Method Of Ventilatory Support Research Articles

Assessment of different positive airway pressure noninvasive ventilation modalities in patients with overlap syndrome

Background Overlap syndrome (OS) is a challenging condition with an associated increased mortality. Noninvasive positive pressure ventilation is the main therapy in OS. Tri-level positive airway pressure (Tri-PAP) therapy is a new method of ventilatory support that was proposed to improve breathing during the cyclic breathing phases and correct the hypercapnia.Objectives To assess different noninvasive modalities of positive airway pressure including continuous positive airway pressure (CPAP), bi-level positive airway pressure (Bi-PAP), and Tri-PAP in the management of OS.Patients and methods This prospective interventional clinical trial was conducted on 45 patients with OS. After confirming the diagnosis of OS, patients were classified into three comparable groups, and in each group, we used one of the following three modalities of noninvasive ventilation: Tri-PAP, Bi-PAP, and CPAP. Arterial blood gas (ABG) was done after the use of the PAP. Data of sleep reports were recorded on each night and then analyzed.Results Patients were divided into three equal numbers and comparable groups in whom CPAP, Bi-PAP, and Tri-PAP were applied, correspondingly. Statistically significant improvement was observed regarding sleep parameters (apnea/hypopnea index, oxygen desaturation index, and snoring index) and ABG parameters [pH, partial pressure of carbon dioxide in arterial blood (mmHg), partial pressure of oxygen in arterial blood (mmHg), and arterial oxyhemoglobin saturation (%)] when Tri-PAP was compared with both Bi-PAP and CPAP.

Success of multiprofessional management of non-invasive ventilation: positive covid-19 pediatric case report

Objective: To describe a pediatric clinical case with positive COVID-19 that was successful in conducting multiprofessional noninvasive ventilation (NIV). Method: Description of the clinical case of a 34-month-old (2y10m) feminine gender patient admitted on May 09, 2020 to the Pediatric Intensive Care Unit (PICU) due to moderate acute ventilatory failure due to COVID-19. The child was submitted to NIV (in bilevel ventilatory mode) by the multiprofessional team (doctor, physiotherapist and nurse), being monitored his vital signs, global functionality (FSS Scale) and nutritional status during his stay in the PICU. Results: In May, 58 patients were admitted to PICU, 02 patient’s COVID-19 being positive. Due to the clinical severity of children with positive COVID-19, only this reported clinical case showed an indication for the use of NIV as the first method of ventilatory support. The MPJA patient, with previous comorbidity (chronic non-progressive encephalopathy - CNPE), remained on NIV (in bilevel mode) for six consecutive days, evolving with decreased respiratory effort and improvement of clinical signs (respiratory rate, pulse saturation) oxygen) as well as the SpO2 / FiO2 and PaO2 / FiO2 ratios. After ventilator weaning and removal of NIV, and was kept in room air in the pediatric ward, discharged after 16 days of hospitalization. Conclusion:This NIV success case report demonstrates that the readiness of the multiprofessional team to establish a ventilatory support plan within the acceptable “window of time” of the evolution in moderate acute ventilatory failure resulting from COVID-19 can help successful ventilatory support even of patients with previous comorbidities.

0887 Diaphragm Pacer Malfunctions Requiring Surgical Repair in CCHS Patients

Abstract Introduction Congenital Central Hypoventilation Syndrome (CCHS) is a genetic disorder that results in the loss of autonomic ventilatory control, and patients require ventilatory support during sleep or both sleep and wakefulness. One method of ventilatory support is diaphragm pacing (DP), where electrodes surgically placed on the phrenic nerve are connected to subcutaneously implanted receivers that communicate with external antennas and transmitter. There are limited data on the frequency of DP malfunctions that require surgical revision. Methods We reviewed the records of 24 CCHS patients ventilated by DP followed at CHLA from 1990-2019. Records were examined for demographics, PHOX2B mutation, pacing duration/day, date and type of malfunctions, age and time since implantation at malfunction occurrence, and repair success rate. Results All 24 patients had thoracoscopic electrode placement. 17/24 (71%) of patients used DP while asleep; 3/24 (13%) during wakefulness only. 4/24 (17%) were not currently using their pacers. 10/24 (42%) patients required at least one surgical intervention (Age at implantation 9 ± 4.6 (SD) years; age at malfunction 12.5 ± 7.4 years). The average time from pacer implantation to malfunction was 3.8 ± 3.5 years. Malfunctions included defective receivers (6), insulation leaks (1), defective electrodes (4), and hardware infection (1). Of 12 unique component repairs, 6/12 (50%) involved changing receivers, 1/12 (8%) involved repairing an insulation leak, 4/12 (33%) involved replacing the electrodes and receivers, and 1/12 (8%) involved hardware extraction. Of the 12 malfunctions, 10 (83%) had successful surgical revision. 2/12 (17%) repairs were not attempted. While awaiting surgical revision, patients were successfully ventilated by unilateral DP. Conclusion Nearly half of CCHS patients on DP experienced malfunctions within 11 years of implantation. The most common DP repair was receiver replacement. Patients who are waiting for repair often successfully ventilate while pacing unilaterally. Support None

Non-invasive ventilation as a prehospital intervention for acute COPD exacerbation

Chronic obstructive pulmonary disease (COPD) is the second most common respiratory illness in the UK, affecting over 1 million people. Acute exacerbations of COPD are a common presentation to the ambulance service and account for thousands of hospital admissions annually. Acute respiratory failure accompanies approximately 20% of exacerbations. Current prehospital treatment focuses on oxygen and pharmacological therapy to treat the underlying causes. Non-invasive ventilation (NIV) is a method of ventilatory support that does not require endotracheal intubation, avoiding significant risks associated with intubation and sedation. While some UK ambulance services have introduced NIV, UK guidelines primarily focus on hospital use. International trials have shown prehospital NIV to be more effective than standard treatment in terms of reducing the need for intubation and invasive ventilation in hospital. However, further research is necessary before NIV is introduced widely in UK prehospital paramedic practice.

Maintenance of equine anaesthesia over the last 50years: Controlled inhalation of volatile anaesthetics and pulmonary ventilation.

In the first edition of this journal, Barbara Weaver wrote a review titled 'Equine Anaesthesia', stating that, at that time, it was quickly becoming accepted practice that many horses were being anaesthetised 'by essentially similar procedures, i.e. premedication, induction and then maintenance by controlled inhalation'. To celebrate the 50th anniversary of the first edition of this journal, this review covers the development of understanding and practice of inhalational anaesthesia and controlled ventilation in horses over the last 50years. We review how the perceived benefits of halothane led to its widespread use, but subsequently better understanding of halothane's effects led to changes in equine anaesthetic practice and the utilisation of different inhalation agents (e.g. isoflurane and sevoflurane). We discuss how more recently, better understanding of the effects of the 'newer' inhalation agents' effects has led to yet more changes in equine anaesthetic practice, and while, further new inhalation agents are unlikely to appear in the near future, further enhancements to anaesthetic practice may still lead to improved outcomes. We review advances in our understanding of the anatomy and pathophysiology of the equine lung as well of the effects of anaesthesia on lung function and how these predispose to some of the common problems of gas exchange and ventilation during anaesthesia. We identify the aims of optimal mechanical ventilation for anaesthetic management and whether the various methods of ventilatory support during equine anaesthesia achieve them. We also highlight that further developments in equipment and optimal ventilator modes are likely in the near future.

Ventilación mecánica no invasiva en el postoperatorio. Revisión clínica

Non-invasive ventilation (NIV) is a method of ventilatory support that is increasing in importance day by day in the management of postoperative respiratory failure. Its role in the prevention and treatment of atelectasis is particularly important in the in the period after thoracic and abdominal surgeries.Similarly, in the transplanted patient, NIV can shorten the time of invasive mechanical ventilation, reducing the risk of infectious complications in these high-risk patients.It has been performed A systematic review of the literature has been performed, including examining the technical, clinical experiences and recommendations concerning the application of NIV in the postoperative period.

Behind a Mask: Tricks, Pitfalls, and Prejudices for Noninvasive Ventilation

It is difficult to exactly date the beginning of mechanical ventilation, but there are no doubts that noninvasive ventilation (NIV) was the first method of ventilatory support in clinical practice. The technique had a sudden increase in popularity, so that it is now considered, according to criteria of evidence-based medicine, the first-line treatment for an episode of acute respiratory failure in 4 pathologies (the Fabulous Four): COPD exacerbation, cardiogenic pulmonary edema, pulmonary infiltrates in immunocompromised patients, and in the weaning of extubated COPD patients. The so-called emerging applications are those for which the evidence has not achieved level A, mainly because the number or sample size of the published studies does not allow conclusive meta-analysis. These emerging applications are the post-surgical period, palliation of dyspnea, asthma attack, obesity hypoventilation syndrome, and to prevent extubation failure. Potentially "risky business" uses include for respiratory failure from pandemic diseases and ARDS, where probably the "secret" for success is early use. Healthcare is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly, if at all, so their clinical use remains limited and heterogeneous. The low rate of NIV use in some hospitals relates to lack of knowledge about or experience with NIV, insufficient confidence in the technique, lack of NIV equipment, and inadequate funding. But NIV use has been increasing around the world, thanks partly to improved technologies. The skill and confidence of clinicians in NIV have improved with time and experience, but NIV is and should remain a team effort, rather than the property of a single local "champion," because, overall, NIV is beautiful!

Outcome of NIV in Critical Care Setting: Experience from a Tertiary Care Center

NIV is a method of ventilatory support which is delivered to the patient without using an invasive airway. For the last two decades it is increasingly used as an accepted method of mechanical ventilatory support as it is proved to have many positive outcomes as it can prevent invasive ventilation & its complication. In a tertiary care hospital of Bangladesh we are using this method in all patients meeting the NIV criteria & not having absolute contraindication irrespective of diagnosis. Our study aimed to access the out come of the NIV trial using our local resource & to compare it with others. This is an ongoing prospective study and till this report data from 82 patients were analyzed here of which 50% patient ended with positive outcome & 50% ended as negative outcome. As the result of this method varies significantly by diagnosis & severity of disease we are generating specific recommendations according to the likely outcome according to the diagnosis. DOI: http://dx.doi.org/10.3329/bccj.v1i1.14358 Bangladesh Crit Care J March 2013; 1: 3-7

Importance of ventilator mode in long-term noninvasive positive pressure ventilation

Long-term noninvasive positive pressure ventilation (NPPV) is associated with an excellent survival rate, especially in post-tuberculosis patients. Nothing is currently known on which method of ventilatory support is associated with a better continuation of long-term NPPV, which itself might lead to longer survival. One hundred and eighty four post-tuberculosis patients, who started NPPV at the Kyoto University Hospital group and the National Tokyo Hospital from June 1990 to August 2007, were examined retrospectively. Ventilator mode (an assisted mode or a pure controlled mode) and potential confounders were examined with the discontinuation of NPPV as the primary outcome. Patients treated with a pure controlled mode had significantly better continuation rates (hazard ratio, 3.09; 95% confidential interval, 1.75-5.47; p=0.0001) and better survival rates (Log-rank test; p=0.0031) than those treated with an assisted mode. Female gender and no pulmonary lesions were also associated with a significantly better probability of continuing NPPV. The five- and ten-year probabilities of continuing NPPV for 106 patients with a pure controlled mode were 68.3% and 41.4%, respectively, while those for 76 patients with an assisted mode were 46.7% and 12.7%, respectively. Patients treated with pure controlled ventilation had significantly better continuation rates and survival rates than those treated with assisted ventilation. Prospective randomized controlled trials are needed to verify the effectiveness of a pure controlled mode in patients with not only restrictive thoracic disease but also other diseases including chronic obstructive pulmonary disease.

Current status of non-invasive ventilation in German ICU's -- a postal survey

The status of non-invasive ventilation (NIV) in intensive care units (ICU) in Germany was analysed by a national survey. Questionnaires consisting of multiple-choice and short-answer questions were sent to ICUs of university hospitals, hospitals with >1000 beds, with 500 - 1000 beds, and hospitals with <500 beds separated with regard to different specialties (anesthesia ICUs, surgical ICUs, cardiac surgical ICUs, neurosurgical ICUs, internal ICUs, interdiscipline ICUs). Of the 716 questionnaires sent 223 (32 %) were returned and analysed. The use of NIV in all specialties increased during the last 3 years. 14 % of ICUs in some specialties treated more than 30 % of patients with NIV. CPAP (88 %), BIPAP (45 %) and ASB/PSV (48 %) were most frequently used as NIV-strategies. 10 % of all ICUs reported to have experience with proportional assist ventilation. NIV was most frequently used for disease states like COPD (82 %), pneumonia (64 %), pulmonary oedema (50 %), bronchial asthma (35 %) and ALI/ARDS (22 %). The use of NIV was considered when clinical signs of ventilation (93 %) and oxygenation [arterial blood gas analysis (92 %) and oxygen saturation (66 %)] were inadequate. Complications observed during NIV were panic reaction (83 %), ulceration of nose (38 %) and aspiration (14 %). The reasons to reject NIV were (total 13 %): lack of ventilators (64 %), expenditure of personnel (57 %) and risk of the procedure (11 %). 38 % of the ventilators used were older than 5 years. 56 % of the ICUs were content with the equipment for NIV. 76 % of the ICUs were interested to buy new equipment of NIV. 99 % of the survey have declined NIV as an alternative method of ventilation. In summary we found NIV as an accepted additional method of ventilatory support in respiratory failure in German ICUs. We found no significant increase in frequency of NIV in the last three years.

Strategies for ventilatory support.

Since the introduction of manual positive pressure ventilation during the Copenhagen polio epidemic of 1952, a range of mechanical devices and methods of ventilatory support have been developed to provide life-saving respiratory therapy to critically ill patients. In addition to the development of the equipment hardware to enable effective mechanical ventilation, there has been a gradual realisation that a single mode of ventilation is not universally applicable to all patients, individual pathologies, or to individual patients at various stages in the evolution of their pulmonary pathology. While mechanical ventilation can undoubtedly be life-saving, it can also cause lung damage as a result of its non-physiological method of promoting effective gas exchange. This iatrogenic problem is known as ventilator induced lung injury and, although it may be a problem in any patient requiring mechanical ventilation for any reason, is of particular importance to those patients requiring mechanical ventilation as a consequence of trauma. This chapter describes the range of ventilatory support techniques available, the problem of ventilator induced lung injury with specific reference to trauma patients and offers a strategy for ventilatory support in the trauma patient.

Noninvasive Mechanical Ventilation with the Iron Lung

Use of the iron lung as a method of ventilatory support is making a comeback. This article demonstrates the effectiveness of continuous negative-pressure ventilation in a patient with neuromuscular disease and severe chest wall deformity. This noninvasive device not only corrected the patient's ineffective breathing pattern and averted intubation, but its continued home use after discharge improved his overall quality of life.

Predicting ventilation failure in children with inhalation injury

Despite advances in mechanical ventilatory support for patients with smoke inhalation injury, including the use of high-frequency flow-interruption ventilators such as the VDR, inhalation injury alone may increase mortality by as much as 20% in patients with thermal injury, and up to 60% when pneumonia occurs. Inhalation injury causes a primary large and small airway epithelial insult that results in ventilation abnormalities, rather than a primary alveolar lesion that results in oxygenation abnormalities as occur in multiple-system organ failure. Patients with inhalation injury requiring high ventilatory pressures experience complications of barotrauma and frequently succumb to necrotizing tracheobronchitis and oxygenation abnormalities after 2 to 4 weeks of mechanical ventilation. Ventilatory indexes obtained early in the postburn period allow the development of accurate predictive formulae that identify patients who will not be adequately supported by mechanical ventilation after smoke inhalation injury. Early identification of such patients will allow rapid conversion to other methods of ventilatory support that effect gas exchange, with minimal risk of further barotrauma, while inhalation injury healing occurs. Such predictors may be developed for other disease processes that are characterized by severe pulmonary ventilatory dysfunction.

Body Ventilator Use for the Ventilatory Support of Individuals with Neuromuscular Disease

Over one hundred individuals with progressive neuromuscular disease, including about fifty individuals with Duchenne muscular dystrophy (DMD), whose lives have been prolonged by three to ten years using body ventilators up to 24 hours a day, have been described. Since noninvasive intermittent positive pressure ventilation (IPPV) methods of ventilatory support were not available to the great majority of these individuals, and many also had inadequate access to effective noninvasive methods of airway. secretion clearance, many patients were forced to prematurely undergo tracheostomy for continued ventilatory assistance and airway secretion management. Negative pressure body ventilators (NPBVs) were most commonly used for nocturnal support, and the intermittent abdominal pressure ventilator (IAPV) was the body ventilator of choice for daytime aid. Of the former, the iron lung was most popular for nocturnal support in the home. However, portable iron lungs, wrap style ventilators, and the convenient chest shell ventilators (CSVs) have recently gained in popularity. Additionally, NPBVs are very useful during the conversion of individuals from ventilatory support via endotracheal intubation or indwelling tracheostomy tubes to noninvasive methods. They have also been used by patients otherwise ventilated by noninvasive IPPV techniques during the management of upper respiratory tract infections when frequent access to nasal and oral passages is necessary for managing airway secretions.

Tracheal Intermittent Positive Pressure ventilation for Patients with Progressive Neuromuscular Disease

The purpose of this work is to review the use of long-term tracheal intermittent positive pressure ventilation (TIPPV) and its advantages and complications in the long-term management of neuromuscular ventilatory failure. Over 500 such individuals have been described who have had prolonged survival due largely to long-term TIPPV. Many of these individuals have remained active both professionally and socially. Long-term TIPPV is generally well tolerated and may become necessary to prolong the survival of individuals who already use noninvasive methods of ventilatory support but whose conditions have progressed to the point of requiring a tracheostomy.

Electrophrenic Ventilation: A Different Perspective

Since 1972, radio-frequency electrophrenic nerve pacing (EPP) has been an option for assisting the ventilation of patients with chronic paralytic respiratory insufficiency. Most of the medical literature has been favorable regarding its continued application. We reviewed the literature to determine how "successful" application of EPP was defined. Our studies indicated that long-term follow-up of EPP patients has been generally inadequate with little emphasis placed on incidence and severity of complications. There was no standardization in defining successful experiences with EPP. Upper airway instability during pacing, lack of internal pacemaker alarms, and the risk of sudden pacemaker failure necessitate permanent tracheostomy in the great majority of patients but complications of the presence of a tracheostomy were not considered in evaluating the desirability of EPP. Some EPP patients became independent of any ventilatory support thus benefiting minimally from the time commitment, effort, and extreme expense needed for EPP placement and training. We conclude that EPP is a valid option for the properly screened patient but that expense, failure rate, morbidity and mortality remain excessive and that alternative methods of ventilatory support should be explored.

Comparison of Blood Gases During Transport Using Two Methods of Ventilatory Support

Transportation of critically ill patients requiring ventilatory support represents a common, yet difficult, problem faced by clinicians. We examined 28 patients requiring transport in a prospective, randomized fashion, comparing manual ventilation with ventilation provided by a transport ventilator. Patients were ventilated to their destination with one method and returned with the alternate method. After manual ventilation, all patients showed a marked respiratory alkalosis (pH increased from 7.39 to 7.51 and PaCO2 decreased from 39 to 30 torr). After ventilation with the transport ventilator, no appreciable changes in pH or PaCO2 were seen. Oxygenation remained stable with both methods. No patient suffered hemodynamic instability, although two patients in the manual ventilation group developed cardiac arrhythmias. We conclude that when ventilatory support is required during transport, a transport ventilator produces reliable control of ventilation.

Airway Pressure Release Ventilation in a Patient with Acute Pulmonary Injury

Airway pressure release ventilation is a recently described method of ventilatory support. It allows spontaneous ventilation with CPAP but differs from conventional ventilatory modes because, with APRV, peak inflation pressure never exceeds the level of CPAP, and airway pressure decreases, rather than increases, when tidal volume is delivered. The risk of pulmonary barotrauma and adverse hemodynamic effects associated with conventional modes of positive-pressure mechanical ventilation may be decreased because of lower peak inflation and mean airway pressures. We describe a patient in whom several risk factors for these complications were present who was treated successfully with APRV.

Mechanical Ventilation Techniques-Reply

In Reply.— Early in my career, I had considerable experience with the breathing methods listed. The over-whelming inadequacies of these techniques, in fact, became a major stimulus that encouraged me to look for more definitive methods of intensive respiratory care and assist in the design of new respirators. Whereas the tank respirator was useful in managing patients with paralytic disorders, particularly poliomyelitis, nursing care was difficult, to say the least. The fixed one-to-one inspiratory expiratory ratio, the difficulties in maintaining a seal around the neck, and the limited pressure capability made effective respiratory support difficult or even impossible for many people, particularly those with obesity. With no ability to vary inspiratory expiratory ratios, modify pressure wave forms, or control flow rate and with no capability of assisted ventilation, this method of ventilatory support is rendered particularly inappropriate in chronic obstructive lung diseases. The chest-abdomen cuirass was and is a method