Noninvasive Intermittent Positive Pressure Ventilation Research Articles

Comparison of noninvasive and intermittent positive pressure ventilation in treating extremely premature and extremely low birth weight infants.

We compared the application value of noninvasive positive pressure ventilation (NIPPV) and intermittent positive pressure ventilation (IPPV) in the treatment of very premature infants and extremely low birth weight infants. Multivariate logistic regression analysis was used to identify factors influencing the transition from noninvasive to invasive ventilation in this infant cohort. Among extremely preterm infants, 83.3% with gestational age <25 weeks transitioned from noninvasive to invasive ventilation, as did 80.6% of those with birth weight <1000 grams. Multivariate analysis indicated that gestational age <25 weeks, birth weight <1000 grams, and Apgar score ≤7 were significant factors affecting the likelihood of transitioning to invasive ventilation. The survival rate at discharge was 94% for the NIPPV group compared with 89% for the IPPV group. The NIPPV group demonstrated significantly lower rates of complications, shorter weaning times, and reduced lengths of hospital stay compared with the IPPV group. Both NIPPV and IPPV effectively improved oxygenation and ventilation in extremely preterm infants. However, NIPPV showed significant advantages in reducing complications, shortening weaning time, and decreasing the hospital stay duration. Prioritizing the use of NIPPV may enhance treatment outcomes and survival quality, providing evidence-based support for clinical practice.

Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

The NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive mechanical ventilation (IMV) in preterm infants, whereas NHFOV and noninvasive intermittent positive pressure ventilation (NIPPV) result in fewer reintubations than nasal continuous positive airway pressure (NCPAP). It is unknown whether NHFOV is similarly effective in extremely preterm neonates or in those with more severe respiratory failure (based on the duration of previous ventilation and CO2 levels). To clarify whether NHFOV is better than NIPPV and NCPAP in reducing the duration of IMV in extremely preterm neonates or those with severe respiratory failure. This study is a predefined secondary analyses of a multicenter randomized clinical trial that was performed at tertiary academic neonatal intensive care units (NICUs) in China. Participants included neonates enrolled in the NASONE trial between December 2017 and May 2021 and belonging to 3 predefined subgroups: (1) born at less than or equal to 28 weeks' (plus 6 days) gestation, (2) invasively ventilated for more than 1 week from birth, and (3) with CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Data analysis was performed in August 2022. NCPAP, NIPPV, or NHFOV since the first extubation and until NICU discharge, with airway pressure higher in NHFOV than in NIPPV and than in NCPAP. The co-primary outcomes were total duration of IMV during the NICU stay, need for reintubation, and ventilator-free days calculated as per the original trial protocol. Outcomes were analyzed on an intention-to-treat basis as for the whole trial, and subgroup analyses followed the original statistical plan. Among 1137 preterm infants, 455 (279 boys [61.3%]) were born at 28 weeks' gestation or less, 375 (218 boys [58.1%]) underwent IMV for more than 1 week from birth, and 307 (183 boys [59.6%]) had CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Both NIPPV and NHFOV were associated with significantly fewer reintubations (risk difference range, -28% [95% CI, -39% to -17%] to -15% [95% CI, -25% to -4%]; number needed to treat, 3-7 infants) and early reintubations (risk difference range, -24% [95% CI, -35% to -14%] to -20% [95% CI, -30% to -10%]) than NCPAP, and these reintubations were less frequently due to refractory hypoxemia. IMV was shorter in the NIPPV and NHFOV groups (mean difference range, -5.0 days [95% CI, -6.8 to -3.1 days] to -2.3 days [95% CI, -4.1 to -0.4 days]) than in the NCPAP group. Co-primary outcomes were not different between NIPPV and NHFOV; there was no significant interaction effect. Infants in the NHFOV group showed significantly less moderate-to-severe bronchopulmonary dysplasia than infants in the NCPAP group (range, -12% to -10%; number needed to treat, 8-9 infants) and better postextubation gas exchange in all subgroups. The 3 interventions were provided at different mean airway pressure and were equally safe. The subgroup analyses of extremely preterm or more ill infants confirm the results obtained in the whole population: NIPPV and NHFOV appeared equally effective in reducing duration of IMV compared with NCPAP. ClinicalTrials.gov Identifier: NCT03181958.

Respiratory Sinus Arrhythmia is Mainly Driven by Central Feedforward Mechanisms in Healthy Humans.

Heart rate variability (HRV) has prognostic and diagnostic potential, however, the mechanisms behind respiratory sinus arrhythmia (RSA), a main short-term HRV, are still not well understood. We investigated if the central feedforward mechanism or pulmonary stretch reflex contributed most to RSA in healthy humans. Ventilatory support reduces the centrally mediated respiratory effort but remains the inspiratory stretch of the pulmonary receptors. We aimed to quantify the difference in RSA between spontaneous breathing and ventilatory support. Nineteen healthy, young subjects underwent spontaneous breathing and non-invasive intermittent positive pressure ventilation (NIV) while we recorded heart rate (HR, from ECG), mean arterial pressure (MAP) and stroke volume (SV) estimated from the non-invasive finger arterial pressure curve, end-tidal CO2 (capnograph), and respiratory frequency (RF) with a stretch band. Variability was quantified by an integral between 0.15–0.4 Hz calculated from the power spectra. Median and 95% confidence intervals (95%CI) were calculated as Hodges–Lehmann’s one-sample estimator. Statistical difference was calculated by the Wilcoxon matched-pairs signed-rank test. RF and end-tidal CO2 were unchanged by NIV. NIV reduced HR by 2 bpm, while MAP and SV were unchanged in comparison to spontaneous breathing. Variability in both HR and SV was reduced by 60% and 75%, respectively, during NIV as compared to spontaneous breathing, but their interrelationship with respiration was maintained. NIV reduced RSA through a less central respiratory drive, and pulmonary stretch reflex contributed little to RSA. RSA is mainly driven by a central feedforward mechanism in healthy humans. Peripheral reflexes may contribute as modifiers of RSA.

Sensory stimulation for apnoea mitigation in preterm infants.

Apnoea, a pause in respiration, is ubiquitous in preterm infants andare often associated with physiological instability, which may lead to longer-term adverse neurodevelopmental consequences. Despite current therapies aimed at reducing the apnoea burden, preterm infants continue to exhibit apnoeic events throughout their hospital admission. Bedside staff are frequently required to manually intervene with different forms of stimuli, with the aim of re-establishing respiratory cadence and minimizing the physiological impact of each apnoeic event. Such a reactive approach makes apnoea and its associated adverse consequences inevitable and places a heavy reliance on human intervention. Different approaches to improving apnoea management in preterm infants have been investigated, including the use of various sensory stimuli. Despite studies reporting sensory stimuli of various forms to have potential in reducing apnoea frequency, non-invasive intermittent positive pressure ventilation is the only automated stimulus currently used in the clinical setting for infants with persistent apnoeic events. We find that the development of automated closed-looped sensory stimulation systems for apnoea mitigation in preterm infants receiving non-invasive respiratory support is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form. IMPACT: This review examines the effects of various forms of sensory stimulation on apnoea mitigation in preterm infants, namely localized tactile, generalized kinesthetic, airway pressure, auditory, and olfactory stimulations. Amongst the 31 studies reviewed, each form of sensory stimulation showed some positive effects, although the findings were not definitive and comparative studies were lacking. We find that the development of automated closed-loop sensory stimulation systems for apnoea mitigation is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form.

Thoracic epidural analgesia vs. intravenous analgesia after lung transplant

Objective: Few reports have evaluated postoperative continuous thoracic epidural analgesia on patients who received a lung transplant. This analgesic modality may facilitate extubation, early ambulation, and achieve adequate pain control with minimization of opioid use. An opioid sparing technique could minimize the side effects of opioids such as ileus, constipation, and somnolence.Methods: A retrospective chart review following local IRB approval was performed. A total of 97 patients’ charts were collected, from April 2015 to March 2017. Forty-eight patients received T6-7 epidural, and forty-nine patients received standard intravenous (IV) analgesia. Outcome measures collected included length of intensive care unit stay, total duration of hospitalization, need for reintubation or noninvasive intermittent positive pressure ventilation (NIPPV), need for IV lidocaine gtt, and total narcotics consumption during hospitalization in milligrams of morphine equivalents (MME).Results: Both groups were comparable in age, BMI, and race/gender distribution. Additionally, patient pain requirements were comparable between groups. However, a significantly smaller proportion of thoracic epidural patients required NIPPV post-operatively, (20.4%, 53.2%: p = .0015). Further, the number of patients requiring reintubation was almost halved, (12.5%, 21.3%: NS). Patients receiving thoracic epidural also experienced shorter ICU times (p = .0335) and on average, an overall reduced length of stay by six days.Conclusions: For patients undergoing lung transplant, epidural analgesia is a viable alternative to IV pain control. Further, it significantly reduced respiratory depression and length of stay in the ICU. More refined comparisons can be made by conducting a precise prospective study with a more structured protocol in place.

Laryngeal closure impedes non-invasive ventilation at birth

BackgroundNon-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site...

Case 4: A Preterm Infant with a Necrotic Ulcer Over the Perianal Area

A 1.07-kg male infant with severe growth restriction is born at 30 weeks’ gestational age to a 36-year-old gravida 3, para 2 mother by emergency cesarean delivery for nonreassuring heart tracing. The parents are of low socioeconomic status and are first-degree consanguineous relatives. The mother received steroids and her membranes ruptured at delivery. At birth, the infant’s cord clamping was delayed, and after an initial weak cry he underwent intubation for poor respiratory efforts. Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. His initial stabilization included surfactant administration, mechanical ventilation with volume guarantee, catheter line placement (umbilical venous and arterial catheters), initiation of total parenteral nutrition, antibiotics, and inotropic support. On day 3, he underwent extubation and received noninvasive intermittent positive pressure ventilation (NIPPV), inotropic support was discontinued, and antibiotics were stopped, because his blood culture was sterile. He demonstrated steady clinical improvement in the next 3 days, was weaned from NIPPV to nasal continuous positive pressure, and nasogastric feeds progressed gradually. On day 6, the bedside nurse noticed a small macule and blister with surrounding erythema over the lateral aspect of his right thigh, which progressed rapidly in hours to blackish-gray discoloration of skin in an area 4 × 1 cm in size with a small hemorrhagic lesion in the center (Fig 1). The infant’s clinical condition worsened rapidly in the next 24 hours; he became lethargic, hypothermic, tachycardic, hypotensive with poor perfusion, and apneic with increased oxygen requirement. He underwent elective reintubation for recurrent apnea and mixed respiratory and metabolic acidosis. A limited sepsis screening (complete blood cell count and cultures from blood, skin wound, and urine) was performed. Empiric antibiotic treatment with piperacillin-tazobactam was commenced. The infant received a bolus of normal saline, and dopamine treatment was commenced for low mean blood pressure. …

Inhibitory Effect of Nasal Intermittent Positive Pressure Ventilation on Gastroesophageal Reflux.

Non-invasive intermittent positive pressure ventilation can lead to esophageal insufflations and in turn to gastric distension. The fact that the latter induces transient relaxation of the lower esophageal sphincter implies that it may increase gastroesophageal refluxes. We previously reported that nasal Pressure Support Ventilation (nPSV), contrary to nasal Neurally-Adjusted Ventilatory Assist (nNAVA), triggers active inspiratory laryngeal closure. This suggests that esophageal insufflations are more frequent in nPSV than in nNAVA. The objectives of the present study were to test the hypotheses that: i) gastroesophageal refluxes are increased during nPSV compared to both control condition and nNAVA; ii) esophageal insufflations occur more frequently during nPSV than nNAVA. Polysomnographic recordings and esophageal multichannel intraluminal impedance pHmetry were performed in nine chronically instrumented newborn lambs to study gastroesophageal refluxes, esophageal insufflations, states of alertness, laryngeal closure and respiration. Recordings were repeated without sedation in control condition, nPSV (15/4 cmH2O) and nNAVA (~ 15/4 cmH2O). The number of gastroesophageal refluxes recorded over six hours, expressed as median (interquartile range), decreased during both nPSV (1 (0, 3)) and nNAVA [1 (0, 3)] compared to control condition (5 (3, 10)), (p < 0.05). Meanwhile, the esophageal insufflation index did not differ between nPSV (40 (11, 61) h-1) and nNAVA (10 (9, 56) h-1) (p = 0.8). In conclusion, nPSV and nNAVA similarly inhibit gastroesophageal refluxes in healthy newborn lambs at pressures that do not lead to gastric distension. In addition, the occurrence of esophageal insufflations is not significantly different between nPSV and nNAVA. The strong inhibitory effect of nIPPV on gastroesophageal refluxes appears identical to that reported with nasal continuous positive airway pressure.

Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders.

Chronic alveolar hypoventilation is a common complication of many neuromuscular and chest wall disorders. Long-term nocturnal mechanical ventilation is commonly used to treat it. This is a 2014 update of a review first published in 2000 and previously updated in 2007. To examine the effects on mortality of nocturnal mechanical ventilation in people with neuromuscular or chest wall disorders. Subsidiary endpoints were to examine the effects of respiratory assistance on improvement of chronic hypoventilation, sleep quality, hospital admissions and quality of life. We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 10 June 2014. We contacted authors of identified trials and other experts in the field. We searched for quasi-randomised or randomised controlled trials of participants of all ages with neuromuscular or chest wall disorder-related stable chronic hypoventilation of all degrees of severity, receiving any type and any mode of long-term nocturnal mechanical ventilation. The primary outcome measure was one-year mortality and secondary outcomes were unplanned hospital admission, short-term and long-term reversal of hypoventilation-related clinical symptoms and daytime hypercapnia, improvement of lung function and sleep breathing disorders. We used standard Cochrane methodology to select studies, extract data and assess the risk of bias in included studies. The 10 eligible trials included a total of 173 participants. Roughly half of the trials were at low risk of selection, attrition or reporting bias, and almost all were at high risk of performance and detection bias. Four trials reported mortality data in the long term. The pooled risk ratio (RR) of dying was 0.62 (95% confidence interval (CI) 0.42 to 0.91, P value = 0.01) in favour of nocturnal mechanical ventilation compared to spontaneous breathing. There was considerable and significant heterogeneity between the trials, possibly related to differences between the study populations. Information on unplanned hospitalisation was available from two studies. The corresponding pooled RR was 0.25 (95% CI 0.08 to 0.82, P value = 0.02) in favour of nocturnal mechanical ventilation. For most of the outcome measures there was no significant long-term difference between nocturnal mechanical ventilation and no ventilation. Most of the secondary outcomes were not assessed in the eligible trials. Three out of the 10 trials, accounting for 39 participants, two with a cross-over design and one with two parallel groups, compared volume- and pressure-cycled non-invasive mechanical ventilation in the short term. From the only trial (16 participants) on parallel groups, there was no difference in mortality (one death in each arm) between volume- and pressure-cycled mechanical ventilation. Data from the two cross-over trials suggested that compared with pressure-cycled ventilation, volume-cycled ventilation was associated with less sleep time spent with an arterial oxygen saturation below 90% (mean difference (MD) 6.83 minutes, 95% CI 4.68 to 8.98, P value = 0.00001) and a lower apnoea-hypopnoea (per sleep hour) index (MD -0.65, 95% CI -0.84 to -0.46, P value = 0.00001). We found no study that compared invasive and non-invasive mechanical ventilation or intermittent positive pressure versus negative pressure ventilation. Current evidence about the therapeutic benefit of mechanical ventilation is of very low quality, but is consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term. In four small studies, survival was prolonged and unplanned hospitalisation was reduced, mainly in participants with motor neuron diseases. With the exception of motor neuron disease and Duchenne muscular dystrophy, for which the natural history supports the survival benefit of mechanical ventilation against no ventilation, further larger randomised trials should assess the long-term benefit of different types and modes of nocturnal mechanical ventilation on quality of life, morbidity and mortality, and its cost-benefit ratio in neuromuscular and chest wall diseases.

Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis.

To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes. This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 hr in PAC mode followed by 2 hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period. The asynchrony index was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, P < 0.0001), and the trigger delay was shorter (43.9 ± 7.2 vs. 116.0 ± 38.9 ms, P < 0.0001). Ineffective efforts were significantly less frequent in NAVA mode (0.54 ± 1.5 vs. 21.8 ± 16.5 events/min, P = 0.01). Patient respiratory rates were similar, but the ventilator rate was higher in NAVA than in PAC mode (59.5 ± 17.9 vs. 49.8 ± 8.5/min, P = 0.03). The TcPCO2 baselines values (64 ± 12 mmHg vs. 62 ± 9 mmHg during NAVA, P = 0.30) were the same and their evolution over the 2 hr study period (-6 ± 10 mmHg vs. -12 ± 17 mmHg during NAVA, P = 0.36) did not differ. Patient-ventilator inspiratory asynchronies and trigger delay were dramatically lower in NAVA mode than in PAC mode during NIV in infants with severe bronchiolitis.

Respiratory sinus arrhythmia stabilizes mean arterial blood pressure at high-frequency interval in healthy humans.

Arterial blood pressure variations are an independent risk factor for end organ failure. Respiratory sinus arrhythmia (RSA) is a sign of a healthy cardiovascular system. However, whether RSA counteracts arterial blood pressure variations during the respiratory cycle remains controversial. We restricted normal RSA with non-invasive intermittent positive pressure ventilation (IPPV) to test the hypothesis that RSA normally functions to stabilize mean arterial blood pressure. Ten young volunteers were investigated during metronome-paced breathing and IPPV. Heart rate (ECG), mean arterial blood pressure and left stroke volume (finger arterial pressure curve) and right stroke volume (pulsed ultrasound Doppler) were recorded, while systemic and pulmonary blood flow were calculated beat-by-beat. Respiratory variations (high-frequency power, 0.15-0.40 Hz) in cardiovascular variables were estimated by spectral analysis. Phase angles and correlation were calculated by cross-spectral analysis. The magnitude of RSA was reduced from 4.9 bpm(2) (95% CI 3.0, 6.2) during metronome breathing to 2.8 bpm(2) (95% CI 1.1, 5.0) during IPPV (p = 0.03). Variations in mean arterial blood pressure were greater (2.3 mmHg(2) (95% CI 1.4, 3.9) during IPPV than during metronome breathing (1.0 mmHg(2) [95% CI 0.7, 1.3]) (p = 0.014). Respiratory variations in right and left stroke volumes were inversely related in the respiratory cycle during both metronome breathing and IPPV. RSA magnitude is lower and mean arterial blood pressure variability is greater during IPPV than during metronome breathing. We conclude that in healthy humans, RSA stabilizes mean arterial blood pressure at respiratory frequency.

O-081 Non-invasive Ventilation In Severe Viral Bronchiolitis With Failure Of Ncpap: Neurally Adjusted Ventilatory Assist Versus Pressure Assist/control Ventilation

Background To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis in infants who failed to respond to nasal continuous positive airway pressure (nCPAP). Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes. Methods This prospective study in a university hospital’s paediatric intensive care unit included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 h in PAC mode followed by 2 h in NAVA mode. Diaphragm electrical activity and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analysed, and the asynchrony index was calculated. Results The asynchrony index (fig. 1) was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, p 2 baselines values (8.6 ± 1.6 kPa vs. 8.1 ± 1.2 kPa during NAVA, p = 0.36) and their evolutions during the study period (-0.8 ± 1.4 kPa vs. -1.6 ± 2.3 kPa during NAVA, p = 0.36) did not differ. Conclusion Severe patient-ventilator inspiratory asynchronies and ventilator response times were much lower in NAVA mode than in PAC mode during NIV in infants with bronchiolitis.

Open circuit mouthpiece ventilation: Concise clinical review

In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

Open circuit mouthpiece ventilation: Concise clinical review

In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

Alternatives to Mouthpiece Noninvasive Ventilatory Support to Permit Dental Care

Patients who are dependent on continuous noninvasive intermittent positive pressure ventilation for ventilatory support via angled mouthpiece interfaces during daytime hours often need dental interventions that are prevented by the presence of the mouthpiece. To permit dental interventions, however, the noninvasive intermittent positive pressure ventilation can most conveniently and safely be delivered via nasal interface using oximetry monitoring as long as both sedation and supplemental oxygen are avoided. Three mouthpiece continuous noninvasive intermittent positive pressure ventilation users are described who were switched to nasal noninvasive intermittent positive pressure ventilation to permit dental care. The most common mistake is to fail to cover the nasal interface exhalation portals when switching from ventilatory assistance by bilevel positive airway pressure devices with passive ventilator circuits to portable ventilators with active ventilator circuits and exhalation valves.

Epidemiology of noninvasive mechanical ventilation in acute respiratory failure - a retrospective population-based study

BackgroundNoninvasive mechanical ventilation (NIV) is a front-line therapy for the management of acute respiratory failure (ARF) in the intensive care units. However, the data on factors and outcomes associated with the use of NIV in ARF patients is lacking. Therefore, we aimed to determine the utilization of NIV for ARF in a population-based study.MethodsWe conducted a populated-based retrospective cohort study, where in all consecutively admitted adults (≥18 years) with ARF from Olmsted County, Rochester, MN, at the Mayo Clinic medical and surgical ICUs, during 2006 were included. Patients without research authorization or on chronic NIV use for sleep apnea were excluded.ResultsOut of 1461 Olmsted County adult residents admitted to the ICUs in 2006, 364 patients developed ARF, of which 146 patients were initiated on NIV. The median age in years was 75 (interquartile range, 60–84), 48% females and 88.7% Caucasians. Eighteen patients (12%) were on Continuous Positive Airway Pressure (CPAP) mode and 128 (88%) were on noninvasive intermittent positive-pressure ventilation (NIPPV) mode. Forty-six (10%) ARF patients were put on NIV for palliative strategy to alleviate dyspnea. Seventy-six ARF patients without treatment limitation were given a trial of NIV and 49 patients succeeded, while 27 had to be intubated. Mortality was similar between the patients initially supported with NIV versus invasive mechanical ventilation (33% vs 22%, P=0.289). In the multivariate analysis, the development of acute respiratory distress syndrome (ARDS) and higher APACHE III scores were associated with the failure of initial NIV treatment.ConclusionsOur results have important implications for a future planning of NIV in a suburban US community with high access to critical care services. The higher APACHE III scores and the development of ARDS are associated with the failure of initial NIV treatment.

Resolution of tracheostomy complications by decanulation and conversion to noninvasive management for a patient with high-level tetraplegia.

To report conversion from tracheostomy (TIV) to noninvasive intermittent positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications. A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff deflated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation. The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community. Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing.

Two-year home-based nocturnal noninvasive ventilation added to rehabilitation in chronic obstructive pulmonary disease patients: A randomized controlled trial

BackgroundThe use of noninvasive intermittent positive pressure ventilation (NIPPV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure remains controversial as long-term data are almost lacking.The aim was to compare the outcome of 2-year home-based nocturnal NIPPV in addition to rehabilitation (NIPPV + PR) with rehabilitation alone (PR) in COPD patients with chronic hypercapnic respiratory failure.MethodsSixty-six patients could be analyzed for the two-year home-based follow-up period. Differences in change between the NIPPV + PR and PR group were assessed by a linear mixed effects model with a random effect on the intercept, and adjustment for baseline values. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were mood state, dyspnea, gas exchange, functional status, pulmonary function, and exacerbation frequency.ResultsAlthough the addition of NIPPV did not significantly improve the Chronic Respiratory Questionnaire compared to rehabilitation alone (mean difference in change between groups -1.3 points (95% CI: -9.7 to 7.4)), the addition of NIPPV did improve HRQoL assessed with the Maugeri Respiratory Failure questionnaire (-13.4% (-22.7 to -4.2; p = 0.005)), mood state (Hospital Anxiety and Depression scale -4.0 points (-7.8 to 0.0; p = 0.05)), dyspnea (Medical Research Council -0.4 points (-0.8 to -0.0; p = 0.05)), daytime arterial blood gases (PaCO2 -0.4 kPa (-0.8 to -0.2; p = 0.01); PaO2 0.8 kPa (0.0 to 1.5; p = 0.03)), 6-minute walking distance (77.3 m (46.4 to 108.0; p < 0.001)), Groningen Activity and Restriction scale (-3.8 points (-7.4 to -0.4; p = 0.03)), and forced expiratory volume in 1 second (115 ml (19 to 211; p = 0.019)). Exacerbation frequency was not changed.ConclusionsThe addition of NIPPV to pulmonary rehabilitation for 2 years in severe COPD patients with chronic hypercapnic respiratory failure improves HRQoL, mood, dyspnea, gas exchange, exercise tolerance and lung function decline. The benefits increase further with time.Trial registrationClinicalTrials.Gov (ID NCT00135538).

Clinical value of noninvasive intermittent positive-pressure ventilation in pneumoconiosis combined with respiratory failure

To evaluate the value of noninvasive intermittent positive-pressure ventilation (NIPPV) in treatment of patients with pneumoconiosis combined with respiratory failure. Three were 46 inpatients with pneumoconiosis combined with respiratory failure. Twenty-six inpatients treated with conventional therapy and NIPPV were categorized as treatment group; Twenty inpatients just treated by conventional therapy served as control group. Compared with the changes of HR, RR and arterial blood gas index (PH, PaCO2, PaO2) in two groups after treatment. The effective ratio of treatment group was 88.5%, control group was 60%, which had significant difference (P < 0.05); The HR in treatment group after treatment was (95.38 +/- 10.75) beats per minute, control group was [(103.00 +/- 12.56) beats per minute; The RR in treatment group was (21.69 +/- 1.37) breaths per minute, control group was [(22.60 +/- 1.57) breaths per minute]; The PaCO2 in treatment group was (52.88 +/- 10.75)mm Hg, control group was [(59.66 +/- 11.49)mm Hg]; All of those were significantly decreased than those in control group (P < 0.05). The PaO2 in treatment group was (100.77 +/- 25.3) mm Hg, control group was [(71.82 +/- 17.94) mmHg]; Compared with the control group, PaO2 in the treatment group increased significantly (P < 0.05). NIPPV is beneficial to pneumoconiosis combined with respiratory failure in different degrees.

Duchenne Muscular Dystrophy

To describe the effect of glucocorticoid treatment on age at wheelchair dependence and at dependence on part-time (<23 hrs/day) and continuous noninvasive mechanical ventilation. In this retrospective study, patients with Duchenne muscular dystrophy who received glucocorticoid therapy were compared with those who did not for ages at wheelchair dependence and when beginning part-time (nocturnal) and continuous noninvasive intermittent positive pressure ventilation (NIV). Respiratory symptoms, end-tidal carbon dioxide, oximetry, and vital capacity were noted every 4-12 mos, and NIV was initiated for symptomatic nocturnal hypoventilation. The daily NIV use increased until some required it continuously to survive. The 117 untreated patients became wheelchair-dependent at 9.7 +/- 1.3 yrs of age. Four then died from cardiac failure, and five were older than 19 yrs without using NIV. The remaining 108 began nocturnal NIV at 19.2 +/- 3.7 yrs of age. Ninety of the 108 became continuously NIV-dependent at 21.9 +/- 4.5 yrs of age, and the 17 treated with glucocorticoid therapy became wheelchair-dependent significantly later at 10.8 +/- 1.3 yrs of age (P = 0.02). Three died from cardiac failure, and three were older than 19 yrs without using NIV. The remaining 11 began nocturnal NIV at 22.9 +/- 5.3 yrs of age (P = 0.05). Eight of the 11 became continuously NIV-dependent at age 28.9 +/- 7.3 yrs (P = 0.005). Intermittent glucocorticoid therapy delays wheelchair dependence and may delay ventilator dependence for patients with Duchenne muscular dystrophy.