Chest
Volume 124, Issue 2, August 2003, Pages 699-713
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Reviews
Acute Applications of Noninvasive Positive Pressure Ventilation*

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Noninvasive positive-pressure ventilation (NPPV) has been used increasingly to treat acute respiratory failure (ARF). The best indications for its use are ARF in patients with COPD exacerbations, acute pulmonary edema, and immunocompromised states. For these indications, multiple controlled trials have demonstrated that therapy with NPPV avoids intubation and, in the case of COPD and immunocompromised patients, reduces mortality as well. NPPV is used to treat patients with numerous other forms of ARF, but the evidence is not as strong for its use in those cases, and patients must be selected carefully. The best candidates for NPPV are able to protect their airway, are cooperative, and are otherwise medically stable. Success is optimized when a skilled team applies a well-fitted, comfortable interface. Ventilator settings should be adjusted to reduce respiratory distress while avoiding excessive discomfort, patient-ventilator synchrony should be optimized, and adequate oxygenation should be assured. The appropriate application of NPPV in the acute care setting should lead to improved patient outcomes and more efficient resource utilization.

Section snippets

Obstructive Lung Diseases

COPD: The most studied application of NPPV is for acute exacerbations of COPD. Just over a dozen years ago, Brochard et al6 showed that pressure support ventilation, administered via a face mask, significantly reduced the need for intubation, the duration of mechanical ventilation, and ICU length of stay compared to historically matched control subjects. Subsequently, six randomized controlled trials have confirmed these findings78910111213(Table 2). Bott et al7 randomized 60 patients who had

Hypoxemic Respiratory Failure

The term hypoxemic respiratory failure refers to a subgroup of patients whose acute respiratory failure is characterized by severe hypoxemia (ie, Pao2/fraction of inspired oxygen [Fio2] ratio, ā‰¤ 200), severe respiratory distress (ie, respiratory rate, > 35 breaths/min), and a non-COPD diagnosis including pneumonia, ARDS, trauma, or cardiogenic pulmonary edema.17 Studies on this subgroup of patients have yielded conflicting results. Meduri et al25 have reported success with NPPV in all four

Restrictive Diseases

NPPV is considered to be the ventilatory modality of first choice to treat chronic respiratory failure in patients with thoracic restriction caused by neuromuscular disease or chest wall deformity.63 However, few studies have examined the use of NPPV when these patients become acutely ill, partly because they constitute a very small portion of the patients with respiratory failure entering acute care hospitals.17 Some retrospective series have suggested that NPPV alleviates gas exchange

Postoperative Patients

Some early case series reported the use of NPPV in the treatment of respiratory insufficiency after surgery in patients with Paco2 levels of > 50 mm Hg, Pao2 values of < 60 mm Hg, or evidence of respiratory muscle fatigue.67686970 Using nasal bilevel pressure ventilation, these studies reported prompt reductions in respiratory rate and dyspnea scores, improvements in gas exchange, and high success rates in avoiding the need for reintubation. Subsequently, prophylactic postoperative use of NPPV

Do-Not-Intubate Patients

The use of NPPV to treat respiratory failure in patients who have declined intubation is common in some centers, accounting for some 10% of short-term applications in one survey.74 Some have argued75 that there is little to lose with this approach, as it may reverse the acute deterioration or, at least, afford relief from dyspnea and a few extra hours to finalize the patientā€™s affairs. However, others have argued that this merely prolongs the dying process, consumes resources inappropriately,

Facilitation of Extubation and Weaning

NPPV has been used to facilitate early extubation after bouts of acute respiratory failure and to avoid extubation failure when the condition of a patient deteriorates following extubation. In the first instance, NPPV is used after extubation in patients who fail to meet standard extubation criteria, based on the presumption that outcomes can be improved by avoiding the complications of prolonged intubation such as nosocomial infection and upper airway trauma. The first controlled trial79 to

Patient Selection

The success of NPPV is partly related to the skill of the medical team in selecting appropriate patients. The selection process takes into consideration a number of factors, including the patientā€™s diagnosis, clinical characteristics, and risk of failure, and ultimately becomes a clinical judgment that depends largely on physician experience. The etiology and reversibility of the respiratory failure are key, and clinicians should consider the evidence supporting the use of NPPV for a particular

Basic Considerations for Initiation of NPPV

In addition to proper patient selection, the successful implementation of NPPV requires the use of a comfortable interface (or mask), the optimal setting of the ventilator, appropriate monitoring, and, most of all, the conscientious attention of a skilled health-care team.

Complications of NPPV

The complications of NPPV are usually minor. The most frequently encountered adverse effects are related to the mask and ventilator airflow pressure.100 Accounting for a large portion of the reported complications are nasal bridge or mucosal pain, or nasal bridge erythema or ulceration.101102 These complications can be minimized or avoided by minimizing strap tension, using forehead spacers, or routinely applying artificial skin to the area.100 Other less common but noteworthy complications

Utilization of NPPV in Acute Settings

A survey of utilization at a university hospital in Canada found that therapy with NPPV was most often begun in the emergency department and that acute pulmonary edema and exacerbation of COPD were the most common indications in 44% and 24% of applications, respectively.103 NPPV therapy was used for a median of only 4.9 h, and the intubation rate was 25.6%. Bilevel ventilation was most often prescribed, at median inspiratory and expiratory pressures of 10 and 5 cm H2O, respectively. The authors

Personnel Time Consumption and Financial Considerations

An early analysis104 that raised concerns about the excessive time consumption associated with using NPPV found that a nurse was at the bedside 91% of the time that NPPV was being administered to patients with COPD exacerbations. However, subsequent analyses have not borne this concern out. In one randomized trial,8 respiratory therapists spent an average of approximately 1 h more treating NPPV patients during the first 8-h shift compared to conventionally treated control subjects, although the

Conclusion

NPPV constitutes a therapeutic advance for certain forms of respiratory failure. Current evidence supports the use of NPPV to reduce the need for intubation and its attendant morbidity and mortality in selected patients with respiratory failure caused by COPD exacerbations or pneumonias in patients with COPD or immunocompromised states. Although NPPV is commonly used to treat acute pulmonary edema, the evidence supports the use of CPAP alone for this entity. Evidence is accumulating to support

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  • Cited by (0)

    Dr. Hill has received research grants from Respironics, Inc, and ResMed, Inc. He is also a member of the Medical Advisory Board of ResMed, Inc.

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