Chest
Volume 102, Issue 3, September 1992, Pages 912-917
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Clinical Investigations in Critical Care
Nasal Mask Ventilation in Acute Respiratory Failure: Experience in Elderly Patients

https://doi.org/10.1378/chest.102.3.912Get rights and content

Nasal mask ventilation (NMV) has been used successfully in chronic restrictive respiratory failure and more recently in acute exacerbations of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the possible role of NMV in acute respiratory failure (ARF) episodes when mechanical ventilation with endotracheal intubation is questionable. Thirty patients (age, 76 ± 8.1 years) were treated by NMV during ARF episodes (COPD, 20; other chronic respiratory failure [CRF], 5; chronic heart failure [CHF], 4). All patients were hypoxemic (PaO2, 5.85 ± 1.62 kPa) and hypercapnic (PaCO2, 8.63 ± 1.89 kPa) with respiratory acidosis (pH, 7.29 ± 0.08). In all cases, clinical or physiologic parameters indicated the need for mechanical ventilation, but endotracheal intubation was either not applied because of the age and the physiologic condition of the patients (17 cases) or was postponed (13 cases). NMV was performed using a volume-cycled ventilator and a customized nasal mask. Ventilation was continuous during the first 12 hours and the following nights and was then intermittent during the day. Twenty-one patients improved clinically, within a few hours. Progressive correction of arterial blood gases was observed: PaO2 increased during the first hour, but PaCO2 decreased more slowly. Eighteen patients were able to be successfully weaned from NMV. Twelve patients foiled to improve despite NMV: eight of them died and four required endotracheal intubation. There was no difference in the success rate between patients in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even in very ill patients, when endotracheal ventilation is controversial or not immediately required.

Section snippets

Material and Methods

This study successively included patients admitted to the unit with ARF defined by the combination of severe dyspnea, profound hypoxia in room air or during nasal oxygen therapy, severe hypercapnia with respiratory acidosis, and/or disturbances of consciousness. Endotracheal ventilation was discussed in every case taking into account the following elements: the patient's age, his or her previous physiologic and pathologic condition, the family's opinion, and the previous decisions of other

Results

Thirty patients were included in the study (Tables 1 and 2): 16 women and 14 men with a mean age of 76 years (range, 59 to 93 years). All patients suffered from severe respiratory distress (mean PaO2, 5.85 ± 1.02 kPa; mean PaCO2, 9.27 ± 1.89 kPa; mean pH, 7.28 ± 0.08; mean respiratory rate, 26.68 ± 7.72/min; disturbances of consciousness, 24/30). The simplified acute physiology score (SAPS),18 calculated at the time of inclusion into the study, was 11.4 ± 3.94. Nasal ventilation was selected as

Discussion

Our study confirms the efficacy of NMV in acute respiratory distress, especially in acute decompensations of COPD. This method enabled us to rapidly obtain better blood oxygenation without any initial aggravation of hypercapnia, followed by a reduction in hypercapnia, reflecting an improvement in alveolar hypoventilation within several hours. This resulted in a rapid clinical improvement, particularly in the level of consciousness, in 70 percent of our patients and a favorable respiratory

Conclusion

Intermittent positive pressure mechanical ventilation using a nasal mask therefore appears to be a valuable alternative to ETV in the treatment of ARF, especially in the course of acute decompensations of COPD. Except in the extreme emergency situations in which immediate ETV is required, it may constitute first-line treatment in very elderly subjects in whom ETV may be questionable. In patients with chronic restrictive or obstructive respiratory failure, it may avoid the need for intubation

References (25)

  • P Leger et al.

    Home positive pressure ventilation with nasal mask for patients with neuromuscular weakness or restrictive lung or chest-wall disease

    Crit Care

    (1989)
  • L Brochard et al.

    Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask

    N Engl J Med

    (1990)
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