Noninvasive Mechanical Ventilation (eBook)

Contents 5
Abbreviations 11
Section I Interface Technology in Critical Care Settings 15
1: Full Mask Ventilation 16
1.1 Introduction 16
1.2 Total-Face Mask During NPPV 17
1.3 Discussion 18
Key Recommendations 18
References 19
2: Helmet Continuous Positive Airway Pressure: Theory and Technology 20
2.1 Introduction 20
2.2 Helmet Technology 20
2.2.1 Helmet to Deliver Noninvasive CPAP 21
2.3 Limitations of the Technique 22
2.3.1 Carbon Dioxide Rebreathing 22
2.3.2 Noise 23
2.3.3 Pressure Monitoring and Generators 24
Key Recommendations 24
References 25
3: Helmet Continuous Positive Airway Pressure: Clinical Applications 26
3.1 Introduction 26
3.1.1 Acute Cardiogenic Pulmonary Edema 27
3.1.2 Acute Noncardiogenic Respiratory Failure 27
3.2 Experience with Helmet CPAP at Our Institution 29
3.3 Conclusion 30
Key Recommendations 30
References 31
Section II Ventilatory Modes and Ventilators: Theory, Technology, and Equipment 32
4: Pressure Support Ventilation 33
4.1 Introduction 33
4.2 Mechanisms of Action 34
4.3 Patient–Ventilator Interaction 35
4.4 Conclusions 37
Key Recommendations 38
References 38
5: Ventilators for Noninvasive Mechanical Ventilation 39
5.1 Introduction 39
5.2 Classification of Ventilators 40
5.3 Technologic Issues 42
5.3.1 Source of Gas and Oxygen Supply 42
5.3.2Circuit 42
5.3.3 Inspiratory Trigger and Expiratory Cycle 44
5.3.4 Inspiratory Flow 45
5.3.5 Backup Respiratory Rate 45
5.3.6 Air Leak Compensation 46
5.3.7 Battery 47
5.3.8 Alarm and Monitoring System 47
5.4 Controversial Issues 48
Key Recommendations 49
References 49
6: Noninvasive Positive Pressure Ventilation Using Continuous Positive Airway Pressure 51
6.1 Introduction 51
6.2 Equipments 51
6.2.1 Continuous Positive Pressure Flow Generators 51
6.2.2 Intensive Care Unit Ventilators (High-Pressure-Driven Ventilators) 52
6.2.3 Ventilators Designed to Administer Noninvasive Positive Pressure Ventilation 52
6.2.4 Boussignac CPAP 53
6.2.5 Bubble CPAP 53
6.3 Discussion 54
Key Recommendations 54
References 54
7: Home Mechanical Ventilators 56
7.1 Introduction 56
7.2 Technology and Equipment 56
7.2.1 Ventilators 56
7.2.2 Mechanical Ventilation Modes 57
7.2.2.1 Initiation of Positive Pressure 57
7.2.2.2 Gas Delivery by the Ventilator During Inspiration 58
7.2.2.3 Cycling Off Variable 59
7.2.3 Interfaces for the Delivery of Noninvasive Ventilation 59
7.2.3.1 Nasal Interfaces 59
7.2.3.2 Oronasal Interfaces 59
7.2.3.3 Mouth Interfaces 59
7.2.4 Humidification 60
7.2.5 Safety 60
7.3 Conclusion 60
References 60
8: Maintenance Protocol for Home Ventilation Circuits 62
8.1 Introduction 62
8.2 Equipment for Home Mechanical Ventilation 62
8.2.1 Dirtiness, Contamination, Colonization 63
8.2.2 Maintenance Is Empirically Driven 63
8.2.3 A European Survey on Maintenance 63
8.2.4 Patients Do Not Clean Their Equipment 64
8.2.5 Sensitivity to Infections 64
8.3 Analysis and Discussion 64
8.3.1 Restrictive Disorders 64
8.3.2 Obstructive Disorders 65
Key Recommendations 68
References 68
9: Nocturnal Noninvasive Mechanical Ventilation 69
9.1 Introduction 69
9.2 Effect of Nocturnal Mechanical Ventilation 70
9.3 Equipment Requirements for Nocturnal Ventilation 71
9.3.1 Type of Ventilator 71
9.3.2 Modes of Ventilation 72
9.3.3 Type of Interface 72
9.4 Conclusion 73
Key Recommendations 73
References 73
Section III Patient–Ventilator Interactions 74
10: Patient–Ventilator Interaction During Noninvasive Pressure-Supported Spontaneous Respiration in Patients with Hypercapnic Chronic Obstructive Pulmonary Disease 75
10.1 Introduction 75
10.2 Patient Response to the Ventilator 75
10.3 Ventilator Response to the Patient 76
Key Recommendations 78
References 79
11: Asynchrony and Cyclic Variability in Pressure Support Ventilation 80
References 82
12: Carbon Dioxide Rebreathing During Noninvasive Mechanical Ventilation 84
12.1 Introduction 84
12.2 General Mechanisms of Carbon Dioxide Rebreathing 84
12.3 CO2 Rebreathing During Mask Ventilation 85
12.4 CO2 Rebreathing During Helmet Ventilation 87
Key Recommendations 89
References 89
13: Carbon Dioxide Rebreathing During Pressure Support Ventilation with Airway Management System (BiPAP) Devices 90
13.1 Introduction 90
13.2 Rebreathing Mechanisms 90
13.3 Bench and Clinical Studies 91
13.4 Exhalation Port Characteristics 92
13.5 Devices Evolution 92
13.6 Conclusion 92
Key Recommendations 93
References 93
14: Carbon Dioxide Rebreathing in Noninvasive Ventilation 94
14.1 Introduction 94
14.2 Main Topics 95
14.2.1 Type of Circuit 95
14.2.2 Type of Mask 95
14.2.3 Devices Attached to the Circuit 95
14.2.4 Level of EPAP Used 96
14.2.5 Patient Characteristics: Hypercapnia or Normocapnia 96
14.3 Discussion 96
Key Recommendations 98
References 98
15: New Adaptive Servo-Ventilation Device for Cheyne–Stokes Respiration 100
15.1 Introduction 100
15.2 Methods 101
15.3 Results 101
15.4 Discussion 103
References 105
Section IV Monitoring and Complications 106
16: Nocturnal Monitoring in the Evaluation of Continuous Positive Airway Pressure 107
16.1 Introduction 107
16.2 Analysis and Discussion 108
Key Recommendations 110
References 111
17: Complications During Noninvasive Pressure Support Ventilation 112
17.1 Introduction 112
17.2 Interface Related Complications 112
17.2.1 Arm Edema and Arm Vein Thrombosis 114
17.2.2 Carbon Dioxide Rebreathing 114
17.2.3 Claustrophobia 114
17.2.4 Discomfort 115
17.2.5 Mechanical Malfunction 115
17.2.6 Nasal Bridge Ulceration 116
17.2.7 Noise 116
17.2.8 Patient–Ventilator Dyssynchrony 117
17.3 Air Pressure and Flow Related Complications 117
17.3.1 Air Leaks 118
17.3.2 Nasal or Oral Dryness and Nasal Congestion 118
17.3.3 Gastric Distension 119
17.4 Patient Related Complications 119
17.4.1 Aspiration Pneumonia 119
17.4.2 Barotrauma 120
17.4.3 Hemodynamic effects 120
Key Recommendations 121
References 121
Section V Chronic Applications of Noninvasive Mechanical Ventilation and Related Issues 123
18: Efficacy of Continuous Positive Airway Pressure in Cardiovascular Complications of Obstructive Sleep Apnea 124
18.1 Introduction 124
18.2 Pathophysiology 124
18.3 Cardiovascular Complications in Patients with OSA 126
18.3.1 Systemic Hypertension 126
18.3.1.1 CPAP Therapy Effects 126
18.3.2 Coronary Artery Disease 126
18.3.2.1 CPAP Therapy Effects 128
18.3.3 Heart Failure 128
18.3.3.1 CPAP Therapy Effects 128
18.3.4 Pulmonary Arterial Hypertension 129
18.3.5 CPAP Therapy Effects 129
18.3.6 Stroke 130
18.3.6.1 CPAP Therapy Effects 130
Key Recommendations 131
References 131
19: Obstructive Sleep Apnea and Atherosclerosis 134
19.1 Introduction 134
19.2 Relation of Obstructive Sleep Apnea to Atherosclerosis 134
Key Recommendations 136
References 137
20: Transnasal Insufflation — A New Approach in the Treatment of OSAs 138
20.1 Introduction 138
20.2 Mechanism of Actions of Nasal Insufflations 139
20.2.1 Effect on Upper Airway 139
20.2.2 Effect on Ventilation 140
20.3 Predictors for Therapeutic Responses to TNI in Adults with OSA 142
20.4 Therapeutic Responses in Children with OSA 142
20.5 Summary 144
References 144
21: Cardiopulmonary Interventions to Prolong Survival in Patients with Duchenne Muscular Dystrophy 146
21.1 Introduction 146
21.2 Respiratory Management 146
21.2.1 NIV for Chronic Respiratory Failure 146
21.2.2 Airway Clearance 147
21.2.3 Management of Chest Colds 148
21.2.4 Long-Term Continuous NIV 148
21.3 Cardioprotection 148
21.3.1 Cardiac Evaluation 148
21.3.2 Combined Drugs and NIV 149
21.4 Anesthesia and Sedation 149
21.5 The Parent as the “Lifeline” for a Child’s Life Using NIV 150
Key Recommendations 150
References 151
22: Noninvasive Ventilation Pressure Adjustments in Patients with Amyotrophic Lateral Sclerosis 152
References 154
23: Noninvasive Positive Pressure Ventilation in Amyotrophic Lateral Sclerosis 155
23.1 Introduction 155
23.2 Respiratory Function Evaluation 156
23.3 Noninvasive Positive Pressure Ventilation 157
23.4 Supportive Care 159
Conclusion and Key Recommendations 161
References 161
24: Noninvasive Mechanical Ventilation as an Alternative to Endotracheal Intubation During Tracheotomy in Advanced Neuromuscul Disease 162
24.1 Introduction 162
24.1.1 Difficulties for intubation and invasive procedures in neuromuscular disease 162
24.2 Conclusion 167
24.2.1 Use of NIV may decrease complications during invasive procedures in neuromuscular disease 167
Key Recommendations 167
References 167
25: Noninvasive Mechanical Ventilation in Patients with Myasthenic Crisis 168
25.1 Conclusion 170
References 171
26: Predictors of Survival in COPD Patients with Chronic Hypercapnic Respiratory Failure Receiving Noninvasive Home Ventilation 172
26.1 Introduction 172
26.2 Predictors of Long-Term Survival in Patients with COPD and CHRF 173
26.3 Implications for the Assessment and Monitoring of Patients with COPD and CHRF 173
26.4 Impact of the Decision to Initiate NIV in Severe COPD 175
Key Recommendations 177
References 178
27: Withdrawal of Noninvasive Mechanical Ventilation in COPD Patients with Hypercapnic Respiratory Failure 179
27.1 Introduction 179
27.2 Use of NIMV in Acute Hypercapnic Respiratory Failure 180
27.3 Rationale for Designing a Protocol to Withdraw NIMV 181
27.3.1 Determining the Readiness to Withdraw NIMV in Hypercapnic Respiratory Failure 181
27.3.2 Methods to Withdraw NIMV in Hypercapnic Respiratory Failure 182
27.4 Long-Term Dependency on NIMV 183
Key Recommendations 184
References 184
28: Noninvasive Ventilation in Patients with Acute Exacerbations of Asthma 185
28.1 Introduction 185
28.2 Case Series 186
28.2.1 The Randomized Controlled Trials 187
28.3 Summary 188
Key Recommendations 189
References 189
29: Noninvasive Positive Pressure Ventilation During Acute Asthmatic Attack 191
29.1 Introduction 191
29.2 Evidence for Use of NPPV in Asthmatic Attacks 192
29.3 Pathophysiology and Mechanism of Action 194
29.4 Setting Up Ventilatory Support and Patient–Ventilator Interaction 195
29.5 Cycling in Commercial Ventilators 196
29.6 Possible Risks and Side Effects of NPPV in Asthma 196
29.7 Conclusion 197
References 197
30: Noninvasive Positive Pressure Ventilation for Long-Term Ventilatory Management 198
30.1 Introduction 198
30.2 Patients Who Need This Technology and Equipment 198
30.3 Purpose of This Technology 199
30.4 How to Introduce This Technology 199
30.5 Ventilators and Ventilator Setting 200
30.6 Interfaces 201
30.7 Surrounding Machines 201
Key Recommendations 201
References 202
31: Home Ventilation for Chronic Obstructive Pulmonary Disease 203
31.1 Introduction 203
31.2 Physiologic Effects of NIV in COPD 203
31.3 Summary of Available Clinical Evidence 204
31.3.1 Mortality and Hospital Admissions 204
31.3.2 Quality of Life, Exercise Capacity, and Sleep 205
31.4 Practical Aspects of Home NIV in COPD 205
31.4.1 Ventilators and Interfaces 205
31.4.2 NIV Initiation and Follow-Up in COPD Patients 206
31.5 Selection of Patients for Home NIV 206
Key Recommendations 208
References 208
Section VI Critical Care Applications of Noninvasive Mechanical Ventilation and Related Issues 212
32: Current Strategies and Equipment for Noninvasive Ventilation in Emergency Medicine 213
32.1 Introduction 213
32.2 Analysis of Main Topics 213
32.2.1 NIV Trial in the ED 213
32.2.2 Prehospital CPAP 214
32.3 Discussion 214
Key Recommendations 216
References 216
33: Noninvasive Ventilation Outside of Intensive Care Units 218
33.1 Introduction 218
33.2 NIV Outside Intensive Care 219
33.3 Evidence of NIV Success Outside the Intensive Care Unit 220
33.3.1 Acute Exacerbation of COPD 220
33.3.2 Acute Cardiogenic Pulmonary Edema 221
33.3.3 Hematological Malignancy and Mixed Etiology 222
33.4 Monitoring 222
33.5Conclusion 222
References 223
34: Noninvasive Positive Airway Pressure and Risk of Myocardial Infarction in Acute Cardiogenic Pulmonary Edema 225
34.1 Introduction 225
34.2 Rationale for the Use of Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema 226
34.3 Noninvasive Ventilation and Risk of Acute Cardiogenic Myocardial Infarction 227
Key Recommendations 229
References 229
35: The Role of Continuous Positive Airway Pressure in Acute Cardiogenic Pulmonary Edema with Preserved Left Ventricular Systolic Function: A Preliminary Study 231
35.1 Introduction 231
35.2 Methods 231
35.3 Study Design 232
35.4 Results 232
35.5 Discussion 232
References 234
36: Noninvasive Ventilation in Acute Lung Injury/Acute Respiratory Distress Syndrome 235
36.1 Introduction 235
36.2 Physiological Basis for NIV in ALI/ARDS 236
36.3 Studies Investigating the Use of NIV in ALI/ARDS 236
36.4 Practical Application of NIPPV in ALI/ARDS 238
36.5 Conclusions 241
References 241
37: Noninvasive Positive Pressure Ventilation in Acute Hypoxemic Respiratory Failure and in Cancer Patients 243
37.1 Introduction 243
37.2 Epidemiology of Hypoxemic ARF 244
37.3 NPPV in Hypoxemic ARF 244
37.4 ARF in Imunosuppressed and Cancer Patients 245
37.5 NPPV in Cancer Patients 245
37.6 Indications and Contraindications 245
37.7 Complications of NPPV 248
Key Recommendations 248
References 249
38: Noninvasive Ventilation as a Preoxygenation Method 250
38.1 Introduction 250
38.2 Preoxygenation in Critically Ill Patients 251
38.3 Noninvasive Ventilation as a Preoxygenation Method 252
38.4 Noninvasive Ventilation Complications and Outcome 253
38.5 Discussion and Recommendations 254
References 254
39: Influence of Staff Training on the Outcome of Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure 256
39.1 Introduction 256
39.2 Influence of Staff Training Regarding Where NIV Occurs 257
39.3 Use of Staff to Initiate NIV 257
39.4 Importance of Training in NIV 257
39.5 Training Programs 258
Key Recommendations 259
References 259
Section VII The Role of Sedation 260
40: Sedation for Noninvasive Ventilation in Intensive Care 261
40.1 Introduction 261
40.2 Which Drug for Sedation? 261
40.3 Monitoring Sedation During NIV 263
40.4 Conclusion 263
Key Recommandations 264
References 264
41: Use of Dexmedetomidine in Patients with Noninvasive Ventilation 265
41.1 Introduction 265
41.2 Analysis Main Topics 265
41.3 Discussion 266
Key Recommendations 267
References 267
Section VIII Weaning from Conventional Mechanical Ventilation and Postextubation Failure 269
42: Extubation and Decannulation of Unweanable Patients with Neuromuscular Weakness 270
42.1 Introduction 270
42.1.1 Respiratory Muscle Aids 270
42.1.2 Acute Respiratory Decompensation and Conventional Management 271
42.1.3 Conventional Outcomes of Acute Respiratory Failure 271
42.2 Extubation of Unweanable Patients to NIV/MAC 272
42.3 Decannulation of Unweanable Patients 274
References 276
43: Mechanically Assisted Coughing and Noninvasive Ventilation for Extubation of Unweanable Patients with Neuromuscular Diseas or Weakness 278
43.1 Introduction 278
43.2 The Respiratory Muscle Groups 279
43.3 Extubation Protocol 281
References 284
44: Noninvasive Positive Pressure Ventilation in the Postextubation Period 286
44.1 Introduction 286
44.2 NPPV to Facilitate Weaning and Extubation 287
44.3 NPPV for Prevention and Treatment of Postextubation Respiratory Failure 289
44.3.1 NPPV to Prevent Postextubation Respiratory Failure 289
44.3.2 NPPV to Treat Postextubation Respiratory Failure 290
44.4 Conclusions 291
Key Recommendations 293
References 293
45: Noninvasive Ventilation in Postextubation Respiratory Failure 296
45.1 Introduction 296
45.2 Pathophysiology of Postextubation Respiratory Failure 297
45.3 Physiological Basis for the Use of NIV in Postextubation Respiratory Failure 297
45.4 Noninvasive Ventilation in Postextubation Respiratory Failure 298
45.5 Noninvasive Ventilation in Patients at Risk for Respiratory Failure After Extubation 300
45.6 Conclusions 302
References 303
Section IX Intraoperative and Postoperative Indications for Noninvasive Mechanical Ventilation 306
46: Intraoperative Use of Noninvasive Ventilation 307
46.1 Introduction 307
46.2 The Rationale 307
46.3 Technical Aspects and Clinical Intraoperative Scenario 308
46.4 Conclusion 309
Key Recommendations 310
References 310
47: Noninvasive Ventilation in Adult Liver Transplantation 311
47.1 Introduction 311
47.2 Pathophysiology of Respiratory Failure in Liver Recipients 311
47.3 NIV as a Tool to Facilitate Early Extubation After OLTx 312
47.4 NIV in the Prevention of Posttransplant Infectious Diseases 314
47.5 NIV in the Prevention of Tracheal Reintubation After OLTx 314
47.6 Conclusion 315
Key Recommendations 316
References 316
48: Noninvasive Positive Pressure Ventilation in Patients Undergoing Lung Resection Surgery 317
48.1 Introduction 317
48.2 NPPV Improves Gas Exchange After Lung Resection Surgery 318
48.3 NPPV Reduces Mortality in Acute Respiratory Failure Following Lung Resection 319
48.4 Prophylactic Use of NPPV Following Lung Resection 319
48.5 Conclusions 320
References 321
Section X Noninvasive Mechanical Ventilation in Neonates and Children 323
49: Equipment and Technology for Continuous Positive Airway Pressure During Neonatal Resuscitation 324
49.1 Introduction 324
49.2 CPAP Interface 325
49.2.1 Nasal Prongs 325
49.2.2 Face Mask 325
49.3 CPAP Device 326
49.4 Problems with the Use of CPAP 327
49.5 Limitations of CPAP and PEEP in the Delivery Room 328
Key Recommendations 329
References 330
50: Air Leakage During Continuous Positive Airway Pressure in Neonates 331
50.1 Introduction 331
50.2 Air Leakage Measurements During CPAP Treatment of Neonates 333
50.2.1 Theory of Air Leakage Measurements During CPAP 333
50.2.2 Computer Simulation 335
50.2.3 In Vitro Experiments 337
50.3 Discussion 339
Acknowledgments 342
Key Recommendations 342
References 342
51: The Use of Noninvasive Ventilation in the Newborn 345
51.1 Introduction 345
51.2 Materials and Methods 345
51.3 Types of NIV 346
51.4 Benefits of NIV in Newborns 346
51.5 Indications for NIV 346
51.6 Comparison of Different Modes of NIV 347
51.7 Contraindications to NIV 347
51.8 Side Effects 347
51.9 Failure Criteria 347
51.10 Weaning from NIV 348
51.11 Patient Care 348
Key Recommendations 348
References 348
52: Nasal High-Frequency Ventilation: Clinical Studies and Their Implications 350
52.1 Introduction 350
52.2 Noninvasive Modes of Ventilation 351
52.3 Nasal High-Frequency Ventilation 352
52.4 Discussion 353
Key Recommendations 354
References 354
53: Bubble Continuous Positive Airway Pressure 356
53.1 Introduction 356
53.2 Bubble CPAP Circuits, Lung Mechanics, and Their Influence on Delivered CPAP 357
53.3 Clinical Studies 358
53.4 Theory and Discussion 359
53.4.1 Airway Recruitment: Power Laws, Avalanches, and Stochastic Resonance 359
53.4.2 Gas Mixing and CO2 Clearance 360
53.4.3 Inflammation and Surfactant Metabolism 361
53.5 Conclusions 361
Key Recommendations 361
References 362
54: Noninvasive Mechanical Ventilation with Positive Airway Pressure in Pediatric Intensive Care 363
54.1 Introduction 363
54.2 The Equipment 363
54.2.1 The Masks 364
54.2.2 The Helmet 364
54.3 The Choice of the Mechanical Ventilator 365
54.4 Humidification 365
54.5 Timing of NIV Initiation 365
54.6 Monitoring 366
54.7 Contraindications 366
54.8 Side Effects 366
54.8.1 Gastric Distension 366
54.8.2 Skin Injury 366
54.8.3 Major Complications 366
54.9 Factors Predicting Success or Failure 367
54.10 Application of NIV in the Acute Setting 367
54.10.1 Cystic Fibrosis 367
54.10.2 Lower Airway Obstruction 368
54.10.3 Upper Airway Obstruction 368
54.10.4 Acute Respiratory Distress Syndrome 368
54.10.5 Postextubation Respiratory Failure/Weaning from Extubation 369
54.10.6 Immunocompromised Patients 369
54.11 NIV in Patients Under 1 Year of Age 369
Key Recommendations 370
References 370
55: Home Mechanical Ventilation in Children with Chronic Respiratory Failure 373
55.1 Introduction 373
55.2 Methods of NIV 373
55.2.1 Negative Pressure Ventilation 373
55.2.2 Positive Ventilation via Mask 374
55.3 Clinical Scenarios for Home Noninvasive Ventilation with Positive Pressure 374
55.3.1 Obstructive Sleep Apnea Syndrome 374
55.3.2 Neuromuscular Diseases 375
55.3.3 Central Hypoventilation 376
55.3.4 Cystic Fibrosis 377
55.4 Relative Contraindications 378
55.5 The Interface in NIV 378
55.5.1 Nasal Versus Full-Face Mask 378
55.5.2 New Masks 378
55.6 Complications of NIV via Mask 379
55.6.1 Poor Mask Fit and Skin Irritation 379
55.6.2 Midfacial Deformity 379
55.7 Initiation of Home Ventilation 379
55.7.1 Initial NIV Adjustments in Children 380
55.8 Discharging the Pediatric Patient on NIV 380
55.9 Follow-Up 381
Key Recommendations 381
References 381
Index 383