Skip to main content
 

Main menu

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Most-Read Papers of 2021
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Reviewer Guidelines: Original Research
    • Reviewer Guidelines: Reviews
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • 2022 Call for Abstracts
    • 2021 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Español
    • Portugûes
    • 国语
  • Videos
    • Video Abstracts
    • Author Interviews
    • Highlighted Articles
    • The Journal

User menu

  • Subscribe
  • My alerts
  • Log in

Search

  • Advanced search
American Association for Respiratory Care
  • Subscribe
  • My alerts
  • Log in
American Association for Respiratory Care

Advanced Search

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Most-Read Papers of 2021
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Reviewer Guidelines: Original Research
    • Reviewer Guidelines: Reviews
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • 2022 Call for Abstracts
    • 2021 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Español
    • Portugûes
    • 国语
  • Videos
    • Video Abstracts
    • Author Interviews
    • Highlighted Articles
    • The Journal
  • Twitter
  • Facebook
  • YouTube
LetterCorrespondence

Volume-Targeted Versus Pressure-Limited Noninvasive Ventilation in Hypercapnic Respiratory Failure: What Could Be Established in Real Practice?

Killen H Briones Claudett and Antonio M Esquinas
Respiratory Care October 2017, 62 (10) 1377-1378; DOI: https://doi.org/10.4187/respcare.05467
Killen H Briones Claudett
Facultad de Ciencias Médicas Universidad de Guayaquil Guayaquil, Ecuador
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Antonio M Esquinas
Intensive Care Unit Hospital Morales Meseguer Murcia, Spain
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • References
  • Info & Metrics
  • PDF
Loading

To the Editor:

We have read with interest the original article titled “Volume-Targeted Versus Pressure-Limited Noninvasive Ventilation in Subjects with Acute Hypercapnic Respiratory Failure: A Multi-Center Randomized, Controlled Trial.”1 In this study, Cao et al1 used a prospective, randomized controlled trial in the general respiratory wards to establish whether the ventilatory strategy with volume-targeted noninvasive ventilation (VT-NIV) was more effective than pressure-limited NIV (PL-NIV).

We have some remarks on this study for practical implications. First, regarding methodology, we believe patient selection was inadequate, as only subjects with exacerbations of chronic pathologies (eg, COPD, asthma, bronchiectasis, and obstructive sleep apnea syndrome) were randomized into 2 groups of 29 subjects with similar demographics and blood gas analysis (pH-PCO2-PaO2/FIO2 and HCO3). The authors randomized subjects with mild to moderate acute-on-chronic hypercapnic respiratory failure, of which 12% reported previous use of NIV. However, they did not specify the causes or conditions for which these subjects received previous treatment with NIV.

Second, evaluation of key determinants of severity and grading needs to be more precisely defined in three aspects. There is an absence of parameters in the evaluation of acute hypercapnic respiratory failure. The authors did not report on (1) severity of mental status impairment;2 (2) HCO3–, mmol/L, base excess at 2–6 h and at 12 h after NIV use, without clearly establishing the moment when they reached their compensation; and (3) conventional therapy such as inhaled ß2-agonists, anticholinergic agents, systemic steroids, and antibiotics, along with the method of delivery, dose, and frequency of treatments in both groups.

The third issue relates to the prolonged use of NIV detailed in the study. The authors reported on duration of NIV – median (IQR) of 6.0 d (4.0–9.5) for PL-NIV versus 9.0 (4.0–13.0) d for VT-NIV. Today, it is known that more than half of patients with acute hypercapnic respiratory failure treated with NIV resolve within the first 24 h, 80% experience resolution within 48 h, and 92% resolve within 72 h. Patients with initial pH values between 7.30 and 7.35 require fewer days of NIV than those with a pH between 7.21 and 7.25.

In accordance with the guidelines, NIV should be first-line therapy in patients with exacerbations of chronic airway diseases, with pH < 7.35 and PCO2 > 45 mm Hg, until pH is normalized to 7.35–7.45. This prolonged use of NIV could indicate that these subjects had chronic hypercapnia, and therefore the reported NIV results may differ from other patient populations.3,4

Fourth, the authors used inadequate ventilation settings. In the non-intervention group, the authors tried to obtain a VT of 8–10 mL/kg predicted body weight. They noted variations in the exhaled VT of approximately 1 mL/kg predicted body weight, with 9.5 mL/kg at the start of the NIV, and 10.3 mL/kg at 6 h. On the other hand, 2 h after the use of NIV, the authors reported an increase in the pressures inspired by the PL-NIV group as shown in Figure 4D, at the moment when a greater decrease of PCO2 in the VT-NIV group was observed. This pressure increase in favor of PL-NIV was maintained for up to 6 h. The maximum inspiratory positive airway pressure target should have been programmed as much as possible during the first hours of PL-NIV.5

We believe that these assessments should be taken into account when analyzing these results for proper clinical practical recommendation.

Footnotes

  • The authors have disclosed no conflicts of interest.

  • Copyright © 2017 by Daedalus Enterprises

References

  1. 1.↵
    1. Cao Z,
    2. Luo Z,
    3. Hou A,
    4. Nie Q,
    5. Xie B,
    6. An X,
    7. et al
    . Volume-targeted versus pressure-limited noninvasive ventilation in subjects with acute hypercapnic respiratory failure: a multicenter randomized controlled trial. Respir Care 2016;61(11):1440–1450.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Scala R,
    2. Naldi M,
    3. Archinucci I,
    4. Coniglio G,
    5. Nava S
    . Noninvasive positive pressure ventilation in patients with acute exacerbation of COPD and varying levels of consciousness. Chest 2005;128(3):1657–1666.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Davidson AC
    ; British Thoracic Society Guideline Group for the Ventilatory Management of Acute Hypercapnic Respiratory Failure in Adults. Managing acute hypercapnic respiratory failure in adults: where do we need to get to? Thorax 2016;71(4):297–298. Erratum: Thorax 2016;71(6):492.
    OpenUrlFREE Full Text
  4. 4.↵
    1. Ekkernkamp E,
    2. Kabitz HJ,
    3. Walker DJ,
    4. Schmoor C,
    5. Storre JH,
    6. Windisch W,
    7. Dreher M
    . Minute ventilation during spontaneous breathing, high-intensity noninvasive positive pressure ventilation and intelligent volume assured pressure support in hypercapnic COPD. COPD 2014;11(1):52–58.
    OpenUrl
  5. 5.↵
    1. Briones Claudett KH,
    2. Briones Claudett M,
    3. Chung Sang Wong M,
    4. Nuques Martinez A,
    5. Soto Espinoza R,
    6. Montalvo M,
    7. et al
    . Noninvasive mechanical ventilation with average volume assured pressure support (AVAPS) in patients with chronic obstructive pulmonary disease and hypercapnic encephalopathy BMC Pulm Med 2013;13:12.
    OpenUrlPubMed
PreviousNext
Back to top

In this issue

Respiratory Care: 62 (10)
Respiratory Care
Vol. 62, Issue 10
1 Oct 2017
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author

 

Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Association for Respiratory Care.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Volume-Targeted Versus Pressure-Limited Noninvasive Ventilation in Hypercapnic Respiratory Failure: What Could Be Established in Real Practice?
(Your Name) has sent you a message from American Association for Respiratory Care
(Your Name) thought you would like to see the American Association for Respiratory Care web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Volume-Targeted Versus Pressure-Limited Noninvasive Ventilation in Hypercapnic Respiratory Failure: What Could Be Established in Real Practice?
Killen H Briones Claudett, Antonio M Esquinas
Respiratory Care Oct 2017, 62 (10) 1377-1378; DOI: 10.4187/respcare.05467

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Volume-Targeted Versus Pressure-Limited Noninvasive Ventilation in Hypercapnic Respiratory Failure: What Could Be Established in Real Practice?
Killen H Briones Claudett, Antonio M Esquinas
Respiratory Care Oct 2017, 62 (10) 1377-1378; DOI: 10.4187/respcare.05467
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • References
  • Info & Metrics
  • References
  • PDF

Related Articles

Cited By...

Info For

  • Subscribers
  • Institutions
  • Advertisers

About Us

  • About the Journal
  • Editorial Board
  • Reprints/Permissions

AARC

  • Membership
  • Meetings
  • Clinical Practice Guidelines

More

  • Contact Us
  • RSS
American Association for Respiratory Care

Print ISSN: 0020-1324        Online ISSN: 1943-3654

© Daedalus Enterprises, Inc.

Powered by HighWire