CMAJ • February 26, 2008; 178 (5). doi:10.1503/cmaj.1070174.
© 2008 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Noninvasive positive-pressure ventilation

Vincenzo Puro, MD, Francesco Maria Fusco, MD, Silvia Pittalis, MD, Simone Lanini, MD and Giuseppe Ippolito, MD

Epidemiological Department, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy

In their in-depth review of noninvasive positive-pressure ventilation in acute respiratory failure,1 Oscar Peñuelas and colleagues did not discuss the use of this treatment in patients with infections that are transmitted through aerosols. The efficacy of noninvasive positive-pressure ventilation in such patients has not been adequately tested, but anecdotal reports and observational studies have shown that this treatment can be successfully used in patients with acute respiratory failure resulting from human-adapted avian influenza, aspergillosis and varicella.2–4 The use of noninvasive positive-pressure ventilation eliminated the need for intubation in most patients with severe acute respiratory syndrome.5,6 When critical care resources are overstretched, such as during an influenza pandemic, noninvasive positive-pressure ventilation may be of value as an alternative to invasive ventilation or it may at least buy clinicians some time until invasive ventilation is available for their patient.

The available data on the risk to health care workers of acquiring infectious diseases through aerosols while they are performing noninvasive positive-pressure ventilation are conflicting and often methodologically flawed.5,6 Indeed, in a recent set of World Health Organization guidelines this procedure was included as one of the aerosol-generating procedures for which the risk of pathogen transmission is still controversial or possible but not documented.6 Nevertheless, experience in the field mostly shows the use of noninvasive positive-pressure ventilation to be safe, if appropriate precautions are taken5,6:infected patients should be placed in appropriate facilities and personal protective equipment should be worn. To further reduce the risk of pathogen diffusion, an exhalation port that generates round-the-tube airflow and a viral-bacterial filter interposed between the mask and the exhalation port should be used.6

Footnotes

Competing interests: None declared.


REFERENCES

  1. Peñuelas O, Frutos-Vivar F, Esteban A. Noninvasive positive-pressure ventilation in acute respiratory failure. CMAJ 2007;177:1211-8.[Abstract/Free Full Text]
  2. Tran TH, Nguyen TL, Nguyen TD, et al. Avian influenza A (H5N1) in 10 patients in Vietnam. N Engl J Med 2004;350:1179-88.[Abstract/Free Full Text]
  3. Antonelli M, Conti G, Bufi M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA 2000;283:235-41.[Abstract/Free Full Text]
  4. Sadovnikoff N, Varon J. CPAP mask management of varicella-induced respiratory failure. Chest 1993;103:1894-5.[CrossRef][Medline]
  5. Kamps BS, Hoffmann C, editors. SARS reference 10/2003. 3rd ed. Flying Publisher; 2003. Available: www.sarsreference.com/ (accessed 2007 Dec 31).
  6. World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. Doc no WHO/CDS/EPR/2007.6. Geneva: The Organization; 2007. Available: www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/ (accessed 2007 Dec 21).




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