Nocturnal Nasal Intermittent Positive Pressure Ventilation Research Articles

Ventilatory response to CO2re-breathing before and after Nocturnal Nasal Intermittent Positive Pressure Ventilation in patients with chronic alveolar hypoventilation

Long-term nocturnal nasal intermittent positive pressure ventilation (NIPPV) has beneficial effects on daytime P a CO2in patients with chronic alveolar hypoventilation. Our aim was to investigate if these beneficial effects are related to improved respiratory drive as measured by ventilatory response to CO2.In 17 hypoventilated patients (mean age 62 years) we obtained daytime arterial blood gases, nocturnal transcutaneous oxygen saturation, nocturnal transcutaneous PaCO2,ventilatory response to CO2re-breathing, spirometry and indices of respiratory muscle strength before and after 9 months of NIPPV. Patients served as their own controls.After 9 months of NIPPV day-time P a CO2decreased from 7·1 kPa to 6·3 kPa, (P<0·001) and P a O2increased from 8·1 kPa to 9·3 kPa, (P<0·01). The changes in morning and daytime P a CO2and in nocturnal transcutaneous oxygen saturation were significantly correlated to the changes in several variables derived from the ventilatory response to CO2re-breathing. In patients with substantial improvement in daytime P a CO2we found significant improvements in ventilatory response to CO2re-breathing.The present study confirms the beneficial effect of long-term NIPPV on daytime arterial blood gases. The results are consistent with the hypothesis that the improvement of daytime P a CO2is related to improved respiratory drive observed after NIPPV.

Central alveolar hypoventilation in neurosarcoidosis

Although the lung is almost always involved in sarcoidosis and respiratory failure is not uncommonly caused by intrinsic lung disease, chronic alveolar hypoventilation on the basis of neurosarcoidosis has not been previously described. This report describes the case of a 42-year-old woman with sarcoidosis and documented involvement of the lungs, muscle, peripheral nerves, and skin. She presented with ventilatory failure and a vital capacity of 700mL and required hospitalization for intubation and mechanical ventilation. After failing ventilator weaning attempts and requiring continuous ventilatory assistance, she was extubated to continuous use of noninvasive intermittent positive pressure ventilation (IPPV). She eventually weaned to nocturnal-only use of noninvasive IPPV. However, her Paco 2 remained elevated during daytime hours despite the fact that her vital capacity had returned to 3,600mL. She was not obese, and her oxyhemoglobin saturation (SaO 2) was normal on room air. Subsequent attempts to discontinue nocturnal nasal IPPV resulted in marked nocturnal decreases in SaO 2 and return of symptoms. This case illustrates successful noninvasive management of an apparently unique occurrence of central alveolar hypoventilation caused by neurosarcoidosis.

Long-term Effects of Nasal Intermittent Positive-Pressure Ventilation on Pulmonary Function and Sleep Architecture in Patients With Neuromuscular Diseases

This article evaluates the long-term clinical and physiologic effects of nocturnal nasal intermittent positive-pressure ventilation (NIPPV) in patients with neuromuscular disease. Before and after 18 +/- 2 months of NIPPV, we measured during the daytime arterial blood gases, lung mechanics, and respiratory muscle strength in 8 patients (51 +/- 5 years; mean +/- SEM). Sleep parameters were also evaluated at 10 +/- 2 months. All patients tolerated NIPPV and none required hospitalization during follow-up. After NIPPV, daytime arterial PO2 increased (71 +/- 4 to 81 +/- 2 mm Hg; p < 0.05) and arterial PCO2 decreased (46 +/- 3 to 41 +/- 1 mm Hg; p < 0.05). The change of PaO2 after NIPPV was related to its baseline value (r2 = 0.78, p < 0.05). Vital capacity (50 +/- 6% predicted), total lung capacity (63 +/- 4% predicted), alveolar-arterial oxygen gradient (20 +/- 3 mm Hg), and maximal inspiratory (39 +/- 9% predicted) or expiratory (32 +/- 5% predicted) pressures did not change after NIPPV. The apnea-hypopnea index fell from 22 +/- 6 to 1 +/- 1 (p < 0.05), and both sleep architecture and sleep efficiency (from 59 +/- 8% to 83 +/- 5%; p < 0.05) were enhanced. The time spent with an arterial oxygen saturation (SaO2) value below 90% decreased from 160 +/- 53 min to 8 +/- 4 min (p < 0.05). Mean (88 +/- 3 to 95 +/- 1%; p < 0.05) and minimal nocturnal SaO2 (67 +/- 5 to 89 +/- 1%; p < 0.001) improved after NIPPV. In patients with neuromuscular disease, long-term NIPPV is well tolerated and easy to implement clinically. In these patients, long-term NIPPV improves daytime arterial blood gas values and sleep-disordered breathing. However, it does not modify lung mechanics or respiratory muscle strength.

Long-term nasal intermittent positive pressure ventilation (NIPPV) in sixteen consecutive patients with bronchiectasis: a retrospective study.

Life expectancy and quality of life are poor in patients with chronic respiratory failure due to bronchiectasis. The indication for nocturnal nasal intermittent positive pressure ventilation (NIPPV) remains controversial in chronic obstructive lung disease. The purpose of the present study was to determine whether some of the objectives of home mechanical ventilation, i.e. improvement in blood gas values and reduced length of hospitalization, were fulfilled by NIPPV and oxygen plus medical treatment in patients with chronic respiratory failure due to bronchiectasis. Sixteen consecutive patients (12 females and four males; mean age 57 +/- 11 yrs) with chronic respiratory failure due to bronchiectasis, treated at home with nocturnal NIPPV in addition to oxygen therapy, were retrospectively studied in terms of blood gas values and duration of hospitalization before and after NIPPV. Details of the therapy received by each patient were recorded. Nine patients agreed to complete a questionnaire to determine their perception of the benefits of the treatment. NIPPV was performed using a volumetric respirator and was applied with a customized nasal mask modelled with silicone paste. NIPPV was used for a mean of 26 months (range 0.5-60 months). Eleven patients were alive 12 months after use of NIPPV. No significant improvement in blood gas values was noted on room air during NIPPV, but arterial carbon dioxide tension (Pa,CO2) stabilized after the period of worsening observed before initiation of NIPPV. Duration of hospitalization, the year before and the year after NIPPV, was 19 (3-40) and 16 (8-37) days, respectively (NS). For the 11 patients who were alive 2 yrs after the start of NIPPV, duration of hospitalization the year before NIPPV and between 12 and 24 months after NIPPV were 17 (4-40) and 7 (2-27) days, respectively (p < 0.05). Nine patients who had received NIPPV for at least 12 months at the time of the study reported an improvement in their quality of life. The results suggest that home ventilatory support by nasal intermittent positive pressure ventilation offers an acceptable alternative to tracheotomy, with less discomfort, in the management of severe respiratory failure due to bronchiectasis, in order to allow the patient to return home. These results should be confirmed by controlled studies.

Effects of long-term nocturnal nasal ventilation on spontaneous breathing during sleep in neuromuscular and chest wall disorders.

Nocturnal nasal intermittent positive pressure ventilation (NIPPV) is an effective means of normalizing awake blood gases in patients with respiratory insufficiency due to neuromuscular or chest wall dysfunction. However, little attention has been paid to the effects of long-term ventilation on spontaneous breathing during sleep in such patients. The purpose of this study was to determine whether spontaneous breathing during sleep improved after long-term nasal ventilation. Fourteen patients with documented nocturnal respiratory failure, who had been treated with nocturnal NIPPV for at least 6 months, were reviewed with an all night polysomnograph on a night without ventilatory support. The severity of nocturnal desaturation both in non-rapid eye movement (NREM) and rapid eye movement (REM) sleep without nocturnal ventilation was compared to desaturation measured during the initial diagnostic study. Spontaneous daytime blood gas values (mean +/- SD) were significantly improved at follow-up compared to values obtained prior to nasal ventilation: arterial oxygen tension (Pa,O2): 7.5 +/- 1.2 to 10.2 +/- 1.3 kPa (p < 0.005); arterial carbon dioxide tension (Pa,CO2) 8.2 +/- 1.6 to 6.4 +/- 0.7 kPa (p < 0.001). Significant improvements in inspiratory muscle strength were also observed with maximal inspiratory pressure (Pl, max) increasing from a baseline value of 41 +/- 18 to 65 +/- 26% predicted measured prior to the night of ventilation withdrawal (p < 0.003). Spontaneous breathing during sleep after long-term treatment was markedly improved although still abnormal. During NREM sleep without ventilatory support, oxygen desaturation was significantly less severe compared to the initial study (arterial oxygen saturation (Sa,O2) 88 +/- 4 vs 78 +/- 8%; p < 0.001). Minimum Sa,O2 during REM sleep similarly improved from a mean value of 49 +/- 14% during the diagnostic night to 73 +/- 10% at review follow-up (p < 0.001). In 12 patients, transcutaneous carbon dioxide was measured continuously during sleep on both occasions and demonstrated significantly less CO2 retention during follow-up compared to control studies both in NREM (p < 0.003) and REM sleep states (p < 0.004). Long-term nocturnal ventilation produces improved respiratory drive both asleep and awake and improved arousal responses to abnormal blood gases.

Sleep Fragmentation in Kyphoscoliotic Individuals With Alveolar Hypoventilation Treated by NIPPV

Intermittent positive pressure ventilation (IPPV) delivered via nasal access can normalize alveolar ventilation for individuals with chronic alveolar hypoventilation (CAH) due to neuromuscular disease, spinal cord injury, or skeletal deformity. The purpose of this study was to evaluate the effect of nasal IPPV (NIPPV) air leakage-associated oxyhemoglobin desaturations (dSATs) on the sleep efficiency of kyphoscoliotic individuals with severe pretreatment nocturnal dSATs. Only individuals using nocturnal NIPPV without supplemental oxygen therapy were studied. Seven such individuals were able to maintain PaO2 greater than 60 mm Hg without supplemental oxygen therapy (five had been using oxygen therapy in the pretreatment period), had fewer hospitalizations, and had improvements in symptoms, arterial blood gas values, and nocturnal oxyhemoglobin saturation (SAT) by nocturnal NIPPV. This occurred despite polysomnographically observed sleep disruption and sleep stage changes associated with frequent transient dSATs and massive insufflation leakage. Arousals and dSATs were most frequent during rapid eye movement (REM) sleep with the latter occurring at a frequency of 10/h. The dSATs resulted in brief arousals or lightening of sleep stage 76% of the time. With or without arousal, central nervous system mediated reflex muscular activity occurred to diminish leak and normalize SAT. We conclude that the effectiveness of nocturnal NIPPV is dependent in part on central mediated muscular activity.

Nasal Intermittent Positive Pressure Ventilation: Analysis of Its Withdrawal

Nasal intermittent positive pressure ventilation (NIPPV) applied during sleep has been demonstrated to be useful in the treatment of restrictive thoracic diseases (RTD). The purpose of this study was to evaluate the repercussions of a withdrawal period from NIPPV of 15 days. This would be sufficient time for patients to go on trips without the respirator. It was hypothesized that once daytime improvement was achieved and was stable, it could be maintained for this period of time. Five volunteer patients with severe RTD who had been receiving treatment with nocturnal NIPPV for at least 2 months before and who had improved at least 5 mm Hg in daytime PO2 and PCO2 were included in the study. No significant differences were disclosed clinically or with arterial blood gas levels, spirometry results, lung volumes, airway resistances, or maximal muscle pressures 15 days following the withdrawal. However, in the sleep studies, a severe worsening of gas exchange was observed, mainly during rapid eye movement (REM) sleep, as well as a trend toward a more disturbed sleep pattern and more important alterations in cardiac rhythm. Consequently, withdrawing the treatment with nocturnal NIPPV cannot be recommended, at least for this particular removal period. Moreover, alterations in daytime gas exchange were found to originate in those produced during REM sleep through the blunting of the respiratory center to CO2. The NIPPV obstructs this mechanism, preventing the deterioration of gas exchange during sleep.

Sleep and Nocturnal Mouthpiece IPPV Efficiency in Postpoliomyelitis Ventilator Users

Intermittent positive pressure ventilation (IPPV) can be delivered via various oral, nasal, or oronasal interfaces as an alternative to tracheostomy for up to 24 h of ventilatory support. Nocturnal nasal IPPV is often associated with frequent transient but at times severe oxyhemoglobin desaturations (dSaO2s) and sleep fragmentation. The purpose of this study was to determine if nocturnal mouthpiece IPPV is also associated with dSaO2s and sleep disruption. Twenty-seven postpolio ventilator-assisted individuals (VAIs) using mouthpiece IPPV with little or no ventilator-free breathing time (VFBT) underwent nocturnal oxyhemoglobin saturation (SaO2) monitoring. In addition, 15 underwent nocturnal capnography and 13 underwent polysomnography. Mean nocturnal SaO2 was normal in 22 of 27 and maximum end-tidal PCO2 was normal in 12 of 15 VAIs. Use of lipseal retention for nocturnal mouthpiece IPPV significantly improved blood gas values during sleep. The polysomnography results demonstrated relatively normal sleep efficiency. Nocturnal mouthpiece IPPV is most effective with lipseal retention. It can provide normal alveolar ventilation and SaO2 during sleep for VAIs with little or no measurable vital capacity or VFBT. Because transient dSaO2s can be eliminated with lipseal retention, it may disrupt sleep less than nasal IPPV.

Randomised trial of preventive nasal ventilation in Duchenne muscular dystrophy

Summary Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy in children. Paralysis of respiratory muscles causes a decrease in forced vital capacity (FVC) from age 12 years, and death occurs between 20 and 25 years old and is usually related to respiratory insufficiency. Uncontrolled studies suggest that early home use of nasal intermittent positive-pressure ventilation (NIPPV) in DMD patients free of respiratory failure could limit progression of the restrictive syndrome and therefore improve survival Because efficacy of preventive NIPPV has not been demonstrated in a controlled trial, we undertook a randomised multicentre study in which 70 patients with DMD were included. Patients were free of daytime respiratory failure and FVC was between 20 and 50% of predicted values. At least 6 h of nocturnal NIPPV (n=35) was compared with conventional treatment (n = 35). During a mean follow-up of 52 months, 10 patients died, 8 in the NIPPV group and 2 in the control group (p=0·05, log-rank test). No differences were observed between the two groups for occurrence of hypercapnia, decrease of FVC below 20% of initial values, or use of necessary mechanical ventilation. Preventive NIPPV did not improve respiratory handicap and reduced survival of DMD patients. Use of NIPPV for preventive purposes should be avoided in patients with FVC between 20 and 50% of predicted values.

Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency.

The non-invasive technique of nasal intermittent positive pressure ventilation (NIPPV) has an established role in providing domiciliary nocturnal ventilatory support in patients with chest wall disorders, neuromuscular disease, and chronic obstructive lung disease. NIPPV was used to simplify ventilatory management and assist the return of spontaneous breathing in patients with chronic respiratory insufficiency who had failed to wean from conventional intermittent positive pressure ventilation (IPPV). A trial of NIPPV was carried out in 22 patients with weaning difficulties. Nine patients had chest wall disorders or primary lung disease, six had neuromuscular conditions, and seven had cardiac disorders with additional pulmonary disease. Conventional IPPV via an endotracheal tube or tracheostomy had been continued postoperatively in nine patients and 13 had been ventilated after acute cardiorespiratory decompensation. Conventional IPPV had been continued for a median of 31 days (range 2-219). Eighteen patients were successfully transferred to NIPPV and discharged home a median of 11 days (range 8-13) after starting this type of ventilation. Sixteen patients remain well 1-50 months after hospital discharge and 10 of these continue on domiciliary nocturnal NIPPV. Seven patients have returned to work. NIPPV can be used to facilitate the return of spontaneous breathing and to reduce the need for intensive care accommodation in patients with an acute exacerbation of chronic respiratory insufficiency that requires intubation and IPPV.

Occult respiratory failure as a cause of neuropsychiatric symptoms in chest wall deformity and neuromuscular disease

Nocturnal hypoventilation occurs in patients with severe kyphoscoliosis (1) and neuromuscular disorders (2,3) and may lead to the development of daytime symptoms and cardio-respiratory failure. The onset is generally insidious and delay in diagnosis common. We report three patients presenting with primarily neuropsychiatric symptoms, in whom an underlying respiratory abnormality was not immediately apparent. All were returned to normal health by domiciliary nocturnal nasal intermittent-positive pressure ventilation (NIPPV).

Management of Chronic Alveolar Hypoventilation by Nasal Ventilation

This is a study of the effect of nocturnal nasal intermittent positive pressure ventilation (NIPPV) on symptoms of chronic alveolar hypoventilation (CAH), sleep oxygen saturation (SaO2), and frequency of hospitalization of patients with progressive neuromuscular respiratory insufficiency or restrictive lung disease from thoracic wall deformity. The nocturnal use of NIPPV is explored in combination with other noninvasive methods of supported ventilation for daytime support as alternatives to tracheostomy and long-term tracheostomy intermittent positive pressure ventilation (TIPPV). Sixteen patients with less than 400 ml of vital capacity (VC) supine and less than 15 minutes of autonomous respiration (free time) maintained a mean SaO2 of 95.9 +/- 2.6 percent (SD) during sleep on NIPPV without added oxygen. Seventeen other patients with adequate free time for a sleep trial unaided had an average SaO2 of 81.8 +/- 11.0 percent which improved to 94.1 +/- 3.4 percent on NIPPV alone. The average length of use of NIPPV by the 42 patients who have used it for one month or more is 21 (3-67) months. All 34 patients who were not dependent on ventilatory support 24 hours a day demonstrated significant improvement and in most cases normalization of ABG when off aid. Thirteen patients were converted from IPPV via an endotracheal tube or TIPPV to NIPPV. Long-term use of a custom molded thermoplastic nasal interface for the delivery of NIPPV is reported for 17 patients. Unnecessary morbidity and hospitalizations can be avoided by early awareness and appropriate management of CAH. NIPPV can be an effective alternative to TIPPV, body ventilators, or oxygen therapy.