Endotracheal Mechanical Ventilation Research Articles

Early versus delayed initiation of nasal continuous positive airway pressure for treatment of respiratory distress syndrome in premature newborns: A randomized clinical trial

Background:This prospective study was performed to identify whether the early use of nasal continuous positive airway pressure (n CPAP) would reduce the rate of endotracheal intubation, mechanical ventilation and surfactant administration.Materials and Methods:This study was conducted from June 2009 to September 2010 in the Shahid Beheshti University Hospital, Isfahan-Iran. A total of 72 preterm infants with 25-30 weeks gestation who needed respiratory support at 5 min after birth entered the study. Infants were randomly assigned to the very early CPAP (initiated 5 min after birth) or to the late CPAP (initiated 30 min after birth) treatment groups. The primary outcomes were need for intubation and mechanical ventilation during the first 48 h after birth and secondary outcomes were death, pneumothorax, intraventricular hemorrhage, duration of mechanical ventilation and bronchopulmonary dysplasia.Results:There were no significant differences between the two groups with regard to mortality rate, bronchopulmonary dysplasia and patent ductus arteriosus. The need for surfactant administration was significantly reduced in the early CPAP group (P = 0.04). Infants in the early CPAP group less frequently required intubation and mechanical ventilation.Conclusions:Early n CPAP is more effective than late n CPAP for the treatment of respiratory distress syndrome. In addition, the early use of n CPAP would reduce the need for some invasive procedures such as intubation and mechanical ventilation.

Diagnostic value of brain biopsy in a pediatric multiple sclerosis mimicking brain stem glioma

Diagnosis of multiple sclerosis (MS) is difficult when the lesion mimics glioma or cerebral enchephalitis. We report a case of pediatric MS initially suspected as brain stem glioma. An 11-year-old boy developed left foot joint pain followed by progressive symptoms such as left arm and leg weakness, dysarthria, paraplegia, and decreased level of consciousness. He subsequently developed respiratory distress requiring endotracheal intubation and mechanical ventilation. Magnetic resonance imaging showed a mass measuring 2 cm in the medulla oblongata. Although this mass was initially suspected as a glioma, the patient's acutely progressive disease course was not consistent with this diagnosis. Open biopsy revealed inflammation and demyelination, but no malignant cells were detected. He was treated with steroid pulse therapy, which showed dramatic effects. Nine months later, he developed another episode characterized by several neurological symptoms, and the diagnosis of MS was clinically confirmed. Open brain stem biopsy is technically demanding, but this case demonstrates that appropriate neurosurgical evaluation can play an important role in diagnosis by ruling out glioma and confirming MS.

Nasal High-Frequency Oscillation for Lung Carbon Dioxide Clearance in the Newborn

Background: Noninvasive ventilation has been used increasingly in recent years to minimize the duration of endotracheal mechanical ventilation in neonates due to its association with lung injury. Nasal high-frequency oscillation (nHFO) is a relatively new noninvasive modality but evidence for its use is limited. Objective: The goal of this study was to compare the CO₂ clearance efficacy of nHFO and noninvasive positive pressure ventilation (NIPPV) in a neonatal lung model. Design/Methods: A newborn mannequin with dimensions and anatomy similar to a term infant was utilized. It was connected to a commercially available neonatal mechanical ventilator using a manufacturer-provided nasal adaptor. Various modes of noninvasive ventilation were compared as CO₂ clearance was measured at the oropharynx by an end-tidal CO₂ analyzer following the addition of a known amount of CO₂ into the lung. Measurements were obtained at two different lung compliances using nHFO and compared with nCMV and nasal continuous positive airway pressure (nCPAP) as a control. Pressures near the nasal adaptor and the larynx were simultaneously measured with in-line pressure transducers. Results: Whereas no CO₂ elimination was observed under nCPAP, its clearance with nHFO was 3-fold greater as compared to NIPPV. On nHFO, CO₂ clearance was inversely proportional to frequency and maximal at 6 and 8 Hz. At a lower lung compliance, CO₂ clearance was significantly higher at 6 Hz as compared to 10 Hz. During nHFO set to deliver a MAP of 10.0, we documented pressures of 7.2 ± 0.3 at the nasal adaptor and only 2.3 ± 0.3 cm H₂O at the larynx. Conclusions: Nasal HFO is effective and superior to NIPPV at lung CO₂ elimination in a newborn mannequin model. The use of nHFO as the preferred mode of noninvasive ventilation warrants further clinical studies.

Atypical upswing at initial part of phase III in capnograms due to technical cause

We sporadically experienced three paediatric cases of atypical upswing at the initial part of phase III in the capnograms via side-stream capnometer immediately following endotracheal intubation and mechanical ventilation. No fault was found in the monitor or anaesthetic system including breathing circuits, carbon dioxide (CO2 ) sampling tube, water trap, and unidirectional valves. The upsurge of CO2 disappeared with increasing the respiratory rate; however, it reappeared with decreasing the respiratory rate and vice versa. We experimentally reproduced the phenomenon of overshooting CO2 measurement after the luer lock connection of the sample gas line at the water trap had been unscrewed a little bit.

Predictive monitoring for respiratory decompensation leading to urgent unplanned intubation in the neonatal intensive care unit

BackgroundInfants admitted to the neonatal intensive care unit (NICU), and especially those born with very low birth weight (VLBW; <1500 grams), are at risk for respiratory decompensation requiring endotracheal intubation and mechanical ventilation. Intubation and mechanical ventilation are associated with increased morbidity, particularly in urgent unplanned cases.MethodsWe tested the hypothesis that the systemic response associated with respiratory decompensation can be detected from physiological monitoring, and that statistical models of bedside monitoring data can identify infants at increased risk of urgent, unplanned intubation. We studied 287 VLBW infants consecutively admitted to our NICU and found 96 events in 51 patients, excluding intubations occurring within 12 hours of a previous extubation.ResultsIn order of importance in a multivariable statistical model, we found the characteristics of reduced O2 saturation, especially as heart rate was falling, increased heart rate correlation with respiratory rate, and the amount of apnea all were significant independent predictors. The predictive model, validated internally by bootstrap, had receiver-operating characteristic area of 0.84 ± 0.04.ConclusionsWe propose that predictive monitoring in the NICU for urgent unplanned intubation may improve outcomes by allowing clinicians to intervene non-invasively before intubation is required.

394 Early Detection of Neonatal Respiratory Decompensation Leading to Intubation using Predictive Monitoring

AimsVery low birth weight (VLBW < 1500 grams) infants in the Neonatal Intensive Care Unit (NICU) are at risk for respiratory deterioration requiring endotracheal intubation and mechanical ventilation, with associated...

Bacterial pneumonia as a result of mechanical ventilation in patients treated in intensive care units – epidemiological importance

Introduction. Ventilator-associated pneumonia (VAP) is among the most common hospital infections in an Intensive Care Unit (ICU). The most important risk factors of VAP are endotracheal catheterization and mechanical ventilation. Aim. The objective of the study was evaluation of the prevalence of ventilator-associated pneumonia, and determination of the type of microbiological agents in specimens collected from the bronchial tree. Material and methods. The study covered 42 patients: 59.5% of males and 40.5% of females, hospitalized in the Intensive Care Unit (ICU), in whom mechanical ventilation was applied. Airway secretion was grown on a solid agar medium: Columbia agar with 5% sheep blood, chocolate agar, McConkey and Sabouraud media. Identification of the bacterial strains grown was based on the determination of their biochemical properties, with the use of commercial assays (bio-Merieux): ID 32E and ID 32GN and tests ID 32 STAPH and API 20 STREP. Results. In the group of 42 patients who received mechanical ventilation (59.5% of the total number of hospitalized patients) VAP developed in 17 patients (40.5%). From the specimens 30 (34.9%) strains of Gram-negative rods, 19 (22%) strains of Gram-positive cocci, and 13 (15.1%) fungi were grown. The largest number of strains was isolated in patients who received artificial ventilation until day 20 of hospitalization. Conclusions. The microorganisms most often isolated from the upper airways were Gram-negative rods; patients admitted to ICU from other wards were colonized with bacterial flora conveyed with them from the original ward; the duration of artificial ventilation increases the risk of occurrence of ventilator-associated pneumonia.

Prevalence of Acute Lung Injury Among Medical Patients in the Emergency Department

Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.

Noninvasive High-Frequency Percussive Ventilation in the Prone Position after Lung Transplantation

Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post–lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.

Noninvasive Ventilation for Post-Pneumonectomy Severe Hypoxemia

ARDS remains a lethal complication after major lung resections. The reported mortality ranges from 50% to 100%, with increased incidence and mortality rates in pneumonectomy patients. The pathogenesis of early ARDS is still not fully understood, and the majority of patients will require mechanical ventilation. A review of the literature reveals that the role of noninvasive ventilation (NIV) in ARDS after lung resection is unclear, in contrast to its well established benefits in other types of respiratory failure. NIV is a technique of augmenting alveolar ventilation delivered by face mask, without introducing an endotracheal tube. NIV may reduce the need for endotracheal mechanical ventilation and improve clinical outcome in patients with acute respiratory failure after lung resection, avoiding complications related to intubation. We present a case of early ARDS following left-sided pneumonectomy, where bi-level positive airway pressure ventilation prompted a successful outcome.

Extracorporeal membrane oxygenation in a nonintubated patient with acute respiratory distress syndrome

To the Editors: Endotracheal intubation and mechanical ventilation are mainstays in the management of patients with acute respiratory distress syndrome (ARDS), but this treatment strategy exposes the patient to several risks and complications. A small number of ARDS patients can be treated with noninvasive ventilation and these patients have less ventilator-associated pneumonia and a lower mortality rate [1]. However, failure to improve oxygenation with noninvasive ventilation indicates the need for endotracheal intubation [1]. In patients with severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is increasingly being used on top of mechanical ventilation to facilitate oxygenation and protective ventilation [2]. A novel concept is the use of ECMO in awake, spontaneously breathing patients to avoid the complications of invasive ventilation. So far, “awake ECMO” has been used predominantly in patients with end-stage lung disease as bridge to lung transplantation [3, 4]. The use of awake ECMO as …

Outstanding ethico-legal-fiqhi issues

To examine the practical issues arising in implementation of DNR from the perspectives of maqasid al shari’at and qawa’id al shari’at . The purposes and principles of the Law provided a conceptual framework for analyzing practical issues related to DNR orders. The issues were identified from a Pubmed literature search with the key word ‘DNR’ covering about 30 years and were analyzed as they related to the principles of intention, certainty and preventing harm and also to the purposes of preserving life and resources. It is proposed that DNR orders be written for patients in an established death process, i.e. cardiorespiratory failure beyond Young’s point ‘ z ’. Patients with terminal incurable conditions who develop acute, reversible cardiorespiratory arrest should be resuscitated if the net benefit will last for a reasonable time. Five components of DNR (cardiopulmonary resuscitation involving chest compression and oxygenation, endotracheal intubation, mechanical ventilation, defibrillation and vasoactive or ionotropic medication) could be provided on a case-by-case basis. The interventions may or may not include renal dialysis, blood transfusion, parenteral nutrition, pulmonary hygiene and normal treatment such as antibiotics. All patients, irrespective of their DNR status, deserve supportive care. To improve DNR processes, training should be given on end-of-life ethical issues for physicians and nurses, DNR orders should specify interventions, the autonomy of physicians who have a conscientious objection to DNR should be respected, more psychosocial support should be given to the families of DNR patients, more empirical research is required on DNR, and DNR decisions should be audited regularly.

Physician Decision Making Variations in Pre-Procedural Intubation of Ischemic Stroke Patients Undergoing Acute Neuro-Endovascular Treatment (P06.217)

Objective: The purpose of this study was to determine the variation in and factors associated with decision making for pre-procedural intubation among patients with acute ischemic stroke. Background There are no established criteria for endotracheal intubation and mechanical ventilation prior to neuro-endovascular procedures in acute ischemic stroke. Due to recent reports identifying intubation as a risk factor for death and disability in such patients, the practice has come under scrutiny. Design/Methods: We developed 10 simulation cases from an actual database of acute ischemic stroke patients undergoing emergent neuro-endovascular procedures. The simulation cases consisted of relevant demographics, presenting symptoms, relevant past medical history, initial National Institute of Health Stroke Scale scores, and initial neuro-imaging findings. After review of the information, twenty clinicians from nine institutions selected the option of pre-procedural intubation (yes/no) for each of the 10 patients, and determined the reasoning. Clinicians were also asked to identify their training background (Neurology, Neurosurgery or Radiology trained neuro-interventionist, vascular neurologist or neuro-intensivist). Reasons for intubation and agreement between clinicians for each case were ascertained. To determine the agreement among different clinicians inter-observer variability was determined using Kappa statistic. Results: The overall agreement between physicians for selecting intubation prior to endovascular treatment as assessed by kappa (±SD) was 30%±5%. Agreement was highest between vascular neurologist and neuro-intensivist (39%). Major reasons for choice of intubation were respiratory insufficiency 15(7.5%); labored breathing plus inability to follow command 9 (4.5%); poor NIHSS 16 (8%); aphasia 8 (4%); seizure 1(0.5%); and no reason 9 (4.5%). Conclusions: There is considerable variability in decision making for intubation in patients undergoing emergent neuro-endovascular procedures. A reduction in death and disability in patients who undergo pre-procedural intubation may not be possible without standardizing intubation practices in such scenarios. Disclosure: Dr. Emiru has nothing to disclose. Dr. Chaudhry has nothing to disclose. Dr. Anderson has nothing to disclose. Dr. Qureshi has nothing to disclose.

Lungentransplantation

Since the early days of lung transplantation the demand for donor organs has outstripped donor organ availability. Consequently waiting times continue to increase with patients of highest priority often waiting several weeks or even months until a suitable donor organ becomes available resulting in considerable mortality on the waiting list. These issues have led to renewed interest in bridging strategies for patients with end-stage lung disease. The use of endotracheal intubation and mechanical ventilation (MV) has been viewed as a last resort as the majority of intubated patients fail to reach transplantation and those who do tend to have a poor postoperative outcome. New bridging strategies with awake extracorporeal membrane oxygenation (ECMO) seem to be hopeful alternatives in some patients. In the early intensive care unit (ICU) phase primary graft dysfunction, acute rejection, infections and surgical complications are common problems. Later, rejection, infection and sepsis, special airway complications and pulmonary bleeding may be reasons for ICU treatment.

Point prevalence and risk factors of hospital acquired infections in a cluster of university-affiliated hospitals in Shiraz, Iran

Hospital-acquired infections (HAIs) are critical and mostly preventable complications that occur in hospitalized patients and lead to major health and economic burdens. Most of the information on HAI risk factors and the recommended preventive measures is based on data acquired from only a few countries. The aim of this point prevalence HAI study conducted in Shiraz, Iran, was to study the local epidemiology of HAIs and the major risk factors for acquiring HAIs in a Middle-Eastern region. The study employed four identical point prevalence surveys in eight university hospitals, each consisting of 60-700 beds. The study was conducted during all four season of 2008-2009. All of the patients admitted for ≥48h were studied, although the patients admitted to emergency wards were excluded. A standardized data collection form that included name, age, gender, presence or absence of HAI, administration of any antibiotics, insertion of a central line, use of an endotracheal tube, mechanical ventilation, and use of an urinary catheter was completed for each patient. The HAI definitions used in this study were based on the US National Nosocomial Infection Surveillance (NNIS) guidelines. Data from 3450 patients were prospectively collected and analyzed. The overall HAI prevalence was 9.4%. The most common HAIs were blood stream infections (2.5%), surgical site infections (2.4%), urinary tract infections (1.4%), and pneumonia (1.3%). A logistic regression analysis showed that the odds ratio OR for males rather than females acquiring infections was 1.56 (95% confidence interval [CI] 1.21-2.02). Other HAI risk factors included using a central intravascular catheter, adjusted OR of 3.86 (95% CI 2.38-6.26), and using an urinary catheter, adjusted OR of 3.06 (95% CI 2.19-4.28). Being admitted to an ICU was not an independent HAI risk factor. For all HAIs, the OR of acquiring infection was 3.24 (95% CI 2.34-4.47) in the patients with hospital stays longer than eight days. A high discrepancy between HAIs and antibiotic use was observed. Antibiotics were administered to 71% of the patients, but only 9.4% of the patients also had at least one documented infection. This point prevalence study showed that HAIs are frequent in Shiraz university hospitals, and that the proportion of patients receiving antibiotics is high. The results imply that more primary prevention efforts are necessary to address HAIs associated with using indwelling devices and to prevent surgical site infections.

Measures to prevent nosocomial infections during mechanical ventilation

Endotracheal intubation and mechanical ventilation are lifesaving measures in critically ill patients. However, these interventions increase the risk of respiratory infections, particularly ventilator-associated pneumonia (VAP). VAP constitutes a serious burden for the healthcare system and worsens the patient's outcomes; thus, several preventive strategies have been implemented. This communication reviews the current knowledge on VAP pathogenesis and the latest preventive measures. Pathogen-laden oropharyngeal secretions leak across the endotracheal tube (ETT) cuff; thus, a continuous control of the internal cuff pressure and cuffs made of polyurethane improve sealing effectiveness and associated risks of infections. Subglottic secretions aspiration prevents VAP, and the latest evidence demonstrated a reduction in the incidence of late-onset VAP. The role of ETT biofilm in the pathogenesis of VAP is not fully elucidated. Nevertheless, antimicrobial-coated ETTs have showed beneficial effects in VAP incidence. Recent experimental evidence has challenged the benefits associated with the use of the semirecumbent position; yet, these findings need to be corroborated in clinical trials. The latest results from trials testing the effects of selective digestive decontamination (SDD) showed beneficial effects on patients' outcomes, but concerns remain regarding the emergence of bacterial resistance, specifically upon digestive tract re-colonization. The use of oropharyngeal decontamination with antiseptics and the use of probiotics are potential alternatives to SDD. There is consistent evidence that strategies affecting the primary mechanisms of VAP pathogenesis efficiently reduce the occurrence of the disease. Preventive measures should be implemented grouped into bundles to improve overall efficacy.

Hemoptysis Associated with Leptospirosis Acquired in Hawaii, USA

Hemoptysis Associated with Leptospirosis Acquired in Hawaii, USA

Tsunami lung

We encountered three cases of lung disorders caused by drowning in the recent large tsunami that struck following the Great East Japan Earthquake. All three were females, and two of them were old elderly. All segments of both lungs were involved in all the three patients, necessitating ICU admission and endotracheal intubation and mechanical ventilation. All three died within 3weeks. In at least two cases, misswallowing of oil was suspected from the features noted at the time of the detection. Sputum culture for bacteria yielded isolation of Stenotrophomonas maltophilia, Legionella pneumophila, Burkholderia cepacia, and Pseudomonas aeruginosa. The cause of tsunami lung may be a combination of chemical induced pneumonia and bacterial pneumonia.

Combination pharmacotherapy improves neurological outcome after asphyxial cardiac arrest

AimTo study the effects of the combination of adrenaline (epinephrine) and vasopressin compared to adrenaline alone on initial resuscitation success, 24h survival, and neurological outcome in a swine model of asphyxial cardiac arrest (CA). MethodsThis prospective randomized experimental study was conducted at a laboratory research department. Twenty female Landrace/Large-White pigs, 12–15weeks of age, were investigated. Asphyxial CA was induced by clamping of the endotracheal tube. After 4min of untreated CA, resuscitation was initiated by unclamping the endotracheal tube, mechanical ventilation, chest compressions and adrenaline (Group A) or a combination of adrenaline with vasopressin (Group A+V) administered intravenously. In case of restoration of spontaneous circulation (ROSC), the animals were monitored for 30min and then observed for 24h. ResultsHemodynamic variables were measured at baseline during CPR and in the post-resuscitation period. Statistically significant difference was observed in groups A and A+V regarding coronary perfusion pressure (CPP) during the first minute of CPR. In both groups, ROSC and survival rates were comparable (p=NS). Neurological deficit score (NDS) was significantly higher in the combination group 24h following CA (p<0.001). Brain histological damage score (HDS) was also better in the combination group (p<0.001). Total HDS and NDS showed a statistical significant correlation (p<0.001). ConclusionsIn this porcine model of asphyxial CA, adrenaline alone as well as the combined administration of adrenaline and vasopressin resulted in similar ROSC and survival rates, but the combination of adrenaline and vasopressin resulted in improved neurological and cerebral histopathological outcomes.

The Total Face Mask Is More Comfortable than the Oronasal Mask in Noninvasive Ventilation but Is Not Associated with Improved Outcome

Background: Noninvasive positive-pressure ventilation (NPPV) is commonly used to improve ventilation and oxygenation and avoid endotracheal intubation and mechanical ventilation. Although clinically indicated, most patients fail to use NPPV due to mask intolerance. A total face mask was designed to increase compliance, but whether this translates into better outcome (improvement in clinical and blood gas parameters and less intubation) is unknown. Objectives: We compared the evolution of the clinical parameters, blood gases, levels of ventilatory support and rate of endotracheal intubation using the total face mask or the traditional oronasal mask during NPPV. Methods: A total of 60 patients were randomized to use either mask during NPPV. The clinical and laboratory parameters, as well as the level of ventilatory support were recorded at different intervals in both groups for up to 6 h. In addition, the tolerance for each mask and the need for endotracheal intubation were compared. Results: Patients tolerated the total face mask significantly better (p = 0.0010) and used NPPV for a longer time (p = 0.0017) when compared with the oronasal mask. Just 1 patient switched to the total face mask because of intolerance. Although better tolerated, the rate of endotracheal intubation was similar in both groups (p = 0.4376), as was the clinical and laboratory evolution. Conclusions: The total face mask was more comfortable, allowing the patients to tolerate NPPV longer; however, these accomplishments did not translate into a better outcome. Due to its comfort, the total face mask should be available, at least as an option, in units where NPPVs are routinely applied.