The use of noninvasive ventilation in pulmonary disease has been shown to improve the blood gases of pati-ents both while awake [1][2][3] and asleep [1,4,5] but it has proved difficult to identify in which patients survival or quality of life can be improved [5][6][7]. Mask intermittent positive pressure ventilation (MIPPV) has been introduced in acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD) as a short-term measure to reduce intubation rates and improve survival [8].Long-term oxygen therapy (LTOT) improves survival in chronically hypoxic COPD patients [9,10]; however, patients with a high arterial carbon dioxide tension (Pa,CO 2 ) had a poor prognosis both prior to oxygen therapy [11,12] and (at least in the first year) with oxygen therapy [13]. In some patients, hypercapnia deteriorates with oxygen therapy manifesting with headaches, confusion, drowsiness and difficulty concentrating such that LTOT is not tolerated. Long-term MIPPV could in principle prevent this complication and improve survival.We report our experience with nocturnal mask ventilation in patients with COPD with hypercapnic respiratory failure in whom oxygen therapy resulted in worsening daytime or nocturnal hypercapnia. Materials and methods Patient selectionThe inclusion criteria were: 1) arterial oxygen tension (Pa,O 2 ) <7.3 kPa and Pa,CO 2 >6.0 kPa while breathing room air; 2) stable clinical state, arterial blood gases and pulmonary function tests over the 3 weeks prior to the study (with a daytime arterial H + concentration between 35-48 nmol -1 ); and 3) supplementary oxygen therapy failed either to raise the daytime Pa,O 2 to >7.3 kPa without a rise in the awake Pa,CO 2 to >8 kPa or failed to raise nocturnal oxygen saturations to >90% without a rise in the transcutaneous carbon dioxide tension (Ptc,CO 2 ) to >9 kPa. Patients with co-existing pulmonary diseases, neuromuscular or chest wall disorders were excluded. Twenty six patients, 13 males and 13 females, fulfilling these criteria were studied retrospectively. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. P. Sivasothy, I.E. Smith, J.M. Shneerson. ERS Journals Ltd 1998.ABSTRACT: Noninvasive ventilation in chronic obstructive pulmonary disease (COPD) has been shown to improve arterial blood gases but its long-term role has not been established.We retrospectively studied 26 consecutive patients with hypercapnic ventilatory failure due to COPD in whom oxygen therapy caused worsening hypercapnia (defined as a rise in the daytime arterial carbon dioxide tension (Pa,CO 2 ) to >8.0 kPa or nocturnal transcutaneous carbon dioxide tension (Ptc,CO 2 ) to >9 kPa). All were treated with mask ventilation (15 with nasal and 11 face masks) at night and during daytime naps. Additional oxygen therapy was required in 15 patients.The mean annualized death rate was 10.8% with a 1 and 3 yr survival of 92 and 68%, respectively. After 1 yr the median daytime Pa,CO 2 had falle...

The initial examination should be bronchoscopy when there is high clinical suspicion of carcinoma and relevant radiographic abnormality, and CT when strong clinical suspicion of carcinoma is not substantiated at bronchoscopy in patients with normal findings on chest radiographs.

A A l la ab bo or ra at to or ry y c co om mp pa ar ri is so on n o of f f fo ou ur r p po os si it ti iv ve e p pr re es ss su ur re e v ve en nt ti il la at to or rs s u us se ed d i in n t th he e h ho om me e I.E. Smith, J.M. Shneerson These results show that distinct brands of ventilator respond to changes in the patient and patient circuit in different ways, which are not always predictable from a simple description of their operating principles. This should be borne in mind when choosing a positive pressure ventilator for noninvasive ventilation.

These results confirm successful weaning outcomes for patients transferred to a specialized weaning and long-term ventilation service. In contrast to other service models, most patients achieved discharge to their own home.

The Monnal D is among the most widely used home ventilators with worldwide sales in excess Background -Some patients started on nasal intermittent positive pressure vent-of 10 000 units (Taema Ltd, Paris, France).Between 1988 and 1993 we started 112 patients ilation (NIPPV) with the Monnal D ventilator deteriorate after a period. The effects on long term nasal intermittent positive pressure ventilation (NIPPV) using the Monnal D. of changing them to the Nippy ventilator were investigated.Most initially responded well to treatment but a number have since deteriorated. The aim of Methods -The records of such patients were examined retrospectively. Com-the present investigation was to examine the effects of transferring these patients to another parisons were made between blood gas tensions and overnight oximetry records ventilator, the Nippy (Friday Medical, Herne Hill, UK). before NIPPV, 12 weeks after the initiation of NIPPV with the Monnal D, at the time of deterioration, and 12 weeks after initiation of treatment with the Nippy ventil-Methods ator.On the Monnal D the minute volume is preset. Results -Ten patients (seven women) were It operates in the assist/control mode with presidentified. Prior to starting NIPPV their sure triggering from expiration to inspiration. mean (SD) age was 59.6 (8.39) years and The maximum inspiratory pressure is aptheir mean arterial oxygen and carbon di-proximately 120 cm H 2 O and the maximum oxide tensions (Pa 2 and Pa 2 ) while minute volume 20 l/min. On the Nippy the breathing air were 6.1 (1.79) and 9.6 peak inspiratory pressure is preset along with (3.28) kPa, respectively. All were started the inspiratory and maximum expiratory time. on NIPPV with the Monnal D with im-The maximum inspiratory pressure is approvements in symptoms, Pa 2 , Pa 2 , and proximately 32 cm H 2 O and the maximum overnight oximetry after 12 weeks of treat-minute volume about 40 l/min. ment. After a mean interval of 118 (69.0)The records of all patients on long term weeks all measures of ventilation had de-NIPPV transferred from the Monnal D to the teriorated and the patients were converted Nippy ventilator were examined. Patients who to the Nippy ventilator. Twelve weeks after changed ventilators during an acute interinitiation of treatment with the Nippy current illness were excluded. Ten patients ventilator symptoms and overnight ox-(seven women) were identified who had initially imetry were improved again and the mean responded well to treatment on the Monnal D Pa 2 and Pa 2 were 8.9 (1.27) and 6.9 but after an interval had developed recurrent (0.45) kPa, respectively. After a total mean symptoms of ventilatory failure or poor sleep period of 59 (26.9) weeks on the Nippy all and deteriorating overnight oximetry (mean but one of the patients have maintained arterial oxygen saturation (Sa 2 ) <90%) or daythis improvement.time arterial blood gas tensions (Pa 2 >7 kPa The RespiratoryConclusions -Support with NIPPV using or Pa 2 <8 kPa). In each case these features is necessary if ...