Noninvasive Positive Pressure Ventilation Via Face Mask: First-Line Intervention in Patients With Acute Hypercapnic and Hypoxemic Respiratory Failure

doi:10.1378/chest.109.1.179

Chest

Volume 109, Issue 1, January 1996, Pages 179-193

https://doi.org/10.1378/chest.109.1.179 Get rights and content

Objectives

We have previously reported our experience with noninvasive positive pressure ventilation (NPPV) via face mask in a small group of selected patients with acute respiratory failure (ARF). NPPV was frequently effective (70% success rate) in correcting gas exchange abnormalities and in avoiding endotracheal intubation (ETI); NPPV also had a low rate of complications. We have evaluated the clinical application of NPPV as first-line intervention in patients with hypercapnic and short-term hypoxemic ARF. A dedicated respiratory therapist conducted an educational program with physicians-in-training rotating through the medical ICUs of a university medical center and supervised implementation of a simplified management protocol. Over 24 months, 164 patients with heterogeneous forms of ARF received NPPV. We report on the effectiveness of NPPV in correcting gas exchange abnormalities, in avoiding ETI, and associated complications, in different conditions precipitating ARF.

Patient population

One hundred fifty-eight patients completed the study. Forty-one had hypoxemic ARF, 52 had hypercapnic ARF, 22 had hypercapnic acute respiratory insufficiency (ARI), 17 had other forms of ARF, and 26 with advanced illness had ARF and refused intubation. Twenty-five percent of the patients developed ARF after extubation.

Intervention

Mechanical ventilation was delivered via a face mask. Initial ventilatory settings were continuous positive airway pressure (CPAP) mode, 5 cm H₂O, with pressure support ventilation of 10 to 20 cm H₂O titrated to achieve a respiratory rate less than 25 breaths/min and an exhaled tidal volume of 7 mL/kg or more. Ventilator settings were adjusted following arterial blood gases (ABG) results.

Results

The mean duration of NPPV was 25 ±24 h. When the 26 patients with advanced illness are excluded, NPPV was effective in improving or correcting gas exchange abnormalities in 105 patients (80%) and avoiding ETI in 86 (65%). Failure to improve ABG values was the reason for ETI in 20 of 46 (43%). The overall average predicted and actual mortality were 32% and 16%, respectively. Survival was 93% in nonintubated patients and 79% in intubated patients. NPPV was effective in lessening dyspnea throughout treatment in all but seven patients. Complications developed in 24 patients (16%). In patients with hypercapnic ARF, nonresponders had a higher PaCO₂ at entrance (91.5±4.2 vs 80±1.5; p<0.01). In patients with hypercapnic ARF and ARI, arterial blood gases response (pH and PaCO₂) within 2 h of NPPV predicted success (p<0.0001). None of the entrance parameters predicted need for ETI.

Conclusions

We conclude that application of NPPV in clinical practice is an effective and safe alternative to ETI in many hemodynamically stable patients with hypercapnic ARF and in those with hypoxemic ARF in whom the clinical condition can be readily reversed in 48 to 72 h. An educational and supervision program is essential to successfully implement this form of therapy.

Section snippets

MATERIALS AND METHODS

The study was conducted from March 1992 to March 1994 at the University of Tennessee Health Science Center in Memphis in the medical ICUs of the Regional Medical Center and Veterans Affairs Medical Center. The study was approved by the Institutional Review Board. An educational program was conducted monthly by a dedicated RT for house staff and fellows rotating through these medical ICUs and for ICU nurses and RTs. This program included an instructional videotape to demonstrate methodology of

RESULTS

Over the 24-month period of the study, the number of patients receiving MV with either ETI or NPPV in the two medical ICUs was 674, an average of 28 per month. During that interval, NPPV was attempted in 164 patients (24%), including 26 patients who had refused intubation prior to study entry. NPPV was successful in avoiding intubation in 65% (86/132) of the patients in which it was attempted and in 13% (86/642) of all patients receiving MV. Most patients in whom NPPV was not attempted had

DISCUSSION

To our knowledge, the present study is the largest published experience using NPPV as first-line intervention in a heterogeneous population of patients with ARF. This study has limitations related to the reality of clinical investigation in a teaching center. Many of the patients with ARF admitted to the ICU were already intubated in the emergency department or the ward. Despite this, in the last 14 months of the study, 36% of all patients with ARF received NPPV. Over the 2-year period of the

CONCLUSION

The findings of this large prospective observational study confirm our and others' previous reports on the effectiveness of NPPV in correcting gas exchange abnormalities and avoiding intubation in selected patients with ARF. The protocol was simple to implement and monitor. Education of physicians in training and direct supervision by an experienced RT were essential to the success of the project. NPPV proved to be effective, comfortable, and safe. Duration of ventilation was short, confirming

ACKNOWLEDGMENTS

We wish to recognize the enthusiastic support from pulmonary attendings and fellows, therapists, nurses, and house staff during the period of the study, and Dr. D. Armbruster for editorial review.

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Influence of total face masks design and circuit on synchrony and performance during pressure support ventilation: A bench study
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Few studies investigated the influence of the circuit applied during non-invasive ventilation (NIV) with a total face mask. The aim of this bench study was to evaluate the effects of separated inflow and outflow ports in a total face mask on patient ventilator interaction and performance during NIV through a total face mask.
A mannequin was connected to an active lung simulator. NIV was applied both via a standard total face mask (STFM) with a Y-piece connector for inflow/outflow gases and a modified total face mask (MTFM) with 2 different connectors for inflow and outflow gases.
The MTFM showed both a significantly better patient-ventilator interaction and a significantly higher performance.
The MTFM showed a significantly lower Δtrigger compared to STFM (p<0.01) and shorter value of PTPtrigger during all ventilator setting tested (p < 0.01).
Significant differences in PTP 200, PTP 300, and PTP 500 were observed between the MTFM and STFM (p < 0.01) in all conditions tested. Concerning PTP 500 ideal index, in all the conditions tested, the MTFM presented higher values compared to STFM, although those differences were not statistically significant.
At both RRsim and ventilator settings tested, the MTFM showed a significantly shorter Delaytrinsp and Delaytrexp compared to STFM (p < 0.01).
At both RRsim tested and both ventilator settings, the MTFM showed a significantly longer Timesync compared to STFM (p < 0.01).
The MTFM showed a significantly better patient ventilator interaction and a better ventilator performance, suggesting that this kind of total face mask design should be preferred in clinical practice.
Predictors of success and failure of non-invasive ventilation use in type-2 respiratory failure
2021, Indian Journal of Tuberculosis
Non-invasive ventilation is widely used now a days in patients with hypercapnic respiratory failure. Non-invasive ventilation can be used in Intensive Care Unit setting and wards provided trained staff is there to monitor.
This was a prospective observational study of 100 adult patients who were admitted with hypercapnic respiratory failure. Demographic information such as Age, Sex were recorded. Clinical parameters like Respiratory Rate, Heart Rate, Oxygen saturation and Arterial Blood Gas variables like pH, PaCO₂, HCO₃ were measured at the time of admission and at 1st hour, 4 hours and 24 hours after start of non-invasive ventilation. Outcome was recorded as success and failure with Non invasive ventilation.
Out of 100 patients, 76 (76%) managed successfully with non-invasive ventilation and 24 patients (24%) needed intubation and invasive mechanical ventilation in this study. Majority of patients (76%) were with clinical diagnosis of Chronic Obstructive Pulmonary Disease. Respiratory Rate and Heart Rate were significantly lower and showed significant improvement at 1st hour, 4 hours and 24 hours in patients who successfully improved with Non invasive ventilation. Oxygen saturation was found to be significantly higher among patients successfully managed with Non invasive ventilation (84.35 ± 8.55 vs 76.87 ± 7.33) as compared to patients who required intubation. pH was found to be significantly higher (7.28 ± 0.06 vs 7.23 ± 0.05) in patients showing good response to Non invasive ventilation and improvement in pH at 1st hour, 4 hours and 24 hours was observed in patients successfully managed with Non invasive ventilation. PaCO₂ level was found to be significantly lower and significant improvement in PaCO₂ at 1st hour, 4 hours and 24 hours was seen in patients with Non invasive ventilation success.
Improvement in clinical parameters like respiratory rate, heart rate, Oxygen saturation and improvement in ABG variables like pH, PaCO2 after 1st and 4 hours of start of Non invasive ventilation and maintaining the improvement at 24 hours are predictors of success of non-invasive ventilation in hypercapnic patients.
Noninvasive Mechanical Ventilation in Acute Respiratory Failure: Happy 30-Year Anniversary!
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The burden of obesity hypoventilation syndrome
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The prevalence of obesity hypoventilation syndrome (OHS) is likely to increase given the increased prevalence of morbid obesity in the United States and other countries. The goal of this chapter is to discuss the prevalence of OHS and its risk factors. OHS is an underrecognized disorder with adverse outcomes on quality of life, healthcare costs, and hospitalizations. Patients with OHS have significant morbidity and mortality if left untreated and early diagnosis and treatment can lead to significant improvement in patient outcomes.
Non-invasive ventilation in children and adults in low- and low-middle income countries: A systematic review and meta-analysis
2018, Journal of Critical Care
We systematically reviewed the effects of NIV for acute respiratory failure (ARF) in low- and low-middle income countries.
We searched MEDLINE, CENTRAL, and EMBASE (to January 2016) for observational studies and trials of NIV for ARF or in the peri-extubation period in adults and post-neonatal children. We abstracted outcomes data and assessed quality. Meta-analyses used random-effect models.
Fifty-four studies (ten pediatric/n = 1099; 44 adult/n = 2904), mostly South Asian, were included. Common diagnoses were pneumonia and chronic obstructive pulmonary disease (COPD). Considering observational studies and the NIV arm of trials, NIV was associated with moderate risks of mortality (pooled risk 9.5%, 95% confidence interval (CI) 4.6–14.5% in children; 16.2% [11.2–21.2%] in adults); NIV failure (10.5% [4.6–16.5%] in children; 28.5% [22.4–34.6%] in adults); and intubation (5.3% [0.8–9.7%] in children; 28.8% [21.9–35.8%] in adults). The risk of mortality was greater (p = 0.035) in adults with hypoxemic (25.7% [15.2–36.1%]) vs. hypercapneic (12.8% [7.0–18.6%]) ARF. NIV reduced mortality in COPD (relative risk [RR] 0.47 [0.27–0.79]) and in patients weaning from ventilation (RR 0.48 [0.28–0.80]). The pooled pneumothorax risk was 2.4% (0.8–3.9%) in children and 5.2% (1.0–9.4%) in adults. Meta-analyses had high heterogeneity.
NIV for ARF in these settings appears to be effective.
Cost-utility of non-invasive mechanical ventilation: Analysis and implications in acute respiratory failure. A brief narrative review
2018, Respiratory Investigation
The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.

View all citing articles on Scopus

: Supported in part by Puritan-Bennett Grant R07-3340-67.

: revision accepted August 22.

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Chest

Clinical Investigations in Critical CareNoninvasive Positive Pressure Ventilation Via Face Mask: First-Line Intervention in Patients With Acute Hypercapnic and Hypoxemic Respiratory Failure

Objectives

Patient population

Intervention

Results

Conclusions

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

ACKNOWLEDGMENTS

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Lancet

Chest

Chest

Chest

Chest

Chest

Crit Care Clin

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Noninvasive nasal mask ventilation for acute respiratory failure: institution of a new therapeutic technology for routine use

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Acute ventilatory failure treated by nasal ventilation

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Noninvasive modalities of positive pressure ventilation improve the outcome of acute exacerbations in COLD patients

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Noninvasive pressure support ventilation (NIPSV) in acute respiratory failure

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Use of bilevel positive airway pressure in patients with acute respiratory failure [abstract]

Chest

The use of noninvasive proportional assist ventilation to avoid intubation in patients with acute respiratory failure

Am Rev Respir Dis

Nasal ventilation vs doxapram in the treatment of type II respiratory failure complicating chronic airflow obstruction

Thorax

Clinical Investigations in Critical Care
Noninvasive Positive Pressure Ventilation Via Face Mask: First-Line Intervention in Patients With Acute Hypercapnic and Hypoxemic Respiratory Failure