Frontiers in Clinical Practice of Long-Term Care of Chronic Ventilatory Failure

Abstract

Home mechanical ventilation (HMV) is an effective long-term treatment for chronic hypercapnic respiratory failure. In addition to the established practice of providing HMV for the treatment of chronic ventilatory failure in slowly progressive neuromuscular and chest wall disease, there is accumulating evidence for improvement of quality of life and prolongation of survival by HMV in highly prevalent diseases like chronic obstructive pulmonary disease and ever-increasing obesity hypoventilation syndrome as well as rapidly progressive neuromuscular disease. The key concepts for successful HMV are an experienced team selecting the right patients, timely initiation of adequate ventilation via an appropriate interface, and monitoring effectiveness during regular long-term follow-up. Coaching of patients with chronic respiratory failure on long-term HMV within a dedicated service and collaborations with community services for home care are essential. The current review describes various important practical aspects of HMV that remain frontiers in the implementation of the current knowledge in clinical practice and may help in providing effective HMV to all those in need.

Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology

“…Table 2 summarizes the ventilator modes most commonly used for long-term NIV [23]. In long-term NIV, bi-level positive pressure support ventilation in spontaneous/timed mode (PSV-ST; Table 2) is presently the most commonly used mode in clinical practice.…”

“…Double-limb circuits are mostly used in acute care settings (ICU) [23, 51]. One tube is for inspiration, the other for expiration.…”

“…For home ventilation, single-limb circuits are most commonly used [23, 51]. They are less cumbersome.…”

Material and Technology: Back to the Future for the Choice of Interface for Non-Invasive Ventilation – A Concise Review

“…With the limit that nPPV is now questioned for the treatment of acute "de novo" hypoxemic patients [5], it has dramatically changed the treatment of both acute and chronic respiratory failure in the last 2 decades [3,4,[6][7][8][9][10][11][12][13][14][15][16]. The use of NIV has also been largely applied in the treatment of stable chronic hypercapnic respiratory failure as well as in the treatment patients with obstructive sleep apnoea and central sleep disorders [17][18][19][20][21][22][23]. The success of NIV is correlated to the application of the "best ingredients" of a patient's "tailored recipe," including the appropriate choice of the selected candidate, the ventilator setting, the interface, the expertise of the team, and the education of the caregiver [1,3,24,[26][27][28].…”

“…Concerning the air leak issue, the distinction between nCPAP and nPPV is very important because even if the same interface may be used during both modalities, the likelihood of unintentional air leaks [26], the type of exhalation system, the amount of skin breakdown, and the degree of patient's tolerance may be deeply different. Although in the acute setting, comfort seems to be less important than the efficacy of the treatment, mask fit and care are needed to prevent interface-related complications as in patient candidates for long-term domiciliary NIV [20][21][22][23]37]. Furthermore, a poorly fitting interface generating excessive air leaks that are not compensated by the ventilator may decrease the clinical effectiveness of nPPV and induce air leaks patient-ventilatory dyssynchrony (through loss of triggering sensitivity or auto-triggering or hindering achievement of the inspiration-termination criterion in pressure support mode).…”