Chronic Noninvasive Ventilation Research Articles

Residual upper airway obstruction during nocturnal noninvasive ventilation despite high positive expiratory pressure. Impact of oronasal mask to nasal mask switch

BackgroundNasal mask (NM) and oronasal masks (OM) can be used to provide noninvasive ventilation (NIV). Recent studies suggested that OM is the most used interface and that there is no difference in efficacy or in tolerance between OM and NM for chronic use. However, studies focusing on video laryngoscopy underlined the impact of OM in residual upper airway obstruction (UAO) under NIV. We sought to assess the real-life practice of switching from OM to NM when UAO events persist despite high EPAP levels. MethodsIn an open-label single center prospective cohort study, data from files and full night polysomnography on NM and OM were collected for patients wearing OM and presenting an UAO index ≥15/h despite an EPAP level ≥ 10 cmH20. ResultsForty-four patients were included in the study. In 31 patients (74 %), switching to a NM reduced UAOi to ≥10/h. Interestingly, 92 % of these patients still had NM at 3 to 12 months of follow-up. Switching to a NM was also associated with a trend in paCO2 reduction and significant improvements in Epworth, sleep quality and NIV compliance. Successful interface switching was significantly associated with female gender, and a trend was observed in non-smokers. ConclusionAs for CPAP, switching to a NM improved NIV efficacy in a selected group of patients presenting residual UAO events despite high EPAP levels. Additionally, this switch has an impact on compliance and subjective sleepiness. Thus, in patients with persisting UAO on OM, switching to a NM could be a first-line intervention before considering further investigation such as polygraphy or video laryngoscopy. We also derive an algorithm for mask allocation and adaptation in acute and chronic NIV use.

Mortality in individuals with COPD on long-term home non-invasive ventilation

BackgroundReal-world evidence regarding survival of patients with chronic obstructive pulmonary disease (COPD) using chronic non-invasive ventilation (NIV) is scarce. Research questionHow do obesity and other factors relate to mortality in patients with COPD on chronic NIV? Study designand Methods: We retrospectively analyzed data from COPD patients enrolled in a home ventilation program between 2014 and 2018. Survival was compared between obese and non-obese groups using the Kaplan-Meier method. Factors associated with mortality were identified using multivariable Cox proportional regression analyses with Least Absolute Selection and Shrinkage Operator (LASSO) regularization. Univariable analyses were also done stratified by obesity. ResultsMedian survival was 80.0 (95% CI: 71.0-NA) months among obese (n = 205) and 30.0 (95%CI: 19.0–42.0) months in non-obese (n = 61) patients. NIV adherence was high in both groups. Mortality was associated with male gender [HR 1.44], chronic opioids or benzodiazepines use [HR 1.07], home oxygen use [HR 1.82], fixed pressure mode of ventilation [HR 1.55], NIV inspiratory pressure [HR 1.05], and thoracic cancer [HR 1.27]; obesity [HR: 0.43], age [HR 0.99] and NIV expiratory pressure [HR 0.94] were associated with decreased mortality. In the obese, univariable analyses revealed that chest wall disease, thoracic cancer, home oxygen use, FEV1% predicted, and ventilation parameters were associated with mortality. In the non-obese, male gender and respiratory comorbidities were related to mortality. InterpretationObesity is associated with improved survival in COPD patients highly adherent to NIV. Other factors associated with mortality reflect disease severity and ventilator parameters, with differences between obese and non-obese patients.

Autologous blood patch pleurodesis for persistent air leak in the setting of chronic non-invasive ventilation: case report

Background: Persistent air leaks (PAL) are associated with significant morbidity and mortality, including prolonged length of hospital stays, increased re-admission rates and increased incidences of pneumonia and pleural space infections. Autologous blood patch pleurodesis (ABPP) may be used in the management of PAL, however it is unclear whether this treatment option can be used in patients requiring chronic non-invasive ventilation.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists.

IMPORTANCE:Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.OBJECTIVES:Describe international pediatric ventilation liberation practices and regional practice variation.DESIGN, SETTING, AND PARTICIPANTS:International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians.MAIN OUTCOMES AND MEASURES:Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support.RESULTS:Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio2 (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H2O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied.CONCLUSION AND RELEVANCE:International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.

Does the Efficacy of High Intensity Ventilation in Stable COPD Depend on the Ventilator Model? A Bench-to-Bedside Study

PurposeThe European Task Force for chronic non-invasive ventilation in stable COPD recommends the use of high pressure-support (PS) level to maximize the decrease in PaCO2. It is possible that the ventilator model can influence the need for higher or lower pressure levels.Research QuestionTo determine the differences between ventilators in a bench model with an increased inspiratory demand; and to compare the degree of muscular unloading measured by parasternal electromyogram (EMGpara) provided by the different ventilators in real patients with stable COPD.Patients and MethodsBench: four levels of increasing progressive effort were programmed. The response of nine ventilators to four levels of PS and EPAP of 5 cm H2O was studied. The pressure-time product was determined at 300 and 500 msec (PTP 300/500).Clinical StudyThe ventilators were divided into two groups, based on the result of the bench test. Severe COPD patients with non-invasive ventilation (NIV) were studied, randomly comparing the performance of one ventilator from each group. Muscle unloading was measured by the decrease in EMGpara from its baseline value.ResultsThere were significant differences in PTP 300 and PTP 500 in the bench study. Based on these results, home ventilators were classified into two groups; group 1 included four models with higher PTP 300. Ten COPD patients were recruited for the clinical study. Group 1 ventilators showed greater muscle unloading at the same PS than group 2.ConclusionThe scale of pressure support in NIV for high intensity ventilation may be influenced by the ventilator model.Clinical Trials.govNCT03373175.

A bench-to-bedside study about trigger asynchronies induced by the introduction of external gas into the non-invasive mechanical ventilation circuit

Treatments that require the introduction of external gas into the non-invasive ventilation (NIV) circuit, such as aerosol and oxygen therapy, may influence the performance of the ventilator trigger system. The aim of the study was to determine the presence and type of asynchronies induced by external gas in the NIV circuit in a bench model and in a group of patients undergoing chronic NIV. Bench study: Four ventilators (one with two different trigger design types) and three gas sources (continuous flow at 4 and 9 l/min and pulsatile flow at 9 l/min) were selected in an active simulator model. The sensitivity of the trigger, the gas introduction position, the ventilatory pattern and the level of effort were also modified. The same ventilators and gas conditions were used in patients undergoing chronic NIV. Bench: the introduction of external gas caused asynchronies in 35.9% of cases (autotriggering 73%, ineffective effort 27%). Significant differences (p < 0.01) were detected according to the ventilator model and the gas source. In seven patients, the introduction of external gas induced asynchrony in 20.4% of situations (77% autotriggering). As in the bench study, there were differences in the occurrence of asynchronies depending on the ventilator model and gas source used. The introduction of external gas produces alterations in the ventilator trigger. These alterations are variable, and depend on the ventilator design and gas source. This phenomenon makes it advisable to monitor the patient at the start of treatment.

Chronic non-invasive ventilation for chronic obstructive pulmonary disease.

Chronic non-invasive ventilation for chronic obstructive pulmonary disease.

Treatment of severe stable COPD: the multidimensional approach of treatable traits.

Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of “there is nothing to improve” any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care.

Late-onset post-lesional paroxysmal hypothermia: a case series and literature review.

Paroxysmal hypothermia (PH) is a rare condition characterized by recurrent episodes of spontaneous hypothermia, bradycardia, disorders of consciousness and, in some cases, hyperhidrosis. When associated with a detectable hypothalamic lesion, PH episodes usually occur shortly after the brain insult. We performed a retrospective study to identify patients who had demonstrated at least one episode of symptomatic spontaneous PH as defined by (i) tympanic temperature < 35°C; (ii) drowsiness and/or confusion state and/or coma; (iii) duration of the episode ≥ 24h; (iv) absence of other condition resulting in hypothermia RESULTS: Among 8824 patients, we identified four patients with recurrent late-onset PH episodes of 1-26-day duration that occurred 6-46years after the brain insult. The lesion always involved the diencephalon. All patients suffered from epilepsy and three of hypopituitarism. PH episode typically included severe hypothermia, bradycardia, drowsiness, thrombocytopenia and in some patients central hypoventilation and narcolepsy-like hypersomnia. In ¼ of episodes, confusion was mistaken as non-convulsive epileptic manifestation resulting in benzodiazepine administration which aggravated symptoms. In the two patients with nocturnal hypoventilation, chronic non-invasive ventilation with bi-level positive airway pressure allowed cessation of symptomatic episodes. Late-onset post-lesional PH is exceptional with only a single case hitherto reported in the literature. Distinguishing hypothermia-related disturbances of consciousness from epileptic seizures or post-ictal phenomena is crucial since treatment with benzodiazepines may worsen hypothermia through their action on GABAa receptors. Lastly, PH may be associated with sleep disorders and hypoventilation, for which investigations and treatment should be considered.

The prevalence of hypercapnia during acute infection in children on chronic noninvasive ventilation: A retrospective study.

Children on chronic noninvasive ventilation are at risk for nonelective hospitalizations, mainly for acute infections. This study examined the prevalence of hypercapnia in children on chronic ventilatory support during an acute admission. This retrospective study included children aged 0 to 18 years who regularly used bilevel positive airway pressure or continuous positive airway pressure at home, and who were diagnosed with an acute infection, and were hospitalized at the pediatrics department or pediatric intensive care unit. Capillary blood gas analysis and parameters of the built-in software of the home ventilator were recorded. Among the 43 cases included, hypercapnia was prevalent in 23% with a mean partial pressure of carbon dioxide of 51.7 ± 6.4 mm Hg. These children also had lower oxygen saturation levels. The respiratory rate 48 hours before admission was significantly higher in the hypercapnic group and the volume guarantee mode was less frequently used in the hypercapnic group. Approximately, a quarter of the cases of chronic home ventilation experience hypercapnia during an acute infection. Our data warrant a prospective study on the monitoring of respiratory rate in patients with chronic respiratory insufficiency as an indicator for hospitalizations with hypercapnia; we also recommend the use of volume guarantee mode of ventilation to prevent hypercapnia.

Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial

IntroductionChronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We...

Non-Invasive Ventilation in Stable Chronic Obstructive Pulmonary Disease

The benefit of non-invasive ventilation (NIV) in stable chronic obstructive pulmonary disease (COPD) remains controversial. However, there is increasingly more evidence of NIV efficiency, especially high-flow NIV. This review presents the old and the new evidence of NIV effectiveness in stable COPD, considering pathophysiological arguments for NIV in COPD. Guidelines, randomized controlled trials (RCTs) and crossover studies included in review and metaanalysis based on patient-reported outcomes (PROs) have been analyzed. The role of NIV in rehabilitation and in palliative care and the role of telemedicine in relation with NIV are still up for debate. Challenges in choosing the right device and the optimal mode of ventilation still exist. There are also discussions on the criteria for patient inclusion and on how to meet them. More studies are needed to determine the ideal candidate for chronic NIV and to explain all the benefits of using NIV.

Procalcitonin, C-reactive protein, PaCO2, and noninvasive mechanical ventilation failure in chronic obstructive pulmonary disease exacerbation.

It is unclear whether procalcitonin (PCT) is correlated with noninvasive ventilation (NIV) failure. This retrospective case–control study aimed to compare PCT levels, C-reactive protein (CRP) levels, and PaCO2 in patients (05/2014–03/2015 at the Harrison International Peace Hospital, China) with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and NIV failure/success.This was a retrospective case–control study of patients with AECOPD who required NIV between May 2014 and March 2015. All consecutive patients with AECOPD admitted at the Department of Critical Care Medicine and transferred from the general ward were included in the study. Hemogram, PCT, erythrocyte sedimentation rate (ESR), arterial blood gas (ABG), and CRP levels were measured ≤1 hour before NIV was used. NIV was considered to have failed if at least one of the following criteria was met: cardiac arrest or severe hemodynamic instability; respiratory arrest or gasping; mask intolerance; difficulty in clearing bronchial secretions; or worsening of ABGs or sensorium level during NIV. The factors associated with NIV failure were determined.A total of 376 patients were included: 286 with successful NIV and 90 wither NIV failure. The multivariate analysis showed that PCT (OR = 2.0, 95%CI: 1.2–3.2, P = .006), CRP (OR = 1.2, 95%CI: 1.1–1.3, P < .001), and PaCO2 (OR = 1.1, 95%CI: 1.1–1.2, P < .001) ≤1 hour before NIV were independently associated with NIV failure. The optimal cutoff were 0.31 ng/mL for PCT (sensitivity, 83.3%; specificity, 83.7%), 15.0 mg/mL for CRP (sensitivity, 75.6%; specificity, 93.0%), and 73.5 mm Hg for PaCO2 (sensitivity, 71.1%; specificity, 100%). The area under the curve (AUC) was 0.854 for PCT, 0.849 for CRP, and 0.828 for PaCO2. PCT, CRP, and PaCO2 were used to obtain a combined prediction factor, which achieved an AUC of 0.978 (95%CI: 0.961–0.995).High serum PCT, CRP, and PaCO2 levels predict NIV failure for patients with AECOPD. The combination of these three parameters might enable even more accurate prediction.

Noninvasive Ventilation Weaning in Acute Hypercapnic Respiratory Failure due to COPD Exacerbation: A Real-Life Observational Study.

The most recent British Thoracic Society/Intensive Care Society (BTS/ICS) guidelines on the use of noninvasive ventilation (NIV) in acute hypercapnic respiratory failure (AHRF) suggest to maximize NIV use in the first 24 hours and to perform a slow tapering. However, a limited number of studies evaluated the phase of NIV weaning. The aim of this study is to describe the NIV weaning protocol used in AHRF due to acute exacerbation of chronic obstructive pulmonary disease (AE-COPD), patients' characteristics, clinical course, and outcomes in a real-life intermediate respiratory care unit (IRCU) setting. We performed a retrospective study on adult patients hospitalized at the IRCU of San Gerardo Hospital, Monza, Italy, from January 2015 to April 2017 with a diagnosis of AHRF due to COPD exacerbation. The NIV weaning protocol used in our institution consists of the interruption of one of the three daily NIV sessions at the time, starting from the morning session and finishing with the night session. The 51 patients who started weaning were divided into three groups: 20 (39%) patients (median age 80 yrs, 65% males) who completed the protocol and were discharged home without NIV (Completed Group), 20 (39%) did not complete it because they were adapted to domiciliary ventilation (Chronic NIV Group), and 11 (22%) interrupted weaning ex abrupto mainly due to NIV intolerance (Failed Group). Completed Group patients were older, had a higher burden of comorbidities, but a lower severity of COPD compared to Chronic NIV Group. Failed Group patients experienced higher frequency of delirium after NIV discontinuation. None of the patients who completed weaning had AHRF relapse during hospitalization. While other NIV weaning methods have been previously described, our study is the first to describe a protocol that implies the interruption of a ventilation session at the time. The application of a weaning protocol may prevent AHRF relapse in the early stages of NIV interruption and in elderly frail patients.

Improvement in hypercapnia does not predict survival in COPD patients on chronic noninvasive ventilation

PurposeIt has recently been shown that chronic noninvasive ventilation (NIV) improves a number of outcomes including survival, in patients with stable hypercapnic COPD. However, the mechanisms responsible for these improved outcomes are still unknown. The aim of the present study was to identify parameters associated with: 1) an improved arterial partial pressure of carbon dioxide (PaCO2) and 2) survival, in a cohort of hypercapnic COPD patients treated with chronic NIV.Patients and methodsData from 240 COPD patients treated with chronic NIV were analyzed. Predictors for the change in PaCO2 and survival were investigated using multivariate linear and Cox regression models, respectively.ResultsA higher level of bicarbonate before NIV initiation, the use of higher inspiratory ventilator pressures, the presence of anxiety symptoms, and NIV initiated following an exacerbation compared to NIV initiated in stable disease were associated with a larger reduction in PaCO2. A higher body mass index, a higher FEV1, a lower bicarbonate before NIV initiation, and younger age and NIV initiation in stable condition were independently associated with better survival. The change in PaCO2 was not associated with survival, neither in a subgroup of patients with a PaCO2 >7.0 kPa before the initiation of NIV.ConclusionPatients with anxiety symptoms and a high bicarbonate level at NIV initiation are potentially good responders in terms of an improvement in hypercapnia. Also, higher inspiratory ventilator pressures are associated with a larger reduction in PaCO2. However, the improvement in hypercapnia does not seem to be associated with an improved survival and emphasizes the need to look beyond PaCO2 when considering NIV initiation.

Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care.

Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease. Prospective observational cohort study. Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014. Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization. The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy. Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.

The Role of Noninvasive Ventilation in the Management and Mitigation of Exacerbations and Hospital Admissions/Readmissions for the Patient With Moderate to Severe COPD (Multimedia Activity)

As seen in this CME online activity (available at http://journal.cme.chestnet.org/home-niv-copd), COPD is a common and debilitating disease and is currently the third leading cause of death in the United States. The role of noninvasive ventilation (NIV) in the management of severe, hypercapnic COPD has been controversial. However, it was concluded that current data would support the following recommendations. Patients with COPD with a waking Paco2 > 50 to 52 mm Hg, an overnight Paco2 > 55 mm Hg, or both who are symptomatic and compliant with other therapies should be eligible for NIV. In addition, multiple previous hospital admissions for COPD exacerbation, requiring noninvasive/invasive mechanical ventilation, strongly suggest a need for chronic NIV. Patients with COPD with a BMI > 30 kg/m2 respond particularly well to this therapy. When the decision is made to start NIV, this treatment is probably best initiated during a short hospitalization, although this can be accomplished in the clinic, home, or sleep laboratory if well-trained clinicians are available. Newer modes of NIV such as volume-assured pressure support, particularly with autotitrating expiratory positive airway pressure (EPAP), may create the opportunity for home NIV initiation easier for less experienced physicians. Regardless of the mode selected, inspiratory pressures must be in the 20 to 25 cm H2O range to meaningfully increase tidal volume, reduce work of breathing, and, importantly, reduce waking arterial Paco2. EPAP is currently set at 4 to 5 cm H2O, although future technologies may allow this to be individualized to maximally reduce auto-positive end expiratory pressure. The NIV device should have a backup rate although it is controversial as to whether this should be set at a high (18-20 breaths/min) vs a low (8-10 breaths/min) rate. The proper use of NIV in appropriately chosen patients with COPD can improve quality of life and increase survival. Ongoing studies are assessing if the frequency of future hospitalizations can be reduced with NIV. Thus, NIV should be strongly considered in any patients with COPD meeting the criteria described here.

Case Report: Bilateral diaphragmatic dysfunction due to Borrelia Burgdorferi.

In this case report we describe a rare case of bilateral diaphragmatic dysfunction due to Lyme disease. A 62-years-old male presented to the hospital because of flu-like symptoms. During initial evaluation a bilateral diaphragmatic weakness with orthopnea and nocturnal hypoventilation was observed, without a known aetiology. Bilateral diaphragmatic paralysis was confirmed by fluoroscopy with a positive sniff test. The patient was referred to our centre for chronic non-invasive nocturnal ventilation (cNPPV). Subsequent investigations revealed evidence of anti- Borrelia seroactivity in EIA-IgG and IgG-blot, suggesting a recent infection with Lyme disease, and resulted in a 4-week treatment with oral doxycycline. The symptoms of nocturnal hypoventilation were successfully improved with cNPPV. However, our patient still shows impaired diaphragmatic function but he is no longer fully dependent on nocturnal ventilatory support. Lyme disease should be considered in the differential diagnosis of diaphragmatic dysfunction. It is a tick-borne illness caused by one of the three pathogenic species of the spirochete Borrelia burgdorferi, present in Europe. A delay in recognizing the symptoms can negatively affect the success of treatment. Non-invasive mechanical ventilation (NIV) is considered a treatment option for patients with diaphragmatic paralysis.

Facial cellulitis secondary to chronic non-invasive ventilation

Facial cellulitis secondary to chronic non-invasive ventilation

Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations

BackgroundReports of non-invasive ventilation (NIV) use in clinical practice reveal higher mortality rates than in corresponding randomised clinical trials.AimTo explore factors related to chronic obstructive pulmonary disease (COPD) admissions and...