Noninvasive Mechanical Ventilation

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References

Figures and Tables. Citations Publications citing this paper. Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure. Noninvasive and invasive positive pressure ventilation for acute respiratory failure in critically ill patients: a comparative cohort study.

Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications Jarrod M Mosier , John C. References Publications referenced by this paper. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema.

Calibration and discrimination by daily Logistic Organ Dysfunction scoring comparatively with daily Sequential Organ Failure Assessment scoring for predicting hospital mortality in critically ill patients. For those with less severe disease, RCTs are clearly needed. Outcomes of these RCTs should include measurements of the trachea and physiological outcomes in addition to clinical outcomes. An UpToDate review on "Tracheomalacia and tracheobronchomalacia in adults" Ernst et al, states that "[c]ontinuous positive airway pressure CPAP can maintain an open airway and facilitate secretion drainage.

Noninvasive positive pressure ventilation: Increasing use in acute care

This is often initiated in the hospital during an acute illness. Patients may use intermittent CPAP as long-term therapy. However, CPAP does not appear to have a long-term impact on dyspnea or cough. Positive airway pressure other than CPAP e. Most respond to conservative management, consisting of humidified air, chest physical therapy, slow and careful feedings, and control of infection and secretions with antibiotics.

The use of continuous positive airway pressure CPAP has been recommended in patients having respiratory distress and may be successful in patients requiring a short-term intervention as the disorder spontaneously resolves. Mask pressure was 3 cm H2O for 10 mins, followed by individual progression up to 4 to 6 cm H2O, whereas placebo was fixed 0 to 1 cm H2O.

A 6-min walk test was performed after placebo and CPAP. The latter studies included patients with various etiologies of respiratory failure but with the common co-morbidity of immunocompromization. For other groups, such as patients with asthma, pneumonia, or acute lung injury, RCT-level evidence is lacking or does not suggest benefit. In a single-center RCT, Menesese et al examined if early nasal intermittent positive-pressure ventilation NIPPV compared with nasal continuous positive airway pressure NCPAP decreases the need for mechanical ventilation in infants with respiratory distress syndrome.

Surfactant was administered as rescue therapy. The primary outcome was the need for mechanical ventilation within the first 72 hours of life. A total of infants, in each arm, were randomly assigned. Moreover, they stated that further studies are needed to to evaluate the potential benefits of non-invasive ventilation, especially for the most vulnerable or preterm infants. These researchers noted that mechanical respiratory support is a critical intervention in many cases of ARF. Several pediatric clinical studies, the majority of which were non-controlled or case series and of small size, have suggested the effectiveness of NPPV in the treatment of ARF due to acute airway upper or lower obstruction or certain primary parenchymal lung disease, and in specific circumstances, such as post-operative or post-extubation ARF, immunocompromised patients with ARF, or as a means to facilitate extubation.

However, many important issues, such as the identification of the patient, the right time for NPPV application, and the appropriate setting, are still lacking. In a Cochrane review, Faria and colleagues compared the safety and effectiveness and safety of NPPV versus standard oxygen therapy in the treatment of acute respiratory failure after upper abdominal surgery.

These researchers evaluated the safety and effectiveness of NPPV i. The date of the last search was May 12, They reviewed reference lists of included studies and contacted experts. They also searched grey literature sources, and checked databases of ongoing trials such as www. They did not apply language restrictions. The authors selected RCTs or quasi-RCTs involving adults with acute respiratory failure after upper abdominal surgery who were treated with CPAP or bi-level NPPV with, or without, drug therapy as standard medical care, compared to adults treated with oxygen therapy with, or without, standard medical care.

Two authors independently selected and abstracted data from eligible studies using a standardized form. They evaluated study quality by assessing allocation concealment; random sequence generation; incomplete outcome data; blinding of participants, personnel, and outcome assessors; selective reporting; and adherence to the intention-to-treat ITT principle. These investigators included 2 trials involving participants. The trials were conducted in China and Italy 1 was a multi-center trial.

Both trials included adults with acute respiratory failure after upper abdominal surgery. These researchers judged both trials at high risk of bias. There was very low quality evidence that the intervention may also reduce ICU length of stay mean difference MD They found no differences for mortality low quality evidence and hospital length of stay.

There was insufficient evidence to be certain that CPAP or NPPV had an effect on anastomotic leakage, pneumonia-related complications, and sepsis or infections.

Findings from 1 trial of 60 participants suggested that bi-level NPPV, compared to oxygen therapy, may improve blood gas levels and blood pH 1 hour after the intervention partial pressure of arterial oxygen PaO2 : MD The trials included in this systematic review did not present data on the following outcomes that these researchers intended to assess: gastric insufflation, fistulae, pneumothorax, bleeding, skin breakdown, eye irritation, sinus congestion, oronasal drying, and patient-ventilator asynchrony.

The authors concluded that the findings of this review indicated that CPAP or bi-level NPPV is a safe and effective intervention for the treatment of adults with acute respiratory failure after upper abdominal surgery. However, they stated that based on the Grading of Recommendations Assessment, Development and Evaluation GRADE methodology, the quality of the evidence was low or very low; and more good quality studies are needed to confirm these findings.

Masa and associates stated that the incidence of obesity hypoventilation syndrome OHS may be increasing in parallel with the present obesity epidemic. Sequentially screened patients with OHS with severe sleep apnea were randomized into the above-mentioned groups for a 2-month follow-up. Arterial blood gas parameters, clinical symptoms, health-related quality-of-life assessments, polysomnography, spirometry, 6-minute-walk distance, drop-outs, compliance, and side effects were evaluated.

Statistical analysis was performed using intention-to-treat analysis, although adjustments for CPAP and NIV compliance were also analyzed. A total of patients were selected, and were randomized; NIV yielded the greatest improvement in PaCO2 and bicarbonate, with significant differences relative to the control group, but not relative to the CPAP group.

However, some health-related quality-of-life assessments, the spirometry, and 6-minute-walk distance results improved more with NIV than with CPAP. Moreover, they stated that long-term studies must demonstrate whether this functional improvement has relevant implications.

An UpToDate review of obesity hypoventilation syndrome Martin, stated that nocturnal noninvasive positive airway pressure is first-line treatment for obesity hypoventilation syndrome, regardless of whether or not the patient has a coexisting sleep-related breathing disorder obstructive sleep apnea. While NPPV is associated with fewer complications than endotracheal intubation ET , it is relatively contraindicated after esophagectomy due to potential injury to the anastomosis. These researchers created ex-vivo and in-vivo pig models to determine the pressure tolerance of an esophagectomy anastomosis and compared it to esophageal pressure during NPPV.

These investigators created a stapled side-to-side, functional end-to-end esophago-gastric anastomosis. With continuous intraluminal pressure monitoring, they progressively insufflated the anastomosis with a syringe until an anastomotic leak was detected, and recorded the maximum pressure before leakage. These researchers performed this experiment in 10 esophageal specimens and 10 live pigs. They then applied a laryngeal mask airway LMA to 5 live pigs and measured the pressure in the proximal esophagus with increasing ventilatory pressures.

The perforation was always at the anastomosis. The authors concluded that the findings from their ovine model suggested that an esophagectomy anastomosis can tolerate a considerably higher pressure than is transmitted to the esophagus during NPPV. These preliminary findings need to be validated in well-designed clinical trials.

Depending on breathing effort, the device will automatically adjust the amount of airflow it delivers in order to maintain a steady minute ventilation. Most studies on the use of ASV have investigated its use for heart failure patients with central apnea or Cheyne-Stokes respiration Teschler et al, ; Pepperell et al, ; Topfer et al, ; Pepin et al, ; Kasai et al, ; Zhang et al, The patients had a periodic breathing pattern resembling CSB.

During polysomnography, the abnormal breathing pattern was present while patients were both awake and asleep. They were then assessed on ASV. The mean abnormal breathing events index decreased from There was a significant reduction in the mean number of arousals caused by abnormal breathing events: from After 6 to 12 months of using ASV, the patients had maintained significant improvement in subjective daytime alertness and mood.

Morrell et al stated that hypercapnic cerebral vascular reactivity HCVR is reduced in patients with CHF and sleep-disordered breathing SDB and that this may be associated with an increased risk of stroke. The HCVR was measured from the change in middle cerebral artery velocity, using pulsed Doppler ultrasound. Hypercapnic cerebral vascular reactivity was determined during the evening before and morning after 1 night of sleep on ASV and 1 night of spontaneous sleep control. The relatively low morning HCVR could be linked with an increased risk of stroke. Morgenthaler et al compared the efficacy of ASV versus NPPV for central, mixed, and complex sleep apnea syndromes in a prospective randomized cross-over clinical trial.

All patients were receiving optimal medical therapy. The single breath nitrogen test SBNT is a pulmonary function test that provides information on the evenness of distribution of ventilation and on closing volume. Expired N 2 concentration is then plotted against expired volume single breath nitrogen washout curve. From this, information about the distribution of ventilation can be obtained. Similar measurements may be made using other tracer gases such as xenon, argon, or helium.

In normal persons in whom the alveoli empty synchronously, phase III shows a plateau during which N 2 concentration rises only slowly. The slope of phase III change in N 2 concentration per ml of expired air should be less than 1. The lung volume at which phase III changes to phase IV is closing volume the volume at which closure of airways occur in the lower part of the lungs. An increase in closing volume, especially when it is larger than functional residual volume, indicates premature closure of intra-pulmonary airways as a result of the narrowing of small airways or reduced elastic recoil.

It was thought that the SBNT might detect chronic airway disease before it is clinically apparent. However, it has not been demonstrated conclusively to be more sensitive than other tests. Most patients with established disease and an abnormal slope of phase III do not produce single breath tests from which closing volumes can be measured. However, the ATS Standards states that indices such as the closing capacity and the slope of the alveolar plateau derived from a SBNT are unable to identify individuals susceptible to chronic airway obstruction with cigarette smoke exposure.

The ATS Standards notes that tests reflecting emphysema e. Fraser explained that, although epidemiological studies have demonstrated that the results of the SBNT is abnormal in many asymptomatic smokers, there is controversy regarding the value of this measurement, as it appears that this test may not offer advantages over simple spirometry in detecting the progression of airflow obstruction. Fraser et al explained that one reason SBNT has been less discriminating than was originally hoped in identifying smokers at risk for the development of progressive disease is the marked inter-subject and intra-subject variability in test results.

In addition, these investigators noted that it has not been convincingly shown that the rate of decrease in forced expiratory flow in smokers correlates with abnormalities in small airway function. A number of empirical studies have documented the limited clinical value of SBNT. Teculescuet et al noted that the SBNT did not detect any effect of involuntary smoking in a limited sample of children. Vestbo et al concluded that in a random population sample indices from only one SBNT do not provide prognostic information concerning hospitalization in addition to that provided by forced expiratory volume in 1 sec FEV1.

Viegi et al stated that the place of SBNT in large scale epidemiologic testing has not been justified. Detels et al reported that the SBNT yielded less specific or different information than spirometry, the flow-volume curve, and the ratio of FEV1 to forced vital capacity FVC in identifying abnormal lung function. Moreover, Bourgkard et al reported that subjects with dust exposure and roentgenologic pneumoconiosis nodulation were unable to adequately perform SBNT; however, these subjects were able to performed spirometry satisfactorily.

Thus, the SBNT has not been proven to be useful in detecting early lung dysfunction and selecting persons at risk for appropriate measures to prevent progression to advanced disease. Momomura and associates noted that adaptive servo-ventilation ASV therapy using an innovative ventilator, originally developed to treat SDB, is a novel modality of NPPV and is gaining acceptance among Japanese cardiologists in expectation of its applicability to treat patients with chronic heart failure CHF based on its acute beneficial hemodynamic effects.

These researchers conducted a multi-center, retrospective, real-world observational study in Japanese patients with CHF, who had undergone home ASV therapy for the first time from January through December , to examine their profile and the effects on their symptoms and hemodynamics. In at least 71 patients Chronic heart failure was more severe, i. The authors concluded that the findings of the present study suggested that ASV therapy would improve the symptoms and hemodynamics of CHF patients, regardless of SDB severity.

Moreover, they stated that a randomized clinical study is needed to verify these effects. Both fixed and randomized models were used in meta-analysis with primary outcomes of LVEF. A total of 19 studies were included with a total of patients. However, the definition of NPPV compliance in those reports was not consistent and the influence of compliance to treatment was not quantified. Thus, the authors did not report the influence of NPPV compliance on studied variables in the present study.

All patients underwent two 6-min walk tests 6MWT , with a min interval between them. At baseline, and after the 1st and 2nd 6MWT, the heart rate, systolic and diastolic blood pressure, peripheral oxygen saturation SaO2 , and dyspnea were evaluated. All 40 patients completed the study safely according to the randomization protocol, and no adverse events AEs were reported during the tests. No serious AEs were reported. The authors stated that this study had several drawbacks. First, it was not possible to define the duration of the effects that were verified as the administration of the non-invasive ventilation was interrupted for the performance of the 6MWT.

It would be important to determine whether several sessions with non-invasive ventilation would maintain the effect for a longer period of time and whether these effects are associated with clinical improvement. Furthermore, the lack of information about the hemodynamic profiles of the patients enrolled was another drawback.


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Clayton and colleagues noted that initial respiratory support with NPPV or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in pediatric intensive care unit PICU patients with bronchiolitis. However, it is unclear if the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation.

Background

These researchers compared the rate of subsequent invasive mechanical ventilation after initial support with NPPV or high-flow nasal cannula in children with bronchiolitis. This trial included a total of 92 participating PICUs. Children less than 2 years of age were admitted to a participating PICU between and with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or NPPV as the initial respiratory treatment modality. Subsequent receipt of invasive mechanical ventilation was the primary outcome.

These investigators identified 6, participants with a median age 3. After initial support with NPPV or high-flow nasal cannula, In a multi-variate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a co-morbid diagnosis, and Pediatric Index of Mortality score, initial support with NPPV was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula OR, 1. The authors concluded that in this large, multi-center database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or NPPV, use of the latter was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, co-morbid condition, and severity of illness.

These investigators stated that a large, prospective, multi-center trial is needed to confirm these findings. If the AHI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events used to calculate the AHI must be at least the number of events that would have been required in a 2-hour period i.

A respiratory cycle is defined as an inspiration, followed by an expiration. In addition, it has a timed backup feature to deliver this air pressure whenever sufficient spontaneous inspiratory efforts fail to occur. Central apnea-hypopnea index CAHI - For diagnosis of CSA, the central apnea-central hypopnea index CAHI is defined as the average number of episodes of central apnea and central hypopnea per hour of sleep without the use of a positive airway pressure device.

If the CAHI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events used to calculate the CAHI must be at least the number of events that would have been required in a 2-hour period i. These individuals have predominantly obstructive or mixed apneas during the diagnostic sleep study occurring at greater than or equal to 5 times per hour.

Complex sleep apnea CompSA is a form of central apnea specifically identified by all of the following:. The member's usual FIO2 refers to the oxygen concentration the member normally breathes when not undergoing testing to qualify for coverage of NPPV. That is, if the member does not normally use supplemental oxygen, their usual FIO2 is that found in room air. It must also include at least the following additional parameters of sleep: airflow, respiratory effort, and oxygen saturation by oximetry. It may be performed either as a whole-night study for diagnosis only or as a split-night study to diagnose and initially evaluate treatment.

A type I sleep test is the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with physician review, interpretation, and report. It may be performed as either a whole night study for diagnosis only or as a split night study to diagnose and initially evaluate treatment.

A portable monitoring device for conducting an HST must meet one of the following criteria:. Other - Devices that monitor and record a minimum of three 3 channels that include actigraphy, oximetry and peripheral arterial tone and for which there is substantive clinical evidence in the published peer-reviewed medical literature that demonstrates that the results accurately and reliably correspond to an AHI or RDI as defined above. This determination will be made on a device-by-device basis. Tubing with integrated heating element for use with a positive airway pressue device describes tubing used with a heated humidifier and has a heated wire running the length of the tubing.

It is designed for use with a positive airway pressure device and a non-invasive interface - i. Pillow for use on nasal cannula type interface, replacement only, pair is used for a replacement nasal cannula-type interface. This interface extends a short distance into the nostrils. For other products, the interface is a single piece with two protrusions that extend into the nostrils.

One of these interfaces equals one unit of service. Liners used with a PAP mask are made of cloth, silicone or other materials. Liners are not interfaces for use with a PAP mask. Consequently, liners should not be billed as replacement features of a PAP mask. Review History. Clinical Policy Bulletin Notes. Links to various non-Aetna sites are provided for your convenience only.

Aetna Inc.

Noninvasive Positive Pressure Ventilation. Print Share. Member has a progressive neuromuscular disease e. Member has symptoms of sleep-associated hypoventilation nocturnal hypoxemia , such as daytime hypersomnolence, excessive fatigue, dyspnea, morning headache, cognitive dysfunction, etc. An arterial blood gas PaCO 2 , done while awake and breathing the member's usual FIO 2 fractional inspired oxygen concentration , is greater than or equal to 45 mm Hg; or.

Significant improvement of the sleep-associated hypoventilation with the use of a bilevel PAP device with or without a backup rate feature on the settings that will be prescribed for initial use at home, while breathing the member's prescribed FIO 2. Durable medical equipment reference list. Current concepts: Noninvasive ventilation. N Engl J Med. Hill NS. Noninvasive mechanical ventilation. In: Pulmonary and Critical Care Medicine. Ferguson G. Noninvasive ventilation.

Respiratory care modalities. Long-term nasal ventilation in neuromuscular disorders: Report of a consensus conference. Eur Respir J. Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation -- A consensus conference report. NHIC, Corp. Respiratory assist devices. ACCP consensus statement: Indications for positive airway pressure treatment of adult sleep apnea patients. American Sleep Disorders Association. Practice parameters for the indications for polysomnography and related procedures.

Brown LK. Sleep-related disorders and chronic obstructive pulmonary disease. Respir Care Clin North Am. Noninvasive positive pressure ventilation.

Before starting NIV

Pride NB. Assessment of long-term changes in airway function. Agents Actions Suppl. Vestbo J, Rasmussen FV. The single-breath nitrogen test, mortality, and cancer. Am Rev Respir Dis. Dahlqvist M. Does abnormal single-breath nitrogen wash-out predict an accelerated decline in FEV1 in lung-healthy subjects? Clin Physiol. Wedzicha JA. Outcome of long-term noninvasive positive-pressure ventilation. Respir Care Clin N Am. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Cochrane Database Syst Rev. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation?

A systematic review of the literature. Ann Intern Med. Noninvasive ventilation for chronic obstructive pulmonary disease. Respir Care. Single breath nitrogen test in an epidemiologic survey in North Italy. Reliability, reference values and relationships with symptoms. No authors listed. Basic pulmonary physiology. In: Respiratory Function in Disease.

DV Bates, ed. Philadelphia, PA: W. Saunders Co. Predictive value of the single-breath nitrogen test for hospitalization due to respiratory disease. The single-breath nitrogen test in coal miners: Factors associated with failure to perform.



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