрагми при використанні технологій P-SIMV та BIPAP у пацієнтів на етапі відлучення від ШВЛ. Матеріали та методи. Проведено проспективне обсерваційне нерандомізоване когортне дослідження серед 27 пацієнтів з гострою дихальною недостатністю. До І (режим P-SIMV) та ІІ груп пацієнтів (режим BIPAP ) увійшло по 10 пацієнтів. Первинними точками оцінювання результатів лікування були тривалість проведення інвазивної ШВЛ; вторинними точками — амплітуда рухів обох куполів діафрагми, фракція стоншення діафрагми, виникнення декомпенсованого респіраторного чи змішаного ацидозу. Результати. Середня тривалість проведення ШВЛ у пацієнтів першої групи становила 14,14 ± 1,83 доби, у пацієнтів другої групи — 13,2 ± 2,56 доби (p = 0,32). Амплітуда рухів куполів діафрагми в першу добу дослідження становила в І групі пацієнтів 7,2 ± 1,8 мм, у ІІ групі — 6,8 ± 1,5 (p = 0,42); на 5-ту добу лікування цей показник вірогідно не відрізнявся між групами та в І групі зростав до 8,1 ± 2,1 мм, у ІІ — до 8,4 ± 1,9 мм (p = 0,12 та p = 0,89). Вже на 9-ту добу лікування амплітуда рухів правого купола діафрагми вірогідно (р = 0,04) відрізнялася у І групі пацієнтів щодо ІІ групи (9,0 ± 2,1 мм та 10,0 ± 1,3 мм відповідно) та щодо попереднього етапу обстеження (p = 0,05 та p = 0,04). Амплітуда рухів правого купола діафрагми залишалася на рівні понад 10 мм у ІІ групі пацієнтів і на 13-ту та 17-ту добу спостереження за пацієнтами. Висновки. Тривалість проведення ШВЛ у дітей з поєднанням обструктивного та рестриктивного типів дихальної недостатності в І та ІІ групах вірогідно не відрізнялася. Спонтанні дихальні зусилля були вірогідно вищими у пацієнтів ІІ групи починаючи з 9-ї доби порівняно з пацієнтами І групи.

Affordable, Compact and Infection-Free BiPAP Machine.

Critical cases of COVID-19 require respiratory support provided primarily by mechanical ventilators. But, as per the current trend, about 15% of the cases require hospitalization and less than 5% cases are critical. Due to the massive number of COVID-19 cases all over the world, the ventilator requirement is increasing, and these traditional ventilators are quite expensive and are occupied for the critical cases, thus available in limited numbers. In this regard, BiPAP (Bilevel Positive Airway Pressure) ventilation support can be used for the less critical cases where patients do not require intubation by specialized staff and also minimizing the risk of infection during the procedure. The current article aims to deliver a design of an inexpensive BiPAP with an infection-free exhaust. BiPAP is a mode of ventilation which maintains positive pressure for air intake, and a low or zero pressure is created for expiration. The BiPAP suggested in the current article uses an air blower connected to an Arduino via a speed controller, the level of pressure and breathing rate are programmed in the Arduino, thus, the blower functions in BiPAP mode. The 3D printed mask proposed here comprises of a unique design for the intake and exhalation of air; and comprises of two sizes to fit all adults while avoiding any leakage. The design suggested is further tweaked for emergency use to support up to four patients using a single BiPAP. The mass production of the same would cost approx. INR 6500 or 85 USD.

Noninvasive tri-level positive airway pressure ventilation: is it a new challenging mode in management of patients with chronic obstructive pulmonary disease?

Background Chronic obstructive pulmonary disease (COPD) is a serious issue of sickness and rise in global fatality rates. Noninvasive positive pressure ventilation is the first-line therapy in patients with COPD with respiratory fialure (RF). Tri-level positive airway pressure (Tri-PAP) is new challenging mode of noninvasive ventilation (NIV). Objectives To compare between two modes of noninvasive positive pressure ventilation [bi-level positive airway pressure (Bi-PAP) and Tri-PAP] and to spell out outcomes, complication, and predictors of favorable outcome of NIV in patients with COPD with respiratory failure. Patients and methods This prospective comparative study was accomplished on 30 patients with COPD with respiratory failure, who were subjected to NIV (Bi-PAP or Tri-PAP) and standard conventional therapy. Arterial-blood gases (ABGs) (initially, 6 h, and finally) were analyzed. NIV outcomes, complications, and predictors of success were encountered. Results Patients were categorized according to managerial therapeutic NIV into Bi-PAP (n=15) or Tri-PAP (n=15) groups. Initial, 6-h, and final ABGs analyses (pH, PO2, PCO2, HCO3, and O2 sat) and NIV outcomes (successful or failed weaning) were analogous, without considerable variation between both Bi-PAP and Tri-PAP groups. pH showed crucial advancement after 6 h of initiation of Tri-PAP NIV. Terminal ABG interpretation (pH, PaCO2, PaO2, and O2 sat) had better outcomes than initial and 6-h ABG analyses of Tri-PAP NIV group. Irritations and ulcerations of nasal bridge, dry nose or mouth, nasal congestion, hypotension, and PaCO2 increase were the most hazardous events in both Bi-PAP and Tri-PAP NIV groups. Shorter duration of NIV, lower BMI, higher pH, and lower PCO2 (initially, 6 h, and final ABGs) as well as higher O2 saturation (in final ABG) were predictors of successful weaning in NIV (Bi-PAP and Tri-PAP) groups collectively. Conclusion Bi-PAP and Tri-PAP are appropriate mode of NIV in patients with COPD with RF with minimal complication and better outcomes. Tri-PAP had no superiority of utilization than Bi-PAP mode. pH and PCO2 are the powerful predictors of favorable NIV outcomes.

Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome.

Ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation are currently set arbitrarily. The impact on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings following extracorporeal membrane oxygenation implantation, and different mechanical ventilation strategies while on extracorporeal membrane oxygenation were investigated. Randomized clinical trial. Nine-month monocentric study. Severe acute respiratory distress syndrome patients on venovenous extracorporeal membrane oxygenation. After starting extracorporeal membrane oxygenation, patients were switched to the bi-level positive airway pressure mode with 1 second of 24 cm H2O high pressure and 2 seconds of 12 cm H2O low pressure for 24 hours. A computer-generated allocation sequence randomized patients to receive each of the following three experimental steps: 1) high pressure 24 cm H2O and low pressure 20 cm H2O (very high positive end-expiratory pressure-very low driving pressure); 2) high pressure 24 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-high driving pressure); and 3) high pressure 17 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-low driving pressure). Plasma and bronchoalveolar lavage soluble receptor for advanced glycation end-products, plasma interleukin-6, and monocyte chemotactic protein-1 were sampled preextracorporeal membrane oxygenation and after 12 hours at each step. Sixteen patients on ECMO after 7 days (1-11 d) of mechanical ventilation were included. "Ultra-protective" mechanical ventilation settings following ECMO initiation were associated with significantly lower plasma sRAGE, interleukin-6, and monocyte chemotactic protein-1 concentrations. Plasma sRAGE and cytokines were comparable within each on-ECMO experimental step, but the lowest bronchoalveolar lavage sRAGE levels were obtained at minimal driving pressure. ECMO allows ultra- protective ventilation, which combines significantly lower plateau pressure, tidalvolume, and driving pressure. This ventilation strategy significantly limited pulmonary biotrauma, which couldtherefore decrease ventilator-induced lung injury. However, the optimal ultra-protective ventilation strategy once ECMO is initiated remains undetermined and warrants further investigations. (Crit Care Med 2019; 47:1505-1512).

Hyperacute Hemodynamic Effects of BiPAP Noninvasive Ventilation in Patients With Acute Heart Failure and Left Ventricular Systolic Dysfunction in Emergency Department.

Acute heart failure (AHF) is one of the leading causes of admission to emergency department (ED); severe hypoxemic AHF may be treated with noninvasive ventilation (NIV). Despite the demonstrated clinical efficacy of NIV in relieving symptoms of AHF, less is known about the hyperacute effects of bilevel positive airway pressure (BiPAP) ventilation on hemodynamics of patients admitted to ED for AHF. We therefore aimed to assess the effect of BiPAP ventilation on principal hemodynamic, respiratory, pulse oximetry, and microcirculation indexes in patients admitted to ED for AHF, needing NIV. Twenty consecutive patients admitted to ED for AHF and left ventricular systolic dysfunction, needing NIV, were enrolled in the study; all patients were treated with NIV in BiPAP mode. The following parameters were measured at admission to ED (T0, baseline before treatment), 3 hours after admission and initiation of BiPAP NIV (T1), and after 6 hours (T2): arterial blood oxygenation (pH, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio, Paco2, lactate concentration, HCO3-), hemodynamics (tricuspid annular plane systolic excursion, transpulmonary gradient, transaortic gradient, inferior vena cava diameter, brain natriuretic peptide [BNP] levels), microcirculation perfusion (end-tidal CO2 [etco2], peripheral venous oxygen saturation [SpvO2]). All evaluated indexes significantly improved over time (analysis of variance, P < .001 in quite all cases.). The BiPAP NIV may rapidly ameliorate several hemodynamic, arterial blood gas, and microcirculation indexes in patients with AHF and left ventricular systolic dysfunction.

Influence of the ventilatory mode on acute adverse effects and facial thermography after noninvasive ventilation.

ABSTRACTObjective:To compare the incidence and intensity of acute adverse effects and the variation in the temperature of facial skin by thermography after the use of noninvasive ventilation (NIV). Methods:We included 20 healthy volunteers receiving NIV via oronasal mask for 1 h. The volunteers were randomly divided into two groups according to the ventilatory mode: bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). Facial thermography was performed in order to determine the temperature of the face where it was in contact with the mask and of the nasal dorsum at various time points. After removal of the mask, the volunteers completed a questionnaire about adverse effects of NIV. Results:The incidence and intensity of acute adverse effects were higher in the individuals receiving BiPAP than in those receiving CPAP (16.1% vs. 5.6%). Thermographic analysis showed a significant cooling of the facial skin in the two regions of interest immediately after removal of the mask. The more intense acute adverse effects occurred predominantly among the participants in whom the decrease in the mean temperature of the nasal dorsum was lower (14.4% vs. 7.2%). The thermographic visual analysis of the zones of cooling and heating on the face identified areas of hypoperfusion or reactive hyperemia. Conclusions:The use of BiPAP mode was associated with a higher incidence and intensity of NIV-related acute adverse effects. There was an association between acute adverse effects and less cooling of the nasal dorsum immediately after removal of the mask. Cutaneous thermography can be an additional tool to detect adverse effects that the use of NIV has on facial skin.

Coordination between respiration and swallowing during non-invasive positive pressure ventilation.

The purpose of this study was to test the hypothesis that the risk of silent aspiration is increased in non-invasive positive pressure ventilation. We analysed the coordination between respiration and swallowing, in 12 young volunteers and 10 elder volunteers, by simultaneously monitoring respiratory flow, laryngeal movement and swallowing sound in three different conditions: control, continuous positive airway pressure (CPAP), and bi-level positive airway pressure (BiPAP). A step-wise multiple regression analysis was performed with the occurrence rate of inspiration after swallows as the dependent variable and various correlated variables as the independent variables. In both subject groups, the occurrence rate of inspiration after swallow was greater with BiPAP compared with control and CPAP conditions. Repetitive saliva swallowing test count and swallow non-inspiratory flow occurrence rate were extracted as predictor variables for risk of inspiration after swallows during BiPAP treatment. We found that the occurrence rate of inspiration after swallow is increased with BiPAP use irrespective of age. The results suggest that swallow non-inspiratory flow may trigger inspiratory support in the BiPAP mode, resulting in a risk of aspiration.

Use of dexmedetomidine to facilitate non-invasive ventilation

Patients with chronic obstructive pulmonary disease and congestive heart failure exacerbations, as well as pneumonia benefit from the use of non-invasive ventilation (NIV), due to increased patient comfort and a reduced incidence of ventilator-associated pneumonia. However, some patients do not tolerate NIV due to anxiety or agitation, and traditionally physicians have withheld sedation from these patients due to concerns of loss of airway protection and respiratory depression. We report our recent experience with a 91-year-old female who received NIV for acute respiratory distress secondary to pneumonia. The duration of NIV was a total time period of 86 h, using the bilevel positive airway pressure mode via a full face mask. The patient was initially agitated with the NIV, but with the addition of the dexmedetomidine, she tolerated it well. The dexmedetomidine was administered without a loading dose, as a continuous infusion ranging from 0.2 to 0.5 mcg/kg/hr, titrated to a Ramsey score of three. This case illustrates the safe use of dexmedetomidine to facilitate NIV, and improve compliance, which may reduce ICU length of stay.

Influence of pulse indicator continuous cardiac output in monitoring on the volume parameters of different tidal volume under pressure control ventilation mode and volume-controlled ventilation mode in sheep

To compare the influence of pulse indicator continuous cardiac output (PiCCO) in monitoring tidal volume (V(T)) under pressure control ventilation mode and volume-controlled ventilation mode in sheep. After anesthesia and tracheotomy, 5 sheep, which were apneic and receiving mechanical ventilation. Twenty minutes later, central venous pressure (CVP) and cardiac function were monitored with different selected V(T) levels of 6, 10, 15, 20 ml/kg under bi-level positive airway pressure (BiPAP) mode by changing the pressure of inspiration, or under the synchronized intermittent mandatory ventilation (SIMV) mode with the same ventilation conditions. In both modes, the increase in V(T) led to an decrease of cardiac index (CI) and intrathoracic blood volume index (ITBVI), reaching a statistically significant difference at 15 ml/kg [SIMV mode: CI (3.94 + or - 1.03) L x min(-1) x m(-2), ITBVI (707 + or - 105) ml/m(2); BiPAP mode: CI (4.11 + or - 1.11) L x mi(-1) x m(-2), ITBVI (715 + or - 122) ml/m(2)] and 20 ml/kg [SIMV mode: CI (3.87 + or - 1.04) L x min(-1) x m(-2), ITBVI (705 + or - 116) ml/m(2); BiPAP mode: CI (3.64 + or - 0.96) L x min(-1) x m(-2), ITBVI (694 + or - 114) ml/m(2)] compared with 6 ml/kg [SIMV mode: CI (4.96 + or - 1.58) L x min(-1) x m(-2),ITBVI(811 + or - 169) ml/m(2); BiPAP mode:CI(5.67 + or - 1.96) L x min(-1) x m(-2), ITBVI (823 + or - 182) ml/m(2), all P<0.05]; an increase in systemic vascular resistance index (SVRI) and mean airway pressure (Pmean) at 15 ml/kg [SIMV mode: SVRI (237.6 + or - 56.2) kPaxs(-1) x L(-1), Pmean (14.0 + or - 3.2) cm H(2)O (1 cm H(2)O=0.098 kPa); BiPAP mode: SVRI (230.8 + or - 32.9) kPaxs(-1) x L(-1), Pmean (13.0 + or - 2.2) cm H(2)O] and 20 ml/kg [SIMV mode: SVRI (253.1 + or - 76.7) kPaxs(-1) x L(-1), Pmean (18.2 + or - 4.8) cm H(2)O ; BiPAP mode: SVRI (246.7 + or - 48.8) kPaxs(-1) x L(-1), Pmean (16.8 + or - 3.3) cm H(2)O] compared with 6 ml/kg [SIMV mode: SVRI (184.8 + or - 47.5) kPaxs(-1) x L(-1); Pmean (8.8 + or - 1.6) cm H(2)O; BiPAP mode: SVRI (184.5 + or - 51.5) kPaxs(-1) x L(-1), Pmean (8.6 + or - 0.5) cm H(2)O, all P<0.05]; but there was no significant effects on CVP, heart rate (HR), mean blood pressure (MBP). There was no significant difference of CI, ITBVI, SVRI and Pmean between the two ventilation modes with various V(T) levels. When the cardiac function was normal, the increase in V(T) led to a decrease of CI and ITBVI, but it had no significant effects on CVP. There was no significant difference of CI and ITBVI in the two ventilation modes, both were decreased. So a relatively constant V(T) should be maintained in determining ITBVI.

Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation

Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.

Clinical application and nursing methods of bilevel positive air way pressure ventilation in patients with neurogenic pulmonary edema

Objective To investigate the clinical effect and nursing methods of bilevel positive air-way pressure(BiPAP)ventilation in patients with neurogenic pulmonary edema(NPE).Methods Totally 11 NPE patients from January 2004 to December 2007 were enrolled.Ventilation support adopted specific invasive BiPAP mode of Puritan-Bennett840.Aiway pressure release ventilation(APRV)tactics was ap- plied in this mode.The blood oxygen saturation rote(SpO2),acidity-alkalinity(pH),arterial oxygen pres-sure(PaO2),arterial carbon dioxide pressure(PaCO2)were analyzed and compared between synchronized intemittent mandatory ventilation(SIMV)mede2 h and 24 h after BiPAP ventilation.Results Among,arterial blood gas analysis of 11 patients,SpO2 and PaO2 were obviously ameliorated after BiPAP ventilation compared with SIMV ventilation.No side-effect occurred.Conclusions The application of invasive Bi- PAP ventilation support in NPE patients proved to be a fast and effective method. Key words: Bilevel positive airway pressure; Neurogenic pulmonary edema; Nursing