Behind a Mask: Tricks, Pitfalls, and Prejudices for Noninvasive Ventilation

Abstract

It is difficult to exactly date the beginning of mechanical ventilation, but there are no doubts that noninvasive ventilation (NIV) was the first method of ventilatory support in clinical practice. The technique had a sudden increase in popularity, so that it is now considered, according to criteria of evidence-based medicine, the first-line treatment for an episode of acute respiratory failure in 4 pathologies (the Fabulous Four): COPD exacerbation, cardiogenic pulmonary edema, pulmonary infiltrates in immunocompromised patients, and in the weaning of extubated COPD patients. The so-called emerging applications are those for which the evidence has not achieved level A, mainly because the number or sample size of the published studies does not allow conclusive meta-analysis. These emerging applications are the post-surgical period, palliation of dyspnea, asthma attack, obesity hypoventilation syndrome, and to prevent extubation failure. Potentially "risky business" uses include for respiratory failure from pandemic diseases and ARDS, where probably the "secret" for success is early use. Healthcare is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly, if at all, so their clinical use remains limited and heterogeneous. The low rate of NIV use in some hospitals relates to lack of knowledge about or experience with NIV, insufficient confidence in the technique, lack of NIV equipment, and inadequate funding. But NIV use has been increasing around the world, thanks partly to improved technologies. The skill and confidence of clinicians in NIV have improved with time and experience, but NIV is and should remain a team effort, rather than the property of a single local "champion," because, overall, NIV is beautiful!

How to enhance experience and skill of non invasive ventilation: suggestions from the literature

“…The effect of the introduction of RTs in NIV management teams has been examined in only one study, by Kareus et al (21). These authors demonstrated an improvement in NIV tolerance after RT involvement, increasing patient tolerance to NIV by about 51%.Nava (22) reports that in Europe, NIV seems to be more popular than elsewhere, perhaps because the first randomized controlled trials were performed in France and the United Kingdom. It may be more popular there also because the physician has the direct responsibility in ordering and applying NIV with the support of all the staff, including nurses and RTs, while in most other continents the prescription is basically ordered by the physician but is independently applied by the RT; this might affect the teamwork (22).…”

Predictors of Noninvasive Ventilation Failure in Critically Ill Obese Patients: A Brief Narrative Review

“…During NIV therapy, observation and monitoring of the level of consciousness, vital signs, respiratory pattern, oxygen saturation and ABG are crucial [20,29,30]. NIV modality and ventilator setting during ARF episode should be adjusted based titration with polysomnography [31].…”

Effectiveness of non-invasive ventilation in acute respiratory failure of obese patients: a brief narrative review

“…NIV reduces the respiratory load, increases minute volume for a given breathing effort and provides ventilation during central apneic events. 19,22,23 The decreased responsiveness in hypoxic and hypercapnic ventilatory drive that characterizes this last category may explain why they need more time than expected to correct respiratory acidosis compared to other patients (e.g., COPD patients). 7,13 No randomized controlled trials comparing different forms of NIV for acute decompensated respiratory failure have been performed.…”

“…4 No ventilatory mode has been shown to lead to better outcome than others. [23][24][25][26] Several modes have been implemented: continuous positive airway pressure (CPAP), bilevel positive airway pressure (Bi-PAP), pressure support ventilation, assisted pressure control ventilation (APCV), Bi-PAP-spontaneoustimed (ST) with volume assured pressure support. 3,13,19,20,22,[25][26][27] More recently the so called highintensity ventilation (APCV with high rate back-up) has demonstrated encouraging results in terms of PaCO 2 reduction and mortality.…”

“…3,10,20,25 During NIV therapy, observation and monitoring of the level of consciousness, vital signs, respiratory pattern, oxygen saturation and arterial blood gases are crucial. 20,23,25,26 NIV modality and ventilator setting during ARF episode should be adjusted based titration with polysomnography. 3,25,26 Predictors of non-invasive ventilation failure NIV failure rates from 2 to 60%.…”