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the specific conditions in which they can be used as well as the indications&#44; recommendations and evidence supporting the efficacy of NIV&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical conditions for NIV</span><p id="par0010" class="elsevierStylePara elsevierViewall">Alveolar hypoventilation is a result of an imbalance between the capability of respiratory muscles to maintain ventilation and gas exchange and is characterized by hypercapnia assessed by blood gas analysis&#46; If pathologies related to either peripheral and&#47;or central nervous system dysfunction are excluded&#44; the other conditions associated with developing alveolar hypoventilation are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Of note&#44; alveolar hypoventilation primarily develops during sleep<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; moreover&#44; in all these entities daytime breathing abnormalities must be considered&#46; These respiratory &#8220;daylight&#8221; deteriorations &#40;particularly in patients with neuromuscular disorders&#41; require an appreciation of the diagnosis&#44; the progression of the disease&#44; and the particular circumstances of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Obstructive sleep apnea&#8211;hypoapnea syndrome &#40;OSA&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">OSA has an incidence of 2&#37; in women and 4&#37; in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> It is characterized by recurrent episodes of partial &#40;hypoapnea&#41; or complete &#40;apnea&#41;&#44; obstruction of the upper airway during sleep&#44; and is associated with episodes of arousal and&#47;or oxyhemoglobin desaturation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Symptoms of the syndrome include excessive daytime sleepiness&#44; choking episodes during sleep&#44; frequent awakenings&#44; unrefreshing and unstructured sleep&#44; daytime fatigue&#44; difficulty concentrating and short-term memory loss<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The pathophysiology of OSA remains controversial&#46; Obesity&#44; the classic hallmark in OSA&#44; is associated with obstruction of the upper airways&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Possible hypotheses include adipose tissue infarction of the tongue and&#47;or the dilator muscles of the pharynx&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The upper airway becomes less efficient&#44; reducing oropharyngeal space especially at the end of exhalation&#46; As a result&#44; at the beginning of the next inspiration the dilator muscles of the pharynx must produce a greater contraction to overcome the tendency of the pharyngeal wall to collapse &#40;due to the negative pressure inside the cavity and pharynx&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The supine position is potentially dangerous in some circumstances<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> because the tongue tends to occlude the rear wall of the oropharynx which can increase the oropharynx occlusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> This syndrome has been associated with the development of hypertension&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> coronary artery disease&#44; bleeding disorders&#44; stroke and increased risk of sudden death during sleep&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> It is also associated with a higher rate and greater severity of traffic accidents&#44; increased use of health care facilities and reduced capacity for work&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;15</span></a> Strong evidence exists that non-invasive ventilation&#44; usually continuous airway positive pressure &#40;CPAP&#41;&#44; has significant advantages in this type of disease&#44; improving sleep quality&#44; daytime wakefulness&#44; and cognitive function<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and so the quality of life improves&#46; These improvements are wide-ranging&#58; reduction of traffic accidents&#44; lower arterial blood pressure and reduction in the morbidity and mortality rates of myocardial infarction and stroke demonstrate the wide spectrum of CPAP&#39;s benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;12&#44;15&#44;16</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Complex sleep apnea</span><p id="par0020" class="elsevierStylePara elsevierViewall">We use the term &#8220;Complex Sleep Apnea&#8221; &#40;CompSAS&#41; to indicate a condition initially diagnosed as OSA&#46; This syndrome is characterized &#40;while CPAP is being used&#41; by the frequent occurrence of central apneoa after elimination of obstructive events&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> CompSAS is diagnosed based on minimal apnea&#8211;hypoapnea index &#40;AHI&#41; of five events per hour of sleep with a majority of obstructive events&#46; If during titration there is a reduction in the number of obstructive events to &#60;5 events per hour of sleep&#44; while the central apnea index &#40;CAI&#41; is &#62;5 events per hour sleep&#44; the diagnosis is established&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Rather than starting further treatments it is useful to consider whether CPAP pressure is too high and is provoking CompSAS &#40;pressure toxicity&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Patients with CompSAS most often respond to positive airway pressure&#44; but the obstruction cannot be eliminated without producing central apnea&#46; A possible preventive measure is the so-called permissive flow-limitation&#58; the pressure is set at a level that permits a mild degree of airway obstruction&#44; without disturbing ventilator control mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Also oxygen administration may lead to a decrease in the hypoxic ventilatory response&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;21&#44;22</span></a> Also BiPAP in the spontaneous-timed &#40;ST&#41; mode<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;23</span></a> or adaptive servo-ventilation &#40;ASV&#41; can be useful in the treatment of CompSAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18&#44;24</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Sleep-disturbances associated with cardiac dysfunction</span><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is estimated to be about 11&#8211;53&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It is also known that the sleep obstructive apnea&#8211;hypoapnea syndrome can worsen a state of congestive heart failure&#44; by causing a periodic increase in negative intrathoracic pressure&#44; by raising arterial blood pressure&#44; and causing tachycardia from sympathetic nervous system stimulation from hypoxia&#44; hypercapnia and arousals&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CPAP treatment produces a reduction in blood pressure and improves left ventricular systolic function in patients with chronic heart failure and obstructive sleep apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;25</span></a> Recent studies in patients with chronic heart failure associated with obstructive sleep apnea have shown a further improvement in cardiac function in patients treated with bilevel positive airway pressure ventilation &#40;BIPAP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> This may be due to the lower respiratory muscle work due to BIPAP&#46; Moreover&#44; reduced work of breathing&#44; a lower positive intrathoracic pressure gives a greater ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Central sleep apnea &#40;CSA&#41; is associated with periodic breathing&#46; Periodic breathing&#44; Cheyne-Stokes respiration&#44; is a particular variety of central sleep apnea which is frequently associated with congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> CSA with its characteristic desaturation &#40;apnea-related&#41; and sympathetic hyperactivity tends to worsen the prognosis of heart failure&#46; CSA is characterized by cessation of respiratory drive during sleep&#44; which causes impaired gas exchange&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Unlike the OSA in which there is a respiratory effort to overcome the resistance of the upper airway&#44; CSA is characterized by the absence of respiratory movement due to the cessation of ventilation&#46; In the heart failure patients&#44; the onset of apnea occurs through a redistribution of blood volume from the lower limbs to pulmonary circulation that is primarily triggered by the supine position&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;29</span></a> Stimulation of pulmonary vagal receptors causes hyperventilation which results in hypocapnia&#46; When the value decreases below the hypocapnic apnoeic threshold&#44; stimulation of the bulbar center ceases&#44; inspiratory drive stops&#44; and apnea occurs&#46; In patients with chronic heart failure&#44; the prolonged circulation time due to the reduction in cardiac output leads to a delay of feedback between chemoreceptors and bulbar centers resulting in hyperventilation and respiratory instability&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The main risk factors for CSA are male sex&#44; hypocapnia&#44; atrial fibrillation and advanced age&#46; CPAP and BIPAP are often unable to correct this category of apneas&#59; therefore&#44; a servo-assisted mode &#40;ASV or adaptive servo ventilation&#41; is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;31</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The ASV device determinate automatically the extent of ventilatory support based on a continuous analysis of the breathing pattern and in more advanced machines also the expiratory pressure adjustment&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24</span></a> Some studies have shown it to be most effective in controlling this type of apnea&#59;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> it remains unclear whether ASV increases survival in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Obesity-hypoventilation syndrome</span><p id="par0040" class="elsevierStylePara elsevierViewall">Obesity hypoventilation refers to a syndrome including daytime hypercapnia &#40;PCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg&#41; in obese people in which no other cause of hypoventilation is present&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Its prevalence among patients with obstructive sleep apnea is 20&#8211;30&#37; and is greater in extremely obese patients &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> Approximately 10&#37; of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea syndrome&#46; Additionally&#44; nocturnal hypoxemia and diurnal hypercapnia persist in about 40&#37; of these patients after the treatment when CPAP eliminated apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> Other factors contribute to the development of obesity-hypoventilation syndrome associated with the persistence of daytime hypercapnia&#58; these include body mass index and apnea&#8211;hypoapnea index&#44; mean overnight oxygen saturation&#44; and the severity of restrictive ventilatory syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> CPAP treatment is most effective when there are certain predictive values&#58; better spirometry results&#44; and a higher apnea&#8211;hypoapnea index&#46; BIPAP therapy may be useful in those patients for whom CPAP has failed or given unsatisfactory results&#46; Titration of non-invasive ventilation pressure should follow the recommendations of pressure titration in obstructive sleep apnea with the goal of eliminating &#40;hypo&#41;apneas&#44; snoring&#44; respiratory effort-related arousals and lowering pCO<span class="elsevierStyleInf">2</span> levels to at least daytime values&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> No recommendations exist regarding the ventilation mode to favor in OHS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Trials exist providing evidence that a high backup respiratory rate leads to superior night-time control of respiratory events&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The average volume-assured pressure support ventilation seems to be able to lower pCO<span class="elsevierStyleInf">2</span>&#44; but data regarding effect on oxygenation and long-term outcome are conflicting&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Neuromuscular and chest wall disorders</span><p id="par0050" class="elsevierStylePara elsevierViewall">NIV has been used in patients with progressive neuromuscular disease or serious abnormalities of the thoracic cage&#44; with recognized benefits&#44; which include an improved survival rate and an improved quality of life&#46; The benefits of NIV in this type of patient includes improvements of daytime levels of blood gas &#40;including hypercapnia&#41;&#44; a reduction in the oxygen cost of breathing&#44; an increase in the ventilatory response to increased carbon dioxide&#44; and improved lung compliance&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Chronic obstructive pulmonary disease and sleep apnea &#40;overlap syndrome&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">COPD is a challenging and ever increasing chronic pulmonary disease&#44; affecting health care systems worldwide&#46; It is projected to be fourth leading cause of mortality by 2030&#46; COPD severely impacts quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In severe COPD acute exacerbations often lead to acute hypoxemic and&#47;or hypercapnic respiratory failure&#44; resulting in further disease progression and possible chronic respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">NIV is considered first-line treatment in acute exacerbations of COPD requiring ventilatory support&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> but recommendations regarding establishment of domiciliary long-term non-invasive ventilation in chronic hypercapnic failure due to COPD are conflicting&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Sleep-disordered breathing &#40;mainly obstructive sleep apnea&#41; and chronic obstructive pulmonary disease &#40;COPD&#41; are the most common lung diseases&#58; a large number of patients have both disorders&#44; hence the term &#8220;overlap syndrome&#46;&#8221;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;52</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The COPD overlap syndrome was first described by Flenley in 1985 as a combination of COPD and obstructive apnea&#8211;hypoapnea syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Epidemiological studies have not shown a consistently higher incidence of sleep apnea&#8211;hypoapnea syndrome in patients with COPD compared to common OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Nevertheless&#44; the coexistence of these conditions can lead to severe episodes of desaturation during sleep &#40;particularly during rapid eye moviment &#8211; REM-sleep&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> thus increasing the risk of hypoxemia&#44; daytime hypercapnia and pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> This results in a substantially greater morbidity and mortality&#44; compared to those with COPD or OSA alone as well as more hospitalizations and higher mortality&#46; Many questions remain about the definition of the disease&#44; the prognosis and the optimal treatment which currently consists of CPAP and oxygen&#46; Non-invasive ventilation may be useful in patients with overlap syndrome&#44; but there are no controlled studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;57</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical criteria for starting non-invasive ventilation</span><p id="par0070" class="elsevierStylePara elsevierViewall">The presence of symptoms and physiological markers of hypoventilation are useful in identifying the clinical severity&#59; moreover&#44; these factors relate to therapeutic decision-making&#44; especially initiating nocturnal non-invasive ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In a typical &#8220;progressive disease&#8221; two consecutive steps occur&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Initial phase of nocturnal hypoventilation reversible during waking hours&#44; associated with few or no clinical symptoms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nocturnal and daylight hypoventilation associated with clinical symptoms &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; which shows a reduced respiratory reserve&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous sleep monitoring of pCO<span class="elsevierStyleInf">2</span> and O<span class="elsevierStyleInf">2</span> saturation values is necessary to document the presence of nocturnal hypoventilation which may be present in all the stages of sleep &#40;in some cases only during REM sleep&#41;&#46; Daytime hypoventilation is defined by reduced values of arterial oxygen tension &#40;PaO<span class="elsevierStyleInf">2</span> &#60;55<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; high levels of arterial carbon dioxide tension &#40;PaCO<span class="elsevierStyleInf">2</span> 46&#8211;50<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and&#47;or high serum bicarbonate levels with a relatively normal pH&#46; Chronic daytime hypoventilation is an important indicator always associated with nocturnal hypoventilation &#40;PaCO<span class="elsevierStyleInf">2</span> &#8805;55<span class="elsevierStyleHsp" style=""></span>mmHg or a rise in PtcCO<span class="elsevierStyleInf">2</span> to &#8805;10<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In the presence of daytime hypoventilation&#44; polysomnography is recommended to exclude sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Clinical symptoms&#44; although modest&#44; should be evaluated carefully&#44; because they are very important determining disease severity and prognosis as well defining the need for NIV&#46; Pulmonary function tests may be helpful in defining the reduction of lung function&#44; but they have a low predictive value for patients with sleep-related hypoventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;52</span></a> However&#44; in patients with neuromuscular disease&#44; there is a good correlation between lung function and nocturnal hypoventilation&#58; it has been shown that hypoventilation during REM only or during all sleep stages or in the daytime&#44; appears respectively with supine inspiratory vital capacities of less than 40&#37;&#44; 25&#37; or 12&#37; of predicted values&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;58</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Types of NIV and their use</span><p id="par0090" class="elsevierStylePara elsevierViewall">We now consider the main types of ventilation used to treat sleep-disordered breathing and respiratory conditions associated with hypoventilation and hypercapnia&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">CPAP &#40;continuous positive airway pressure&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">CPAP is currently the most widely used mode of NIV in the treatment of obstructive sleep-disordered breathing<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> and acute hypoxemic failure associated with chronic heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#44;60</span></a> It consists in the application of a constant level of positive pressure during spontaneous breathing&#46; However&#44; it has to be noted that CPAP should be only applied in sufficiently spontaneous breathing patients&#46; It is not considered as a mode of mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> The mechanism of action of CPAP includes a series of actions on pathophysiological mechanisms&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">It prevents intermittent narrowing and collapse of the airways in patients with obstructive sleep apnea&#8211;hypoapnea syndrome &#40;by acting a virtual splint during sleep&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">It counteracts auto-positive end-expiratory pressure&#44; which reduces respiratory muscles load&#44; the work of breathing and daytime PaCO<span class="elsevierStyleInf">2</span> in patients with overlap syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">It improves lung function&#44; particularly the functional residual capacity&#44; daytime gas exchange in patients with obstructive sleep apnea&#8211;hypoapnea syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;d&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">It improves systolic function of the left ventricle in patients with heart failure coexisting with obstructive sleep apnea&#8211;hypoapnea syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Auto-CPAP &#40;automatic adjustment of continuous positive airway pressure&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Auto-CPAP &#40;APAP&#41; is delivered via a self-titrating CPAP device&#44; which uses algorithms to detect variations in the degree of obstruction and adjusts the pressure level to restore normal breathing&#46; Auto-CPAP compensates for factors that modify the upper airway collapsibility&#44; such as body position during sleep&#44; stage of sleep&#44; use of alcohol&#44; and drugs that affect upper airway muscle tone&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> The auto-CPAP can be used during polysomnography or cardiorespiratory monitoring to titrate a single pressure value to be used later with fixed CPAP for treatment of OSA in patients without comorbid conditions &#40;chronic heart failure&#44; COPD&#44; central apnea syndrome or hypoventilation&#41;&#46; The use of auto-CPAP is reserved only for those patients with sleep apnea syndrome only present during REM or respiratory events related to position&#44; in whom constraining positional maneuvers are poorly tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Adaptive servo-ventilation &#40;ASV&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The adaptive servo-ventilation &#40;ASV&#41; has been developed for the treatment of Cheyne-Stokes respiration-central apnea syndrome in patients with chronic heart failure who have a breathing pattern characterized by periods of crescendo&#8211;decrescendo change in tidal volume&#46; This more complex device can use patient expiratory positive airway pressure &#40;EPAP&#41; level sufficient to control the obstructive apnea&#46; The device then automatically adjusts the inspiratory pressure support for each inspiration within a pre-specified range&#44; to maintain a moving-target ventilation set at 90&#37; of the patient&#39;s recent average ventilation&#46; The aim is the stabilization of breathing patterns and to reduce the respiratory alkalosis which can trigger apnea re-entry cycles&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30&#44;63&#44;64</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">BIPAP &#40;bilevel positive airway pressure&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Bilevel positive airway pressure &#40;BIPAP&#41; is also used for sleep-related disorders&#44; but its main indication is in pathological conditions associated with hypoventilation&#46; The BIPAP devices deliver a higher pressure during inspiration &#40;IPAP &#8211; inspiratory positive airway pressure&#41; and a lower pressure during expiration &#40;EPAP &#8211; expiratory positive airway pressure&#41;&#46; The gradient between IPAP and EPAP &#40;pressure support ventilation&#41; is crucial in maintaining adequate alveolar ventilation and reducing paCO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> The IPAP acts also in reducing the work of breathing and fatigue&#44; reducing the workload of respiratory muscles&#59; EPAP has the function of maintaining the patency of the upper airway&#44; to control obstructive apnea and to improve the functional residual capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;65</span></a> BIPAP is now proposed for the type of patients who require high expiratory pressures to control obstructive sleep apnea&#8211;hypoapnea&#44; but who cannot tolerate exhaling against a high-fixed CPAP pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Other indications of BIPAP are the treatment of coexisting central apnea or hypoventilation&#44; the obesity-hypoventilation syndrome&#44; the overlap syndrome and neuromuscular disorders&#46; Although the patient should be able to maintain spontaneous breathing&#44; it is used to set a back-up rate option for those patients whose ventilation during sleep may be particularly impaired &#40;neuromuscular disorders&#44; complex sleep apnea&#44; central apnea in chronic heart failure&#44; obesity-hypoventilation syndrome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;65</span></a> Recently a new device has been introduced&#58; an auto-adjusting bi-level positive airway pressure &#40;auto-BIPAP&#41; to provide greater flexibility in pressure changes for bi-level therapy&#46; This treatment results in AHI &#40;apnea&#8211;hypoapnea index&#41; reduction equivalent to that provided by a conventional BIPAP&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Average volume-assured pressure support ventilation &#40;AVAPS&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Average volume-assured pressure support ventilation &#40;AVAPS&#41; is used in patients with chronic hypoventilation and in particular with obesity hypoventilation syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> neuromuscular diseases&#44; and sometimes&#44; in chronic obstructive pulmonary disease&#46; In this mode a target tidal volume is set&#59; the device adjusts the pressure support which to reach the selected tidal volume&#46; It guarantees a delivered tidal volume adjusted despite variability in the patient effort&#44; airway resistance&#44; and lung or chest wall compliance&#46; A particular benefit of this mode is that it may be modified as the disease progresses &#40;as it occurs in neuromuscular disorders such as amyotrophic lateral sclerosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Yet&#44; this system remains controversial&#46; It is not known if and to what extent hybrid ventilation modes &#40;i&#46;e&#46; pressure-targeted ventilation with assured volume support&#41; are beneficial in the management of chronic hypercapnic failure&#46; Further large-scaled studies are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The various types of non-invasive positive pressure ventilation and their indications for the non-invasive ventilation for the various disorders are shown in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Application and management of NIV</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Nocturnal CPAP titration</span><p id="par0145" class="elsevierStylePara elsevierViewall">The titration of the therapeutic value of CPAP &#40;value of positive pressure necessary to eliminate the sleep apnea&#41; can be made with one of the following methods&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and manual CPAP titration performed during polysomnography &#40;the pressure is gradually increased to normalize the breathing pattern during sleep&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Complete polysomnographic study &#40;with or without the continued presence of dedicated staff&#41; with titration performed with auto-CPAP &#40;usually the value of the 90th percentile&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Polysomnographic full study or complete cardiorespiratory monitoring performed during nocturnal CPAP therapy whose value has been obtained on the basis of data extracted from the device auto-CPAP in the previous nocturnal recording &#40;usually the value of the 90th percentile&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and titration of CPAP polysomnography performed in the course of using the split-night in which the patient is evaluated for 50&#37; of the night in spontaneously breathing and the other 50&#37; in incremental CPAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#44;70</span></a></p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">Titration of PAP obtained by auto-CPAP therapy should be derived from visual analysis of a large recording period free of artifacts&#46; The optimum pressure value of CPAP is the value which eliminates &#40;in the course of a complete polysomnographic investigation&#41; each apnea&#44; hypoapnea&#44; arterial desaturation&#44; snoring&#44; respiratory effort-related arousal &#40;RERA&#41; in each stage of sleep and body position&#46; The same applies in the course of a complete cardiorespiratory monitoring&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> An acceptable level of CPAP leads to a low number of events residues during the titration procedures&#46; The final value of pressure &#40;PAP&#41; is always a compromise between the function of patient adherence&#44; the absolute value of PAP reached&#44; and the clinical benefits derived&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is also recommended that the procedures for titration of CPAP in points 2&#44; 3 and 4 are made exclusively in patients with OSA in the absence of comorbidities such as COPD&#44; chronic heart failure&#44; and neuromuscular disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#8211;71</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Management of non-invasive ventilation</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Initiation and settings in case of nocturnal ventilation</span><p id="par0180" class="elsevierStylePara elsevierViewall">The main objective of NIV use is the correction of blood gas values to near &#8220;normal&#8221; with the least possible discomfort or sleep disturbance&#46; It is good practice to proceed in three successive steps&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The first step is to choose and adjust the ventilator settings while the patient is awake&#44; assuring physiological adequacy and patient comfort for at least 1 or 2<span class="elsevierStyleHsp" style=""></span>h&#46; In the second step the clinician should evaluate the adequacy of the settings when sleeping during a nap and a night&#39;s sleep&#46; Different options&#44; according to the resources available in each center&#44; are used&#46; A full polysomnography recording oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; and trans-cutaneous pCO<span class="elsevierStyleInf">2</span> &#40;PtcCO<span class="elsevierStyleInf">2</span>&#41; or end-tidal &#40;PetCO<span class="elsevierStyleInf">2</span>&#41;&#44; flow&#44; tidal volume&#44; airway pressure&#44; rib cage and abdomen excursion and sleep-staging allows a complete assessment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;52</span></a> When the resources are not available fewer parameters may be used&#46; The minimum required is recording SpO<span class="elsevierStyleInf">2</span> on room air&#44; assessing that the normalization of SpO<span class="elsevierStyleInf">2</span> accompanies the normalization&#44; or at least the improvement in PaCO<span class="elsevierStyleInf">2&#46;</span></p><p id="par0185" class="elsevierStylePara elsevierViewall">The second step relates to patient tolerance&#44; comfort&#44; changes in sleep quality and well-being&#59; these data should be obtained&#46; The third step consists of looking for reduction in PaCO<span class="elsevierStyleInf">2</span> and augmentation of PaO<span class="elsevierStyleInf">2</span> without dyspnea during the day in free ventilation after several nights of NIV&#46; This is done to confirm that the settings are adequate for the patient&#39;s needs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;71</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The main purpose for the application of NIV is the correction of hypercapnia to physiological levels&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Lately&#44; a technique called &#8220;high-intensity NIV&#8221; has emerged&#44; applying inspiratory pressure levels up to 28<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and high back-up respiratory rates in order to achieve pCO<span class="elsevierStyleInf">2</span> control in stable hypercapnic COPD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> This approach has been physiologically proven to reduce inspiratory effort&#44; when compared to conventional ventilation strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Furthermore&#44; high-intensity NIV does not negatively influence sleep quality&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> and improves blood gases&#44; lung function&#44; hematocrit&#44; and decrease COPD exacerbations rates&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> However&#44; it remains controversial what impact the setting of the breathing frequency has on ventilation quality in COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">If the results are not satisfactory&#44; changes must be made to the settings&#46; One may also change the type of mask and ventilator&#46; At the beginning a starting level of pressure support of 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is recommended&#46; Continuing the adaptation&#44; the pressure level can progressively be increased to achieve evidence of improvement&#46; Pressure support higher than 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is rarely necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A back-up frequency set close to the spontaneous frequency of the patient during sleep is a reasonable step&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> When employing a volume-preset ventilator&#44; the initial suggested setting may be established by adjusting the frequency of ventilator-delivered breaths so that it approximates the patient&#39;s spontaneous breathing frequency during sleep&#44; an inspiratory time&#47;total breathing time between 0&#46;33 and 0&#46;5 and a relatively high tidal volume of around 10&#8211;15<span class="elsevierStyleHsp" style=""></span>ml&#47;kg to insure sufficient tidal volume in case of leaks&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;71</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Supplemental oxygen &#40;O<span class="elsevierStyleInf">2</span>&#41; will be added to the ventilator circuit&#44; especially in those patients who require oxygen during the daytime &#40;COPD&#44; cystic fibrosis&#44; bronchiectasis&#41;&#46; However&#44; oxygen delivery varies greatly with the tubing system used &#40;active valve port&#44; leak port circuit&#41;&#46; Furthermore&#44; optimal mask fitting must be titrated in a clinical setting&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> In the absence of obstructive pulmonary disease&#44; the addition of O<span class="elsevierStyleInf">2</span> to the ventilation circuit may be justified only to maintain an acceptable level of PaO<span class="elsevierStyleInf">2</span> during sleep and only after all the parameters have been optimized&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">The choice of the mask</span><p id="par0205" class="elsevierStylePara elsevierViewall">The interface is of paramount importance for adherence to NIV therapy&#46; The choice of this device should be done with special care to meet patient&#39;s needs&#46; Considering the type of treatment planned and favoring masks which deliver positive pressure through both the nose and the mouth &#40;if the patient is a mouth breather&#41; is of great importance&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Every effort should be made to minimize air leaks&#44; maximize patient comfort and optimize patient&#8211;ventilator interaction&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> Technological issue to consider when choosing the NIV interface include the site and type of exhalation port&#44; and how the ventilator algorithm functions with different masks&#46; Heating and humidification may be needed to prevent adverse effects from cool dry gas&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80&#44;81</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Continuous NIV</span><p id="par0210" class="elsevierStylePara elsevierViewall">In patients with neuromuscular disorders &#40;to a lesser degree in end-stage stage lung disease&#41;&#44; ventilatory dependency can be total at the starting of non-invasive ventilation or may gradually increase following the progressive worsening of the disease&#46; In case of continuous need for assisted ventilation&#44; non-invasive ventilation may be started and maintained with modifications of the mode of ventilation &#40;e&#46;g&#46; changing ventilation mode between day and night and&#47;or alternating various interface types&#58; nasal&#44; oral&#44; oronasal&#44; mouth-piece&#41; and associated&#44; where possible&#44; with assisted coughing&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;82</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Follow-up</span><p id="par0215" class="elsevierStylePara elsevierViewall">Clinical follow-up and daytime arterial blood gases should be performed at least twice a year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The recordings during sleep &#40;possibly identical to those performed for the adaptation to non-invasive ventilation&#41;&#44; are useful&#46; At any time&#44; when there are indications of unsatisfactory results such as the recurrence of clinical symptoms and&#47;or signs of hypoventilation on arterial blood gases&#44; inadequate non-invasive ventilation should be suspected&#44; and a complete objective assessment of ventilation during sleep with polysomnography must be undertaken&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">When the NIV is not proven to be optimal&#44; a change of ventilation modality and&#47;or parameters of the ventilator and&#47;or a revision of the interface may be indicated&#46; In case of disease progression one should be considered increasing the duration of ventilation during the day&#46; The interfaces need to be regularly checked and modified or adapted to changing needs of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#44;71</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Management of complications</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Air leaks during ventilation</span><p id="par0225" class="elsevierStylePara elsevierViewall">The major potential adverse effect is the loss of effectiveness of the ventilation and therefore the potential fragmentation of sleep&#46; A variety of more or less effective measures have been suggested to tackle the problem of leaks during NIV&#46; These include the prevention of neck flexion&#44; the semi-recumbent positioning of the patient&#44; the use of a chin rest or a cervical collar to prevent opening of the mouth&#44; switching to controlled pressure mode&#44; decreasing the peak inspiratory pressure and increasing the delivered volume&#44; optimizing the interface &#40;using full face masks if possible&#41;&#46; The effectiveness of each of these measures must be confirmed during sleep recording&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Nasal dryness&#44; congestion</span><p id="par0230" class="elsevierStylePara elsevierViewall">As shown in the CPAP literature&#44; the side effects of nasal dryness&#44; congestion&#44; and rhinitis are related to a defect of humidification&#46; For the patients with nasal and mouth dryness&#44; a cold pass over or a heated humidifier can be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#44;85</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Aerophagia</span><p id="par0235" class="elsevierStylePara elsevierViewall">Aerophagia &#40;swallowing air&#41; is frequently reported but is rarely intolerable&#46; Minor clinical signs are eructation&#44; flatulence and abdominal discomfort&#46; Aerophagia usually depends on the level of inspiratory pressure and is more common when using a volume-controlled ventilation&#44; especially with mouthpiece&#44; in patients with neuromuscular disorders&#46; The incidence decreases if the peak inspiratory pressure is maintained below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;85</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The management of the most important complications and side effects is reported in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0245" class="elsevierStylePara elsevierViewall">Optimizing patient acceptance and adherence to non-invasive ventilation treatment is challenging and can be influenced by several factors &#40;i&#46;e&#46; age&#44; outcome expectations&#44; leakages&#44; and measured efficacy&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86&#44;87</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Sleep-related disorders are life-threatening conditions&#46; The optimal level of treatment should be determined in a sleep laboratory&#46; Side effects directly affecting the patient&#39;s adherence to treatment are known&#46; The most common are discomfort wearing the mask and leakages followed by nasopharyngeal symptoms including increased congestion and rhinorrea&#59; these effects are related to reduced humidity of inspired gas&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Humidification of delivered gas may improve these symptoms&#46; Sleep specialists should review the results of objective testing with the patient&#46; Education of the patient is mandatory&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The choice of ventilator&#44; its setting&#44; the choice of interface between patient and ventilator are crucial for the success of NIV&#46; A variety of masks are now available and manufacturers continue to improve mask design&#46; Oronasal mask should be considered if the patient is mouth breather to avoid leaks through open mouth&#46; In the past there were ventilators which had only pressure or volume controlled modes&#46; Today most ventilators can work in either mode and the choice of the equipment should be considered by the patient&#39;s point of view&#46; The patient&#39;s point of view is clinically relevant because better patient well-being is related to a better treatment adherence&#46; This is a critical issue especially in patients chronically treated with non-invasive ventilation&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Ethical disclosures</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Protection of human and animal subjects</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Confidentiality of data</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Right to privacy and informed consent</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Clinical conditions for NIV"
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              "titulo" => "Obstructive sleep apnea&#8211;hypoapnea syndrome &#40;OSA&#41;"
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                2 => array:2 [
                  "identificador" => "sec0130"
                  "titulo" => "Aerophagia"
                ]
              ]
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Conclusions"
        ]
        11 => array:3 [
          "identificador" => "sec0140"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0145"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0160"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-05-16"
    "fechaAceptado" => "2014-03-29"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec567281"
          "palabras" => array:4 [
            0 => "Sleep-related respiratory disorders"
            1 => "Non-invasive ventilation"
            2 => "Continuous positive airway pressure"
            3 => "Bi-level positive airway pressure"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec567280"
          "palabras" => array:4 [
            0 => "Dist&#250;rbios respirat&#243;rios do sono"
            1 => "Ventila&#231;&#227;o n&#227;o invasiva"
            2 => "Press&#227;o positiva cont&#237;nua das vias a&#233;reas"
            3 => "Press&#227;o positiva em dois n&#237;veis nas vias a&#233;reas"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Non-invasive mechanical ventilation &#40;NIV&#41; was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation&#46; Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea&#44; the overlap syndrome &#40;COPD and obstructive sleep apnea&#41;&#44; neuromuscular disorders&#44; obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this review we discuss the different types of NIV&#44; the specific conditions in which they can be used as well as the indications&#44; recommendations&#44; and evidence supporting the efficacy of NIV&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A ventila&#231;&#227;o mec&#226;nica n&#227;o invasiva &#40;VNI&#41; foi originalmente usada em doentes com insufici&#234;ncia respirat&#243;ria aguda ou em exacerba&#231;&#245;es de doen&#231;a respirat&#243;ria cr&#243;nica&#44; como uma alternativa &#224; intuba&#231;&#227;o&#46; Nos &#250;ltimos trinta anos&#44; a VNI tem sido usada durante a noite&#44; em doentes com doen&#231;as pulmonares cr&#243;nicas est&#225;veis&#44; como a apneia obstrutiva do sono&#44; a s&#237;ndrome de sobreposi&#231;&#227;o &#40;DPOC - doen&#231;a pulmonar obstrutiva cr&#243;nica - e apneia obstrutiva do sono&#41;&#44; disfun&#231;&#245;es neuromusculares&#44; s&#237;ndrome de hipoventila&#231;&#227;o e obesidade&#44; e em outras doen&#231;as como os dist&#250;rbios do sono associados a insufici&#234;ncia card&#237;aca congestiva&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nesta an&#225;lise discutimos os diferentes tipos de VNI&#44; as condi&#231;&#245;es espec&#237;ficas em que cada um deles pode ser usado&#44; assim como as indica&#231;&#245;es&#44; recomenda&#231;&#245;es e a evid&#234;ncia que comprova a efic&#225;cia da VNI&#46;</p></span>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Parietal disorders</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chest wall</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Kyphoscoliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sequelae of tuberculosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slow worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obesity hypoventilation syndrome &#40;OHS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neuromuscular</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spinal muscular atrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Acid maltase deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slow worsening &#40;&#62;15<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Duchene dystrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermediate worsening &#40;5&#8211;15<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Myotonic myopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermediate worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Amyotrophic lateral sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rapid worsening &#40;0&#8211;3<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Lung diseases</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic obstructive pulmonary disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bronchiectasis and Cystic fibrosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Predominant ventilatory control abnormalities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ondine&#39;s curse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cheyne-Stokes breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Upper airway abnormalities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pierre Robin syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888004.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Main diseases which can benefit from NIV classified according the cause and progressiveness of the respiratory impairment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Snoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nocturia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Unrefreshing sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Choking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Daytime sleepiness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Decreased libido&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Morning headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Enuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888009.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Typical symptoms of OSA&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Shortness of breath during activities of daily in the absence of paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Orthopnea in patients with disordered diaphragmatic dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Poor sleep quality&#58; insomnia&#44; nightmares and frequent arousals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nocturnal or early morning headaches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Daytime fatigue&#44; drowsiness&#44; loss of energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Decrease in intellectual performance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Appearance of recurrent complications&#58; respiratory infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical signs of cor pulmonale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888007.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical features frequently associated with alveolar hypoventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Continuous positive airway pressure &#40;CPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea&#59; congestive heart failure with coexisting obstructive sleep apnea&#59; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; CPAP level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; simple to use&#59; relatively inexpensive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; minimal or no ventilation support&#59; preset pressures may not address variability in obstructive sleep apnea or severity with sleep stages and positional stages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">AUTO-CPAP</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea&#59; congestive heart failure with coexisting obstructive sleep apnea&#59; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements range of allowable CPAP levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; reduces number of titration studies&#59; self-adjusting to adapt to variability in obstructive sleep apnea with sleep stages and positional changes&#59; maybe useful for patients with ongoing weight loss such as after bariatric surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than fixed CPAP&#59; may not be effective for patients with cardiopulmonary disorders or other conditions in which desaturation may be unrelated to obstructive events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Adaptive servo-ventilation &#40;ASV&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; congestive heart failure&#59; central sleep apnea&#59; complex sleep apnea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; maximum and minimum inspiratory pressures&#59; end-expiratory pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; adapts pressure to maintain more consistency of respiration over time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than other modes&#59; may worsen ventilation in disease with chronic ventilator insufficiency such as COPD or restrictive thoracic disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Bilevel positive airway pressure &#40;BIPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without backup rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea with CPAP intolerance&#59; obstructive sleep apnea with central sleep apnea&#59; restrictive thoracic disorders&#59; severe chronic obstructive pulmonary disease&#59; obesity hypoventilation syndrome with coexisting obstructive sleep apnea and residual hypoventilation despite CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; inspiratory and expiratory positive airway pressures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Advantages&#58; promotes alveolar ventilation&#59; unloads respiratory muscles&#59; decreases the work of breathing&#59; controls obstructive hypopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than CPAP&#59; may generate central apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>With backup rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; central sleep apnea&#59; complex sleep apnea syndrome&#59; worsening restrictive disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; inspiratory and expiratory positive airway pressure&#59; backup rate&#59; ratio of inspiratory time to expiratory time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; provides mandatory respiratory support during central or pseudo-central apneas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than conventional BIPAP&#59; may generate central apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Average volume-assured pressure support &#40;AVAPS&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obesity-hypoventilation syndrome&#59; neuromuscular disease&#59; chronic obstructive pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; target tidal volume &#40;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of ideal weight&#41;&#59; inspiratory positive airway pressure limits&#59; respiratory rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; ensures a delivered tidal volume&#59; compensates for diseases progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than other modes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Types of non invasive positive pressure ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;50&#44;59</span></a></p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Chronic obstructive pulmonary disease &#40;COPD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;50<span class="elsevierStyleHsp" style=""></span>mmHg when the patient is awake and O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry&#41; while on the higher of 2<span class="elsevierStyleHsp" style=""></span>L per minute of O<span class="elsevierStyleInf">2</span> and obstructive sleep apnea and CPAP treatment have been considered and ruled out by facility-based nocturnal polysomnography&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate&#44; anytime after use without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg greater than the original qualifying result and O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; while on NIV without backup rate and apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Restrictive thoracic disorders&#58; progressive neuromuscular disease or thoracic cage abnormalities</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;45<span class="elsevierStyleHsp" style=""></span>mmHg or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#37;minutes &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry&#41; or &#40;for neuromuscular diseases only&#41; maximal inspiratory pressure &#40;MIP&#41; &#8804;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or FVC &#8804;50&#37; of predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Central sleep apnea or complex sleep apnea syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>All the following on facility-based on nocturnal polysomnography&#58; apnea&#8211;hypopnea index &#62;5&#44; central events &#62;50&#37; of total&#44; central events &#8805;5 per hour&#44; excessive daytime sleepiness or disrupted sleep and significant improvement on NIV and FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Obstructive sleep apnea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Continuous positive airway pressure &#40;CPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Apnea&#8211;hypopnea syndrome index&#47;respiratory disturbance index &#8805;15 &#40;minimum 30 events&#41; or apnea&#8211;hypopnea index&#47;inspiratory disturbance index 5&#8211;14 with symptoms or cardiovascular risks &#40;excessive daytime sleepiness&#44; impaired cognition&#44; mood disorders&#44; insomnia&#44; hypertension&#44; ischemic heart disease&#44; history of stroke&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Above criteria and CPAP ineffective on polysomnography or at home cardio-respiratory monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Hypoventilation syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> &#8805;45<span class="elsevierStyleHsp" style=""></span>mmHg and PaCO<span class="elsevierStyleInf">2</span> &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg greater during sleep or upon awakening or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; with an apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> up &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg from initial qualifying PaCO<span class="elsevierStyleInf">2</span> despite using NIV without backup rate or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; while on NIV without backup and apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Non-invasive ventilation indication&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;50&#44;59</span></a></p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complication and&#47;or side effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Air leaks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevention of neck flexion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Semi-recumbent positioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use of chin rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use of cervical collar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switch to controlled pressure mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease peak inspiratory pressure and increase volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Optimize the interfaces &#40;using oro-nasal mask&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nasal dryness&#44; congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cold pass over&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heated humidifier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Aerofagia&#44; eructation&#44; flatulence&#44; abdominal discomfort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease peak inspiratory pressure below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Management of complications and side effects of NIV&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:87 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Non-invasive positive ventilation in the treatment of sleep-related breathing disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.sleep.2007.03.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Sleep Med"
                        "fecha" => "2007"
                        "volumen" => "8"
                        "paginaInicial" => "441"
                        "paginaFinal" => "452"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive positive ventilation in the treatment of sleep-related breathing disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/B978-0-444-52006-7.00030-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Handb Clin Neurol"
                        "fecha" => "2011"
                        "volumen" => "98"
                        "paginaInicial" => "459"
                        "paginaFinal" => "469"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive positive pressure ventilation for stable outpatients&#58; CPAP and beyond"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3949/ccjm.77a.10060"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cleve Clin J Med"
                        "fecha" => "2010"
                        "volumen" => "77"
                        "paginaInicial" => "705"
                        "paginaFinal" => "714"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Physiology of breathing and respiratory control during sleep"
                      "autores" => array:1 [
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Review
Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update
Ventilação não invasiva no tratamento de distúrbios respiratórios do sono: análise e actualização
A. Nicolinia,
Corresponding author
, P. Banfib, B. Grecchic, A. Laxb, S. Walterspacherd, C. Barlascinie, D. Robertf
a Respiratory Diseases Unit, Hospital of Sestri Levante, Italy
b Neuromuscular Diseases Unit, Don Gnocchi Foundation, Milan, Italy
c Rehabilitation Department ASL 4 Chiavarese, Italy
d Department of Pulmonology, University Hospital, Freiburg, Germany
e Forensic Medicine Unit, ASL 4 Chiavarese, Italy
f Emeritus Professor of Medicine, Claude Bernard University Lyon, France
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            "nombre" => "D&#46;"
            "apellidos" => "Robert"
            "referencia" => array:1 [
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                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
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        "afiliaciones" => array:6 [
          0 => array:3 [
            "entidad" => "Respiratory Diseases Unit&#44; Hospital of Sestri Levante&#44; Italy"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Neuromuscular Diseases Unit&#44; Don Gnocchi Foundation&#44; Milan&#44; Italy"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Rehabilitation Department ASL 4 Chiavarese&#44; Italy"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Department of Pulmonology&#44; University Hospital&#44; Freiburg&#44; Germany"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Forensic Medicine Unit&#44; ASL 4 Chiavarese&#44; Italy"
            "etiqueta" => "e"
            "identificador" => "aff0025"
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          5 => array:3 [
            "entidad" => "Emeritus Professor of Medicine&#44; Claude Bernard University Lyon&#44; France"
            "etiqueta" => "f"
            "identificador" => "aff0030"
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          0 => array:3 [
            "identificador" => "cor0005"
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    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Ventila&#231;&#227;o n&#227;o invasiva no tratamento de dist&#250;rbios respirat&#243;rios do sono&#58; an&#225;lise e actualiza&#231;&#227;o"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Noninvasive mechanical ventilation &#40;NIV&#41; is any form of ventilatory support without an endotracheal tube&#46; NIV was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases&#44; as an alternative to the endotracheal tube&#46; Over the last thirty years NIV has been also used during the night in patients with stable chronic lung disease such as obstructive sleep apnea &#40;OSA&#41;&#44; chronic obstructive pulmonary disease &#40;COPD&#41;&#44; the overlap syndrome &#40;COPD and obstructive sleep apnea&#41;&#44; neuromuscular disorders&#44; obesity-hypoventilation syndrome &#40;OHS&#41;&#44; and sleep disorders associated with congestive heart failure &#40;Cheyne-Stokes respiration&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In this review we discuss the different types of NIV&#44; the specific conditions in which they can be used as well as the indications&#44; recommendations and evidence supporting the efficacy of NIV&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical conditions for NIV</span><p id="par0010" class="elsevierStylePara elsevierViewall">Alveolar hypoventilation is a result of an imbalance between the capability of respiratory muscles to maintain ventilation and gas exchange and is characterized by hypercapnia assessed by blood gas analysis&#46; If pathologies related to either peripheral and&#47;or central nervous system dysfunction are excluded&#44; the other conditions associated with developing alveolar hypoventilation are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Of note&#44; alveolar hypoventilation primarily develops during sleep<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; moreover&#44; in all these entities daytime breathing abnormalities must be considered&#46; These respiratory &#8220;daylight&#8221; deteriorations &#40;particularly in patients with neuromuscular disorders&#41; require an appreciation of the diagnosis&#44; the progression of the disease&#44; and the particular circumstances of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Obstructive sleep apnea&#8211;hypoapnea syndrome &#40;OSA&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">OSA has an incidence of 2&#37; in women and 4&#37; in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> It is characterized by recurrent episodes of partial &#40;hypoapnea&#41; or complete &#40;apnea&#41;&#44; obstruction of the upper airway during sleep&#44; and is associated with episodes of arousal and&#47;or oxyhemoglobin desaturation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Symptoms of the syndrome include excessive daytime sleepiness&#44; choking episodes during sleep&#44; frequent awakenings&#44; unrefreshing and unstructured sleep&#44; daytime fatigue&#44; difficulty concentrating and short-term memory loss<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The pathophysiology of OSA remains controversial&#46; Obesity&#44; the classic hallmark in OSA&#44; is associated with obstruction of the upper airways&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Possible hypotheses include adipose tissue infarction of the tongue and&#47;or the dilator muscles of the pharynx&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The upper airway becomes less efficient&#44; reducing oropharyngeal space especially at the end of exhalation&#46; As a result&#44; at the beginning of the next inspiration the dilator muscles of the pharynx must produce a greater contraction to overcome the tendency of the pharyngeal wall to collapse &#40;due to the negative pressure inside the cavity and pharynx&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The supine position is potentially dangerous in some circumstances<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> because the tongue tends to occlude the rear wall of the oropharynx which can increase the oropharynx occlusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> This syndrome has been associated with the development of hypertension&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> coronary artery disease&#44; bleeding disorders&#44; stroke and increased risk of sudden death during sleep&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> It is also associated with a higher rate and greater severity of traffic accidents&#44; increased use of health care facilities and reduced capacity for work&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#44;15</span></a> Strong evidence exists that non-invasive ventilation&#44; usually continuous airway positive pressure &#40;CPAP&#41;&#44; has significant advantages in this type of disease&#44; improving sleep quality&#44; daytime wakefulness&#44; and cognitive function<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and so the quality of life improves&#46; These improvements are wide-ranging&#58; reduction of traffic accidents&#44; lower arterial blood pressure and reduction in the morbidity and mortality rates of myocardial infarction and stroke demonstrate the wide spectrum of CPAP&#39;s benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;12&#44;15&#44;16</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Complex sleep apnea</span><p id="par0020" class="elsevierStylePara elsevierViewall">We use the term &#8220;Complex Sleep Apnea&#8221; &#40;CompSAS&#41; to indicate a condition initially diagnosed as OSA&#46; This syndrome is characterized &#40;while CPAP is being used&#41; by the frequent occurrence of central apneoa after elimination of obstructive events&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> CompSAS is diagnosed based on minimal apnea&#8211;hypoapnea index &#40;AHI&#41; of five events per hour of sleep with a majority of obstructive events&#46; If during titration there is a reduction in the number of obstructive events to &#60;5 events per hour of sleep&#44; while the central apnea index &#40;CAI&#41; is &#62;5 events per hour sleep&#44; the diagnosis is established&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Rather than starting further treatments it is useful to consider whether CPAP pressure is too high and is provoking CompSAS &#40;pressure toxicity&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Patients with CompSAS most often respond to positive airway pressure&#44; but the obstruction cannot be eliminated without producing central apnea&#46; A possible preventive measure is the so-called permissive flow-limitation&#58; the pressure is set at a level that permits a mild degree of airway obstruction&#44; without disturbing ventilator control mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Also oxygen administration may lead to a decrease in the hypoxic ventilatory response&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;21&#44;22</span></a> Also BiPAP in the spontaneous-timed &#40;ST&#41; mode<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;23</span></a> or adaptive servo-ventilation &#40;ASV&#41; can be useful in the treatment of CompSAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18&#44;24</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Sleep-disturbances associated with cardiac dysfunction</span><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is estimated to be about 11&#8211;53&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It is also known that the sleep obstructive apnea&#8211;hypoapnea syndrome can worsen a state of congestive heart failure&#44; by causing a periodic increase in negative intrathoracic pressure&#44; by raising arterial blood pressure&#44; and causing tachycardia from sympathetic nervous system stimulation from hypoxia&#44; hypercapnia and arousals&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CPAP treatment produces a reduction in blood pressure and improves left ventricular systolic function in patients with chronic heart failure and obstructive sleep apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;25</span></a> Recent studies in patients with chronic heart failure associated with obstructive sleep apnea have shown a further improvement in cardiac function in patients treated with bilevel positive airway pressure ventilation &#40;BIPAP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> This may be due to the lower respiratory muscle work due to BIPAP&#46; Moreover&#44; reduced work of breathing&#44; a lower positive intrathoracic pressure gives a greater ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Central sleep apnea &#40;CSA&#41; is associated with periodic breathing&#46; Periodic breathing&#44; Cheyne-Stokes respiration&#44; is a particular variety of central sleep apnea which is frequently associated with congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> CSA with its characteristic desaturation &#40;apnea-related&#41; and sympathetic hyperactivity tends to worsen the prognosis of heart failure&#46; CSA is characterized by cessation of respiratory drive during sleep&#44; which causes impaired gas exchange&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Unlike the OSA in which there is a respiratory effort to overcome the resistance of the upper airway&#44; CSA is characterized by the absence of respiratory movement due to the cessation of ventilation&#46; In the heart failure patients&#44; the onset of apnea occurs through a redistribution of blood volume from the lower limbs to pulmonary circulation that is primarily triggered by the supine position&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;29</span></a> Stimulation of pulmonary vagal receptors causes hyperventilation which results in hypocapnia&#46; When the value decreases below the hypocapnic apnoeic threshold&#44; stimulation of the bulbar center ceases&#44; inspiratory drive stops&#44; and apnea occurs&#46; In patients with chronic heart failure&#44; the prolonged circulation time due to the reduction in cardiac output leads to a delay of feedback between chemoreceptors and bulbar centers resulting in hyperventilation and respiratory instability&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The main risk factors for CSA are male sex&#44; hypocapnia&#44; atrial fibrillation and advanced age&#46; CPAP and BIPAP are often unable to correct this category of apneas&#59; therefore&#44; a servo-assisted mode &#40;ASV or adaptive servo ventilation&#41; is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;31</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The ASV device determinate automatically the extent of ventilatory support based on a continuous analysis of the breathing pattern and in more advanced machines also the expiratory pressure adjustment&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24</span></a> Some studies have shown it to be most effective in controlling this type of apnea&#59;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> it remains unclear whether ASV increases survival in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Obesity-hypoventilation syndrome</span><p id="par0040" class="elsevierStylePara elsevierViewall">Obesity hypoventilation refers to a syndrome including daytime hypercapnia &#40;PCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg&#41; in obese people in which no other cause of hypoventilation is present&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Its prevalence among patients with obstructive sleep apnea is 20&#8211;30&#37; and is greater in extremely obese patients &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> Approximately 10&#37; of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea syndrome&#46; Additionally&#44; nocturnal hypoxemia and diurnal hypercapnia persist in about 40&#37; of these patients after the treatment when CPAP eliminated apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;36</span></a> Other factors contribute to the development of obesity-hypoventilation syndrome associated with the persistence of daytime hypercapnia&#58; these include body mass index and apnea&#8211;hypoapnea index&#44; mean overnight oxygen saturation&#44; and the severity of restrictive ventilatory syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> CPAP treatment is most effective when there are certain predictive values&#58; better spirometry results&#44; and a higher apnea&#8211;hypoapnea index&#46; BIPAP therapy may be useful in those patients for whom CPAP has failed or given unsatisfactory results&#46; Titration of non-invasive ventilation pressure should follow the recommendations of pressure titration in obstructive sleep apnea with the goal of eliminating &#40;hypo&#41;apneas&#44; snoring&#44; respiratory effort-related arousals and lowering pCO<span class="elsevierStyleInf">2</span> levels to at least daytime values&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> No recommendations exist regarding the ventilation mode to favor in OHS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Trials exist providing evidence that a high backup respiratory rate leads to superior night-time control of respiratory events&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The average volume-assured pressure support ventilation seems to be able to lower pCO<span class="elsevierStyleInf">2</span>&#44; but data regarding effect on oxygenation and long-term outcome are conflicting&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Neuromuscular and chest wall disorders</span><p id="par0050" class="elsevierStylePara elsevierViewall">NIV has been used in patients with progressive neuromuscular disease or serious abnormalities of the thoracic cage&#44; with recognized benefits&#44; which include an improved survival rate and an improved quality of life&#46; The benefits of NIV in this type of patient includes improvements of daytime levels of blood gas &#40;including hypercapnia&#41;&#44; a reduction in the oxygen cost of breathing&#44; an increase in the ventilatory response to increased carbon dioxide&#44; and improved lung compliance&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Chronic obstructive pulmonary disease and sleep apnea &#40;overlap syndrome&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">COPD is a challenging and ever increasing chronic pulmonary disease&#44; affecting health care systems worldwide&#46; It is projected to be fourth leading cause of mortality by 2030&#46; COPD severely impacts quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> In severe COPD acute exacerbations often lead to acute hypoxemic and&#47;or hypercapnic respiratory failure&#44; resulting in further disease progression and possible chronic respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">NIV is considered first-line treatment in acute exacerbations of COPD requiring ventilatory support&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> but recommendations regarding establishment of domiciliary long-term non-invasive ventilation in chronic hypercapnic failure due to COPD are conflicting&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Sleep-disordered breathing &#40;mainly obstructive sleep apnea&#41; and chronic obstructive pulmonary disease &#40;COPD&#41; are the most common lung diseases&#58; a large number of patients have both disorders&#44; hence the term &#8220;overlap syndrome&#46;&#8221;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;52</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The COPD overlap syndrome was first described by Flenley in 1985 as a combination of COPD and obstructive apnea&#8211;hypoapnea syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Epidemiological studies have not shown a consistently higher incidence of sleep apnea&#8211;hypoapnea syndrome in patients with COPD compared to common OSA&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Nevertheless&#44; the coexistence of these conditions can lead to severe episodes of desaturation during sleep &#40;particularly during rapid eye moviment &#8211; REM-sleep&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> thus increasing the risk of hypoxemia&#44; daytime hypercapnia and pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> This results in a substantially greater morbidity and mortality&#44; compared to those with COPD or OSA alone as well as more hospitalizations and higher mortality&#46; Many questions remain about the definition of the disease&#44; the prognosis and the optimal treatment which currently consists of CPAP and oxygen&#46; Non-invasive ventilation may be useful in patients with overlap syndrome&#44; but there are no controlled studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#44;57</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical criteria for starting non-invasive ventilation</span><p id="par0070" class="elsevierStylePara elsevierViewall">The presence of symptoms and physiological markers of hypoventilation are useful in identifying the clinical severity&#59; moreover&#44; these factors relate to therapeutic decision-making&#44; especially initiating nocturnal non-invasive ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In a typical &#8220;progressive disease&#8221; two consecutive steps occur&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Initial phase of nocturnal hypoventilation reversible during waking hours&#44; associated with few or no clinical symptoms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nocturnal and daylight hypoventilation associated with clinical symptoms &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; which shows a reduced respiratory reserve&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous sleep monitoring of pCO<span class="elsevierStyleInf">2</span> and O<span class="elsevierStyleInf">2</span> saturation values is necessary to document the presence of nocturnal hypoventilation which may be present in all the stages of sleep &#40;in some cases only during REM sleep&#41;&#46; Daytime hypoventilation is defined by reduced values of arterial oxygen tension &#40;PaO<span class="elsevierStyleInf">2</span> &#60;55<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; high levels of arterial carbon dioxide tension &#40;PaCO<span class="elsevierStyleInf">2</span> 46&#8211;50<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and&#47;or high serum bicarbonate levels with a relatively normal pH&#46; Chronic daytime hypoventilation is an important indicator always associated with nocturnal hypoventilation &#40;PaCO<span class="elsevierStyleInf">2</span> &#8805;55<span class="elsevierStyleHsp" style=""></span>mmHg or a rise in PtcCO<span class="elsevierStyleInf">2</span> to &#8805;10<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In the presence of daytime hypoventilation&#44; polysomnography is recommended to exclude sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Clinical symptoms&#44; although modest&#44; should be evaluated carefully&#44; because they are very important determining disease severity and prognosis as well defining the need for NIV&#46; Pulmonary function tests may be helpful in defining the reduction of lung function&#44; but they have a low predictive value for patients with sleep-related hypoventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;52</span></a> However&#44; in patients with neuromuscular disease&#44; there is a good correlation between lung function and nocturnal hypoventilation&#58; it has been shown that hypoventilation during REM only or during all sleep stages or in the daytime&#44; appears respectively with supine inspiratory vital capacities of less than 40&#37;&#44; 25&#37; or 12&#37; of predicted values&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;58</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Types of NIV and their use</span><p id="par0090" class="elsevierStylePara elsevierViewall">We now consider the main types of ventilation used to treat sleep-disordered breathing and respiratory conditions associated with hypoventilation and hypercapnia&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">CPAP &#40;continuous positive airway pressure&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">CPAP is currently the most widely used mode of NIV in the treatment of obstructive sleep-disordered breathing<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> and acute hypoxemic failure associated with chronic heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#44;60</span></a> It consists in the application of a constant level of positive pressure during spontaneous breathing&#46; However&#44; it has to be noted that CPAP should be only applied in sufficiently spontaneous breathing patients&#46; It is not considered as a mode of mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> The mechanism of action of CPAP includes a series of actions on pathophysiological mechanisms&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">It prevents intermittent narrowing and collapse of the airways in patients with obstructive sleep apnea&#8211;hypoapnea syndrome &#40;by acting a virtual splint during sleep&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">It counteracts auto-positive end-expiratory pressure&#44; which reduces respiratory muscles load&#44; the work of breathing and daytime PaCO<span class="elsevierStyleInf">2</span> in patients with overlap syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">It improves lung function&#44; particularly the functional residual capacity&#44; daytime gas exchange in patients with obstructive sleep apnea&#8211;hypoapnea syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;d&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">It improves systolic function of the left ventricle in patients with heart failure coexisting with obstructive sleep apnea&#8211;hypoapnea syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Auto-CPAP &#40;automatic adjustment of continuous positive airway pressure&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Auto-CPAP &#40;APAP&#41; is delivered via a self-titrating CPAP device&#44; which uses algorithms to detect variations in the degree of obstruction and adjusts the pressure level to restore normal breathing&#46; Auto-CPAP compensates for factors that modify the upper airway collapsibility&#44; such as body position during sleep&#44; stage of sleep&#44; use of alcohol&#44; and drugs that affect upper airway muscle tone&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> The auto-CPAP can be used during polysomnography or cardiorespiratory monitoring to titrate a single pressure value to be used later with fixed CPAP for treatment of OSA in patients without comorbid conditions &#40;chronic heart failure&#44; COPD&#44; central apnea syndrome or hypoventilation&#41;&#46; The use of auto-CPAP is reserved only for those patients with sleep apnea syndrome only present during REM or respiratory events related to position&#44; in whom constraining positional maneuvers are poorly tolerated&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Adaptive servo-ventilation &#40;ASV&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The adaptive servo-ventilation &#40;ASV&#41; has been developed for the treatment of Cheyne-Stokes respiration-central apnea syndrome in patients with chronic heart failure who have a breathing pattern characterized by periods of crescendo&#8211;decrescendo change in tidal volume&#46; This more complex device can use patient expiratory positive airway pressure &#40;EPAP&#41; level sufficient to control the obstructive apnea&#46; The device then automatically adjusts the inspiratory pressure support for each inspiration within a pre-specified range&#44; to maintain a moving-target ventilation set at 90&#37; of the patient&#39;s recent average ventilation&#46; The aim is the stabilization of breathing patterns and to reduce the respiratory alkalosis which can trigger apnea re-entry cycles&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30&#44;63&#44;64</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">BIPAP &#40;bilevel positive airway pressure&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Bilevel positive airway pressure &#40;BIPAP&#41; is also used for sleep-related disorders&#44; but its main indication is in pathological conditions associated with hypoventilation&#46; The BIPAP devices deliver a higher pressure during inspiration &#40;IPAP &#8211; inspiratory positive airway pressure&#41; and a lower pressure during expiration &#40;EPAP &#8211; expiratory positive airway pressure&#41;&#46; The gradient between IPAP and EPAP &#40;pressure support ventilation&#41; is crucial in maintaining adequate alveolar ventilation and reducing paCO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> The IPAP acts also in reducing the work of breathing and fatigue&#44; reducing the workload of respiratory muscles&#59; EPAP has the function of maintaining the patency of the upper airway&#44; to control obstructive apnea and to improve the functional residual capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;65</span></a> BIPAP is now proposed for the type of patients who require high expiratory pressures to control obstructive sleep apnea&#8211;hypoapnea&#44; but who cannot tolerate exhaling against a high-fixed CPAP pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Other indications of BIPAP are the treatment of coexisting central apnea or hypoventilation&#44; the obesity-hypoventilation syndrome&#44; the overlap syndrome and neuromuscular disorders&#46; Although the patient should be able to maintain spontaneous breathing&#44; it is used to set a back-up rate option for those patients whose ventilation during sleep may be particularly impaired &#40;neuromuscular disorders&#44; complex sleep apnea&#44; central apnea in chronic heart failure&#44; obesity-hypoventilation syndrome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;65</span></a> Recently a new device has been introduced&#58; an auto-adjusting bi-level positive airway pressure &#40;auto-BIPAP&#41; to provide greater flexibility in pressure changes for bi-level therapy&#46; This treatment results in AHI &#40;apnea&#8211;hypoapnea index&#41; reduction equivalent to that provided by a conventional BIPAP&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Average volume-assured pressure support ventilation &#40;AVAPS&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Average volume-assured pressure support ventilation &#40;AVAPS&#41; is used in patients with chronic hypoventilation and in particular with obesity hypoventilation syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> neuromuscular diseases&#44; and sometimes&#44; in chronic obstructive pulmonary disease&#46; In this mode a target tidal volume is set&#59; the device adjusts the pressure support which to reach the selected tidal volume&#46; It guarantees a delivered tidal volume adjusted despite variability in the patient effort&#44; airway resistance&#44; and lung or chest wall compliance&#46; A particular benefit of this mode is that it may be modified as the disease progresses &#40;as it occurs in neuromuscular disorders such as amyotrophic lateral sclerosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Yet&#44; this system remains controversial&#46; It is not known if and to what extent hybrid ventilation modes &#40;i&#46;e&#46; pressure-targeted ventilation with assured volume support&#41; are beneficial in the management of chronic hypercapnic failure&#46; Further large-scaled studies are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The various types of non-invasive positive pressure ventilation and their indications for the non-invasive ventilation for the various disorders are shown in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Application and management of NIV</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Nocturnal CPAP titration</span><p id="par0145" class="elsevierStylePara elsevierViewall">The titration of the therapeutic value of CPAP &#40;value of positive pressure necessary to eliminate the sleep apnea&#41; can be made with one of the following methods&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and manual CPAP titration performed during polysomnography &#40;the pressure is gradually increased to normalize the breathing pattern during sleep&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Complete polysomnographic study &#40;with or without the continued presence of dedicated staff&#41; with titration performed with auto-CPAP &#40;usually the value of the 90th percentile&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Polysomnographic full study or complete cardiorespiratory monitoring performed during nocturnal CPAP therapy whose value has been obtained on the basis of data extracted from the device auto-CPAP in the previous nocturnal recording &#40;usually the value of the 90th percentile&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Sleep study with complete laboratory staff dedicated to monitoring and titration of CPAP polysomnography performed in the course of using the split-night in which the patient is evaluated for 50&#37; of the night in spontaneously breathing and the other 50&#37; in incremental CPAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#44;70</span></a></p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">Titration of PAP obtained by auto-CPAP therapy should be derived from visual analysis of a large recording period free of artifacts&#46; The optimum pressure value of CPAP is the value which eliminates &#40;in the course of a complete polysomnographic investigation&#41; each apnea&#44; hypoapnea&#44; arterial desaturation&#44; snoring&#44; respiratory effort-related arousal &#40;RERA&#41; in each stage of sleep and body position&#46; The same applies in the course of a complete cardiorespiratory monitoring&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> An acceptable level of CPAP leads to a low number of events residues during the titration procedures&#46; The final value of pressure &#40;PAP&#41; is always a compromise between the function of patient adherence&#44; the absolute value of PAP reached&#44; and the clinical benefits derived&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is also recommended that the procedures for titration of CPAP in points 2&#44; 3 and 4 are made exclusively in patients with OSA in the absence of comorbidities such as COPD&#44; chronic heart failure&#44; and neuromuscular disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#8211;71</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Management of non-invasive ventilation</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Initiation and settings in case of nocturnal ventilation</span><p id="par0180" class="elsevierStylePara elsevierViewall">The main objective of NIV use is the correction of blood gas values to near &#8220;normal&#8221; with the least possible discomfort or sleep disturbance&#46; It is good practice to proceed in three successive steps&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The first step is to choose and adjust the ventilator settings while the patient is awake&#44; assuring physiological adequacy and patient comfort for at least 1 or 2<span class="elsevierStyleHsp" style=""></span>h&#46; In the second step the clinician should evaluate the adequacy of the settings when sleeping during a nap and a night&#39;s sleep&#46; Different options&#44; according to the resources available in each center&#44; are used&#46; A full polysomnography recording oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; and trans-cutaneous pCO<span class="elsevierStyleInf">2</span> &#40;PtcCO<span class="elsevierStyleInf">2</span>&#41; or end-tidal &#40;PetCO<span class="elsevierStyleInf">2</span>&#41;&#44; flow&#44; tidal volume&#44; airway pressure&#44; rib cage and abdomen excursion and sleep-staging allows a complete assessment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;52</span></a> When the resources are not available fewer parameters may be used&#46; The minimum required is recording SpO<span class="elsevierStyleInf">2</span> on room air&#44; assessing that the normalization of SpO<span class="elsevierStyleInf">2</span> accompanies the normalization&#44; or at least the improvement in PaCO<span class="elsevierStyleInf">2&#46;</span></p><p id="par0185" class="elsevierStylePara elsevierViewall">The second step relates to patient tolerance&#44; comfort&#44; changes in sleep quality and well-being&#59; these data should be obtained&#46; The third step consists of looking for reduction in PaCO<span class="elsevierStyleInf">2</span> and augmentation of PaO<span class="elsevierStyleInf">2</span> without dyspnea during the day in free ventilation after several nights of NIV&#46; This is done to confirm that the settings are adequate for the patient&#39;s needs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;71</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The main purpose for the application of NIV is the correction of hypercapnia to physiological levels&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Lately&#44; a technique called &#8220;high-intensity NIV&#8221; has emerged&#44; applying inspiratory pressure levels up to 28<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and high back-up respiratory rates in order to achieve pCO<span class="elsevierStyleInf">2</span> control in stable hypercapnic COPD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> This approach has been physiologically proven to reduce inspiratory effort&#44; when compared to conventional ventilation strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> Furthermore&#44; high-intensity NIV does not negatively influence sleep quality&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> and improves blood gases&#44; lung function&#44; hematocrit&#44; and decrease COPD exacerbations rates&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> However&#44; it remains controversial what impact the setting of the breathing frequency has on ventilation quality in COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">If the results are not satisfactory&#44; changes must be made to the settings&#46; One may also change the type of mask and ventilator&#46; At the beginning a starting level of pressure support of 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is recommended&#46; Continuing the adaptation&#44; the pressure level can progressively be increased to achieve evidence of improvement&#46; Pressure support higher than 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O is rarely necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A back-up frequency set close to the spontaneous frequency of the patient during sleep is a reasonable step&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> When employing a volume-preset ventilator&#44; the initial suggested setting may be established by adjusting the frequency of ventilator-delivered breaths so that it approximates the patient&#39;s spontaneous breathing frequency during sleep&#44; an inspiratory time&#47;total breathing time between 0&#46;33 and 0&#46;5 and a relatively high tidal volume of around 10&#8211;15<span class="elsevierStyleHsp" style=""></span>ml&#47;kg to insure sufficient tidal volume in case of leaks&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;71</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Supplemental oxygen &#40;O<span class="elsevierStyleInf">2</span>&#41; will be added to the ventilator circuit&#44; especially in those patients who require oxygen during the daytime &#40;COPD&#44; cystic fibrosis&#44; bronchiectasis&#41;&#46; However&#44; oxygen delivery varies greatly with the tubing system used &#40;active valve port&#44; leak port circuit&#41;&#46; Furthermore&#44; optimal mask fitting must be titrated in a clinical setting&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> In the absence of obstructive pulmonary disease&#44; the addition of O<span class="elsevierStyleInf">2</span> to the ventilation circuit may be justified only to maintain an acceptable level of PaO<span class="elsevierStyleInf">2</span> during sleep and only after all the parameters have been optimized&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">The choice of the mask</span><p id="par0205" class="elsevierStylePara elsevierViewall">The interface is of paramount importance for adherence to NIV therapy&#46; The choice of this device should be done with special care to meet patient&#39;s needs&#46; Considering the type of treatment planned and favoring masks which deliver positive pressure through both the nose and the mouth &#40;if the patient is a mouth breather&#41; is of great importance&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Every effort should be made to minimize air leaks&#44; maximize patient comfort and optimize patient&#8211;ventilator interaction&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> Technological issue to consider when choosing the NIV interface include the site and type of exhalation port&#44; and how the ventilator algorithm functions with different masks&#46; Heating and humidification may be needed to prevent adverse effects from cool dry gas&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80&#44;81</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Continuous NIV</span><p id="par0210" class="elsevierStylePara elsevierViewall">In patients with neuromuscular disorders &#40;to a lesser degree in end-stage stage lung disease&#41;&#44; ventilatory dependency can be total at the starting of non-invasive ventilation or may gradually increase following the progressive worsening of the disease&#46; In case of continuous need for assisted ventilation&#44; non-invasive ventilation may be started and maintained with modifications of the mode of ventilation &#40;e&#46;g&#46; changing ventilation mode between day and night and&#47;or alternating various interface types&#58; nasal&#44; oral&#44; oronasal&#44; mouth-piece&#41; and associated&#44; where possible&#44; with assisted coughing&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;82</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Follow-up</span><p id="par0215" class="elsevierStylePara elsevierViewall">Clinical follow-up and daytime arterial blood gases should be performed at least twice a year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The recordings during sleep &#40;possibly identical to those performed for the adaptation to non-invasive ventilation&#41;&#44; are useful&#46; At any time&#44; when there are indications of unsatisfactory results such as the recurrence of clinical symptoms and&#47;or signs of hypoventilation on arterial blood gases&#44; inadequate non-invasive ventilation should be suspected&#44; and a complete objective assessment of ventilation during sleep with polysomnography must be undertaken&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">When the NIV is not proven to be optimal&#44; a change of ventilation modality and&#47;or parameters of the ventilator and&#47;or a revision of the interface may be indicated&#46; In case of disease progression one should be considered increasing the duration of ventilation during the day&#46; The interfaces need to be regularly checked and modified or adapted to changing needs of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;69&#44;71</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Management of complications</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Air leaks during ventilation</span><p id="par0225" class="elsevierStylePara elsevierViewall">The major potential adverse effect is the loss of effectiveness of the ventilation and therefore the potential fragmentation of sleep&#46; A variety of more or less effective measures have been suggested to tackle the problem of leaks during NIV&#46; These include the prevention of neck flexion&#44; the semi-recumbent positioning of the patient&#44; the use of a chin rest or a cervical collar to prevent opening of the mouth&#44; switching to controlled pressure mode&#44; decreasing the peak inspiratory pressure and increasing the delivered volume&#44; optimizing the interface &#40;using full face masks if possible&#41;&#46; The effectiveness of each of these measures must be confirmed during sleep recording&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Nasal dryness&#44; congestion</span><p id="par0230" class="elsevierStylePara elsevierViewall">As shown in the CPAP literature&#44; the side effects of nasal dryness&#44; congestion&#44; and rhinitis are related to a defect of humidification&#46; For the patients with nasal and mouth dryness&#44; a cold pass over or a heated humidifier can be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#44;85</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Aerophagia</span><p id="par0235" class="elsevierStylePara elsevierViewall">Aerophagia &#40;swallowing air&#41; is frequently reported but is rarely intolerable&#46; Minor clinical signs are eructation&#44; flatulence and abdominal discomfort&#46; Aerophagia usually depends on the level of inspiratory pressure and is more common when using a volume-controlled ventilation&#44; especially with mouthpiece&#44; in patients with neuromuscular disorders&#46; The incidence decreases if the peak inspiratory pressure is maintained below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;85</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The management of the most important complications and side effects is reported in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0245" class="elsevierStylePara elsevierViewall">Optimizing patient acceptance and adherence to non-invasive ventilation treatment is challenging and can be influenced by several factors &#40;i&#46;e&#46; age&#44; outcome expectations&#44; leakages&#44; and measured efficacy&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86&#44;87</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Sleep-related disorders are life-threatening conditions&#46; The optimal level of treatment should be determined in a sleep laboratory&#46; Side effects directly affecting the patient&#39;s adherence to treatment are known&#46; The most common are discomfort wearing the mask and leakages followed by nasopharyngeal symptoms including increased congestion and rhinorrea&#59; these effects are related to reduced humidity of inspired gas&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Humidification of delivered gas may improve these symptoms&#46; Sleep specialists should review the results of objective testing with the patient&#46; Education of the patient is mandatory&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The choice of ventilator&#44; its setting&#44; the choice of interface between patient and ventilator are crucial for the success of NIV&#46; A variety of masks are now available and manufacturers continue to improve mask design&#46; Oronasal mask should be considered if the patient is mouth breather to avoid leaks through open mouth&#46; In the past there were ventilators which had only pressure or volume controlled modes&#46; Today most ventilators can work in either mode and the choice of the equipment should be considered by the patient&#39;s point of view&#46; The patient&#39;s point of view is clinically relevant because better patient well-being is related to a better treatment adherence&#46; This is a critical issue especially in patients chronically treated with non-invasive ventilation&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Ethical disclosures</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Protection of human and animal subjects</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Confidentiality of data</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Right to privacy and informed consent</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Obesity-hypoventilation syndrome"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Neuromuscular and chest wall disorders"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Chronic obstructive pulmonary disease and sleep apnea &#40;overlap syndrome&#41;"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Clinical criteria for starting non-invasive ventilation"
        ]
        7 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Types of NIV and their use"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "CPAP &#40;continuous positive airway pressure&#41;"
            ]
            1 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Auto-CPAP &#40;automatic adjustment of continuous positive airway pressure&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Adaptive servo-ventilation &#40;ASV&#41;"
            ]
            3 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "BIPAP &#40;bilevel positive airway pressure&#41;"
            ]
            4 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Average volume-assured pressure support ventilation &#40;AVAPS&#41;"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0080"
          "titulo" => "Application and management of NIV"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Nocturnal CPAP titration"
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0090"
          "titulo" => "Management of non-invasive ventilation"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Initiation and settings in case of nocturnal ventilation"
            ]
            1 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "The choice of the mask"
            ]
            2 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Continuous NIV"
            ]
            3 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Follow-up"
            ]
            4 => array:3 [
              "identificador" => "sec0115"
              "titulo" => "Management of complications"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0120"
                  "titulo" => "Air leaks during ventilation"
                ]
                1 => array:2 [
                  "identificador" => "sec0125"
                  "titulo" => "Nasal dryness&#44; congestion"
                ]
                2 => array:2 [
                  "identificador" => "sec0130"
                  "titulo" => "Aerophagia"
                ]
              ]
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Conclusions"
        ]
        11 => array:3 [
          "identificador" => "sec0140"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0145"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0160"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-05-16"
    "fechaAceptado" => "2014-03-29"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec567281"
          "palabras" => array:4 [
            0 => "Sleep-related respiratory disorders"
            1 => "Non-invasive ventilation"
            2 => "Continuous positive airway pressure"
            3 => "Bi-level positive airway pressure"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec567280"
          "palabras" => array:4 [
            0 => "Dist&#250;rbios respirat&#243;rios do sono"
            1 => "Ventila&#231;&#227;o n&#227;o invasiva"
            2 => "Press&#227;o positiva cont&#237;nua das vias a&#233;reas"
            3 => "Press&#227;o positiva em dois n&#237;veis nas vias a&#233;reas"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Non-invasive mechanical ventilation &#40;NIV&#41; was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation&#46; Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea&#44; the overlap syndrome &#40;COPD and obstructive sleep apnea&#41;&#44; neuromuscular disorders&#44; obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this review we discuss the different types of NIV&#44; the specific conditions in which they can be used as well as the indications&#44; recommendations&#44; and evidence supporting the efficacy of NIV&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A ventila&#231;&#227;o mec&#226;nica n&#227;o invasiva &#40;VNI&#41; foi originalmente usada em doentes com insufici&#234;ncia respirat&#243;ria aguda ou em exacerba&#231;&#245;es de doen&#231;a respirat&#243;ria cr&#243;nica&#44; como uma alternativa &#224; intuba&#231;&#227;o&#46; Nos &#250;ltimos trinta anos&#44; a VNI tem sido usada durante a noite&#44; em doentes com doen&#231;as pulmonares cr&#243;nicas est&#225;veis&#44; como a apneia obstrutiva do sono&#44; a s&#237;ndrome de sobreposi&#231;&#227;o &#40;DPOC - doen&#231;a pulmonar obstrutiva cr&#243;nica - e apneia obstrutiva do sono&#41;&#44; disfun&#231;&#245;es neuromusculares&#44; s&#237;ndrome de hipoventila&#231;&#227;o e obesidade&#44; e em outras doen&#231;as como os dist&#250;rbios do sono associados a insufici&#234;ncia card&#237;aca congestiva&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nesta an&#225;lise discutimos os diferentes tipos de VNI&#44; as condi&#231;&#245;es espec&#237;ficas em que cada um deles pode ser usado&#44; assim como as indica&#231;&#245;es&#44; recomenda&#231;&#245;es e a evid&#234;ncia que comprova a efic&#225;cia da VNI&#46;</p></span>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Parietal disorders</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chest wall</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Kyphoscoliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sequelae of tuberculosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slow worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obesity hypoventilation syndrome &#40;OHS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neuromuscular</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spinal muscular atrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Acid maltase deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slow worsening &#40;&#62;15<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Duchene dystrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermediate worsening &#40;5&#8211;15<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Myotonic myopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermediate worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Amyotrophic lateral sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rapid worsening &#40;0&#8211;3<span class="elsevierStyleHsp" style=""></span>y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Lung diseases</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic obstructive pulmonary disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bronchiectasis and Cystic fibrosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continuous worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Predominant ventilatory control abnormalities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ondine&#39;s curse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cheyne-Stokes breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depends on heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Upper airway abnormalities</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pierre Robin syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888004.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Main diseases which can benefit from NIV classified according the cause and progressiveness of the respiratory impairment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Snoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nocturia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Unrefreshing sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Choking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Daytime sleepiness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Decreased libido&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Morning headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Enuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888009.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Typical symptoms of OSA&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Shortness of breath during activities of daily in the absence of paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Orthopnea in patients with disordered diaphragmatic dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Poor sleep quality&#58; insomnia&#44; nightmares and frequent arousals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nocturnal or early morning headaches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Daytime fatigue&#44; drowsiness&#44; loss of energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Decrease in intellectual performance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Appearance of recurrent complications&#58; respiratory infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical signs of cor pulmonale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab888007.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical features frequently associated with alveolar hypoventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Continuous positive airway pressure &#40;CPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea&#59; congestive heart failure with coexisting obstructive sleep apnea&#59; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; CPAP level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; simple to use&#59; relatively inexpensive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; minimal or no ventilation support&#59; preset pressures may not address variability in obstructive sleep apnea or severity with sleep stages and positional stages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">AUTO-CPAP</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea&#59; congestive heart failure with coexisting obstructive sleep apnea&#59; Obesity-hypoventilation syndrome with coexisting obstructive sleep apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements range of allowable CPAP levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; reduces number of titration studies&#59; self-adjusting to adapt to variability in obstructive sleep apnea with sleep stages and positional changes&#59; maybe useful for patients with ongoing weight loss such as after bariatric surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than fixed CPAP&#59; may not be effective for patients with cardiopulmonary disorders or other conditions in which desaturation may be unrelated to obstructive events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Adaptive servo-ventilation &#40;ASV&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; congestive heart failure&#59; central sleep apnea&#59; complex sleep apnea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; maximum and minimum inspiratory pressures&#59; end-expiratory pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; adapts pressure to maintain more consistency of respiration over time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than other modes&#59; may worsen ventilation in disease with chronic ventilator insufficiency such as COPD or restrictive thoracic disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Bilevel positive airway pressure &#40;BIPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without backup rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obstructive sleep apnea with CPAP intolerance&#59; obstructive sleep apnea with central sleep apnea&#59; restrictive thoracic disorders&#59; severe chronic obstructive pulmonary disease&#59; obesity hypoventilation syndrome with coexisting obstructive sleep apnea and residual hypoventilation despite CPAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; inspiratory and expiratory positive airway pressures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Advantages&#58; promotes alveolar ventilation&#59; unloads respiratory muscles&#59; decreases the work of breathing&#59; controls obstructive hypopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than CPAP&#59; may generate central apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>With backup rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; central sleep apnea&#59; complex sleep apnea syndrome&#59; worsening restrictive disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; inspiratory and expiratory positive airway pressure&#59; backup rate&#59; ratio of inspiratory time to expiratory time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; provides mandatory respiratory support during central or pseudo-central apneas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than conventional BIPAP&#59; may generate central apnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Average volume-assured pressure support &#40;AVAPS&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Applications&#58; obesity-hypoventilation syndrome&#59; neuromuscular disease&#59; chronic obstructive pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Setup requirements&#58; target tidal volume &#40;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of ideal weight&#41;&#59; inspiratory positive airway pressure limits&#59; respiratory rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Advantages&#58; ensures a delivered tidal volume&#59; compensates for diseases progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disadvantages&#58; more expensive than other modes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Types of non invasive positive pressure ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;50&#44;59</span></a></p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Chronic obstructive pulmonary disease &#40;COPD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;50<span class="elsevierStyleHsp" style=""></span>mmHg when the patient is awake and O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry&#41; while on the higher of 2<span class="elsevierStyleHsp" style=""></span>L per minute of O<span class="elsevierStyleInf">2</span> and obstructive sleep apnea and CPAP treatment have been considered and ruled out by facility-based nocturnal polysomnography&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate&#44; anytime after use without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg greater than the original qualifying result and O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; while on NIV without backup rate and apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Restrictive thoracic disorders&#58; progressive neuromuscular disease or thoracic cage abnormalities</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span> &#8805;45<span class="elsevierStyleHsp" style=""></span>mmHg or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#37;minutes &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on nocturnal oximetry&#41; or &#40;for neuromuscular diseases only&#41; maximal inspiratory pressure &#40;MIP&#41; &#8804;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O or FVC &#8804;50&#37; of predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Central sleep apnea or complex sleep apnea syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with or without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>All the following on facility-based on nocturnal polysomnography&#58; apnea&#8211;hypopnea index &#62;5&#44; central events &#62;50&#37; of total&#44; central events &#8805;5 per hour&#44; excessive daytime sleepiness or disrupted sleep and significant improvement on NIV and FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Obstructive sleep apnea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Continuous positive airway pressure &#40;CPAP&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Apnea&#8211;hypopnea syndrome index&#47;respiratory disturbance index &#8805;15 &#40;minimum 30 events&#41; or apnea&#8211;hypopnea index&#47;inspiratory disturbance index 5&#8211;14 with symptoms or cardiovascular risks &#40;excessive daytime sleepiness&#44; impaired cognition&#44; mood disorders&#44; insomnia&#44; hypertension&#44; ischemic heart disease&#44; history of stroke&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Above criteria and CPAP ineffective on polysomnography or at home cardio-respiratory monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Hypoventilation syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV without backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> &#8805;45<span class="elsevierStyleHsp" style=""></span>mmHg and PaCO<span class="elsevierStyleInf">2</span> &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg greater during sleep or upon awakening or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; with an apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV with backup rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Awake PaCO<span class="elsevierStyleInf">2</span> up &#8805;7<span class="elsevierStyleHsp" style=""></span>mmHg from initial qualifying PaCO<span class="elsevierStyleInf">2</span> despite using NIV without backup rate or O<span class="elsevierStyleInf">2</span> saturation &#8804;88&#37; for &#8805;5<span class="elsevierStyleHsp" style=""></span>min &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>h of recording on facility-based nocturnal polysomnography&#41; while on NIV without backup and apnea&#8211;hypopnea index &#60;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Non-invasive ventilation indication&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;49&#44;50&#44;59</span></a></p>"
        ]
      ]
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        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complication and&#47;or side effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Air leaks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevention of neck flexion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Semi-recumbent positioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use of chin rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use of cervical collar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switch to controlled pressure mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease peak inspiratory pressure and increase volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Optimize the interfaces &#40;using oro-nasal mask&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nasal dryness&#44; congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cold pass over&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heated humidifier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Aerofagia&#44; eructation&#44; flatulence&#44; abdominal discomfort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Decrease peak inspiratory pressure below 25<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Management of complications and side effects of NIV&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:87 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
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ISSN: 08732159
Original language: English
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