Monitoring Of Noninvasive Ventilation Research Articles

Mask interfaces and devices for home noninvasive ventilation in children.

Home noninvasive ventilation (NIV), including continuous (CPAP) and bilevel (BPAP) positive airway pressure, is increasingly used in children worldwide. In this narrative review, we present a comprehensive summary of the equipment available for home NIV in pediatrics, excluding neonates. NIV may be challenging in young children, as the majority of the equipment has been developed for adults. Regarding the interfaces, only a few masks have been specifically developed for young children in recent years, while older children may benefit from a large variety of interfaces. Even though much progress has been made, skin injuries are still present, and need to be managed rapidly. Several studies addressed the management of the side effects, but recent studies are lacking regarding orofacial anomalies. No recent study reported the available interfaces for young children and the strategies for an optimal mask fit. Regarding the devices, an adapted NIV device to pediatrics that allows an adequate patient's breathing detection should guarantee optimal ventilatory efficiency and monitoring of NIV. A close follow-up and regular monitoring should be mandatory to rule out the potential issues, optimize NIV therapy and ascertain the efficacy of NIV. However, studies are lacking to guide the choice of devices in young children and the optimal management of home NIV in pediatrics. We summarized the characteristics of the different interfaces available for young children and the limitations of NIV devices. We finally addressed potential areas for future research on long-term home NIV in children.

Home NIV treatment quality in patients with chronic respiratory failure having participated to the French nationwide telemonitoring experimental program (The TELVENT study)

BackgroundThe ETAPES program is a national telemedicine experiment conducted in France between 2018 and 2023 to investigate whether home non-invasive ventilation (NIV) telemonitoring improves healthcare pathways in patients with chronic respiratory failure (CRF) and impacts healthcare organization. The program provides a combination of therapeutic education and NIV telemonitoring with data processed by an algorithm generating alerts. The TELVENT study objective was to analyze the evolution of ventilation quality in patients included in the ETAPES program. MethodsMulticentric cohort study on patients undergoing long-term NIV included in the ETAPES program between September 2018 and December 2020 and who did not refuse the use of their data for this research. Data were obtained from homecare provider databases. The primary endpoint was to attain successful NIV treatment, which was determined by a combination of daily NIV usage for > 4 h per day, low leaks, and a low apnea-hypopnea index (AHI) identified by the NIV device. Respiratory disability was assessed using the DIRECT questionnaire. Results329 patients were included in the study of which 145 had COPD and 83 had started NIV and ETAPES within one-month delay. Approximately 25% of patients did not achieve the criteria for successful NIV at ETAPES entry. The proportion of patients with successful NIV treatment increased to 86.8% at six months (p = 0.003, Cochran-Armitage trend test) regardless of NIV history and continued to increase at 12 months in newly equipped NIV patients (93.8%, at month 12, p = 0.0026 for trend test). Over time, a significant increase in NIV use and compliance was observed, while AHI significantly decreased in the overall population. No significant decrease was observed for non-intentional leaks. Approximately 4.9 alerts were generated per patient per 6 months. Their number and type (low NIV use, high AHI or leaks) differed among patients based on their NIV history. Respiratory disability score decreased over time compared with baseline. ConclusionThe TELVENT study highlights the importance of remote NIV monitoring to rapidly identify patients with unsuccessful ventilation. The combination of remote monitoring and therapeutic education may improve the quality of home NIV, especially in the first months of treatment.

Performance and labor conditions of physiotherapists in Brazilian intensive care units during the COVID-19 pandemic. What did we learn?

To describe the role of physiotherapists in assisting patients suspected to have or diagnosed with COVID-19 hospitalized in intensive care units in Brazil regarding technical training, working time, care practice, labor conditions and remuneration. An analytical cross-sectional survey was carried out through an electronic questionnaire distributed to physiotherapists who worked in the care of patients with COVID-19 in Brazilian intensive care units. A total of 657 questionnaires were completed by physiotherapists from the five regions of the country, with 85.3% working in adult, 5.4% in neonatal, 5.3% in pediatric and 3.8% in mixed intensive care units (pediatric and neonatal). In intensive care units with a physiotherapists available 24 hours/day, physiotherapists worked more frequently (90.6%) in the assembly, titration, and monitoring of noninvasive ventilation (p = 0.001). Most intensive care units with 12-hour/day physiotherapists (25.8%) did not apply any protocol compared to intensive care units with 18-hour/day physiotherapy (9.9%) versus 24 hours/day (10.2%) (p = 0.032). Most of the respondents (51.0%) received remuneration 2 or 3 times the minimum wage, and only 25.1% received an additional payment for working with patients suspected to have or diagnosed with COVID-19; 85.7% of them did not experience a lack of personal protective equipment. Intensive care units with 24-hour/day physiotherapists had higher percentages of protocols and noninvasive ventilation for patients with COVID-19. The use of specific resources varied between the types of intensive care units and hospitals and in relation to the physiotherapists' labor conditions. This study showed that most professionals had little experience in intensive care and low wages.

Monitoring of noninvasive ventilation: comparative analysis of different strategies

BackgroundNoninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure. However, empirically determined NIV settings may not achieve optimal ventilatory support. Therefore, the efficacy of NIV should be systematically monitored. The minimal recommended monitoring strategy includes clinical assessment, arterial blood gases (ABG) and nocturnal transcutaneous pulsed oxygen saturation (SpO2). Polysomnography is a theoretical gold standard but is not routinely available in many centers. Simple tools such as transcutaneous capnography (TcPCO2) or ventilator built-in software provide reliable informations but their role in NIV monitoring has yet to be defined. The aim of our work was to compare the accuracy of different combinations of tests to assess NIV efficacy.MethodsThis retrospective comparative study evaluated the efficacy of NIV in consecutive patients through four strategies (A, B, C and D) using four different tools in various combinations. These tools included morning ABG, nocturnal SpO2, TcPCO2 and data provided by built-in software via a dedicated module. Strategy A (ABG + nocturnal SpO2), B (nocturnal SpO2 + TcPCO2) and C (TcPCO2 + builtin software) were compared to strategy D, which combined all four tools (NIV was appropriate if all four tools were normal).ResultsNIV was appropriate in only 29 of the 100 included patients. Strategy A considered 53 patients as appropriately ventilated. Strategy B considered 48 patients as appropriately ventilated. Strategy C misclassified only 6 patients with daytime hypercapnia.ConclusionMonitoring ABG and nocturnal SpO2 is not enough to assess NIV efficacy. Combining data from ventilator built-in software and TcPCO2 seems to represent the best strategy to detect poor NIV efficacy.Trialregistration Institutional Review Board of the Société de Pneumologie de Langue Française (CEPRO 2016 Georges)

Ventilation non invasive. Les conseils 2015 du Groupe assistance ventilatoire (GAV) de la Société de pneumologie de langue française (SPLF)

A task force issued from the Groupe Assistance Ventilatoire (GAV) of the Société de Pneumologie de Langue Française (SPLF) was committed to develop a series of expert advice concerning various practical topics related to long-term non invasive ventilation by applying the Choosing Wisely® methodology. Three topics were selected: monitoring of noninvasive ventilation, the interpretation of data obtained from built-in devices coupled to home ventilators and the role of hybrid modes (target volume with variable pressure support. For each topic, the experts have developed practical tips based on a comprehensive analysis of recent insights and evidence from the literature and from clinical experience.

Hot Topics in Noninvasive Ventilation: Report of a Working Group at the International Symposium on Sleep-Disordered Breathing in Leuven, Belgium.

During the last few decades, attention has increasingly focused on noninvasive ventilation (NIV) in the treatment of chronic respiratory failure. The University of Leuven and the University Hospitals Leuven therefore chose this topic for a 2-day working group session during their International Symposium on Sleep-Disordered Breathing. Numerous European experts took part in this session and discussed (1) NIV in amyotrophic lateral sclerosis (when to start NIV, NIV and sleep, secretion management, and what to do when NIV fails), (2) recent insights in NIV and COPD (high-intensity NIV, NIV in addition to exercise training, and NIV during exercise training), (3) monitoring of NIV (monitoring devices, built-in ventilator software, leaks, and asynchronies) and identifying events during NIV; and (4) recent and future developments in NIV (target-volume NIV, electromyography-triggered NIV, and autoregulating algorithms).

Risk factors for noninvasive ventilation failure in cancer patients in the intensive care unit: A retrospective cohort study

PurposeThe purpose of the study is to identify risk factors for noninvasive ventilation (NIV) failure in cancer patients with acute respiratory failure (ARF). Materials and methodsA retrospective cohort study of adult patients admitted to intensive care unit (ICU), who received NIV for treatment of ARF, was conducted. We conducted a chart review to estimate the NIV failure rate and used logistic regression to identify risk factors. ResultsOf 2258 patients admitted to the ICU during the study period, 114 (5%) received NIV for ARF. Noninvasive ventilation was successful in 67 patients (59%) and failed for 47 (41%), of whom 36 were intubated and 11 were sedated for palliation. Factors associated with NIV failure were infection as the primary cause of ARF (odds ratio [OR], 4.90; 95% confidence interval [CI], 1.78-13.45; P = .002), male sex (OR, 2.58; 95% CI, 1.20-5.56; P = .015), and Simplified Acute Physiology Score 3 (OR, 1.04; 95% CI, 1.01-1.07; P = .006). Overall ICU mortality was 40%, and hospital mortality was 56%. Noninvasive ventilation failure was the only independent predictor of ICU mortality (OR, 16.6; 95% CI, 6.5-41.5; P < .001). ConclusionsNoninvasive ventilation can avert ARF for most ICU cancer patients with ARF. For patients with pulmonary infections and high severity scores, NIV should be used with caution. Identifying risk factors for NIV failure using a comprehensive diagnostic approach and monitoring of NIV are paramount to improve outcomes.

An Update on Domiciliary Non-Invasive Ventilation

Chronic respiratory failure (CRF) should be considered a syndrome defined by arterial blood gas abnormalities. Domiciliary non-invasive ventilation (NIV) is an increasingly used intervention to curtail the detrimental effects of CRF in individuals with a broad range of cardiorespiratory disorders. Progress in the provision, monitoring and improvement in patient centred outcomes with NIV has simply been staggering over the last decade. Despite this, questions still remain in terms of the ideal mode of delivery, the most efficient techniques to monitor its effectiveness, and the timing of NIV initiation for several of the more common diseases which can require NIV support. There are a number of mechanisms accounting for the reduced ventilation that is apparent during sleep, even in normal subjects. This represents a particularly unique physiological state whereby changes in upper airway resistance control of respiration and changes in lung mechanics have an impact on the adequacy of tidal volume breathing. Abnormal respiratory events tend to occur specifically during sleep, and so NIV which is appropriate for the awake patient may not be suitable when asleep at night. These factors need to be kept in mind both for the optimal timing of NIV, and the manner in which it should be monitored. This article aims to provide an overview of current concepts in the appropriate mode of delivery of NIV, discusses the patient groups who benefit from its application, highlights challenges with interface design, and aspects that need to be kept in mind in terms of the optimal monitoring of NIV

Capnography Improves Detection of Apnea During Procedural Sedation for Percutaneous Transhepatic Cholangiodrainage

Capnography provides noninvasive monitoring of ventilation and can enable early recognition of altered respiration patterns and apnea. To compare the detection of apnea and the prediction of oxygen desaturation and hypoxemia using capnography versus clinical surveillance during procedural sedation for percutaneous transhepatic cholangiodrainage (PTCD). Twenty consecutive patients scheduled for PTCD were included in the study. All patients were sedated during the procedure using midazolam and propofol. Aside from standard monitoring, additional capnographic monitoring was used and analyzed by an independent observer. The mean (± SD) cumulative duration of apnea demonstrated by capnography was significantly longer than the mean cumulative duration of clinically detected apnea (207.5 ± 348.8 s versus 8.2 ± 17.9 s; P=0.015). The overall number of detected episodes of apnea was also significantly different (113 versus seven; P=0.012). There were 15 events of oxygen desaturation (decrease in oxygen saturation [SaO2] ≥ 5%), which were predicted in eight of 15 cases by capnography and in one of 15 cases by clinical observation. There were three events of hypoxemia (SaO2 <90%) that were predicted in three of three cases by capnography and in one of three cases by clinical observation. Capnographic monitoring was superior to clinical surveillance in the detection of apnea and in the prediction of oxygen desaturation during procedural sedation for PTCD.

Monitoring of Noninvasive Ventilation by Built-in Software of Home Bilevel Ventilators: A Bench Study

Current bilevel positive-pressure ventilators for home noninvasive ventilation (NIV) provide physicians with software that records items important for patient monitoring, such as compliance, tidal volume (Vt), and leaks. However, to our knowledge, the validity of this information has not yet been independently assessed.Testing was done for seven home ventilators on a bench model adapted to simulate NIV and generate unintentional leaks (ie, other than of the mask exhalation valve). Five levels of leaks were simulated using a computer-driven solenoid valve (0-60 L/min) at different levels of inspiratory pressure (15 and 25 cm H(2)O) and at a fixed expiratory pressure (5 cm H(2)O), for a total of 10 conditions. Bench data were compared with results retrieved from ventilator software for leaks and Vt.For assessing leaks, three of the devices tested were highly reliable, with a small bias (0.3-0.9 L/min), narrow limits of agreement (LA), and high correlations (R(2), 0.993-0.997) when comparing ventilator software and bench results; conversely, for four ventilators, bias ranged from -6.0 L/min to -25.9 L/min, exceeding -10 L/min for two devices, with wide LA and lower correlations (R(2), 0.70-0.98). Bias for leaks increased markedly with the importance of leaks in three devices. Vt was underestimated by all devices, and bias (range, 66-236 mL) increased with higher insufflation pressures. Only two devices had a bias < 100 mL, with all testing conditions considered.Physicians monitoring patients who use home ventilation must be aware of differences in the estimation of leaks and Vt by ventilator software. Also, leaks are reported in different ways according to the device used.

Comparison of combined oximetry and cutaneous capnography using a digital sensor with arterial blood gas analysis

Background: Cutaneous carbon dioxide tension (PcCO2) is a promising non-invasive surrogate measure of arterial partial pressure of carbon dioxide (PaCO2). Objectives: To compare values of PcCO2 and oxygen saturation (SpO2) with arterial blood gas (ABG) analysis. Methods: SpO2 and PcCO2 were measured with a v-Sign™-sensor (Sentec AG, Therwil, Switzerland) and the values compared with simultaneously obtained SaO2 and PaCO2 obtained from ABG analysis (ABL 725, Radiometer, Copenhagen, Denmark) in 275 adult patients referred to the lung function laboratory. Results: Median of the PcCO2 was 4.7 kPa (interquartile range [IQR] 0.9 kPa). Median of the SpO2 was 97% (IQR 3%). Bland-Altman analysis for comparison of PcCO2 with PaCO2 showed a bias of −0.1 kPa with a precision of ± 0.9 kPa with 3.7% outlying values. Bland-Altman analysis for the comparison of SpO2 and SaO2 showed a bias of 20.1 % with a precision of ± 3.5%. There were no complications. Conclusion: There is a good agreement between combined cutaneous capnography and oximetry values with ABG analysis. Due to the excellent safety profile and the short time to get a continuous measurement, this technique should be examined in settings where it can complement repeated ABG analysis when ventilatory disturbances are suspected or non-invasive monitoring of ventilation is needed.

Review of non‐invasive ventilation in the emergency department: clinical considerations and management priorities

We aimed to synthesise evidence from published literature on non-invasive ventilation to inform nurses involved in the clinical management of non-invasive ventilation in the emergency department. Non-invasive ventilation is a form of ventilatory support that does not require endotracheal intubation and is used in the early management of acute respiratory failure in emergency departments. Safe delivery of this intervention requires a skilled team, educated and experienced in appropriate patient selection, available devices and monitoring priorities. Systematic review. A multi-database search was performed to identify works published in the English language between 1998-2008. Search terms included: non-invasive ventilation, continuous positive airway pressure and emergency department. Inclusion and exclusion criteria for the review were identified and systematically applied. Terminology used to describe aspects of non-invasive ventilation is ambiguous. Two international guidelines inform the delivery of this intervention, however, much research has been undertaken since these publications. Strong evidence exists for non-invasive ventilation for patients with acute exacerbation of congestive heart failure and chronic obstructive pulmonary disease. Non-invasive ventilation may be delivered with various interfaces and modes; little evidence is available for the superiority of individual interfaces or modes. Early use of non-invasive ventilation for the management of acute respiratory failure may reduce mortality and morbidity. Though international guidelines exist, specific recommendations to guide the selection of modes, settings or interfaces for various aetiologies are lacking due to the absence of empirical evidence. Monitoring of non-invasive ventilation should focus on assessment of response to treatment, respiratory and haemodynamic stability, patient comfort and presence of air leaks. Complications are related to mask-fit and high air flows; serious complications are few and occur infrequently. The use of non-invasive ventilation has resource implications that must be considered to provide effective and safe management in the emergency department.

Is continuous transcutaneous monitoring of P CO2(Tc P CO2) over 8 h reliable in adults?

Monitoring of non-invasive ventilation (NIV) in a non-intensive care unit (non-ICU) setting requires a method of evaluating nocturnal P aCO2, such as transcutaneous CO2monitoring (Tc P CO2). However, changing the probe site after 4 h and recalibrating (as recommended) is time-consuming and impractical. Continuous (8-h) Tc P CO2monitoring at a lower electrode temperature (43°C) in this setting has never been formally studied.Patients under intermittent NIV were studied (n=28, aged 69±9 years, P aO2: 71±13 mmHg, P aCO2: 49±9 mmHg). After calibration and stabilization of TcP CO2(Radiometer®Tina TCM3 capnograph), arterial blood gases (ABG) were measured and compared with transcutaneous readings. In 10 patients who underwent continuous 8-h Tc P CO2recording, ABGs were also measured after 4 and 8 h.The correlation between Tc P CO2and P aCO2was highly significant (r2=0·92, P<0·0001). Mean (Tc P CO2–P aCO2) gradient (bias) was: −2·8±3·8 mmHg; limits of agreement were: (−10·4; +4·8 mmHg). Tc P CO2–P aCO2gradient was lowest (i.e. within-bias±2 mmHg) between 40 and 54 mmHg, increasing below and above these values. Over 8 h, no significant drift of the Tc P CO2signal occurred (ANOVA). No discomfort or skin lesion was noted.In conclusion, with an electrode temperature of 43°C, 8-h continuous monitoring of Tc P CO2was well tolerated, without any local side-effects or significant drift of Tc P CO2signal; when compared to previous reports, lowering the electrode temperature did not decrease performance for CO2monitoring.

Erfahrungen mit der Kapnometrie in der pädiatrischen Intensivtherapie

We investigated the correlation between arterial and end-tidal pCO2 in 17 children during intensive care. The indications for using capnometry were noninvasive monitoring of ventilation after cardiac surgery or during complicated course of illness or for control of intended hyperventilation. We found a good correlation between arterial and end-tidal pCO2 in the overall patient population (r = 0.82), but the relationship varied widely from patient to patient. There was only a weak correlation (r = 0.44) in pCO2 over 45 mm Hg. Hyperventilation could be identified in 64.2%, whereas hypoventilation was correctly indicated in only 23%.

Non-invasive monitoring of ventilation during wakefulness and sleep

Non-invasive monitoring of ventilation during wakefulness and sleep