Comparative Physiologic Effects of Noninvasive Assist-Control and Pressure Support Ventilation in Acute Hypercapnic Respiratory Failure

doi:10.1378/chest.111.6.1639

Chest

Volume 111, Issue 6, June 1997, Pages 1639-1648

https://doi.org/10.1378/chest.111.6.1639 Get rights and content

Study objective

To compare the effects of noninvasive assist-control ventilation (ACV) and pressure support ventilation (PSV) by nasal mask on respiratory physiologic parameters and comfort in acute hypercapnic respiratory failure (AHRF).

Design

A prospective randomized study.

Setting

A medical ICU.

Patients and interventions

Fifteen patients with COPD and AHRF were consecutively and randomly assigned to two noninvasive ventilation (NIV) sequences with ACV and PSV mode, spontaneous breathing (SR) via nasal mask being used as control. ACV and PSV settings were always subsequently adjusted according to patient's tolerance and air leaks. Fraction of inspired oxygen did not change between the sequences.

Measurements and results

ACV and PSV mode strongly decreased the inspiratory effort in comparison with SR. The total inspiratory work of breathing (WOBinsp) expressed as WOBinsp/tidal volume (VT) and WOBinsp/respiratory rate (RR), the pressure time product (PTP), and esophageal pressure variations (ΔPes) were the most discriminant parameters (p<0.001). ACV most reduced WOBinsp/VT (p<0.05), ΔPes (p<0.05), and PTP (0.01) compared with PSV mode. The surface diaphragmatic electromyogram activity was also decreased >32% as compared with control values (p<0.01), with no difference between the two modes. Simultaneously, NIV significantly improved breathing pattern (p<0.01) with no difference between ACV and PSV for VT, RR, minute ventilation, and total cycle duration. As compared to SB, respiratory acidosis was similarly improved by both modes. The respiratory comfort assessed by visual analog scale was less with ACV (57.23±30.12 mm) than with SB (75.15± 18.25 mm) (p<0.05) and PSV mode (81.62±25.2 mm) (p<0.01) in our patients.

Conclusions

During NIV for AHRF using settings adapted to patient's clinical tolerance and mask air leaks, both ACV and PSV mode provide respiratory muscle rest and similarly improve breathing pattern and gas exchange. However, these physiologic effects are achieved with a lower inspiratory workload but at the expense of a higher respiratory discomfort with ACV than with PSV mode.

Section snippets

Materials and Methods

The study was conducted in a medical ICU and approved by the Ethical Committee of the Charles Nicolle University Hospital. All patients or their families gave a written informed consent. Patients enrolled in the study had known COPD or a high probability of the disease on the basis of the clinical history, results of physical examination, chest radiograph, and/or previous pulmonary function tests data. Additional criteria for enrollment included AHRF requiring NIV according to the following

Results

The main clinical and respiratory characteristics of the 15 COPD patients are shown in Table 1. All patients showed evidence of severe AHRF requiring NIV. These AHRF episodes were related to bronchial superinfection in 14 cases and pneumonia in one case (patient 3). Table 1 also shows the main individual ventilatory settings finally used with ACV and PSV mode during the trial.

In comparison with SB mode, NIV strongly decreased the inspiratory effort. The WOBinsp parameters (WOBinsp/eyele,

Discussion

This prospective randomized study emphasizes the physiologic mechanisms underlying the clinical benefit of noninvasive ACV and PSV mode in the management of AHRF in COPD patients. To our knowledge, our study is the first to compare the physiologic effects of ACV and PSV in these circumstances. It shows that, using settings adapted to patient's tolerance and mask air leaks, both ACV and PSV modes may decrease the inspiratory muscle effort and similarly improve breathing pattern and gas exchange.

ACKNOWLEDGMENTS

The authors would like to thank Jean-François Gibon, Françoise Burel, and Yann Lacoume for their valuable technical assistance.

References (42)

BottJ. et al.
Randomized controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease
Lancet
(1993)
WysockiM. et al.
Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy
Chest
(1995)
WysockiM. et al.
Noninvasive pressure support ventilation in patients with acute respiratory failure
Chest
(1993)
MarinoW.
Intermittent volume cycled mechanical ventilation via nasal mask in patients with respiratory failure due to COPD
Chest
(1991)
BenhamouD. et al.
Nasal mask ventilation in acute respiratory failure: experience in elderly patients
Chest
(1992)
MeduriG.U. et al.
Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure
Chest
(1991)
CarreyZ. et al.
Ventilator muscle support in respiratory failure with nasal positive pressure ventilation
Chest
(1990)
FoglioC. et al.
Acute exacerbations in severe COLD patients: treatment using positive pressure ventilation by nasal mask
Chest
(1992)
LansingR. et al.
Chest surface recording of diaphragm potentials in man
Electroencephalogr Clin Neurophysiol
(1989)
MariniJ.J. et al.
The inspiratory work of breathing during assisted mechanical ventilation
Chest
(1985)

MacIntyreN. et al.

The Nagoya Conference on system design and patient-ventilator interactions during pressure support ventilation

Chest

(1990)

BrochardL. et al.

Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

N Engl J Med

(1995)

KramerN. et al.

Randomized prospective trial of noninvasive positive pressure ventilation in acute respiratory failure

Am J Respir Crit Care Med

(1995)

BrochardL. et al.

Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask

N Engl J Med

(1990)

FernandezR. et al.

Pressure support ventilation via face mask in acute respiratory failure in hypercapnic COPD patients

Intensive Care Med

(1993)

VitaccaM. et al.

Non-invasive modalities of positive pressure ventilation improve the outcome of acute exacerbations in COLD patients

Intensive Care Med

(1993)

Le GallJ.R. et al.

A simplified acute physiologic score for ICU patients

Crit Care Med

(1984)

Milic-EmiliJ. et al.

Improved technique for estimating pleural pressure from esophageal balloons

J Appl Physiol

(1964)

Milic-EmiliJ. et al.

Topography of esophageal pressure as a function of posture in man

J Appl Physiol

(1964)

BaydurA. et al.

A simple method for assessing the validity of the esophageal balloon technique

Am Rev Respir Dis

(1982)

SmithT.C. et al.

Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction

J Appl Physiol

(1988)

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Chest

Clinical Investigations in Critical Care: NIPPVComparative Physiologic Effects of Noninvasive Assist-Control and Pressure Support Ventilation in Acute Hypercapnic Respiratory Failure

Study objective

Design

Setting

Patients and interventions

Measurements and results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

ACKNOWLEDGMENTS

Lancet

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Electroencephalogr Clin Neurophysiol

Chest

Chest

Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

N Engl J Med

Randomized prospective trial of noninvasive positive pressure ventilation in acute respiratory failure

Am J Respir Crit Care Med

Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask

N Engl J Med

Pressure support ventilation via face mask in acute respiratory failure in hypercapnic COPD patients

Intensive Care Med

Non-invasive modalities of positive pressure ventilation improve the outcome of acute exacerbations in COLD patients

Intensive Care Med

A simplified acute physiologic score for ICU patients

Crit Care Med

Improved technique for estimating pleural pressure from esophageal balloons

J Appl Physiol

Topography of esophageal pressure as a function of posture in man

J Appl Physiol

A simple method for assessing the validity of the esophageal balloon technique

Am Rev Respir Dis

Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction

J Appl Physiol

Clinical Investigations in Critical Care: NIPPV
Comparative Physiologic Effects of Noninvasive Assist-Control and Pressure Support Ventilation in Acute Hypercapnic Respiratory Failure