Noninvasive Ventilation Modalities Research Articles

Humidification during Invasive and Non-Invasive Ventilation: A Starting Tool Kit for Correct Setting.

The humidification process of medical gases plays a crucial role in both invasive and non-invasive ventilation, aiming to mitigate the complications arising from bronchial dryness. While passive humidification systems (HME) and active humidification systems are prevalent in routine clinical practice, there is a pressing need for further evaluation of their significance. Additionally, there is often an incomplete understanding of the operational mechanisms of these devices. The current review explores the historical evolution of gas conditioning in clinical practice, from early prototypes to contemporary active and passive humidification systems. It also discusses the physiological principles underlying humidity regulation and provides practical guidance for optimizing humidification parameters in both invasive and non-invasive ventilation modalities. The aim of this review is to elucidate the intricate interplay between temperature, humidity, and patient comfort, emphasizing the importance of individualized approaches to gas conditioning.

Short-term Non-invasive Ventilation for Children with Palliative Care Needs

Objectives: Non-invasive ventilation (NIV), namely continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), delivers mechanical ventilation without endotracheal intubation. Short-term NIV (planned for <21 days during initiation) can be used for the management of acute respiratory distress (ARD) among paediatric palliative patients with “Do Not Resuscitate or Intubate” (DNI) as the ceiling of care. This study aimed to describe the usage of short-term NIV among paediatric palliative patients in a woman and child hospital with a paediatric palliative subspecialty. Materials and Methods: A retrospective and observational study was conducted on all paediatric palliative patients who received short-term NIV in Tunku Azizah Hospital Kuala Lumpur, Malaysia, from March 2020 to May 2022. Results: During the study period, short-term NIV was offered on 23 occasions for 20 different children. Indications for short-term NIV include 16 (69.6%) occasions of potentially reversible ARD (NIV Category 1) and 7 (30.4%) occasions of comfort care at the end of life (NIV Category 2). The main cause of ARD was pneumonia (90.3%) due to either aspiration or infection. The modality of NIV used was BiPAP only (14 occasions, 60.9%), CPAP only (three occasions, 13%) and both BiPAP and CPAP (six occasions, 26.1%). The median duration of NIV usage was four days (minimum one day and maximum 15 days). NIV was initiated as an escalation from nasal prong, Ventimask or high-flow mask oxygen on 22 occasions and as weaning down post-extubation on one occasion. For the 22 occasions of escalating therapy, there was significant improvement at six hours compared to pre-NIV in the median heart rate (136 to 121, P=0.002), respiratory rate (40 to 31, P=0.002) and oxygen saturation (96% to 99%, P=0.025). All 17 documented parental impressions of the child’s condition post six hours of NIV were that the child had improved. Adverse events during short-term NIV include five episodes (21.7%) of stomach distension, four episodes (17.4%) of skin sores on the face and one episode (4.3%) of excessive drooling. Three patients passed away while on NIV in the hospital. For the other 20 (87%) occasions, patients were able to wean off NIV. Post-weaning off NIV, three patients passed away during the same admission. On 17 occasions, patients were discharged home after weaning off NIV. Conclusion: Usage of short-term NIV in paediatric palliative care, where children have an advanced directive in place indicating DNI, as seen in our study, can be a valuable modality of management for distressing symptoms, in addition to the pharmacological management of breathlessness. This is shown through our study to be of benefit in potentially reversible ARD as well as comfort care at the end of life. Further rigorous studies will need to be conducted for a clearer understanding of short-term NIV that would enable the formulation of guidelines to improve the quality of life and death in children.

Doing more with less: The use of non-invasive ventilatory support in a resource-limited setting.

Bubble CPAP (bCPAP), a non-invasive ventilation modality, has emerged as an intervention that is able to reduce pneumonia-related mortality in children in low resourced settings. Our study primarily aimed to describe a cohort of children who were started on CPAP in the Medical Emergency Unit (MEU) of Red Cross War Memorial Children's Hospital 2016-2018. A retrospective review of a randomly selected sample of paper-based folders was conducted. Children started on bCPAP at MEU were eligible for inclusion. Demographic and clinical data, management, and outcomes regarding admission to PICU, need for invasive ventilation and mortality were documented. Descriptive statistical data were generated for all relevant variables. Percentages depicted frequencies of categorical data while medians with interquartile ranges (IQR) were used to summarise continuous data. Of 500 children started on bCPAP, 266 (53%) were male; their median age was 3.7 (IQR 1.7-11.3) months and 169 (34%) were moderately to severely underweight-for-age. There were 12 (2%) HIV-infected children; 403 (81%) had received appropriate immunisations for their age; and 119 (24%) were exposed to tobacco smoke at home. The five most common primary reasons for admission were acute respiratory illness, acute gastroenteritis, congestive cardiac failure, sepsis and seizures. Most children, 409 (82%), had no underlying medical condition. Most children, 411 (82%), were managed in high care areas of the general medical wards while 126 (25%) went to PICU. The median time on CPAP was 1.7 (IQR 0.9-2.8) days. The median hospitalisation time was 6 (IQR 4-9) days. Overall, 38 (8%) children required invasive ventilatory support. Overall, 12 (2%) children with a median age of 7.5 (IQR 0.7-14.5) months died, six of whom had an underlying medical condition. Seventy-five percent of children initiated on bCPAP did not require PICU admission. This form of non-invasive ventilatory support should be considered more widely in the context of limited access to paediatric intensive care units in other African settings.

Noninvasive Ventilation Alone Cannot Solve COVID-19 Respiratory Failure.

The respiratory management of severe coronavirus disease (COVID-19) acute hypoxemic respiratory failure has vacillated since the onset of the pandemic. Initially the consensus was to favor early intubation and initiation of invasive mechanical ventilation. Noninvasive ventilation modalities, which include continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP), and humidified high flow oxygen were avoided. This was done to reduce aerosol generation risking infection in others and unrestricted tidal volumes causing injurious transpulmonary pressures.

Non-invasive Ventilation to Provide a More Positive Outlook in Neuromuscular Disease: An Update on the CHEST Guidelines

In this editorial, the American College of Chest Physicians (CHEST) guidelines for the respiratory management of patients with neuromuscular disease are discussed. The importance of personalizing treatment to the patient by using specific modalities of non-invasive ventilation is discussed, with emphasis on its benefits and the endpoints of successful treatment and the management of bulbar symptoms, such as secretion management and cough assistance. Finally, disease monitoring and the management of expectations throughout the course of the disease are explored.

6-Year-Old Male Drowning Complicated by Cardiac Arrest and Ensuing Metabolic and Respiratory Acidosis: Should Presence of Pulses Lead Clinicians to Pursue Prolonged Cardiopulmonary Resuscitation?

BackgroundDrowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. Case ReportWe present a case of 6-year-old boy was found by his friends submerged in sea water for 10–15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student.Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.

Cardiovascular autonomic control during application of different modes of noninvasive ventilation in patients affected by amyotrophic lateral sclerosis

BackgroundCardiovascular events commonly cause death in amyotrophic lateral sclerosis (ALS) even in patients treated by noninvasive ventilation (NIV). Objectivesto evaluate autonomic function with the assessment of heart rate variability (HRV) in ALS patients treated by assist pressure control ventilation (APCV) and assist control ventilation (ACV) during sleep. MethodsConsecutive ALS patients underwent one polysomnography during APCV and one during ACV. HRV was analyzed both in the total sleep period (from first stage N1 to last awakening) and in a 5-minute period of stable stage N2. Time domain, frequency domain and nonlinear indexes of HRV were measured. ResultsNineteen patients (age 62.0 ± 8.7, 9F/10 M) were studied. The analysis did not reveal differences in blood gasses between NIV modalities, but a longer expiratory time (3.01±0.6 vs 2.8 ± 0.6 s, respectively APCV vs ACV, p = 0.001) and a lower arousal index (17.5 ± 9.1 vs 23.1 ± 13.9, p = 0.02) during APCV. HRV was indicative of higher vagal activity during APCV, especially in the 5-minute periods. In the total sleep periods, the HRV time domain indexes reflecting parasympathetic activity were positively correlated with the expiratory time and negatively with the inspiratory/expiratory time ratio. Low frequencies were positively, and high frequencies negatively, correlated with inspiratory time. HRV and sleep structure parameters were not correlated, except very low frequencies that were correlated to the arousal index. ConclusionsRespiratory influences on autonomic control can be preserved in ALS. The slower breathing pattern during APCV may help to maintain a higher vagal activity. Through this mechanism, in the long-term APCV could more beneficial to ALS patients than ACV.

Pediatric Average Volume Assured Pressure Support.

Average volume assured pressure support (AVAPS) is a modality of non-invasive ventilation that enables the machine to deliver a pre-set tidal volume by adjusting the inspiratory pressure support within a set range. Data on its use in the pediatric population are limited to case reports and single centre case series. This article reviews paediatric data on use of AVAPS and highlights the need for validation to help develop specific guidelines on use of AVAPS in children.

Discordant ROP (Retinopathy of prematurity) development in twins less than 32 weeks of gestational age.

Background and aim:Retinopathy of prematurity (ROP), is a vasoprolipherative disorder of the immature retina and a major cause of preventable blindness in childhood. Although the development of ROP is multifactorial, the principal reasons are lower gestational age and lower birth weight. However, in twins their gestational ages were the same, ROP development can be discordant. This study aims to evaluate the etiologic factors of discordant ROP development in twins.Methods:We reviewed the last 5 years' records and found the twins whose discordant ROP development. This discordance was; 1. Different stages of ROP, 2. One sibling treated the other is not, 3. One sibling has aggressive posterior ROP the other is not, 4. One sibling has more influenced area as zones the other is not. We documented some data of these twins, as birth order, birth weight, resuscitation at birth, morbidities, the number of hemotransfusion, age of regaining birth weight, relative weight gain at 28 weeks.Results:We evaluated a total of 26 cases of 13 twins. The mean gestational age and birth weight of the entire study group were 27.7 ± 2, and 1053 ± 364 grams, respectively. We found that more transfused preterm baby in twins is more likely to show severe ROP. Sepsis and the duration of mechanical ventilation may be risk factors for more severe ROP in twins.Conclusion:We can reduce discordant retinopathy in less than 32-weeks premature twins by using methods such as cord milking and by improving non-invasive ventilation modalities. (www.actabiomedica.it)

Acute hypercapnic respiratory failure and its management on the acute medical take.

Acute hypercapnic respiratory failure accounts for 50 000 hospital admissions each year in the UK. This article discusses the pathophysiology and common causes of acute hypercapnic respiratory failure, and provides practical considerations for patient management in acute medical settings. Non-invasive ventilation for persistent acute hypercapnic respiratory failure is widely recognised to improve patient outcomes and reduce mortality. National audits highlight a need to improve patients' overall care and outcomes through appropriate patient selection and treatment initiation. Multidisciplinary involvement is essential, as this underpins inpatient care and follow up after hospital discharge. New non-invasive ventilation modalities may offer better patient comfort and compensate better for sleep-related changes in respiratory mechanics. Emerging therapies, such as nasal high flow, may offer an alternative treatment approach in those who cannot tolerate non-invasive ventilation, but more research is required to completely understand its effectiveness in treating acute hypercapnic respiratory failure.

NON-INVASIVE VENTILATION WITH AVERAGE VOLUME-ASSURED PRESSURE SUPPORT FOR ACUTE HYPERCAPNIC RESPIRATORY FAILURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Average volume-assured pressure support (AVAPS) is a comparatively newer modality of non-invasive ventilation that incorporates the properties of both volume and pressure-control ventilation. Though its benefits were well documented in chronic respiratory failure, studies illustrating its usage in acute respiratory failure are still insubstantial. Herein, we aim to showcase the utility of AVAPS in the management of acute on chronic hypercapnic respiratory failure. CASE PRESENTATION: An 80-year-old female with a body mass index (BMI) of 37 kg/m2 and chronic opiate use presented to the Emergency Department (ED) following a two-day history of increasing shortness of breath and confusion. Her medical history was notable for hypersensitivity pneumonitis secondary to bird exposure, former smoker, paroxysmal atrial fibrillation, and recent acute pericarditis for which she is taking aspirin and colchicine. An arterial blood gas (ABG) showed a pH of 7.14, PaCO2 of 124 mmHg (FiO2 28%), PaO2 of 94 mmHg, and bicarbonate of 41 mmol/L. A chest x-ray showed increased bilateral interstitial infiltrates. The patient received IV methylprednisolone and was placed on Spontaneous/Timed mode Bilevel positive airway pressure (BiPAP S/T) with an Inspiratory positive airway pressure (IPAP) of 10 mmHg, Expiratory positive airway pressure (EPAP) of 5 mmHg, and a respiratory rate of 12/min. At these set pressures, her inspired tidal volumes were around 400ml. The patient continued to remain confused (GCS 12/15) and thus, she was switched to average volume-assured pressure support (AVAPS) with a target tidal volume of 500ml. With this modality, she displayed rapid improvement in her symptoms and an ABG drawn eight hours after initiation revealed a pH of 7.34, PaO2 of 66 mmHg, PaO2 of 135 mmHg (FiO2 50%), and bicarbonate of 34 mmol/L. The patient was discharged home on the 5th day after admission. DISCUSSION: AVAPS is an intelligent modality of non-invasive pressure support that gives us the option to set a maximum and a minimum IPAP, in place of one fixed IPAP setting, along with a target tidal volume. The ventilator automatically adjusts the inspiratory pressure within the set range to ensure the delivery of pre-set tidal volume. Patient-ventilator dyssynchronization is prevented and previous studies have reported better patient comfort and satisfaction with AVAPS, thereby, improving patient compliance to the treatment. AVAPS was shown to be superior to BiPAP S/T and associated with a rapid improvement of ABG values and GCS score in patients with acute hypercapnic respiratory failure complicated with hypercapnic encephalopathy (GCS <10/15). CONCLUSIONS: Our case highlights the valuable utility of AVAPS and how, in certain clinical situations, it may be a preferred first-line modality over standard BiPAP S/T for the treatment of acute hypercapnic respiratory failure. REFERENCE #1: Yarrarapu SNS, Saunders H, Sanghavi D. Average Volume-Assured Pressure Support. 2021 Jan 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32809435. DISCLOSURES: No relevant relationships by Pramod Guru, source=Web Response No relevant relationships by Devang Sanghavi, source=Web Response No relevant relationships by Hollie Saunders, source=Web Response No relevant relationships by Siva Naga Yarrarapu, source=Web Response

Changes in Use of Respiratory Support for Preterm Infants in the US, 2008-2018

In preterm infants, mechanical ventilation (MV) is associated with adverse pulmonary and neurodevelopmental outcomes. Multiple randomized clinical trials over the past 2 decades have shown the effectiveness of early noninvasive ventilation (NIV) in decreasing the use of MV in preterm infants. The epidemiologic factors associated with respiratory support in US preterm infants and any temporal changes after these trials is unknown. To evaluate temporal changes in MV and noninvasive respiratory support in US preterm infants. In a cohort design, 2 large national data sets (Pediatrix Clinical Data Warehouse for the clinical cohort and National Inpatient Sample for the national cohort) were used to collect data on preterm infants (<35 weeks' gestation) without congenital anomalies who received active intensive care and were discharged home or died in the birth hospital from January 1, 2008, to December 31, 2018. Data analysis was conducted from December 10, 2019, to December 16, 2020. Discharge year. In the clinical cohort, detailed respiratory support data were generated, including days of MV and NIV modalities, and temporal trends were evaluated using multivariable modified Poisson or negative binomial regression models with discharge year as a continuous variable. In the national cohort, observed and expected national MV use were calculated. Among 259 311 infants (47.2% female) in 359 neonatal intensive care units in the clinical cohort, decreases were noted in the use (from 29.4% of infants in 2008 to 18.5% in 2018, relative risk for annual change, 0.96; 95% CI, 0.95-0.96) and duration (mean days, from 10.3 in 2008 to 9.7 in 2018; rate ratio for annual change, 0.98; 95% CI, 0.97-0.98) of MV. Noninvasive ventilation use increased from 57.9% of infants in 2008 to 67.4% in 2018 (adjusted relative risk for annual change, 1.02; 95% CI, 1.02-1.03), and mean NIV duration increased by 3.2 days (95% CI, 2.9-3.6 days). With increased use of continuous positive airway pressure and nasal intermittent positive-pressure ventilation as the main factors in the increase, the mean duration of respiratory support increased from 13.8 to 15.4 days (adjusted rate ratio for annual change, 1.03; 95% CI, 1.02-1.04) from 2008 to 2018. Among 1 169 441 infants in the national cohort, MV use decreased from 22.0% in 2008 to 18.5% in 2018, with an estimated 29 700 fewer ventilated infants and 142 000 fewer days of MV than expected during this period. These findings suggest that preterm respiratory support changed significantly from 2008 to 2018, with decreased use and duration of MV, increased use and duration of NIV, and an overall increase in respiratory support duration.

Trends in Therapy and Outcomes Associated With Respiratory Failure in Patients Admitted to the Cardiac Intensive Care Unit.

To describe the epidemiology, outcomes, and temporal trends of respiratory failure in the cardiac intensive care unit (CICU). Retrospective cohort analysis of 2,986 unique Mayo Clinic CICU patients from 2007 to 2018 with respiratory failure. Temporal trends were analyzed, along with hospital and 1-year mortality. Multivariable logistic regression was used to determine adjusted hospital mortality trends. The prevalence of respiratory failure in the CICU increased from 15% to 38% during the study period (P < 0.001 for trend). Among patients with respiratory failure, the utilization of invasive ventilation decreased and noninvasive ventilation modalities increased over time. Hospital mortality and 1-year mortality were 24% and 54%, respectively, with variation according to the type of respiratory support (highest among patients receiving invasive ventilation alone: 35% and 46%, respectively). Hospital mortality was highest among patients with concomitant cardiac arrest and/or shock (52% for patients with both). Hospital mortality decreased in the overall population from 35% to 25% (P < 0.001 for trend), but was unchanged among patients receiving positive-pressure ventilation. The prevalence of respiratory failure in CICU more than doubled during the last decade. The use of noninvasive respiratory support increased, while overall mortality declined over time. Cardiac arrest and shock accounted for the majority of deaths. Further research is needed to optimize the outcomes of high-risk CICU patients with respiratory failure.

Effects of two modalities of noninvasive ventilation on breathing pattern of very low birth weight preterm infants immediately after extubation: a quasi-experimental study

Aim The primary objective of this study was to investigate the effects of two modalities of noninvasive ventilation, continuous positive airway pressure-CPAP and non-synchronized nasal intermittent positive pressure ventilation-nsNIPPV, on breathing pattern of very low birth weight preterm infants immediately after extubation. Methods It was conducted a quasi-experimental study at a public university hospital. Infants with gestacional age ≤32 weeks and birth weight ≤1,500 g were randomized into the sequences, prior extubation: CPAP – nsNIPPV (1) or nsNIPPV – CPAP (2). Each preterm infant was studied for a period of 60 min in each ventilatory mode. Respiratory inductive plethysmography was used to assess breathing pattern. Inferential analysis was performed by repeated measures ANOVA or Friedman test. Results Eleven preterm infants were studied and a total of 7,564 respiratory cycles were analyzed. No significant differences were observed in any of the comparisons made for any of the breathing pattern variables (p > .05). Conclusions There was no significant difference on breathing pattern between CPAP and nsNIPPV of preterm infants after extubation.

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.

Comparative Efficacy of Aerosolized Particle Filtration by Non-Invasive Ventilation Modalities: Simulation of SARS-CoV-19 Transmission

Patients with COVID-19 with severe respiratory disease may require non-invasive ventilation (NIV) devices, and selection should consider the greatest ability to reduce coronavirus-sized particles aerosolization. The objective of this study was to characterize the aerosolization of coronavirus-sized particles using different oxygen delivery systems.

A comparison between high-flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU.

Different modalities of noninvasive respiratory support have been recommended for the management of acute bronchiolitis in the pediatric intensive care unit (PICU). High-flow nasal cannula (HFNC) is among the new modalities that have been widely used in the last decade. This is a retrospective study involving infants and young children between the ages of 1 month and 2 years during the respiratory season of 2016-2017 (October-May). We compared the failure rate of HFNC with the failure rates of bi-level positive airway pressure (BiPAP) vs continuous positive airway pressure (CPAP) in the management of acute bronchiolitis in the PICU. Failure was defined as a change to another respiratory support modality or endotracheal intubation and mechanical ventilation. One hundred thirty-seven patients met the inclusion criteria, of which 77 patients needed HFNC, 10 needed CPAP, and 50 were on BiPAP. Among baseline characteristics, there were significant variations in age among the three groups. HFNC had a higher failure rate compared with the other two noninvasive ventilation modalities (50.6% for HFNC [n = 39 out of 77] vs 0% for CPAP [n = 0 out of 10] vs 8% for BiPAP [n = 4 out of 50], P < .01). Among the 39 patients who failed HFNC, 90% were successfully shifted to BiPAP and weaned off later, whereas the other 4 were intubated and required mechanical ventilation. However, all four patients who failed BiPAP were intubated and mechanically ventilated. No respiratory complications or mortalities were reported in the three groups. No differences were observed among the three groups in terms of the lengths of PICU or hospital stays. We observed a higher failure rate of HFNC compared with BiPAP or CPAP in the management of infants and children with acute bronchiolitis in the PICU. Further prospective randomized trials are recommended to confirm this finding.

New modalities for non-invasive positive pressure ventilation: A review article.

Efficiency of non-invasive positive pressure ventilation in the treatment of respiratory failure has been shown in many published studies. In this review article, we introduced new modalities of non-invasive ventilation (NIV), clinical settings in which NIV can be used and a practical summary of the latest official guidelines published by the European Respiratory Clinical Practice. Clinical trials and review articles in four databases up to 25 February 2018 about new modalities of non-invasive positive pressure ventilation were reviewed. Commonly used modalities for treatment of respiratory failure include: CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) or NIPSV (noninvasive pressure support ventilation). The limitations of the BiPAP method are the trigger and cycle asynchrony, inadequate volume delivery and increased respiratory rate. Newer methods, such as adaptive servo-ventilation, have been developed to treat central and complex sleep apnea and the NAVA (neutrally adjusted ventilatory assist) to improve the trigger and cycle asynchrony. In the proportional assist ventilation, unlike the pressure support ventilation, with increased patient effort (flow) the tidal volume increases and it prevents the increase in the respiratory rate and respiratory distress. High-flow nasal cannula is a non-invasive technique that does not provide respiratory support, but provides a mixture of oxygen to the patient. The use of non-invasive pursed-lip breathing ventilation in chronic obstructive pulmonary disease (COPD) patients reduces dyspnea (decreases respiratory rate) and increases blood oxygen saturation. New modalities of NIV improve patient comfort and patient–ventilator interactions, and are recommended in patients with respiratory failure.

Noninvasive Ventilation and High-Flow Nasal Cannulae Therapy for Children with Acute Respiratory Failure: An overview.

Noninvasive ventilation (NIV) refers to the use of techniques to deliver artificial respiration to the lungs without the need for endotracheal intubation. As NIV has proven beneficial in comparison to invasive mechanical ventilation, it has become the optimal modality for initial respiratory support among children in respiratory distress. High-flow nasal cannulae (HFNC) therapy is a relatively new NIV modality and is used for similar indications. This review discusses the usefulness and applications of conventional NIV in comparison to HFNC.

Continuous positive airway pressure plus low flow oxygen versus usual care of severe acute cardiogenic pulmonary edema in the pre-hospital setting: A randomised controlled trial

Background: Acute cardiogenic pulmonary edema (ACPE) is characterized by acute breathlessness and hypoxia and is associated with poor prognosis. Standard pre-hospital management of ACPE includes high-flow oxygen, nitroglycerin and, in severe cases, assisted ventilation. Patients with ACPE can be supported with newer modalities of non-invasive ventilation, specifically continuous positive airway pressure (CPAP). The aim of this study was to determine whether patients with ACPE treated with CPAP plus low-flow oxygen pre-hospitally have a lower mortality rate than those treated conventionally. Methods: This study was a pre-hospital randomised, non-blinded controlled trial conducted July 2009–July 2010. Included were all participants transported by ambulance and admitted to the Royal Hobart Hospital, Tasmania, Australia. The study population was consecutive persons ≥18 years of age with sudden onset of severe respiratory distress, diagnosed as ACPE. Patients were included if they required ventilatory assistance. Patients required a GCS &gt;12 and blood pressure &gt;90 mmHg systolic to safely receive CPAP. The primary outcome was pre- or in-hospital mortality. Results: In total, 50 patients were enrolled with mean age of 79.8 (±11.9) years. There were two deaths (8.3%) in the CPAP arm and nine (34.6%) in the control arm (RR, −0.24; 95% CI, 0.06–1.00; p=0.051) with a number needed to treat of 4. CPAP plus low-flow oxygen was significantly less likely to result in respiratory acidosis (mean difference in pH, −0.11; 95% CI, −0.04–−0.17; p=0.002), with elevated pCO2 (mean difference, −10.0 mmHg; 95% CI, −19.2–−0.78; p=0.026). The length of hospital stay was significantly shorter in the surviving patients who received CPAP (ratio of means, 0.45; 95% CI, 0.29–0.70; p≤0.001). Discussion: This study, which provides interim results due to early termination of the trial, shows CPAP in the pre-hospital setting for ACPE is practicable and is associated with improved patient outcomes.