Comfort During Non-invasive Ventilation

Abstract

Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.

An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study

“…The fractional concentration of oxygen was set to achieve peripheral oxygen saturation greater than 92%. In addition, appropriate strategies were used to improve NIV tolerance, such as controlling leakage, keeping the anchoring system as comfortable as possible, providing adequate humidification, alternatively using different interfaces, and administering sedation [ 18 ].…”

Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study

“…In the selection of the drug, clinical and side effects should be considered. Sedative drugs should be administered in ICU, in the presence of well-trained personnel in airway emergency management, with monitoring of vital signs and depth of sedation ( 37 ).…”

Monitoring the patient–ventilator asynchrony during non-invasive ventilation

“…As mentioned earlier, the presence of patient-ventilator asynchronies may impair the tolerance and comfort of the patient to NIV, leading to treatment failure (3,4,8,9). AI% values of ≥ 10% significantly reduce the comfort and NIV tolerance in 60 patients who are critically ill (8) and another population including 69 acute patients undergoing NIV through oral-nasal masks (79).…”

“…In patients affected with moderate to severe forms of ARF, including cardiogenic pulmonary edema and acute-on-chronic respiratory failure, non-invasive ventilation (NIV) plays a major role ( 1 ). However, NIV is affected by a certain percentage of treatment failure, requiring mostly orotracheal intubation and institution of invasive mechanical ventilation ( 3 ).…”

“…Behind the type and severity of ARF, worsening of gas change, respiratory distress, hemodynamic instability, or neurological deterioration, NIV may also fail because of the patient’s intolerance to the treatment ( 3 , 4 ). Among the reasons for treatment intolerance, there is a type of interface applied to the patient, the presence of massive air leaks, and the occurrence of patient – ventilator asynchronies ( 5 ).…”